Mental Health

For gender-expansive youth and their families, mental health professionals have an exceptionally important role helping them in navigating their experiences.

Families may seek specialists from a wide range of fields as they seek to understand their child’s gender. But when it comes to the manner in which the family (or child) ultimately accepts and supports the young person’s gender-expansiveness, mental health professionals may hold more sway than anyone. A wide range of mental health care providers, including community-based practitioners, school-based counselors, or psychologists providing private therapy, may be called upon to help assess the situation. When reassured by a mental health care provider about their child’s atypical gender expression or identity, they become empowered with the necessary “permission” to be fully open to their child’s evolving gender narrative. Conversely, professional recommendations encouraging them to reign in their child’s exploration of gender may well set the child on a dangerous path towards negative self image and shame. Make no mistake about it: mental health care professionals play a key role in the affirmation or negation of a child’s gender diversity.

This role is particularly influential in light of the divide that persists between mental health providers on what constitutes proper care for gender-expansive young people. Whether affirming a child’s gender exploration or to curbing it will have lifelong consequences for the young person and the family alike. Given this critical divide, and its implications for larger social views about gender-expansive children and youth, it is imperative that mental health care professionals are able to identify effective practices for attending to the healthy gender development of their young clients.

Principles of Gender Affirmative Care

Professionals across various fields are calling for the affirmative care and support for gender-expansive young people. There exists a body of knowledge about what such care looks like. Increasingly, psychologists, therapists, social workers, counselors and many others charged with supporting the healthy development of their young patients are recognizing the need to help them understand (and navigate the reaction of others to) their own gender. Networks of mental health professionals are clearly establishing a set of practices that allow for a young person’s safe and healthy exploration of gender. These practices, in turn, are informed by a number of core principles:

  • There exist naturally occurring variations in gender, and these variations are not inherently negative and should not be categorized as disordered
  • Gender roles and presentations are diverse and varied across societies and over time, and any attempt to analyze them must account for various cultural and historical factors
  • One’s authentic gender emerges from the complex interaction of biology, gender expression and gender identity
  • Gender is not binary, but rather fluid, both at a particular time and sometimes within an individual across time
  • Pathologies associated with a child’s gender diversity most often result from the negative reactions of those surrounding, rather than from within, the child

These principles in turn, inform a growing field of gender affirmative care and practice. Rather than being grounded in strictly binary, socially normative notions  about gender, such affirming care is marked by a number of characteristics.  Specifically, gender affirmative care:

  • Acknowledges the child’s own perceptions of gender as being real and genuinely held. A hallmark of gender affirmative practice is the notion of following the child’s lead. Rather than assuming they know the correct way  for the patient’s gender to unfold, affirming providers instead create space in which the child’s own experiences of self are valued as authentic and real. This does not mean the provider does not encourage the child to explore this aspect of self. Quite the opposite, in fact. It does, however, appreciate that for such exploration to take place the young person must feel seen and heard as experts of their own experiences.
  • Avoids rushing to conclusions. Many parents who approach a mental health care provider will be seeking concrete answers. They may be desperate to know how this will all work out. It is important to acknowledge this desire while at the same time creating the space in which the child’s authentic gender may emerge. This may mean that the family itself may also need counseling. In fact depending on the situation, it may be the caregivers, and not the young person, who needs mental health support. Regardless, it is critical for the mental health care professional to avoid the temptation of finding a fast answer, and to instead work with those around the child to be more comfortable with the uncertainty (their own as well as others’) that is inherent in the situation.
  • Celebrates the child’s strength and courage. Along this same line, it is important that a young person and their family have an opportunity to perceive the child’s gender in a balanced light. Almost certainly, they have received from those around them many negative messages about the child’s evolving gender story; it may well be what has pushed them to seek your services in the first place. For too many families, their child’s gender has been viewed as a problem to be fixed, including by the providers they have approached about their child’s gender. Rather, mental health practitioners must help them see the child’s gender diversity from all angles. Despite a variety of challenges, there are also many positive aspects to be affirmed as the child seeks to discover – or insists – on being seen for who they truly are.
  • Supports the child and family in navigating the world around them. Much of the fear that families have about a child’s gender-expansiveness derives from anticipating how others will respond to it. This includes both individuals in the child’s life as well as the institutions with which they will come in contact. Mental health care providers therefore must become problem solvers capable of understanding the various contexts of the child’s life, the manner in which gender will play out there, and various strategies for responding or adjusting. Whether with other family members, within the neighborhood or community, at school or places of worship, a child’s gender may be seen as fair game for any manner of public comment or questioning, and perhaps outright condemnation. Helping families and kids anticipate and respond to these possibilities is a critical aspect of affirmative care and support.
  • Acknowledges genuine issues of safety. Affirmative practice recognizes the need to protect the gender-expansive child and their family. Even as you seek to affirm the child’s authentic sense of self, it may mean helping them decide when it may not be safe to assert it. While recognizing that thwarting a child’s gender development has negative consequences, it must also be clear that there are situations in which the child’s safety might be compromised, emotionally or physically, were they to assert their gender identity or expression. Mental health care professionals must work to help their patients recognize these situations, and provide them with the tools necessary to avoid or minimize the negative impact of such instances. An important mantra of gender affirmative care is safety first, safety last. It is perhaps here that an affirmative approach can have it most important impact. When affirmed in the authenticity of their experience, young people are more likely to treat themselves more positively, and expect and insist upon the same from those around them.
Best Practices

