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Reflections and (un)learnings on supporting transgender and gender diverse people and their families in a mental health family service new to this work

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Henry von Doussa, Julie Beauchamp, Sally Goldner & Belinda Zipper

 

Introduction

As the space for transgender and gender diverse (TGD) people to affirm their gender expands in the Australian context, families are increasingly seeking support. It is estimated that about 1.2% of Australian adolescents are TGD (Telfer, Tollit, Pace, & Pang, 2018). With increasing visibility and social acceptance, it is expected that TGD people from across the age-range will access healthcare services more and more (Riggs, Power, & von Doussa, 2016; von Doussa, Power, & Riggs, 2017). Part of this increase will be seeking support with family relationships as gender identities are questioned and affirmed.

The evidence base and clinical guidance for working in the family counselling setting with people with TGD lived experience is growing (e.g., Applegarth & Nuttall, 2016; Behan, 2006; Bradstreet et al., 2014; Lev, 2013; Moon, 2014; Riggs & Bartholomaeus, 2018). There are several guidelines that set out standards of care for TGD people nationally and internationally in a variety of contexts (e.g., Coleman et al., 2012; Meriggiola, Jannini, Lenzi, Maggi, & Manieri, 2010; Telfer et al., 2018; Zucker & Lawrence, 2009), as well as practice guides for therapists working relationally in the room with families are available (e.g., Riggs, 2019a). Historically, however, TGD issues rarely featured in the annals of family therapy. A review of articles published in marriage/couple and family therapy journals between 1997 and 2009 found that of the 10,739 articles that fit the research parameters, only nine pertained to TGD issues (Blumer, Green, Knowles, & Williams, 2012). Twenty-one of the other articles found that used the term “LGBT” (lesbian, gay, bisexual, transgender) did not actually address TGD issues. The authors of the current article note that academic scholarship concerning TGD people has grown since 2009 but cite the above review to demonstrate the historical erasure of TGD and family issues in the literature, and beyond. Additionally, while professional literature regarding the health and wellbeing of people with TGD lived experience has expanded, the pervasive and ubiquitous nature of gender normative ideologies and the language and practices that perpetuate them—what Ansara and Hegarty (2012) call cisgenderism—are often reproduced in it, even by those working in the field. This illustrates, as Ansara and Hegarty show in their extensive review of psychological literature on childhood gender identity and expression between 1999 and 2008, “that shifting the discourse [of entrenched cisgendersim] is extremely difficult even for those engaged in critical analysis” (p.152).

In an environment where demand for services is growing, how, therefore, do generalist organisations not already engaged in supporting TGD people and their families “step-up” to offer support to communities where there is a clear need? Stepping-up will often require work from cisgender family therapist or counsellors, for example, from outside of TGD communities, who have expertise that can be transferable to the needs of TGD clients and their families. What do such clinicians need to keep in mind to become strong, useful allies in this work? And can they offer active support at the same time as upskilling and reflecting on where cisgender bias may be a limit to what they can offer?

The first and second authors of this paper work in a mental health family therapy organisation engaged in the ongoing process of upskilling. Currently there are no TGD people as part of the clinical staff.  As such, the work of supporting the families where there is a trans and gender diverse person referred to our service was left to two cisgender staff (the first and second authors of the article).

Ongoing development of a larger clinical approach to this work will see expanded involvement of TGD people and clinicians in the work. In the meantime, however, the organisation has undertaken:

  • whole of organisation training from Transgender Victoria;
  • Trauma Informed Transgender and Gender Diverse Affirmative Care training for relevant staff;
  • relationship building with external specialist organisations, including peak bodies led by the TGD community (e.g., Transgender Victoria), those that support families (e.g., Trans Families), and those geared towards workforce development and service provision (e.g., Rainbow Health Victoria and Royal Children’s Hospital Gender Service);
  • secondary consultation services with people working in the gender field;
  • extensive and continual self-reflection on, and empathy for, the needs of TGD people;
  • keeping abreast of recent research in the field;
  • ongoing consultation and collaboration with TGD community leaders and TGD people with lived experience on organisational training and workforce development. (Note, the organisation is still building its capacity to extend that collaborative approach more thoroughly throughout the organisation, e.g. to reviewing clinical services and providing oversight, similar to the peer-led model); and,
  • co-authorship on this paper.

