Parental support and condom use among transgender female youth

Abstract

Evidence suggests that transgender female youth (TFY), much like their adult transgender female peers, are at high risk for HIV. Yet little attention has been given to important developmental experiences of TFY that may impact HIV risk for this youth population. The overall purpose of this study was to explore HIV risk in TFY. A re-occurring theme from the qualitative data was the importance of parents. To better understand the impact of parents on HIV risk among TFY, in-depth individual interview data from 21 TFY in Los Angeles and Chicago were analyzed, suggesting a potential link between HIV-related risk behavior and parental support. Youth with parental support in this sample reported regular condom use, while those without such support reported inconsistent condom use. Implications for the unique research and interventions needs of TFY related to parental support and sexual risk behaviors are discussed.

Transgender female youth (TFY; young people who were born male but identify as female or something other than the gender assigned at birth) are a population at high risk for HIV. Two studies of TFY report HIV prevalence rates of 22% and 19% (Garofalo, Deleon, Osmer, Doll, & Harper, 2006; Wilson et al., 2009). HIV risk in both studies was primarily attributed to high-risk sexual behaviors, including unsafe sex. Yet little research has been conducted to explain why TFY engage in sexual risk behaviors. Much of the literature addressing adult transgender women has tied HIV-related risk behaviors to having a highly stigmatized status. Sugano, Nemoto, and Operario (2005) found that transgender females with higher exposure to transphobia (stigma and discrimination against transgender people) were 3.2 times more likely to engage in HIV risk behaviors than their less stigmatized peers. For adult transgender women, transphobia has been linked to low self-esteem, internalized transphobia, and social isolation that ultimately lead to sexual risk behaviors (Bockting, 2008). For youth, developmental factors may also play an important role in sexual behavior decisions. To date these factors are missing from the HIV risk literature on TFY, but they are important to identify in order to meet the youth development needs of this population.

Research has demonstrated that parents are an integral part of adolescents’ socialization and the development of attitudes that affect sexual risk behaviors (Minuchin, 1985; Pequegnat & Szapocznik, 2000). Parental influence in general occurs through the transmission of parental values and expectations, role modeling, external reinforcement, parenting style, and the use of different parenting practices (Bouris et al., 2010). Research has also shown that family cohesion, support, and connectedness can mitigate high-risk sexual behaviors among adolescents (Donenberg, Paikoff, & Pequegnat, 2006). In fact, a study in Scotland found that parental support was positively associated with delayed first intercourse and greater condom use (Parkes, Henderson, Wight, & Nixon, 2011). However, little research has been conducted on parental social support among transgender youth despite the widely recognized influence of parents on sexual risk behaviors among adolescents overall.

Obtaining or maintaining a supportive relationship with parents may be challenging for TFY due to the discrimination they often encounter from family members. Research has found that sexual minorities report lower levels of parental support compared to heterosexual youth (Eisenberg & Resnick, 2006). An important form of parental support for sexual minority youth is acceptance of their child’s sexual orientation. Parental rejection of the youth’s sexual identity is particularly harmful and is related to low self-esteem, low life satisfaction, and depression, which are, in turn, related to engaging in sexual risk behaviors (Hong, Espelage, & Kral, 2011). Rejection of a TFY’s gender identity may be similarly detrimental to the mental health and risk-seeking behaviors of this youth population, yet little research to date exists.

Just as parental rejection can be harmful, parental support remains a key protective factor for health and preventing high risk behavior among sexual minority youth (Eisenberg & Resnick, 2006). Sexual-minority youth who have disclosed their identity to friends and families have been found to report more social support, higher self-esteem, and less anxiety (D’Augelli, 2003). And sexual-minority youth who report high levels of parental support, good communication, and emotional closeness with their parents evidence fewer depressive symptoms and less suicidal ideation and attempts (Floyd, Stein, Harter, Allison, & Nye, 1999). A qualitative study of 30 families with a gay son indicated that feeling obligated to remain healthy for parents was an important factor in a young gay man’s decision to practice safer sex (LaSala, 2007). In fact, 83% of parents in the study tried to discuss safer sex with their gay sons because they knew their sons were at higher risk of acquiring HIV.

