Transcript for
Supporting children and young people through gender-affirming care

Damien Riggs (00:00): 

You can be gender-affirming, which is accepting that trans people exist and have a right to exist and doing your best to use the right language that you’ve been given by the person. But I think beyond that, there’s also knowledge. It’s about being connected to trans people outside of your practise. It’s about being an advocate for trans communities outside your practise. It’s about knowing the research that sits around the work that you’re doing. 

Narrator (00:25): 

Welcome to The Emerging Minds podcast. 

Nicole Rollbusch (00:30): 

Hi, I’m Nicole Rollbusch, and you’re listening to an Emerging Minds podcast. We would like to pay respect to the traditional custodians of the land on which this podcast is recorded, the Kaurna people of the Adelaide Plains. We also pay respect to all Aboriginal and Torres-Strait Islander peoples, their ancestors and elders past, present, and emerging from the different First Nations across Australia. In today’s episode, I’m pleased to be joined by Professor Damien Riggs. Damien is a professor in psychology at Flinders University in South Australia, and is the author of over 200 publications on gender, family, and mental health. Damien is also a psychotherapist who specialises in working with transgender young people. Gender diverse children and young people face unique stresses that impact their mental health at greater levels compared to their peers, including bullying, harassment, discrimination, and abuse. Their support network, comprising not only of family and friends but also support services, is crucial to their well-being. 

(01:34): 

Many families report difficulty finding services that can support their gender-diverse child or even negative experiences when they do engage with services. Practitioners may feel underconfident or unable to provide support if they’ve never completed any formal training in gender-affirming practise. However, practitioners who work with children have many existing skills in their toolkit that can aid them in providing the acceptance and responsiveness that gender-diverse children and young people need. Damien joins us today to share some of the ways practitioners working in general services can use their skills to work with children in gender-affirming ways that support their mental health and well-being, as well as how practitioners can seek out learning opportunities to increase their knowledge and confidence in working with gender-diverse children and young people. Welcome, Damien. Thank you so much for joining me today. 

Damien Riggs (02:26): 

Thanks. 

Nicole Rollbusch (02:27): 

Just wanted to start by getting you to tell us a little bit about yourself and your work. 

Damien Riggs (02:31): 

I am a professor at Flinders University, where lots of my research focuses on trans people and trans young people specifically, and I also have a small private practise as a psychotherapist, where I work with young people under 12 years. 

Nicole Rollbusch (02:49): 

Based on your experience, when might a family seek support for a child who’s exploring their gender identity? 

Damien Riggs (02:56): 

Some people come to speak to me when their child has given them indications or something’s just isn’t sitting right in terms of how they understand their child’s gender. They might come to me for support for them to understand what might be going on. They might come to me if the child wants to explore their gender. They might come to me as well where they have a pretty good idea, but as with even a society, where people like some kind of authorization from a professional that they know what they’re doing, they sometimes come to me looking for that professional authorization. That could be for themselves, it could be for family members who are questioning, and then, I also obviously work with families who are completely on board, the child’s already socially transitioned, but they need some kind of support in addition to what they’re already receiving. 

Nicole Rollbusch (03:51): 

I’m thinking specifically for children under the age of 12. What might some of the challenges be that they’re facing, particularly in relation to their mental health and well-being? 

Damien Riggs (04:02): 

Some of it is generic counselling work. It could be around generalised anxiety or depression. It could be around struggles with school attendance. That’s certainly the case because trans kids are kids, so they’re going to face all the same things that every other kid faces. But then, there can also be specific things around gender dysphoria, though I less often see that with the really young kids, they’re more okay with themselves and their bodies. It can be around families struggling to support, and so the young person’s needing that extra sort of boost or that person to have their corner and advocate for them to the family. It can also be around thinking about what I want for my future. Obviously, some people are going to explore medical pathways to care and wanting to know what that’s going to look like and how that’s going to be for them in the hospital setting. 

Nicole Rollbusch (04:54): 

When gender-diverse children or young people experience challenges with their mental health and well-being, how much of that is related to how people respond around them or, I guess, environmental factors? 