Previous research has shown that clinicians newer to working with the LGBT communities can be nervous about “mucking up” and often seek practical advice beforehand about how to proceed (von Doussa et al., 2016). While the authors do not have decades of experience working with TGD people and their families in a family therapy setting, this paper offers reflections from our past four years of practice. We hope our contribution helps build family counsellors’ confidence to meaningfully and practically support TGD people and their families. This may often mean making referrals to relevant specialist services, particularly to services offering peer-led, community-based support from people with lived experience, where this is available. We also aim to develop a community of practice and demonstrate the benefits of co-work and collaboration.

Terminology

In this paper, the phrase “trans and gender diverse” (TGD) is used as an umbrella term to describe people whose imposed legal sex designation is not stereotypically associated with their gender. This may include trans(gender) men, trans(gender) women, transmasculine, transfeminine, or simply men or women who have transgender lived experience but who do not consider “trans” their identity. It also includes people who are non-binary, gender-fluid, or gender queer (neither exclusively male or female), and people who do not live within any gender category (Sinclair-Palm & Gilbert, 2018). It can have overlap with various cultural identities (e.g., Sistergirls and Brotherboys for some Aboriginal and/or Torres Strait Islander people). The term “cisgender” is also used in this paper, describing the gender of people for whom the gender ascribed to them at birth is how they see themselves (Johnson, 2013).

Background

Research is clear about the importance of strong family support for the health and wellbeing of TGD people, particularly at the formative times of gender questioning and/or affirming, but also across the life span (Giammattei, 2015; Lev & Gottlieb, 2019; Malpas, 2011; Nichols, 2018; Riggs, 2019a; Ryan, 2009; Smith et al., 2014). Involvement of family has been shown to drastically reduce the risk of self-harm and suicide in younger TGD people (Ryan, Huebner, Diaz, & Sanchez, 2009; Smith et al., 2014). Recent Australian standards of care and treatment guidelines for TGD children and adolescents draw on this growing body of evidence to suggest that, “where there is lack of family understanding or support of a child’s gender diverse expression, a clinician may work with family to help develop a common understanding of the child’s experience” (Telfer et al., 2018, p. 134). This is particularly important for minors, as parents and caregivers may be required to provide informed consent for medical gender affirmation processes in situations where children and adolescents are assessed by clinicians as lacking the legal capacity and competence to provide this themselves.

There is a growing body of literature that explores family relationships from a “systemic family perspective” in the context of TGD experiences (Blumer, Ansara, & Watson, 2013; Healy & Allen, 2019;; Moon, 2014; von Doussa et al., 2017). A systemic perspective is one way to understand and explore the shifts in relationships that occur within a family when a family member questions their gender and later affirms their authentic sense of gender. From this perspective, the family is a system of interrelated parts, where a change in any one part can shift other parts of the system/family (Burck, 2018). Recent research by von Doussa et al. (2017) has shown that people affirming their gender are seeking whole of family support and are hopeful that with the right support, family relationships might move forward strongly during the period of gender affirmation. A woman from that study reflected on her relationships with her former wife and children at the time she began affirming her gender publicly:

If support had been available for my wife and I and the family in terms of a family counselling situation, I think that would have been a godsend no matter which way it eventually went. It would have been a healing process for each and every one of us I’m sure. (p. 275) 

“Family” is sometimes considered to be the person affirming their gender and their parents or partner(s), however there may be a myriad of relationships within a family that may shift when a person transitions (e.g., the person affirming their gender and each other family member, parents who may have different views that might lead to conflict, siblings relationships with their parents and each other). And of course, there are extended family relationships to consider, including (but not limited to) grandparents, aunts, uncles, cousins, in-laws, close friends, local community, and school community. TGD people also often rely on what is called “family of choice” as a means of support. All of these will be included in the relational matrix of the family “system” and all relationships are likely to be changed—some will be allies and some will not. The family may find themselves in a situation where the person affirming their gender is like the “stone in the pond”—a singular event with potentially vast ripples that may occur within the household and beyond (Barrett, Mansfield, Bradshaw, Paynter, & Conning, 2019; Somer & Nizri, 2014).