Sexual-minority youth are likely to communicate more with their mothers about their sexual orientations (Friedman & Morgan, 2008; Garofalo, Mustanski, & Donenberg, 2008; Savin-Williams & Ream, 2003), and mothers may play a similarly important role for TFY. Based on a growing body of research, HIV prevention researchers who work with young gay men point to the need for family-based interventions because many youth disclosed their sexual orientations to parents, and parents often reported wanting to be supportive (Garofalo et al., 2008). Parents of TFY may also need to be targeted with HIV prevention interventions to help this high-risk population of youth.

There is a paucity of research with TFY to date. The little research that exists primarily explores suicide (Grossman & D’Augelli, 2006) and HIV risk (Garofalo et al., 2006; Wilson, Garofalo, Harris, & Belzer, 2010; Wilson et al., 2009). Given evidence that TFY are perhaps the youth group at highest risk for HIV, more research to identify strategies for healthy outcomes and HIV prevention are needed. Evidence in research with adolescents in general, and sexual-minority youth specifically, suggests that parents play a critical role in HIV prevention among young people. Our study is the first attempt to explore parental social support as reported by TFY and reported condom use by level of parental support. Using data from the largest study of HIV risk among transgender youth to date, we qualitatively explored perceived parental support and reported condom use in TFY. We analyzed in-depth interview data from 21 TFY in Los Angeles and Chicago. Findings from this study will provide the first source of information about parental support of TFY and the potential impact on HIV-related risk behaviors.

Method

Research Design

This study is a secondary analysis of qualitative data from a sub-sample of adolescent and young adult transgender females who were recruited to participate in the Transgender Research Youth Project (TRYP), a 2-year mixed methods research study of the HIV risk behaviors of TFY in Los Angeles and Chicago (Wilson et al., 2009). The TRYP study surveyed 151 transgender females, 16–24 years of age, who were recruited from service organizations and street locations in Los Angeles (n = 75) and Chicago (n = 76). Individual in-depth semi-structured face-to-face interviews were conducted with 43 TFY who were recruited from the original survey sample of 151 youth. During the survey section that discussed sex work, TFY survey participants were asked if they would be willing to participate in a separate individual in-depth interview to explore reasons for engaging in sex work or not. The goal was to have a qualitative sub-sample of 50 participants stratified equally into youth with and without a history of sex work to explore reasons for the high prevalence of sex work within this community; 43 youth were interested and ultimately enrolled in the qualitative sub-sample. TFY in-depth interview participants were given an incentive of $50 for a 2-hour interview.

This article reports findings from a secondary analysis of the qualitative sub-sample that specifically examined parental support and condom use. Data for this report come from the transcripts of 21 participants who, without being prompted, discussed parental support when asked about social support during the in-depth interviews. All 21 participants were sexually active. Data used for this study were de-identified. Human subjects’ approval was obtained from the Committee for Protections of Human Subjects at the University of California, Berkeley.

Interview Guide Development

Community members in Los Angeles were invited to serve as a Transgender Advisory Committee (TAC) and participated in the design and development of the qualitative instrument used for this study (Wilson et al., 2009). The final interview guide was developed in collaboration with the TAC. The in-depth interview guide explored transgender identity, social support, discrimination, sex work, and sexual risk behavior. Assessment of social support was based on responses to a prompt asking participants to describe a time in the recent past when they went through a particularly hard time (e.g., lost a job, got kicked out of school, lost a friend), to whom they turned for support in that situation, and why. Condom use with the most recent casual or main sexual partner was asked about in order to avoid recall bias.

The final qualitative interview guide was translated into Spanish. Standard forward and backward translation procedures for Spanish translation were used to ensure that the language was culturally sensitive and appropriate for participants whose first language was Spanish. Two of the interviews in this sample were collected, transcribed, and analyzed in Spanish, with verification of findings from a native Spanish speaker.

Qualitative Analysis

A phenomenological exploratory approach was used to examine HIV risk in TFY (Giorgi, 2005). Initially, data were coded using a priori codes based on the interview guide and then inductively through gradual analysis of the data and emerging themes (Wengraf, 2001). Based on the purpose of the larger study, particular attention was paid to identifying themes that illuminated challenges specific to the lives of TFY that might have played a part in HIV-related risk behaviors. Using this approach, emergent themes from within large segments of coded text on the topics of interest (e.g., social support and HIV-related risk behaviors) were identified and the participants’ experiences were condensed, using phenomenological reduction, into narratives with public health implications. Inter-coder reliability between the two coders was assessed after the first round of coding and again after a second round of coding in order to constructively measure the interpretation of the findings and conduct phenomenological reduction of the data based on findings throughout the analysis (Morse, Barrett, Mayan, Olson, & Spiers, 2002). Initial inter-coder reliability was .75, and final reliability was .80, suggesting that the investigators gained consensus on the concept of parental support for TFY and reporting of sexual risk behaviors.