Damien Riggs (05:08): 

I think it really is a mix of both. There’s a lot of internal stuff that goes on around do I fit, where do I fit, or I feel I don’t fit, and that’s really challenging for me and upsetting for me. But then, there is also the stuff around peers at school, often there’s challenges, and particularly for child transitions at an existing school, then there can be challenges in how less often, thankfully, it’s the schools is the problem. It’s more often the peers who are struggling to or to make the shift or who are intentionally not making the shift with the young person. There’s those trans-specific aspects as well that I work with the young people around how do they push back? How do they decline? How do they focus on what’s going on in their head rather than letting other peoples who use compound their own concerns? 

Nicole Rollbusch (06:00): 

You’ve spoken before about supporting parents. What are some of the things you might do with a parent to support them, so that they can support their child? 

Damien Riggs (06:09): 

I think someone said it to me, a parent of a trans person said it to me a while back that you need to get out of your kid’s way. It’s easy for us as parents to think we know best and sometimes we do, but when it comes to a young person knowing who they are, we need to step back and trust that they know who they are. That this is not a phase, that this is not a trend, this is a young person’s genuine expression of who they are. I think a big thing is about encouraging parents to step back, at the same time is pairing that with you’re still a responsible parent and you still need to parent your child. Part of it is also about listening to the child and particularly around dysphoria, what does that look like, so that we can brainstorm ideas for how to mitigate that. 

(06:55): 

I have to listen to the child first to then be able to give the tips and tricks to the parents, to be able to go, “Right, these are the things.” A common thing is distress around bath times. Talking parents through ideas around, well, maybe you remove that big full-length mirror from your bathroom, maybe you dim the lighting. Young people often look at me like, “Oh, that’s really radically useful.” And I’m like, “Well, to me, it’s obvious.” But again, that’s experience of working in this space. Whereas, a young person who comes along with not those concerns, well, I’m not going to say that to them. It’s about knowing their concern and then giving the parents the tips and tricks for how to address that. 

(07:31): 

And then, I think the third thing is often just coming from that place of knowing that this is right, and this is okay, that many parents often come down when they hear that. And it’s something I’ve struggled with over the decades, that I don’t think our job as clinicians is to say, “Well, I know, so therefore, you should believe me, and then, you’ll be fine.” That doesn’t work with most mental illnesses. But when it comes to something which is not a mental illness, which is being trans, I think it’s more possible to say to people, “Actually, this is legit. Let’s go with this.” 

Nicole Rollbusch (08:05): 

What are some of the challenges that you’ve come across in your practise with children and families? 

Damien Riggs (08:10): 

When it comes to kids, challenges can be around that development of that idea that I’m in their corner. Some kids are cheeky and they think, “Well, I’m going to advocate for them to have anything.” But of course, I say to kids, “Well, a random example, you’re a 6-year-old girl, you want to wear nail polish because you think that’s part of what will affirm your gender, but your older sister’s not allowed to. So actually, I’m on board with your parents. They’re allowed to have values around that and they have reasons for that, and we’ll talk through that. We won’t just go point blank no, we’ll talk through what the logic is behind that, and occasionally, parents will shift their views on that. It’s that challenge of being “I’m a hundred percent on your side in terms of who you are,” but there’s allowed to be rules and boundaries around how you express yourself in terms of your age. 

(08:58): 

I often frame it in terms of a need and a want. There’s things that you need. You need gender-affirming care. That’s a given, that’s a human right. But a want, an iPad is a want. Doing X, Y, and Z is a want. Lollies are a want. You can frame some of them around being gender-affirming, but you can say that for any kid. A 15-year-old who’s a cis girl, who’s told she can’t wear nail polish by her parents. For her, that might be gender-affirming, but the parents are allowed to say, “That’s not in our cup of tea,” so we can sort of break down those things I think productively, and it’s very uncommon for that to become a stalemate with young people. And certainly, if we think about it as things that we work towards or things that we might do, okay, the compromise might be we wear it during school holidays or we wear it during weekends, or we wear it for a special occasion. We sort of think about what goes on in the family more broadly and what’s gender-affirming and what is gender-affirming but is negotiable. 

Nicole Rollbusch (09:59): 

What does it mean to work in a gender-affirming way? What does it look like? 