A broader systemic perspective recognises that identity always exists in relation to family, community, and broader social structures. A systemic perspective is broader than the family unit and places a key focus on how cisgenderism functions in a society to make it difficult for all people in the family but often, and especially, places the weight of family struggles (the ripples in the pond) at the feet of the gender-questioning person rather than gender normativity and oppression itself. As such, Ansara and Hegarty (2012) have highlighted “how people with self-designated gender can benefit from therapeutic interventions in the form of advocacy and activism to address societal inequalities” (p. 151). This means that clinicians working with families may have to do more than work towards “emotional acceptance”—which Ansara and Hegarty identify as “an intrapsychic ‘affirming’ approach that does little to address cisgenderist structural violence” (p. 151)—they may need to strongly advocate on the side of the TGD person for actions and referrals that challenge cisgender normative structures. This might include, for example, helping to facilitate pathways to access medical technologies. It is noteworthy here that a significant piece of Australian research with young TGD people found involvement in social activism around gender and sexuality to be a key protective factor for mental health and wellbeing (Smith et al, 2014).

In 2015, the Bouverie Centre (“the Centre”), in Victoria, Australia, conducted a research project exploring the experiences and needs of TGD people in relation to family of origin and family of creation. This project was part of a larger workforce development project aimed at assisting service providers to be sensitive to the needs of LGBT people and their families (see Power et al., 2010; Raj, 2007). As a result of the project, the Centre increased its connections with the local TGD community in Victoria and increased its visibility as an organisation doing a small amount of research and workforce development associated with TGD people and their families. It is noteworthy here that participatory action research methods, which closely involve the group about which the research is focused and which encourage a close examination of the researchers (dis)articulations with research participants and their community, is cited as best research practice (Singh, Richmond, and Burses, 2013). A checklist for considerations for ethical participatory action research for researchers working with TGD communities is included in the article by Singh et al. (2013).

Although the Centre has both research and clinical programs, the research and workforce development agenda (as described above) were more developed than the Centre’s capacity and skills to work with TGD people and their families in a clinical setting. Nevertheless, the Centre’s engagement with local TGD community leaders in seeking advice about the research project, along with its published research outputs, saw it become a site of interest for local TGD people, their families, and community seeking support. This occurred in an environment where there were otherwise long waiting lists and sometimes clinical referrals made to organisations less confident in working with families.

To respond to the demand for clinical services, the Centre developed an internal partnership between the researcher who conducted the TGD research activities (the first author) and a clinician with more than 30 years’ experience as a family therapist (the second author). This co-work model allowed a mutually beneficial synthesis of skills. It combined the researcher’s TGD content knowledge about the concerns and needs faced by TGD people and their families—and a cultural brokerage aspect after being “vouched for” by key leaders in the TGD community who had been involved in previous research—and the family therapist’s systemic skills and understanding about how family respond to change. The “content knowledge” of the researcher involved was developed from studying the literature, from interviews with Australian TGD people about their experiences of both family relationships and of health service use (see von Doussa et al., 2015; von Doussa et al., 2017), and from participating in the TGD community and building friendships in both professional and personal environments. In reflecting on the successes and limits of our approach, we note that TGD community leaders should have been—yet were not—embedded at the outset of the initiative to provide ongoing guidance, evaluation, and critique.

The Centre did not shy away from the growing need among families with TGD members, but instead prepared itself to offer support. In doing so, we set out to learn more and become useful supports to individuals and families. The Centre felt that it was important to recognise relevant competencies and capacity that, when synthesised strategically, could offer a service that was “good enough” to support families in crisis. As Reynolds (2013) has said of being an ally to communities or individuals subject to abuses of power, “We invite good-enough allies, despite past acts that are not trustworthy, as imperfect allies are required when the stakes are high, and risk is near” (p. 56). While wanting to be a good-enough ally may be a worthy desire, this alone is not sufficient. It is important that intentional acts are taken to prevent abuses of power reoccurring. What follows is an outline and some reflections of how we attempted to work in ways that were anti-oppressive and offered meaningful support.