Parental social support

A recurring theme that emerged from the data was the importance of social support from parents. When asked about social support, most youth referred specifically to their biologic parents, not extended family members (e.g., siblings, aunts/uncles) or other individuals (e.g., friends, teachers). Taking a phenomenological approach, youth defined whether or not their parents supported them; thus, parental support in this analysis represented a range of experiences reported by individual participants. Youth who stated that they felt supported by their parents (n = 11) reported an array of experiences that they considered supportive. Some participants described having parents with whom they could talk about sex and gender transitioning, and from whom they could receive protection from discrimination and get financial assistance. Others said their parents were not open to discussing gender-related issues but respected their children and were still struggling to accept the change in gender. Participants with unsupportive parents (n = 10) described situations ranging from total estrangement from the family because of being transgender, to limited contact with a family that openly disapproved of the youth’s gender identity and expression. Some of these youth identified alternative sources of social support, which are described below.

Results

Of the 21 youth transcripts analyzed for this study, 19% percent of participants were Hispanic/Latina, 33% were Black/African American, 5% were Native American/Alaskan Native, 14% were Asian/Pacific Islander, 14% were multi-racial, and 14% were White. More than two thirds (67%) of participants were in the oldest age range (22 to 24 years of age). Youth in the middle age group, ages 19 to 21 years, made up 14% of the sample, and the youngest group (ages 16 to 18) comprised 19% of the sample. Twenty-four percent of youth reported being infected with HIV, 57% reported being HIV uninfected, and 19% did not know their HIV status. Twenty-four percent of the participants reported engaging in sex work in the previous 3 months, while 76% reported no such history.

Youth with Parental Support

Youth in the study reported varying degrees of acceptance and rejection from parents, with approximately half of the participants feeling supported (n = 11). Most of the participants who reported positive parental support were in the oldest age range of 22–24 years. At the most accepting level, parents expressed unconditional love for their transgender child regardless of changes in gender. Eight of the 11 youth who reported feeling supported received their primary support from their mothers. Some participants mentioned that they told their mothers everything about their lives, including experiences transitioning to another gender, relationships, sex work, and HIV status. Acceptance of the change from a mother-son to mother-daughter relationship was an important component of feeling supported by mothers for TFY. A number of the youth who reported feeling most supported by their mothers also reported feeling a new kinship as women.

I think - at first it made me much more distant from them [parents]. But with my mom, I’ve actually come full circle and I am actually much closer to her than I have ever been, which is an amazing wonderful thing to be friends with my mom, you know. To be a fellow woman with my mom, you know, and have something in common with her and, you know, be her daughter.

Other youth reported feeling supported despite the fact that they knew a parent or both parents were struggling with their gender identity.

Yeah. Because like ever since I started dressing like 2 years ago, my mother, it’s changed, her attitude. Like she is treating me different. Like she will treat me better. Like now it’s whatever. She still gives me mind, like she used to, but we’re close but not really close. I know she wants her son, but she is not going to get her son. That’s what she is thinking.

Youth who reported feeling at least partially supported by their parents were committed to maintaining a relationship with their parents, despite the challenges.

I think they preferred that I lived as a man and did the transgender thing at times. You know, or and if I just did a show, I don’t think they like seeing it as much just on an everyday basis. Sometimes I come over and maybe be in a wig or makeup or something like that. I try not to come around my family like that a lot. But I think they prefer that, that part of my life I did, you know, when they’re not around, or I wouldn’t let them see that part of my life. But at that time maybe I think they should - they are going to, you know, love me or not, you know. I am not losing my family because I decided to be a transgender.

Youth Without Parental Support

The other half of youth in this study reported feeling unsupported by their parents (n = 10). Some did not have a relationship with their parents for reasons not directly tied to gender identity, such as being separated from parents and in the foster system. Yet most of the youth in this group reported being rejected by their parents because of gender identity issues.