Damien Riggs (10:05): 

I think it is very simple. It is, you come and tell me who you are and absent of other things that might be concerning, which would be very serious mental health concerns, which is not a space I work in, I will go with that. And if that shifts and change over time, then I’ll shift and change with you. It’s also about being a very firm advocate, so if parents are struggling, if parents are misgendering children, really politely engaging with them around the language they’re using and helping them expand their thinking, so that I’m a safe space and that young person knows that I’m in their corner. I think the other aspect, you can be gender-affirming, which is accepting that trans people exist and have a right to exist and doing your best to use the right language that you’ve been given by the person. 

(10:54): 

But I think beyond that, there’s also knowledge. It’s about being connected to trans people outside of your practise. It’s about being an advocate of trans communities outside your practise. It’s about knowing the research that sits around the work that you’re doing. For me, why it works is, I think, an example I had recently, where a family came along and they were, I think, okay, but they were still like, “This is very new to us and we don’t know how to talk to people.” And so, I shared a lot of knowledge and I shared a lot of ways for them to advocate for their child, and a lot of ways, practical tips for how to be supportive. At one point, the mum just said, “Oh, my god, you know everything.” And I said, “Well, I don’t. I’m always learning, but I’m immersed in this world, and so it’d be rather disappointing if I didn’t know what to share with you.” 

(11:44): 

I think there’s that immersion that you are not just a clinician with some knowledge who’s kind and you are giving tips and tricks as an outsider. I think, for me, as someone who’s quite immersed in the world, the trans space and in trans communities, that what I’m really inviting the families and the young people into is to community. That could be linking people in with things outside of the work that I do. It could be connecting them in with support services. It’s really, I think, that broader knowledge, in addition to my specific clinical knowledge, that means that gender-affirming work is really useful, I think. 

Nicole Rollbusch (12:24): 

What can get in the way of practitioners working in a gender-affirming way. You and I have spoken before about confidence can get in the way. How can that get in the way and what are some of the other things that might stand in the way of practitioners working in this way? 

Damien Riggs (12:41): 

I think you’re right, it’s about confidence, but I think that confidence sits in a broader context. I think, when you remind people, most of this is generic skills with a bit of specialist knowledge on top when you’re doing that work. They’ll think, “Okay, I could do that.” But then, they think, “Oh, my goodness, I see this stuff in the media, and I think this work is going to make me vulnerable. This work is going to open me up to litigation.” All those things are potentially true, but that’s true in lots of spaces that we work in as clinicians. And so, our job is to always be brave, I think, and to have a social justice focus. And so, we shouldn’t be stepping back or stepping out or refusing to even step into this work just out of fear of what could come of it. 

(13:27): 

If it’s about I have no knowledge in this space, well then absolutely, you’re right. You shouldn’t step into the space, but you should upskill yourself. You should learn, because it’s unlikely you are never going to receive referrals for working with trans people. You may have a referral who comes to you for anxiety or depression and you spend sessions with them, and then, they disclose they’re trans. You’re not going to refer on then. We all need those basic skills and we need to find ways to bracket off our concerns, and that includes through supervision, through talking with peers. 

Nicole Rollbusch (14:01): 

If you had advice for practitioners who were really wanting to provide more support to children and families in this space, what would you suggest to them? Where can they start? 

Damien Riggs (14:13): 

I think there’s lots of periodic training that is run across Australia, and often that’s webinars, and most of them are recorded. There’s certainly different organisations like MHPM, Mental Health Professionals Network, Transcend, which is an organisation for parents of trans kids, LGBTI Health Alliance. They all make available these recordings, which are clinicians talking about the work that they do. I think watching those, seeing people’s passion, seeing people’s enthusiasm, and then, really stopping and thinking, “Do I share that?” Because I think any specialisation you have should come from a place of passion and a place of commitment. If you watch those and you look at that and you think, “No, this is still beyond me,” well then, that’s okay. Not everyone has to do this work. But if you do think that this is something for you, then you would reach out and look for supervision. You would reach out and look for further ongoing training and engaging with the literature and making sure that if at some point you’re going to put up a shingle that says you do this work, that you are capable of doing the work. 