As mental health care professionals seek to hone their skills to provide gender affirmative care, there are a number of important actions they can take along the way

Developing Your Own Gender Literacy

Currently there is little, if any formal training about gender diversity within preparation programs for mental health providers. When there is, it usually comes under the larger umbrella of LGBT awareness. Yet an understanding about this aspect of identity will be critical to supporting gender-expansive patients and their families. There exist a growing number of resources for understanding gender diversity and its impact on young people. Along with these written and online resources, there are a growing number of professional gatherings such as the Gender Spectrum Professionals’ Symposium and other regionally based training opportunities to further refine one’s practice. Another way to deepen one’s background is to engage in an exploration of one’s own experiences with gender. As you seek to counsel these children and youth, as well as their families, providers should also be mindful of their own assumptions and biases that may influence the care they provide. Consider taking time to formally examine your own evolving gender journey as you work with the families and young people in your care.

Creating a Network of Practice

Another effective way of building your capacity around gender is to be part of larger learning communities focused on the subject. Professional associations, online communities and consultation groups are paying more attention than ever to this topic. Not only will participation in these expand your own perspectives about effective care and support, they also provide an opportunity to contribute to the growing body of practice constituting affirmative care.

Beyond the mental health field, such networks will connect you with a host of professionals who play an essential role in the overall health and well being of a gender-expansive young person. Mental health care providers play a critical role in linking families to a variety of other services—including medical, educational and legal providers they may need either currently or down the road. Through networking with other affirming professionals, you are able to identify trusted resources and direct your patients and their families accordingly.

Inter-disciplinary Connections

Becoming part of a larger community of professionals focused on the gender health of your patients also provides a rich sense of support for yourself as you work within this complex and emotional field of practice. Because there is no single path down which a child’s gender will unfold, the professionals who work with them must often sit with a great deal of ambiguity and uncertainty as they seek to provide support. The myriad of decisions and vast amounts of information and opinion from various fields requires the ability balance multiple factors, often in areas beyond one’s professional expertise. While there are no guarantees that a selected path will always be the correct one, being part of a team of professionals working together to support all aspects of child’s life greatly increases the possibility of identifying the best path forward.

Key Questions and Considerations:

A Mental Health Provider’s Starter Kit Because of their unique role in working with a gender-expansive child and/or their family, it is critical that mental health professionals stay abreast of an incredible array of issues. Below are some of the key questions that should inform providers as they work with a gender-expansive child and/or their family. By no means is this an exhaustive list. There are a number of assessment tools for designing a care plan for gender- expansive youth that incorporate many of the questions below. Instead of a map with specific directions, they might be considered more of a compass by which mental health professionals might gauge their work within this complex area of practice.

Family and Home
  • Does the child feel safe enough at home to be open about gender?
  • What are the views about the child’s gender among primary caregiver(s)?
  • If caregivers are not aligned in their views, to what extent do their different perspectives create stress in identifying a plan for care and support for the child?
  • If the child lives in more than one household, who has medical custody to make treatment decisions, sign waivers for sharing information, etc.?
  • How are perceptions about gender being communicated to the child?
  • How is the child’s gender impacting other members of the household, such as siblings? How is their gender impacting the child?
  • What additional factors within the family (i.e. religious affiliation, cultural background, extended family, sexual orientation, power dynamics, physical health, psychological health, family formation, substance abuse, family violence, etc.) need to be accounted for as you work with the child’s gender?
School
  • Does the child feel safe at school?
  • To what extent is the school aware of the child’s needs with regard to gender?
  • Does the child and/or family identify any adults who have been or could be allies?
  • Are any peers aware of the child’s feelings about gender? If so, who, and what have been their reactions to the child? What has been their reaction to how others treat the child?
  • Has a gender support plan been established with the school?
  • Does the child know where to go to the bathroom? If so, is this a comfortable option and are they using it?
  • Does the child present any specific learning needs independent of gender?
  • What is the relationship like between the caregivers and the school: collaborative? Adversarial?
Social and Community Issues
  • Does the child have a network of friends?
  • Are there any specific social dynamics playing out for the child (bullying, feeling isolated, specific areas of support)?
  • What activities (sports leagues, faith-based activities, scouting, etc.) is the child involved with outside of school, and how might these be impacted by the child’s gender?
Adolescents and Teens
  • To what extent is the child experiencing issues related to body dysphoria?
  • Are there other issues related to healthy diet, body image, or cutting that need to be considered?
  • What, if any, is the young person’s level of alcohol or drug use?
  • Are signs of clinical depression present? Are there any signs of suicidal ideation or attempts?
  • Is the youth involved in any kind of romantic relationship? What issues may be coming up related to the child’s gender?
  • Is the youth sexually active, and if so, what are their practices around sexual health and pregnancy prevention?
Medical and Legal Concerns
  • What is the young person’s awareness, knowledge and desires about possible medical interventions they might pursue?
  • What role will the mental health provider need to play in accessing these services, such as conducting gender assessments or completing letters of readiness?
  • How will these issues be surfaced and discussed with caregivers? What if caregivers are not on board with moving forward with medical interventions, or if they have significantly different feeling from the young person about the timing for doing so?