Uh, the most hard time that I ever had living the life of a transsexual was basically when I first became a transsexual. When I presented myself to my family, it was like, at first, everybody was like, oh my gosh. The whole family – and I’ll never forget it – it was on Thanksgiving. I thought I was doing something right, you know, about showing the family, coming out. Showing the family that this is what I wanted to be and it was like the family was like so not accepting of me at the time that it was like, it really struck me down. And I left home for about like for almost a year and a half. And when I left home, I was like I was living with a few friends of mine and I started to get depressed. Because it was like my mother wasn’t talking to me, wasn’t nobody talking to me. It was like my family had totally just [abandoned] me, you know what I’m saying?

Some youth participants thought their parents felt as if they had lost a child, and that loss was what prevented parents from being accepting. Others cited parents’ religious beliefs as the reason why participants were not accepted.

Because my mother practiced to be a witness, Jehovah’s Witness. And as we all know they shun homosexuality, transsexual, anything like that. So yeah, she is a Jehovah Witness and when they ask you, yeah, so where is your oldest son? “Oh, he’s out in Chicago trying to pretend to be a woman.” I can hear her now. And before I lie to them I just leave it alone. You see it’s hard for me because I really want to go. I really want to have a normal relationship with my mother.

Changes in gender seemed to be particularly difficult for fathers to cope with and for families where the participant was the only son. Interviewers did not specifically ask about experiences of abuse, yet about one third of TFY in this sample reported being abused by parents, other family members, schoolmates, sexual partners, and strangers on the street. The experiences with parents appeared to be the most traumatic.

Well, the day I came out, not too many people were happy with that. Like my father, for example. My father was pissed off, he wanted to beat my ass and try to change me. Like him and my oldest brothers, they were, like literally, they would have to tie me down in order for me to shave my head. That’s how bad it was. And that was the only reason. That was like a real difficult part of my life was when – like what the fuck did you go and tie me down for and shave my head for? Just let me be me. You know?

For many youth, abuse and discrimination from family was especially difficult to endure when they were already being discriminated against and harassed by others in society.

Most of the problems that I had were my people judging me. And the worst thing was my own family judging me. So if I was going to get it from people outside, I didn’t really need it from people inside.

Alternatives to Family of Origin and Connection to the Transgender Community

A number of youth who reported rejection from parents sought out alternative sources of social support, especially from other transgender women. Youth looked to adult transgender women for guidance on transitioning and for economic support through introductions to the sex work industry. Yet most youth regarded the transgender female community as competitive and unsupportive. Participants reported that adult transgender women were known to withhold information on where and how to get help with transitioning for fear of competition for commercial sex work clients or dates. Others cited an overall mistrust in the community.

Interviewer: How would you describe the transgender community?

Participant: Some cold-hearted bitches.

Interviewer: Why do you say that?

Participant: Some of them are actually. Some of them are very deceitful. They’re always trying to grab somebody’s man or sleep with somebody else’s man, you know. They’re very competitive. If one looked better than this one, they are evil with that one. They’re just a bunch of bitches.

Some youth, however, especially participants who had emigrated from Mexico to the United States seeking asylum from the persecution they experienced in their home country, viewed the transgender community as a healthy familial type of support system.

Interviewer: Tell me how do you describe the transgender community? What are they like?

Participant: Like a family… a family of unity. Unity… and they, they are like very supporting and they understand and it’s not, you know, it’s not like I woke up in the morning and they don’t care. They understand, go through. And we have like the same feelings, all of us do. I was like, I’m very happy about that.

Youth who were estranged from parents also looked to “play mothers,” extended family members like grandmothers, or as in the case below, to friends for support.

They [friends] will let me know that I have people that are not related to me by blood, that really do love me, that really do care about me. They respect me. They give me the utmost respect. My identity. They never mistake me as a he or something like that. They never do anything like that, like they won’t forget to call me she, you know.

One participant described her “play mother” as a lesbian woman who served as a mentor and support system.

Risk Behaviors of Supported and Unsupported Youth

The recurring theme from these data was that consistent condom use occurred among those with at least one supportive parent, and inconsistent or no condom use was reported among those without parental support. Most youth who reported having parental support consistently practiced safe sex (8 of 11 supported youth), most noting that they were well aware of the sexual risks and unwilling to expose themselves or their partners to HIV or other sexually transmitted diseases.