Nicole Rollbusch (15:16): 

For practitioners who might not be specialising in this area and are working in generalist settings, what role or scope is there for them in doing this work? 

Damien Riggs (15:25): 

I think there is a huge scope for those people. I think that a greater majority of clinical work with trans people is generalist work. One would hope you are asking people, is this related to being trans? Is this a part of the story that we’re going with here or is it largely separate? And if it’s largely separate and you are trans-affirming, and you know the Gender 101, and you listen to what your client says and what want language they want to use, you’ll be fine. I think it’s a different kettle of fish if you’re thinking, “Right, I want to make this my bread and butter.” Then, I think the skillset’s quite different. They overlap, obviously, but I think it is a different skillset in terms of connectedness to community and feedback and engagement. That’s different than if you’re just doing generalist work, where a generalist should be able to treat anyone. And if that means your client is trans and/or your client is Muslim, and/or they’re indigenous, you need the skillsets around knowing those communities. 

(16:26): 

I always say, when I teach people, you have one appointment. You have the first appointment, which is intake “How are you? What’s the story?” The next appointment’s not going to be the next day. You’ve got time in between to learn. If that’s someone from a community you don’t know much about, go out away, go ahead and get supervision, go out and talk to people. That’s totally fine if you’re doing generalist work. But if you do more and more and more of that generalist work and you think, “I love working in this space,” then you also start need to develop relationships in that space. 

Nicole Rollbusch (16:54): 

You and I have spoken before about some of the small things that can mean a lot in practise, using correct names and pronouns. We’ve also spoken about how, if practitioners get things wrong, not necessarily saying sorry, but the importance of owning and acknowledging that. Can you speak a bit more about these things that might seem small, but can mean so much to the person you’re working with? 

Damien Riggs (17:20): 

Yeah. I think when I first work with a family, I ask the young person who they are, and how often they’re already using the pronouns in front of me or I’ll ask and then I’ll say to parents, so I’m going with that. I’ve never had a parent say, “Well, no. You’re not allowed to.” I suspect those parents don’t come to see me. But I’ll then say, “And if you struggle or if you trip, then I’ll just say something.” Again, never had a parent feel offended by that. They often look at me with gratitude of like, “Oh, thank you.” Obviously, the young person typically looks at me with like, “Thank you. I’m used to not having anyone correct people.” 

(17:57): 

But I think, over the years it has been the case that if someone’s misgendered and the trans person corrects the other person, the socially typical response is to say sorry. When we make a mistake, we say sorry. But of course, what does that then elicit? The other person is meant to say, “That’s okay.” And I think that’s a line of thinking that’s possibly true in many situations that’s not useful, but I think for trans people, in particular, it’s not okay. It’s not the burden of trans people to say, “That’s okay, you are forgiven.” I think it’s more productive to say, “Thanks,” or “Great, of course, yeah, I’m going to do better,” so that you’re not falling to that trap of trans people having to prop up cis people to be reminded about pronouns. 

(18:39): 

I think some of the cute things I do with kids is, we are going to give mum and dad a set amount of time and we will talk in the session about how long that might be. Some parents, it’s very quick and some parents, it’s longer. I’ll say to the young person, say, “What prompts are we going to use? Because I’m not going to be there. I’m not going to be at home with you, so what do we use?” And kids come up with hilariously cute things. Mum’s going to get a poke on the nose and dad’s going to get a pinch on the wrist or something. Empowering kids to not just be passive recipients of misgendering, but rather being able to politely, because if it’s intentional misgendering, well that’s a whole different coefficient. If it’s unintentional, I think our response can still be kind, even if we’re not having to say, “That’s okay,” to your sorry. 

(19:23): 

Encouraging kids to be kind to their parents, but still having cheeky, playful ways of reminding them. I’ve used lots of things, like some kids are like, “Oh, granny is not very responsive.” I’m like, “Have a card. Have a flag. Hold it up to her, so then she … It’s very hard to forget when something’s right in front of your face, a card that says he, or get a baseball cap that says he on or a T-shirt.” Some people are like, “Oh, my god, that’s a bridge too far.” But then, they try it and they’re like, “Oh, wow. Actually made it harder for granny to forget.” 