The legacy of past untrustworthy acts can be seen in the data from recent Australian studies. For example, Riggs, Ansara, and Treharne (2015) outlined the poorer mental health status of many TGD people when compared with the wider population, and the discrimination and marginalisation that contribute to this. Similarly, in a cohort of 537 TGD Australians 18 years of age and over, Kerr, Fisher, and Jones (2019) reported that 81.3% of the cohort said they felt either “very uncomfortable” or “uncomfortable” discussing their physical or mental health needs with a health provider they did not know. The “near risks” of mental health struggles, self-harm, and suicide are clear for TGD people in Australia, and service providers may have to work with this group before they feel confident.

What We Learned

The Value of Collaboration

At the Centre it is usual practice to employ the single session therapy framework when seeing families (Young, Weir, & Rycroft, 2012). This framework does not mean a family is only offered one session, but rather, based on the knowledge that not all families return after the first session, it treats every session as though it may be the last or only one. Every family, regardless of whether they return, receives a client-led session focussing on family members’ most pressing concerns and develops a shared plan for what comes next. The framework is designed to make sessions as collaborative as possible: the family establishes the agenda of the session, each person shares what they hope to achieve in the session, and then the therapist follows a set process of “checking in” throughout the session (e.g., “Given the goals we set at the start, are we on track?”, “We’re half way through the session, are we talking about what you hoped we would talk about today?”). It is hoped that needs can be met and the family leaves with useful strategies to begin to address the reason that has bought them to therapy (Young et al., 2012). This framework was particularly useful for the families we saw, as many of them had been seen at several other services before arriving at ours and had told their story many times. They wanted to start with what was most urgent for them on that day. Allowing families to collaboratively set the agenda gave them a good opportunity to openly articulate their feelings and what they hoped might be different and helpful. This was something the families had often not been able to do in the secrecy and silence, both inside and outside the home, that can surround gender affirmation. It also allowed us as practitioners to understand from the families in an expedient way what they needed, what their struggles were, and how outside supports might be most useful. Getting to know family members (their work, interests, and so on) is important, as is developing a trusting therapeutic relationship over time, if ongoing work is their choice.

The Need for Educating Yourself

Several of the families who contacted the Centre had done so after unhelpful experiences with other service providers. Important in the reservations they had had about previous service engagement was a lack of basic information by the counsellor about the transition processes (for the person affirming their gender) and the needs of a family. One of the parents of a young trans man said she had been exhausted by the few sessions she had had and came away feeling she was supporting the counsellor in a process of learning and change, rather than the other way around.

Von Doussa et al.’s (2016) focus groups conducted with LGBT parents about their needs when engaging health services revealed that parents can feel let down and frustrated when basic information is not sought by therapists/counsellors, given that information about LGBT people and their needs is so easily accessible on the internet . Parents also felt that a basic level of preparation should not be difficult, but often did not occur. This included things like basic language and a knowledge of some of the key services and referral points. For example, knowledge of the term “cisgender” is important as it helps to avoid phrases such as “TGD and regular people”.

At the same time, however, we learned that it was important to be honest and upfront as practitioners about what we did not know. We were upfront about the experiences and strengths that each of us bought to the sessions, and equally upfront about the limits of our knowledge when we did not have an answer they needed. We were knowledgeable and forthcoming about appropriate referral points and researching/forwarding information after sessions. This was key to establishing rapport and honesty with the family and to creating a collaborative framework for the session where the family’s knowledge about their unique journey was privileged. Being candid about knowledge limitations and clear about the evidence-based strength of what we did offer was also important to contradict many of the well-intended but often unhelpful platitudes given to families by extended family members and friends, about an experience they themselves often know little about.