Oh yeah. I hope people, you know, I’m the type of person if I see you’re not going to rush to put on a condom, that means you didn’t do that with somebody else. And that means you have probably 9 times out of 10 got something that I don’t want to catch or re-catch, you know. So. For everybody, I want to make sure they use a condom.

The remaining youth who were reportedly committed to condom use admitted to having limited instances of engaging in unsafe sex (3 of 11 supported youth).

In contrast, most of the youth who reported feeling unsupported by parents, even if they found support elsewhere, reported frequent unsafe sex either in terms of inconsistent condom use or no condom use at all (8 out of 10 unsupported youth). An interesting finding was that 4 of these youth were in steady relationships and described having sexual agreements with their partners wherein they had unsafe sex with each other but used condoms with casual or commercial partners. Reasons given for having unsafe sex with their main partners were because the couple had been tested for HIV together before having unprotected sex, they had been in their main relationship for a long time (at least 1 year and up to 5 years), or they trusted the main partner. As one youth said,

I mean, we just trust each other and just, you know, I don’t know, I just feel, we don’t need to use it. I mean, I’ve always known there’s a lot of risks, you know. But for now it seems like it’s okay.

One HIV-infected youth reported not using condoms consistently because her main partner did not want to use them despite being aware of her being HIV-infected.

The remaining youth (i.e., 3) stated that they were not committed to consistent condom use. Here, a participant described the difficulty using a condom during sex:

You may get real hot and real arousal or whatever, and you don’t have a condom at the time, and they don’t have a condom. Who is going to stop the action? Well, I know a person that cares will stop the action and will get a condom. But at the time you just don’t be thinking about it.

In four cases, condom use and parental support did not follow the recurring theme (i.e., those who reported consistent condom use also reported an unsupportive family or those with supportive parents reported risky sexual behavior). In one instance, a youth reported being rejected by her parents due to religious beliefs, yet this young person reported consistent condom use with all partners; her commitment to condom use was because she was a sex worker who had a policy of consistent condom use due to the risks related to her job. Another youth who engaged in sex work and felt supported by her family reported using condoms during the riskiest sexual activity including anal sex, but not during oral sex, which is a behavior that confers a very low risk for HIV (Page-Shafer et al., 2002). The final two youth reported having difficult relationships with their mothers and not feeling entirely supported; yet they both reported always using condoms during sexual encounters. Both of these youth reported having had very close relationships with their mothers before transitioning.

Discussion

More than half of the TFY in this sample reported having parental support. An interesting finding in these data is what TFY considered support from parents. Using their words, we found that parental support encompassed a wide range of experiences, ranging from completely supportive parents to parents still struggling with accepting their child’s new gender. Results showed that most of the youth in this sample who reported having parental support were in the older age range. It is possible that older TFY may have had more time to work on building positive relationships with their parents. An alternative theory is that older TFY may have disclosed their identities to parents when they were no longer adolescents and living on their own, thus limiting the parents’ exposure to gender changes.

Most youth who expressed having parental support reported consistent condom use or a commitment to having safe sex, although occasionally failing, while those without parental support reported having sex without condoms. These findings mirror reports from other youth and emerging adult populations that found a relationship between parental support and sexual risk behavior. A systematic review of parental influences on the health of lesbian, gay, and bisexual youth found that parental support is generally associated with less risky behavior and improved health outcomes among sexual minority youth (Bouris et al., 2010). However, the exact ways in which parental support has translated into less risky behaviors are unknown.

For most youth in our sample with parental support and less reported sexual risk behavior, mothers primarily provided support. Literature with other youth populations has also found that support from mothers is linked to less sexual risk behavior. For example, research with young African Americans shows that youth with supportive mothers were less likely to have unprotected sex (Crosby et al., 2001). Less is known about how support from mothers contributes to less sexual risk behavior. A longitudinal study of adolescents and their families attributed decreased likelihood of sexual risk among girls to mother-child communication about sex (Henrich, Brookmeyer, Shrier, & Shahar, 2006). In many cases, the relationships between participants and their mothers evolved in such a way that mothers appeared to have accepted the child’s new gender. The new mother-daughter relationship may have opened doors of communication about sex and contributed to the safer sex behaviors reported by TFY in this sample. Yet few youth in this sample described the ways in which mothers’ support encouraged safe sex. More research is needed to identify ways in which mothers are supportive of TFY and how this support translates into less sexual risk behavior in this population. Such research may be particularly important for the design of interventions to enhance this key protective factor for youth.