Nicole Rollbusch (19:56): 

Yeah, and on those reminders, I was thinking you could even, as a practitioner, talk to children about what’s our sign going to be in sessions? If you’re new to this work, and you and I have spoken about this before, it does take practise to get out of that automatic gendering that we do. 

Damien Riggs (20:13): 

I think, to me, when I run training primarily for mental health professionals, I say to people, “Why is it relevant to 95% of your practise what the person’s assigned sex was?” For a medical professional? Possibly, maybe, yeah, sure. For a allied health professional, for a mental health professional, that’s something we may know on intake, but we actually need to actively work on forgetting, because that’s where people trip up. They trip up on thinking about, “Oh, this person was assigned a boy,” and then he comes out and it comes out and it comes out again. Whereas, if the young person comes along and the name’s Mary and she says she’s she, then stop thinking about what that child was assigned about. Think about her, think about Mary, and that’s, to me, the way that people can shift their thinking. 

(20:59): 

I think another tip is, a friend said to me many years ago when I was starting to know or more people I knew were coming out as non-binary, a friend said to me, “People really need a third box in their head.” Cognitively, we have, typically, in our culture two boxes around gender. And so people, I think it’s much easier for people to slip up around non-binary people, because they haven’t created that box in their head, and that takes work. When you’re learning a new job, when you are learning a new route to work, you have to put cognitive effort into learning that pattern because you didn’t have it before. I think the same thing comes for supporting and caring for non-binary people. You have to make sure you have that space in your head. Otherwise, where do you put the information? It’s always bouncing around, not landing somewhere, that sort of demographic information about the person. 

Nicole Rollbusch (21:50): 

You’ve spoken about some of the things that practitioners in generalist settings can be thinking about, but for those practitioners who want to do more of this work and maybe specialise in it, this is your specialist area and you’ve been working in this space for a long time, as you said, immersed in the community, and that obviously feeds into your practise and your knowledge. Was it always that way? 

Damien Riggs (22:13): 

That’s a good question. No, it wasn’t. I think I remember years ago writing the first edition of a textbook on LGBTQ psychology, and someone I was involved in working with at on was like, we were hanging out one day and they said, “I kind of just don’t get trans people.” And I was like, “What?” And it made me realise at that point in time, “Oh, I’ve always fundamentally gotten that trans people exist and always thought, yeah, that’s normal.” And then, not long after that, I was practising clinically and the service had a call, had a referral for a young trans person when that was very uncommon at the time. They sent him along to me because I was the person who took on lesbian and gay couples primarily. I remember finding that work exciting. I don’t remember being nervous about doing it because I love working with kids. And so, it was really exciting work to do. 

(23:03): 

But then, fast forward a few years and I started getting no one as someone who’s doing this work and encountering different families. This is quite a while ago, back then I saw a great number of families who were really struggling or not at all willing to be affirming. It was hard work. I often felt like I was getting things wrong. I often felt like I wasn’t, and sometimes I was literally getting things wrong. I was learning alongside people, which didn’t always feel okay to me. 

(23:35): 

I always felt, “Well, as I’ve been advocating in our chat today, I should know more.” The world turns away, the world turns, and my circle of friendship and family expanded a lot, not through any sort of instigation of my own to include probably a greater number of trans people and cis people, and as a result of that, I got a much greater connection to community and started doing research in this space that was, again, not something that I sort of directed. It was trans community members coming to me and saying, “We’ve heard about you,” and people have spoken well of you, and sort of vouched for me. And so, I was able to move into the research space as well. 

(24:11): 

Along with this came all this extra knowledge. This, I wouldn’t say a surge of confidence, but certainly a greater sense of competency in doing the clinical work. But I still would have these fears of lingering from when maybe I wasn’t as skilled as now I think I should have been, that I might slip up. I really had to look at myself and have some supervision and think around, “Am I the right person to do this work? Do I know enough? Even though I’m ongoing learning, of course, do I know enough? 

