Supporting trans and gender diverse children and their families

Creating a safe space for a child to explore their gender identity will contribute to positive mental health outcomes. This resource provides an overview of ways to support a child who is questioning their gender identity or who has come out as trans or gender diverse. It is not designed to give medical or psychological expertise and advice on working with trans and gender diverse children. For this the Australian Standards of Care and Treatment Guidelines for trans and gender diverse children and adolescents (‘Standards of Care and Treatment’) are a great place to start. It is also recommended practitioners connect with a gender specialist in their state. You can download a Referral Matrix of support services here.

Definitions

The following are just a few key terms – longer lists of definitions can be found in several of the resources suggested at the end of this guide:

Trans and gender diverse

“These are umbrella terms that describe people who identify their gender as different to the legal sex that was assigned to them at birth.” (ACON language guide, 2017)

There is a difference between sex, which is a biological characteristic, and gender, which is how someone feels and identifies. Not everyone who is trans will want to have an identity of being ‘trans’ but rather will just want to live in their affirmed gender. This is important to keep in mind when supporting a child who may simply see themselves as a boy or a girl, not as a trans girl or trans boy.

In addition, whilst many trans people might use binary terms, such as boy or girl to describe their gender identity, language and ways of describing identity are constantly evolving. It is good practice to ask a person who is trans or gender diverse what language they are using to describe their identity.

Non-binary

“This is an umbrella term for any number of gender identities that sit within, outside of, across or between the spectrum of the male and female binary. A non-binary person might identify as gender fluid, trans masculine, trans feminine, agender, bigender etc.” (ACON Language Guide, 2017).

If a child identifies as non-binary, they might say that they don’t feel like a boy or a girl, or describe not feeling like they fit into society’s expectations and gender stereotypes of how to behave. This child might want to be referred to with the pronoun ‘they/them’. It is important to consider here that gender is socially constructed and often strictly controlled. What is considered a masculine trait in one culture, community or family may be the main role of the female in another. Historically gender roles also shift, and we have also seen these changes across generations. Think about how gendered toys and clothing are and the way that before a child is even born, people will often ask what sex it is.

Gender dysphoria

“The distress or unease sometimes experienced from being misgendered and/or when someone’s gender identity and body personally don’t feel connected or congruent.

Gender dysphoria does not equal being trans or gender diverse. Many trans and gender diverse people do not experience gender dysphoria and if they do it may cease with access to gender affirming health care.” (ACON Language Guide, 2017)

Language is very powerful and labelling a child with ‘gender dysphoria’ can be quite stigmatising and give the impression that they are disordered or have a medical problem. The term ‘gender dysphoria’ is listed in the DSM5, where it was previously called ‘gender identity disorder’. One of the main reasons for changing the label was to recognise that being transgender is not a mental illness.

Often the distress a child experiences comes from not being listened to and told that they must be the gender that they were assigned at birth. Particularly in the early stages, using language like ‘exploring gender identity’ steers the discussion away from giving a ‘diagnosis’ and allows for a less stigmatising conversation.

Children become aware of their gender and begin displaying ‘gendered’ roles from a very young age. They may also begin to express gender diverse behaviour at the same time (Telfer, et al., 2018).  Gender diverse behaviour may be a phase, but that does not diminish the intensity of the child’s experience and the need for a supportive and safe environment in which to explore their identity.

Preventing children from exploring their gender identity and expressing themselves in ways that come naturally to them can negatively impact their development and mental health. Having a conversation about gender identity will not cause a child to change their gender, but may help them to feel more comfortable.

The ‘Trans Pathways: The mental health experiences and care pathways of trans young people’ [Trans Pathways] report found that “the mean age at which parents realised their young person was trans was 11 years of age” (Strauss, et al., 2017, p. 21) and that:

• 26.5% realised when their child was in early childhood (0–5 years)
• 21.8% realised when their child was of primary school age (6–12 years)
• 43.9% realised when their child was an adolescent (13–18 years)
• 8.0% realised when their child was a young adult (19–24 years) (Strauss, et al., 2017, p. 21)

As the following quote from a mother of a 7-year-old trans child shows, some parents of trans and gender diverse children start having conversations about gender identity with their child from early childhood.

“Just as any 3 year old can tell you if they are a boy or girl, so can she. She has never wavered in this, I remember at the earliest age having to say to her no you are a boy, you have a penis, thinking she was just confused. Or telling her she was a boy & boys stand up to wee when she didn’t want to. We have finally now she is 7 recently fully transitioned & she is just so amazingly happy & confident, the change in her is remarkable for the better. I’m ashamed it’s taken us this long to take her at face value & just let her be her.” (Strauss, et al., 2017, p. 92)

“My child also has an Autism diagnosis – how can they really know if they are trans or gender diverse?”