Almost half of the sample reported having no parental support. Most youth without parental support also did not report consistently having safe sex. Interestingly, all youth who reported being infected with HIV also reported not having parental support. Many unsupported TFY reported that their parents were discriminatory and had even been violent because of their child’s gender identity. The discrimination reported from some parents is supported by literature showing that gender nonconforming youth are significantly more likely to be maltreated by parents (Corliss, Cochran, & Mays, 2002; Harry, 1989; Stieglitz, 2010). Discrimination and violence from parents has been linked to a host of challenges for transgender youth including homelessness, isolation, and increased sexual risk behaviors (Grossman & D’Augelli, 2006). This may be especially true for youth who are younger and transitioning without parental support, making them more vulnerable to high-risk environments, homelessness, depression, and thus more likely to engage in high risk sexual behaviors.

Most youth in our study without parental support were also in steady relationships, perhaps finding support through these partners. However, youth in steady relationships in the absence of parental support reportedly did not use condoms with main partners. This qualitative finding was supported in the analysis of quantitative data from our larger study, which found that TFY were more likely to engage in unprotected sex with main partners when compared to casual or commercial partners (Wilson et al., 2010). This finding was also supported by studies demonstrating that condom use declined for young women as they transitioned to adulthood and changed from having multiple sexual partners to being in monogamous relationships where condoms were not used (Fergus, Zimmerman, & Caldwell, 2007; Matson, Adler, Millstein, Tschann, & Ellen, 2011).

Some TFY in this sample reported that they had been tested for HIV infection with their partners and knew that they were having unsafe sex with an uninfected person. Having unsafe sex within sero-concordant relationships is a common practice that confers low risk for HIV transmission as long as both partners are monogamous (Crawford, Kippax, & Van de Ven, 1999). However, TFY in this sample cannot be considered low risk because they also reported having concurrent sexual relationships with casual and commercial partners. When compared with those in monogamous relationships, youth who engaged in concurrent sexual relationships had a significantly greater risk for sexually transmitted diseases (Kelley, Borawski, Flocke, & Keen, 2003). Concurrent sexual relationships may put TFY at risk directly through their own sexual behaviors and indirectly through those of their sexual partners (Senn, Carey, Vanable, Coury-Doniger, & Urban, 2009; Wilson et al., 2010).

Youth in our sample without parental support did report seeking out alternative forms of support other than from partners. Some youth were supported and reliant on their connections to mentors who were part of the larger lesbian, gay, bisexual, and transgender community (e.g., play mothers). Research with sexual minority youth has suggested that peers in the lesbian, gay, and bisexual community are an important form of support that is often more supportive than parents or other family members (Nesmith, Burton, & Cosgrove, 1999). Others looked to adult transgender women for support, including transgender women who were sex workers. Sausa, Keatley, and Operario (2007) found that the social networks among adult transgender sex workers provided an important form of social support that often replaced non-existent family support and aided in the process of transitioning. Many adult transgender women have reported that community connections on the street where they had been introduced to sex work often affirmed their female gender identity and provided connections to other transgender women (Bockting, Robinson, & Rosser, 1998). However, youth participants in this study reported that their relationships with other transgender women, especially those who were sex workers, were mostly unsupportive due to tensions related to feelings of competitiveness within the community and the perceived threat that younger transwomen posed to the economic survival of adult transgender sex workers (Wilson et al., 2009). Because of this tension and the inherent risks associated with sex work, sex working older peers may well have represented an unreliable source of social support and guidance for young transgender women. Thus, findings support the need for interventions to help strengthen and broaden healthy social support networks of TFY to reduce the possible reliance on steady sexual relationships as the only source of social support for TFY.