As there is increasing evidence about the risk and protective factors for the health of TGD people, it is also important that counsellors are familiar with current literature and best practice guidelines. As Malpas (2011) has said in relation to the importance of psychoeducation for family members, “While parents have often researched the issue of transgender children thoroughly and are quite expert on the topic, it is useful to assess their level of information and potential misinformation and review the existing research” (p. 458). Being able to offer families concrete evidence-based information is vital at a time of often heightened emotions when family members may be drawing on emotion and anecdote rather evidence. Such information includes the knowledge that family support is a key protective factor for the mental and physical health of young people affirming their gender (Smith et al., 2014), or that the time of affirmation is a high-risk time for suicide and self-harm (Hillier et al., 2010). As Nichols (2018) has noted regarding access to accurate information, “While many gender variant people already have acquired information through the internet, younger clients, and especially their families, often need a great deal of psychoeducation” (p. 206). We talked with families about the risks to TGD people’s health and well-being when there is an absence of family support, and conversely, the protective factors of what the family was already doing well, like openness to understanding, reaching out for support and attending a counselling session. When talking alone with parents, the risk/protection framework was also used to explore how the parents conceptualised the “risks” to the family unit or the family’s identity, what they worried about, and what supports they might need to shift to being protective of their child’s wellbeing. This was a useful way to understand more deeply parents’ concerns, fears, and hopes.  

Changes to Family Identity

Gender transition and/or non-conformity challenge some of the most deeply held beliefs in society. Families, of course, are not immune to this. The families we saw were at different points of understanding regarding their family member’s gender. All families need space to talk about what it means to the family and to explore how changes to the family are experienced by those within it, or how they are being seen by others outside the family. As Norwood (2013) has said, “Because family members must redefine their understanding of the gender-variant relative, transitions may happen not only for trans persons, but also for their families” (p. 250). Some parents felt for the first time what it was like to be in a position of “other,” feeling that their family was different to what was generally expected from families around them. While their child or loved one may have felt a sense of difference for a long time, it was new to the parents. For most parents there was a deep sense of having to reconfigure their own and their family’s identity and negotiate anew some relationships with extended family and friends. This was the case for partners and siblings also. A recently developed Australian resource (Barret et al., 2019) takes the metaphor of dropping a stone in a pond (the TGD person affirming their gender in a family) and the ripples of change that follow. This “Ripplegram” resource provides an anti-oppressive framework to explore relational changes in a family. It was carefully developed by people with TGD lived experience so that families and relationships can be “mapped,” much like with traditional genograms, but to avoid misgendering by documenting what people have experienced and are hoping for rather than trying to capture who they are in static (often misgendering) symbols.  The resource was developed specifically for supporting older people who are affirming their gender but has application for working with family relationships across the age range.

For some family members of a person affirming their gender there was a sense of “What about me?”. The opportunity to tell their story and unravel the complexity of changes happening in the family was highly significant for them. It is understandable that each member of the immediate family may have entirely different experiences of and feelings about their brother, sister, son, daughter, mother, or father questioning or affirming their gender. It is not unusual for one family member to be totally “on board” and another still in shock or in states of reluctance to accept. Family members may also be immobilised by “how to be in the world” now that their family member has become more open in their affirmed identity. It is possible that each family member must think about how their own life will be different in different spheres. How do family members go about talking about their loved one affirming their gender in each aspect of their lives? Or do they keep it secret? A family member affirming their gender can shift a family’s sense of normalcy and belonging. Providing a safe place for parents or other family members to talk about what was happening in the family was very important for them and indeed, in the long run, for their TGD relative. This is a time when sub-system work—meeting with sub-groups or different individuals—is helpful so that the TGD person is not overburdened by, or feels responsible when, witnessing the struggles or strong emotions of family members. We also met with the TGD person individually in most cases. While the TGD person usually had individual counselling support prior to attending the Centre, we always offered them an individual session or sessions. This was for several reasons: first, and most importantly, to make sure that their worries, concerns, and agenda were heard and understood by us; second, as a way of maintaining engagement with them; third, to balance any time we spent with their parents (or other family members); and, finally, to give them the opportunity to explore concerns privately (with the option of giving us permission to share some of this with their family). This is adapted from Sheinberg and True’s (2008) work at the Ackerman Institute for the Family and is particularly helpful when working with children and young people who want their parents to understand them but have concerns that they will upset one or other parent, that they will not be listened to, or will not be believed.