Research suggests a high percentage of children and young people who identity as transgender or gender diverse are also on the Autism spectrum. Trans Pathways found that 22% of young people who took part in the study also had an autism diagnosis, with a further 35% warranting further testing. (Strauss, et al., 2017)

Autism spectrum disorder (ASD) does not prevent a child from being able to clearly describe their feelings and understanding of their gender. Strang et al. (2016, p. 109) state that the “diagnosis of ASD should not exclude an adolescent from also receiving a GD diagnosis and, when indicated, appropriate GD-related treatment.” The Trans Pathways report states, “a diagnosis of ASD should not be seen as inherently undermining the authenticity or validity of a person’s gender identity.” (Strauss, et al., 2017, p. 31).

Practitioners working with trans and gender diverse children with ASD should explore how the ASD influences other areas of the child’s life, and to what degree it is integrated with the child’s experience of being trans or gender diverse. Having ASD should not prevent children from receiving further support and engaging in conversations about their gender identity.

Being trans does not make a person anxious or cause mental illness and being trans is not a mental illness itself. However, the experiences of discrimination and marginalisation, of having to constantly hide and keep secrets about their identity, and of being forced to be and act in ways that do not align with their true sense of self can cause distress for trans and gender diverse children.

Support at an early age can have important long-term positive mental health benefits for trans and gender diverse children and decrease their chances of poor mental health outcomes, such as depression, eating disorders, self-harm and suicidal ideation (Strauss, et al., 2017; Smith, et al., 2014). The Trans Pathway report showed that:

• almost three-quarters (74.6%) of Trans Pathways participants have at some time been diagnosed with depression
• 72.2% have been diagnosed with an anxiety disorder
• self-harm and suicidality are also very high amongst trans and gender diverse young people, with 79.7% of participants having self-harmed; and
• 48.1% have attempted suicide at some point in their life. (Strauss, et al., 2017)

When young people in this same study were asked what they thought was contributing to their mental health issues, their responses were all related to factors external to their trans identity and included things like discrimination, bullying, lack of family support, and difficulty in accessing the help they needed to support their gender affirmation (Strauss, et al., 2017; Smith et al., 2014).

In terms of treatment, the Australian Standards of Care and Treatment Guidelines state that the “[w]itholding of gender affirming treatment is not considered a neutral option, and may exacerbate distress in a number of ways including increasing depression, anxiety and suicidality, social withdrawal, as well as possibly increasing chances of young people illegally accessing medications.” (Telfer, et al., 2018, p. 5)

The words ‘affirmation’ and ‘transition’ can both be used to describe the journey a person takes to live as the gender that they feel themselves to be. Many trans and gender diverse people prefer the use of the word ‘affirmation’ because they are affirming their gender identity. ‘Transition’ on the other hand implies they are transitioning from one to another, when in fact many trans people have always felt the way they do. The word ‘transition’ has often been used in a medical framework, and its use can add to the feelings of being pathologised and medicalised that many trans people experience.

Gender affirmation can be broadly categorised into ‘social affirmation’ and ‘medical affirmation’.  There is no one ‘correct’ way to affirm one’s gender, and not everyone will medically affirm their gender. This can be for a variety of reasons; including that medical services are not accessible due to distance or expense, or because the individual is happy with their body. It is important to remember to treat every child as an individual. A child who is expressing that they are trans should also not be forced to conform to gendered stereotypes, such as how to dress or how to behave for the gender that they are identifying as.

For a prepubescent child the affirmation support provided will be in the form of social affirmation because there is nothing medically to offer. Where a child is experiencing significant psychological distress, a referral to a psychologist may be necessary. Support for social affirmation can simply mean allowing a child to dress in the clothes that they feel most comfortable wearing or changing their hairstyle (e.g. growing or cutting their hair). Some children might ask to be referred to as a gender different to that which was assigned at birth; others might ask to change their name. These simple things, whilst they may seem confronting to the family, will go a long way towards improving the happiness and wellbeing of the child.

Social affirmation for a child can also include:

• choosing and changing their name
• changing pronouns (from ‘he’ to ‘she’, ‘she’ to ‘he’, or ‘he/she’ to ‘they’)
• changing the type of clothing they wear – including school uniform – to match their gender identity
• changing hair styles – growing hair long or cutting it short
• changing information of personal records such as Medicare card and passport
• playing in the sporting team that matches their gender identity.

As a child moves into adolescence other things that will support social affirmation include:

• wearing make-up
• practicing body language
• wearing a Packer (prosthetic penis)
• wearing prosthetic breasts/bras
• using a breast binder
• stopping shaving
• receiving voice training
• taking up gym training.