Implications

Perhaps the most important implication of this research was that parents might be critical targets for HIV prevention interventions for TFY because of their potential ability to influence their children’s sexual behaviors. Research with parents of lesbian, gay, and bisexual children has found that many parents are open to learning how to support their children and want assistance in doing so (Bouris et al., 2010), but there are notable challenges for parents of TFY. Parents of sexual-minority youth whose children are able to hide their sexual orientation in many situations do not have to actively face their children’s sexual identity at all times. Because much of living one’s true gender requires changes in appearance, parents of TFY are forced to face the changes in gender identity. Abuse has been consistently related to risky sexual behaviors among transgender women and might also be important precursors of risk behaviors in TFY (Clements-Nolle & Bachrach, 2003; Simon, Reback, & Bemis, 2000; Valera, Sawyer, & Schiraldi, 2001).

Reducing the kind of discrimination and abuse TFY faced from parents in this study should be a particular focus for interventions with this population. Research is needed to systematically examine relationships between parental support and risk behaviors before targeted interventions can be developed. Such studies should include larger samples and examine pathways in which social support impacts sexual risk behaviors for TFY. For example, research with adolescents and young adults has established that parent-child communication about sexuality influences the sexual behaviors of youth (Friedman & Morgan, 2008). These data suggest the need to examine how social support from mothers, from whom TFY were more likely to have support, may be a protective factor for HIV-related sexual risk behaviors. TFY may be more likely to seek support from mothers because of an ability to talk openly about their gender and sex in the context of a similar-gender relationship.

Research with TFY is also needed to determine whether any level of parental social support is sufficient to decrease HIV-related sexual risk behaviors. Youth in our sample appeared to be able to cope with limited social support as long as their parents did not express outright rejection. Research with sexual minority youth has found that acceptance of their sexual orientation is critical for healthy outcomes (D’Augelli et al., 2005), but TFY may be able to receive limited, ambiguous, or evolving levels of gender identity support and still maintain a good parent-child relationship.

Interventions focused on increasing safe sex practices within steady relationships are also needed. An important point of comparison in our data looked at youth in steady relationships who did and did not use condoms. Youth who reported social support at home also reported consistently using condoms, even in steady relationships. Couples-based interventions and programs that focus on condom use with steady partners, especially given the likelihood of concurrent sexual partnerships, are needed for this population.

Finally, community connectedness may be an important protective factor for TFY. Transgender youth need mentors who can guide them in the process of transitioning, as well as in ways to maintain relationships with parents and other supportive people. However, these mentors need to have knowledge of adolescent development and healthy strategies for dealing with the challenges of transitioning, family rejection, and social discrimination. Buddy programs that match screened and trained transgender women who would be appropriate mentors with transgender youth would be a good starting place for such efforts.

Limitations

A primary limitation to this study is that we used qualitative data that were not intended for the explicit purposes of this analysis. However, taking a phenomenological approach to analysis, the data allowed for an exploratory examination of life experiences of TFY, which led to the grounded findings in this analysis. Also, the study from which these data were drawn used a purposive convenience sampling strategy to ensure equal numbers of youth with and without histories of sex work. Because the transgender community is a dispersed and hidden population, randomization could not have been achieved. This dataset was also over-represented by youth in the older age range (22–24 years). Older youth may have had the benefit of having already gone through gender transition and disclosing their gender identity to family, thus giving them time to restore relationships with parents. Also, our dataset included a large number of youth participants who were connected to social services because of the ways in which participants were recruited. This led to a sample of TFY who may have been more savvy and resilient as evidenced by the fact that they accessed the few services in their respective metropolitan areas that were available to transgender community members.

Another important limitation is that abuse and victimization may have been under-reported in this sample. During the TRYP study consent process, youth were warned that if they reported any form of abuse and were under 18 years of age, the research interviewer would have to report the abuse to child protective services. Therefore, some experiences of abuse and victimization may not have been reported. In addition, because this was a two-site study, responses may have varied by site. For example, the sample was almost split on how they viewed the adult transgender community; differences in opinion about the adult transgender community may have been due to the fact that participants were referring to two different transgender communities. Another potential limitation was that, because these data were de-identified, we could not tease out differences that may have occurred by important demographic characteristics such as race/ethnicity or age. Finally, due to the way in which these data were collected, it was difficult to understand the ways in which social support helped the youth practice safe sex. Despite these limitations, however, this analysis supports the existing body of literature about parental support and sexual risk behavior that may be applicable to TFY in general.