Implications for Clinicians: Individual & Family (Micro) Level

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• Do a family member-specific assessment, which includes: 

  • Mental health history of all family members and any current diagnosis

    • Be aware that when assessed traditionally, family members can appear to have symptoms such as anxiety, depression, and somatic illness that may be accounted for by ambiguous loss (Boss, 1999)​

    • Due to the prevalence of ambiguous loss, assess family members' tolerance for dealing with the unknown and ambiguity

  • Trauma history of transgender person, as well as that of all family members

  • School or employment history of transgender person (as appropriate to age) and of family members, as well as the potential effect of transition on these histories

  • Age and gender of the transgender parent’s children or the transgender child's siblings

  • Family members’ religious affiliations and any related spiritual concerns

• Provide information: term definitions, data on research, scientific knowledge on gender development, and facts on gender treatment.   If your level of knowledge needs to be strengthened in order to accomplish this activity, consider taking continuing education courses on transgender identity-related topics in order to boost your skills.  These continuing education trainings can sometimes be available from professional organizations, such as the North American Association of Christians in Social Work or the National Association of Social Workers.  The professional organizations for other mental health professional groups such as the Christian Association for Psychological Studies, or the Psychiatry Section of the Christian Medical & Dental Associations, may also offer continuing education on this topic.

  • There are a few continuing education programs that offer certificates to licensed mental health clinicians who work with transgender people and some of these programs may cover content that is relevant for their families:​

    • ​Affirmative Therapy for Transgender Communities Program - Widener University-College of Health & Human Services-Center for Human Sexuality Studies

    • Trans Affirmative Therapy Certificate - Antioch University-Couple & Family Therapy Program

    • WPATH Certification - World Professional Association for Transgender Health

    • Sexual and Gender Minority Mental Health Certificate - Fairfield University-School of Education & Human Development, Dept. of Family Therapy & Social Work

    • Affirmative Therapy with LGBTQ+ Clients Program - Southern Methodist University-Simmons School of Education & Human Services-Counseling Graduate Studies

• Validate family members' thoughts, feelings, and questions

  • Attend to disenfranchised grief which can occur when losses are stigmatizing since family members can sometimes feel judged (Doka, 2016)

  • Attend to ambiguous loss (Boss, 1999)

    • Assist family members' to recognize what they are experiencing as ambiguous loss

    • Improve family members' awareness of each other's experience of this loss

    • Support family members' acquisition of information about gender transition and related loss, including the clinical literature

    • Be aware that due to ambiguous loss, family members may be slow to consider possibly redefining their family structure due to the lack of clarity in it related to gender transition.  They may instead prefer the status quo until they are able to deal with and move past their feelings of grief.​

    • Listen to family members' experience of ambiguous loss and stress

• Prepare family members for possible closure of the pre-transition relationship with the transgender family member

  • Address any anticipatory grief (defined as the normal grief that occurs because a loss is expected; Walsh, 2012)​

  • Monitor family members who are grieving, with social support

  • Provide counseling for loss as appropriate. For counseling models, see Grief and Loss: Theories and Skills for the Helping Professions

• Facilitate communication among family members

• Help families give meaning to their experiences (Norwood, 2013)

• Assist families to forgive in cases where forgiveness is needed

 

Facilitating the acceptance process

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Due to the already existing risks that transgender youth have for substance use and suicide, as well as the possible consequences of family rejection and estrangement such as homelessness or child welfare system involvement discussed in Reflections on Forgiveness, clinicians may be led to push parents to accept their child’s gender identity when some parents may feel ambivalent about this matter (for example, see Support Services for Transgender and Gender Nonconforming Children and Families).  This situation may also apply to the family members of transgender adults.  Clinicians should carefully consider this approach as it may have unintended consequences and might not fully account for the greater power of the parent over the child.  For example, some parents may feel that they know their child better than the clinician does and may be offended by being pushed to do something that they aren’t ready to do, even if acceptance is a desirable long-term goal.  This sentiment may also be true of other relatives of the transgender person.  A consequence of this focus on the transgender person as the primary client is that the other family members may feel alienated at a time when having their support for the transgender family member is paramount.  

 

Instead, clinicians might think of this complex situation from a family systems theory perspective and treat all family members equally as clients.  This approach recognizes that the transgender family member’s disclosure of his/her identity is a stressor on the whole family unit.  It may be hard on all family members in different ways depending on their relationship to the transgender family member. Starting from a point of recognizing the stress that a family member’s gender identity disclosure may have on all family members may eventually lead to the kind of support the clinician hopes to build for the transgender relative.  Working with non-transgender family members to help them recognize and deal with their ambiguous loss and disenfranchised grief may be a more fruitful strategy than pushing them to accept this situation before they are ready to do so.  Eventually they may be able to consider forgiveness and reconciliation (in cases when family members have become estranged from each other - for more information, see Reflections on Forgiveness).

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Protective factors and resiliency

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Clinicians can help develop and strengthen family protective factors (Dierckx, 2017)

• Continuity - in the transgender person's behavior after transition, such as participating in similar family activities as before transition

• Communication - open communication to answer questions as honestly as possible.  In particular, see the section on Communication in What helps family members cope? in Resources for Families for suggestions for potential family discussion topics.

• Acceptance - support immediate family members as they go through the stages of grief to arrive at acceptance

• Attribution of meaning - reflection on the effect of the transition on the biological and social role of the transgender person

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Clinicians can support and build family members' resiliency, a term that describes positive adaptation despite adversity (Luthar & Cicchetti, 2000)

• Clinicians can assist family members to build resiliency factors by doing the following (Garmezy, 1991)

  • Help family members build social skills  

  • Assist family members to develop impulse control (e.g., anger, aggression)

  • Support family members to strengthen close ties, minimize family conflict

  • Promote family members’ social connections (e.g., school, work, church)

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Therapeutic resource development

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Clinicians can develop family-specific therapeutic resources to deal with the effect of the transition of the transgender person

• Most therapy resources are directed toward the individual who is transitioning

• Resources to assist family members to deal with the effect of a family member who is transitioning are generally oriented toward acceptance without addressing: 

  • Grieving process (Canfield-Lenfest, 2008; Norwood, 2012, 2013b) 

  • Ambiguous loss (McGuire et al 2016; Norwood 2012, 2013a; Zamboni 2006; McGuire, Catalpa, Lacey, & Kuvalanka, 2016; Norwood, 2012, 2013a; Zamboni, 2006)

 

Support groups and psychoeducational groups are a place to start

• The most commonly available type of support group is for Christian parents with transgender children.  An example is available here.  Other examples are available in the Resources for families with a transgender member section, 'Consider joining a support group.'

• Few, if any, groups are oriented toward Christian children (regardless of age) who have transgender parents or siblings.  One example is available at a church in Texas. Consider creating one if there is demand for it in your area.

• Consider developing a grief psychoeducational group with the main goal of educating members rather than providing emotional support.  This kind of group meets for a set number of sessions and has a set agenda that may include topics such as normal grief responses, grief stages, coping skills, making meaning, and moving on (Walsh, 2012).

• Develop social work interventions to address ambiguous loss and disenfranchised grief (Knight & Gitterman, 2018)

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Implications for Clinicians: Program & System (Macro) Level

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Train therapists to address the wide range of issues surrounding a family member’s transition

• Family function and relationships - especially difficulties with transgender or non-transgender parents; concerns about peer relationships (Freedman et al 2002)

• Living arrangements

• Family members’ well-being (e.g., emotional health, coping) 

• Social support

• Disenfranchised grief and ambiguous loss