Practitioners can assist children and their parents by discussing these elements of social transition, and what supports might need to be put in place. To help with this discussion, practitioners can use the Gender Affirmation template as a guide.

As a child nears puberty, puberty blockers are something that should be considered, and the child should be referred to a GP, or a gender clinic who is able to support them with this choice (Telfer, et al., 2018). There can be long waiting lists for these services, so making an early referral (when the child is 8 or 9 years old) is good practice (see Referral Matrix). Puberty blockers are completely reversible and can give a child some time to explore their gender identity without the distress of secondary sex characteristics beginning. If a child decides that they are not trans, then they can simply stop taking them, and puberty will begin. Please refer to the Australian Standards of Care and Treatment Guidelines for trans and gender diverse children and adolescents for more detail on this.

It is also recommended that the child and their family see a mental health professional such as a psychiatrist or a psychologist. This is not to assess whether they are trans or gender diverse, but rather to check their general health and wellbeing and any co-existing mental health needs. The Australian Standards suggest that seeing a mental health professional can help to develop “a shared understanding” which “allows the child to feel genuinely supported and affirmed in who they are and for the family to be able to make considered and informed treatment decisions in the future”. (Telfer et al., 2018, p.9)

Other aspects of medical affirmation can include beginning to take gender affirming hormones. This process does not usually begin until mid to late adolescence, following a comprehensive assessment by a clinician or multidisciplinary team with experience in trans healthcare. Some trans people consider gender reassignment surgery, but this does not usually occur in Australia until a person is over 18.

Understanding the different elements of gender affirmation will help practitioners in conversations with families who are often very anxious about this process.

Once a child has decided to affirm their gender, they will begin the ‘coming out’ process. This will include telling their extended family, friends, school, schoolmates and other support networks. This does not have to happen all at once. Talking about when, how and who to tell, and developing a plan can help to reduce a child’s anxiety.

It is vital to ensure that the child is at the centre of these conversations, to give them a sense of agency over their own lives. You can use the Gender Affirmation template to help facilitate this conversation.

As already mentioned, trans and gender diverse people often face discrimination in many areas of their lives including at school, as part of clubs and when accessing health services, including GPs and mental health services. This often means that parents of trans and gender diverse children must become educators and advocates for change in areas of policy, the law and health service practices.

This can create a sense of uncertainty, distrust and contribute to a lack of confidence in accessing these services and can impact on the mental health and wellbeing of the child and their parents. By demonstrating a level of understanding of these issues and offering informed support and practical guidance, a practitioner will instil in the child and their family a sense of trust and relief that they are being heard.

Family support is crucial to children’s mental health. Parents of trans and gender diverse children often struggle with this new knowledge, so providing assistance and information will help them to support their child. Trans Pathways revealed that the 65% of young people who reported a lack of family support also showed higher rates of:

• suicidal thoughts
• desire to hurt themselves
• suicide attempts
• self-harm
• reckless behaviour; and
• diagnoses of eating disorders, anxiety, depression and PTSD. (Strauss, et al., 2017)

Parents will experience a range of emotions, including confusion (“how did this happen?”), guilt (“what did I do wrong?”) and often grief (they are now raising a child of a different gender and perhaps a new name). In time though, most parents will also feel relief and happiness as they see the positive changes in their child who is being supported to be the gender that they feel that they are.

Parents can also feel worried for their child. This can play a role in the acceptance journey. Parents might be concerned about what the future holds for their child in terms of possible discrimination – for example experiencing bullying at school, or rejection from extended family. They may initially show less acceptance and be in denial rather than think about how they might navigate these issues.

Professionals can make time to engage in conversations with parents about how they are feeling, acknowledging that it might take some time to process the things that their child is communicating to them. Finding other parents to talk to and educating themselves can be helpful for parents and professionals. You can find a list of parent peer support groups in the Referral Matrix.

Encourage parents to take the time to listen without judgement and as openly as they can to what their child is saying – this will help to build their understanding. Suggest they ask open and respectful questions of their child, and try to listen without debating or arguing. This will encourage a safer space for conversation and help everyone to understand each other.

Siblings

You may also need to consider support for siblings as this can be a big change for them too.

The sibling may feel confused or upset about what is happening for their brother or sister and might need some extra support and information, as well as an opportunity to talk to someone about how they are feeling.

They will also take some time to adjust to using a new name and pronouns. The sibling may also be experiencing bullying at school or protecting their sibling from harassment, which can be stressful for them.

On the other hand, they may also not be supportive of their trans sibling. Encouraging parents to make time to help them understand what is going on and to express how they are feeling away from their trans sibling will be helpful for the whole family.