(24:43): 

It really was a process of self-authorization, where I could look at what I know and where I’m situated and the communities I’m a part of and say, “I actually know what I’m doing.” That sort of fear or lack of confidence that I was holding before vanished because I could actually say all of these things, not me as some standalone individual out in the world who’s just suddenly decided to put up a shingle, but me with this history of working with people in community, with friends, with family, meant actually, I’m good. Not I know everything, not that I could never make a mistake again, but that I felt like I could authorise myself to do this work. 

Nicole Rollbusch (25:29): 

That really speaks back to what you were saying before about what can get in the way and some of the things that can support practitioners to step into this work is building that knowledge, seeking that supervision, which, obviously, he’ll do in good stead for your work. 

Damien Riggs (25:47): 

Yeah, I think it is that leaping into this space is unwise. You need to know the global context you’re working in and how that’s going to affect you in the work you might do and how that sits with your own mental health. You need to have connections to community. I think that with any marginalised community, if you’re just stepping in as an outsider doing this work and you don’t have those connections, there’s a greater risk that something isn’t going to go right. Obviously, coming to a point where you feel competent to authorise yourself to do the work, but also, that’s again, never in isolation. It’s always checking back with people, talking to people. It is through those close relationships, so I think you either realise, “Yes, I’m doing this right,” or, “Actually, I need to tweak some of this stuff.” 

Nicole Rollbusch (26:32): 

We’re coming to the end of our time together, but is there anything else that you would like to add that we haven’t covered? 

Damien Riggs (26:38): 

I think, for me, a big thing is joy. I think it’s easy to get a referral. Often, parents are desperate. They’ve struggled to find someone, or they’ve experienced long wait times in other services, or family members have said, “What are you doing?” Or the school has said, “What are you doing?” And so, they’re fearful and they’re anxious. In that time, we know for any person of any gender, the time between I need help and getting the help is an incredibly vulnerable time. My wait lists tend to be not that long, but other services they are long, and so people are waiting in that holding pattern. I think it is about acknowledging that, acknowledging that people have been in the holding pattern and working quite quickly towards what are the needs and how do we address them? We’re often presented with fearful parents or kids who have been desperate for services or kids who have gender dysphoria, and it’s quite significant. 

(27:36): 

It’s easy to be step into, invited into the space as a therapist, like therapists mostly are, “I’m not coping, I’m in crisis, help me.” And that’s something we’re trained to do, I think, for all therapists, but I think particularly for therapists working with trans kids, because we need to be able to also create joy, co-create joy with the young people, look at those moments, and these aren’t things that are meant to offset. They’re not, “Oh, well, you’ve got dysphoria, so we’ll find some joy to offset it.” That’s not how it works. It’s not about, “Oh, well, life can’t be all bad. Surely something’s nice.” It’s not that, that’s simplistic. It’s about a bigger sense of the joy of being trans, the joy of celebrating who you are and the agency that sits with that. I think that’s something I don’t typically do in a first session, but it’s always at the back of my mind, that when something comes up that the young person’s done or the parents have done then, I think, “Wow, that’s so powerful.” “You’re so brave,” or, “That shows great agency.” 

(28:37): 

I’ll flag that and talk about what sat around that and what has come from that, so that even if we’re still ongoing dealing with the challenges, we’re also flagging and orienting ourselves also to joy. I often thank people. People will often thank me, but I’ll say, “You are a joy to talk to. I love spending time.” Obviously, it’s not about pretending there’s not a power differential, but it’s about saying one-to-one person-to-person, I’m really loving these interactions. The young person is reminded they’re a person of value and they’re a person that other people enjoy being around, which sometimes can get lost in the mix of explicit messages, “I don’t want you around,” or implicit messages, which is “You are a challenge to be around.” 

Nicole Rollbusch (29:22): 

Yeah. I think that’s a really nice message for us to finish on. Thank you so much for joining. Damien. It’s been great to speak with you. 

Damien Riggs (29:29): 

Thank you. 

Narrator (29:31): 

Visit our website at emergingminds.com.au to access a range of resources to assist your practise. Brought to you by the National Workforce Centre for Child Mental Health. Led by Emerging Minds, the Centre is funded by the Australian Government Department of Health and Aged Care under the National Support for Child and Youth Mental Health Program