Navigating Grief and “Loss”

Disenfranchised grief—“grief that is experienced when loss cannot be openly acknowledged, socially sanctioned, or publicly mourned” (Doka, 2002, p. 160)—played a substantial part in the journey of some of the parents we saw. Doka argued that what can and cannot be grieved in a culture is governed by “grieving rules” and norms that determine who may legitimately grieve what losses and in which way. This was certainly true for some families we saw, who seemed to have very few reference points to signal how to process what they experienced as a loss. We supported families to work on what in other research has been called “ambiguous loss” (Norwood, 2013, p. 25); loss where the family member affirming their gender identity is seen by family members as both present and absent; being seen by family members as the same but different. This can be a very emotional time for families, where “loss” may feel ever-present. Much like the cultural “rules of grieving,” normative rules of what is cherished and celebrated in a culture run deep. It must also be noted that any notion of “loss” in the context of a loved one affirming their gender functions in an economy where normative views of gender are most often valued above gender variance. Supporting parents or partners to do the emotional work of change—often unexpected and unanticipated changes—while advocating strongly for the TGD person at times was a sensitive balance, which on some occasions necessitated secondary consultations from people with lived experience and/or working in the area of gender affirmation support.

Understanding and accepting loss need not be a point of rejection; if loss is productive, it can become a source of family bonding. Even the most supportive of parents can (and have a right to experience) loss, albeit they will need to get counselling for this separate from the TGD family member. Even outside of TGD experiences, parents may frequently experience a sense of loss—as they watch their children grow and take on ideas, characteristics, and behaviours they had not imagined. The idea of loss should not be seen as taboo or inherently bad in counselling; it is a healthy response to a situation and needs to be accepted and worked through. However, Riggs and Bartholomaeus (2018) caution about circumstances where TGD children (and the same can apply for adult relationships) are asked, subconsciously or otherwise, to do the emotional work of relatives (i.e., shoulder the emotional burden of “loss” that parents may experience when a person affirms their gender). As these authors have said, narratives of loss as voiced by parents have been found to act as a barrier to TGD people being wholly supported, and we would add, celebrated. Further, Riggs and Bartholomaeus caution health professionals working with families “not to accept the cisgenderist assertion that a TGD child is a loss, nor that any feelings of loss experienced by parents should be the responsibility of the child” (p. 391).

Pressures of Everyday Life

Gender affirmation rarely occurs outside of family life and, for the families we saw, it occurred in the shadow of other family pressures and changes. Gender affirmation of a family member often added another dynamic for families in already complex and stressful situations. For example, families were in the process of buying and selling homes, putting other children through the final year at school, juggling career pressures, and caring for other dependent family members. Some were affirming their gender during marriage separation and negotiating the access arrangements of their children. Other families of young people we saw were struggling with the very common challenges of parenting in an increasing techno-mediated world. When identifying the needs of the TGD person by talking with family members, it may be useful to remember the words of Malpas (2011): “in some cases parent’s [or other family member’s] anxiety and coping mechanisms participate in underestimating or overestimating the level of distress or the clarity of the child’s [or adult’s] wish to identify with one particular gender” (p. 460). The pressures of everyday family life, along with the significant pressures related to stigma and a family’s sense of belonging in their extended family or community, can contribute to the obfuscation of a child or adult’s needs.

Circular questioning (Gonzalez, 2017) to facilitate the inclusion of the opinions and perspectives of other family members can be useful in establishing the context of family anxiety and distress as well as the strengths and coping strategies families employ in times of change and upheaval. Once again, however, it is essential that  the TGD person is removed from hearing family struggles as somehow being their fault or adding an extra burden to family life—the TGD person may well be feeling this anyway and it needs to be challenged with everyone. Importantly, Riggs (2019b) has commented specifically on the technique of circular questioning with families where a person is affirming their gender and cautions that the technique could facilitate a space where the TGD person becomes the family “problem” around which concerns circulated. He said,

The question remains as to the extent to which, through this process [circular questioning], gender diverse young people are further exposed to negative views by their family. The point here is not that young people will likely be unaware of negative views, but the point is as to whether further exposure many be distressing. (p. 413)