Localised services and health care professionals play a critical role in providing support, care and advice to trans and gender diverse children and their family. Families often face barriers to access specialised gender support services such as distance, cost and considerable waiting lists, so it is important practitioners do all they can to help families waiting for or unable to access specialised support.

Listen and affirm

The most important first step is to acknowledge that what this child is experiencing is real.

You might be the first person that the family has told. Thank them for talking to you about this. Ask some questions to find out more about what supports they are looking for, and what you might be able to provide.

Be open to having a discussion with the child and their family about what they are experiencing and affirm for them that how they are feeling is valid.

Show that you understand and care by asking them what pronoun they would like to be referred to by, and whether they have a different name they would like you to use. Make sure you make appropriate changes in your records, so that when you next see them you do not use the wrong pronoun (known as ‘misgendering’) or name.

Get informed

If you haven’t had much experience in this area, take some time to do more research to improve your understanding. The trans community often have to act as educators for the services they are seeking support from. The child and their family should not have to educate you about their experience. You will find suggestions for further reading at the end of this paper. The Referral Matrix also contains a list of websites and organisations with more information.

You should also read the Australian Standards of Care and Treatment Guidelines for trans and gender diverse children and adolescents, which were developed by the Royal Children’s Hospital in Melbourne.

Refer and keep checking in

It is crucial to make a referral to a paediatrician with experience in this area (see Referral Matrix). This should be made well before puberty (when the child is 8 or 9 years old) as there are often long wait times to see these specialists. During this waiting period the child and family will still require support and advice. It would be helpful to work alongside the paediatrician or gender specialist to find out what ongoing support can be provided.

Waiting and the feeling of being ‘in limbo’ can be very detrimental to a child’s mental health. Your role might be to create a safe ‘holding space’ for this child and their family during this time.

The Support Plan template will assist you to have a more detailed and informed conversation with the child and their family about their needs, and may help to anticipate some of their concerns and questions.

Inform relevant staff in your service but maintain confidentiality

Identify who else in your organisation might need to know about the child’s situation. This might save the child and family from having to re-tell their story numerous times.

Talk to other staff about how to receive and respond to this information. Staff might have lots of questions, but the first question they should ask themselves is “Do I need to ask this in order to support the child or family?” or “Is the gender of this child medically relevant to the treatment they are seeking?”

Making comments like, “the last time I saw you, your name was…” is very disrespectful and can be distressing for the child and their family. However, simply using their new name and pronoun can be life-affirming for them.

The health sector is difficult to navigate at the best of times. Trans and gender diverse children and their families often experience the added barriers of lack of knowledge and – at times – discrimination from the people that are supposed to be supporting them. They do not expect you to have all the answers, but they do deserve to be treated with respect and dignity.

You may not be a specialist in the area of trans and gender diverse health care. But you do have an important role to play in supporting and affirming a trans or gender diverse child and their family.  You may be the first person they have told, and your support will be a protective contributing factor in positive mental health outcomes for this child.

Further reading

Trans Pathways: the mental health experiences and care pathways of trans young people

https://www.telethonkids.org.au/globalassets/media/documents/brain–behaviour/trans-pathwayreport-web2.pdf

From Blues to Rainbows: Mental health and wellbeing of gender diverse and transgender young people in Australia

https://www.beyondblue.org.au/docs/default-source/research-project-files/bw0268-from-blues-to-rainbows-report-final-report.pdf?sfvrsn=2

References

ACON. (2017). Trans Inclusive Language Guide. Retrieved from: http://www.transhealthsa.com/wp-content/uploads/2018/02/ACON-Trans-Inclusion-Language-Guide.pdf Accessed, May 2019

Smith, E., Jones, T., Ward, R., Dixon, J., Mitchell, A., & Hillier, L. (2014). From Blues to Rainbows: Mental health and wellbeing of gender diverse and transgender young people in Australia. Melbourne: The Australian Research Centre into Sex Health and Society.

Strauss, P., Cook, A., Winter, S., Watson, V., Wright Toussaint, D., & Lin, A. (2017). Trans Pathways: the mental health experiences and care pathways of trans young people. Summary of results. Perth: Telethon Kids Institute.

Telfer, M.M., Tollit, M.A., Pace, C.C., & Pang, K.C. (2018). Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents Version 1.1. Melbourne: The Royal Children’s Hospital.Wiggins, J. (2019). Trans and Gender Diverse Health: Churchill recommendations. Retrieved from: https://static1.squarespace.com/static/5ace3cf53917ee2eaf49e2e4/t/5c9afd4b3c7a0b0001edf6d0/1553661261802/Churchill-Recommendations_Jeremy+Wiggins.pdf