Secondary Consultation

Early in our work with families it became clear that some parents contacted the Centre in the hope we might support them to guide their child away from the gender they were affirming. This desire was usually identified in the intake phone call. Where this was recognised, a first session was made with parents alone to help explore their fears and concerns. For other families, it was clear that parents (or other family members) were strongly supporting the gender affirming loved one but needed support in the process, often to deal with relationships and systems outside the immediate family. With some families who were struggling—sometimes functionally ‘filibustering’ their loved one’s transition (Healy & Allen, 2019)—we found it hard to find a balance between keeping parents engaged (feeling heard and supported) in the hope they would return, but at the same time never wavering from our commitment to the gender affirmation of the TGD person. Knowing how far to challenge parents or other family members when they found it hard to support their loved one was at times difficult. On these occasions, we chose to seek secondary consultation from other more experienced people in the field with lived expertise. It is important to note that numerous laws and ethical codes of conduct require clinicians to affirm and support a young person’s gender. It is important for parents to know that there are laws that protect young people from harmful practices like conversion therapy, and that this will be governing a clinician’s practice. We also sought external guidance from other services when families presented with family violence issues and when support was needed for TGD people with clinical mental health concerns.

Reaching out to other services and seeking out expertise you don’t have—for example, we contacted the local adolescent gender clinic to understand more about the psychosocial supports that accompanied physical interventions for young TGD people—is on way that counsellors can educate themselves to be most helpful to current families and to be more knowledgeable and prepared for the next family they see. Supporting and fulfilling the needs of non-binary young people may also require counsellors to seek out the advice of people with this lived experience.

Good Supervision: A Space to (Un)learn

Good supervision after sessions is important for reflecting on session content, process, and reactions to it (Nichols, 2018). In many services there may not be clinical supervision available internally that is targeted to clinicians working with TGD clients. In these cases, it is advised that external clinical supervision be sought. At the very least, our co-therapy relationship allowed us to debrief together, spend time thinking about what needed to happen, and consider what internal and external supports we could draw on to keep the sessions as relevant, useful, and, most importantly, safe for the TGD person as possible. As researcher/therapists over 45 years of age, we spent considerable time supporting each other to reflect on how our own experiences as mid-life, cisgender, White Australians were impacting our ability to be present with our TGD clients and to be, as Riggs and Bartholomaeus (2018) assert, “strong in our approach to what is often a sensitive and delicate series of negotiations between clinicians and parents” (p. 383).

The vast and recent changes that have taken place in how TGD people are positioned within legal, social, and mental health frameworks mean that, no matter how well intentioned, service providers must also reposition much of what they have been taught or come to think about TGD people through the unstoppable force of cultural osmosis. This process often requires unlearning oppressive information that was socially sanctioned in the past. In our organisation we are continually building alliances with TGD organisations and individuals, taking on criticism if it comes our way as we attempt to do better, and placing high value on reflecting on whether cisgenderist bias might be limiting our work. Where strong, anti-oppressive supervision is not available, gaining insights from listening to people lived experience on blogs and vlogs is enormously useful.

Conclusion

Changes in community acceptance of TGD people, coupled with the high chance they will experience negative health outcomes (self-harm or suicide) in their lifetime, demands that services be willing and ready when TGD people or their families present for help. There is much good information and many resources on the internet that can support an individual healthcare professional or their service increase readiness. TGD people themselves, however, have told us that readiness does not mean perfection. While services must strive to offer the most appropriate service possible, being a “good enough” ally will be enormously helpful in supporting TGD people who experience cultural oppression and exclusion. Stepping up to do work you may be less familiar with can feel uncomfortable, but it is necessary if services are to not turn away or otherwise fail TGD families. When asked what constitutes a good ally, a young Australian transgender activist, Georgie Stone (2019), responded with:

Learn the pronouns. It’s good to ask questions about this; don’t feel embarrassed. Like: “What pronouns do you want me to use?” and “What do you feel comfortable with?”. Then listen. Really just listen to what they have to say. (p. 142)

Finally, another young Australian TGD activist and writer, Nevo Zisin (in Fink & Bush, 2015), reminds us of the magnitude of affirming their gender for the TGD person above and beyond the difficulties experienced by those around them:

It’s always harder for you [the transgender person] than it is for anyone else. No one understands that. When you come out, people say, “This is so hard on me, look what you’ve done to me,” and it’s like, “Look, you have no idea what I’m going through!”

References

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