What about the family in youth gender diversity? A literature review

Abstract

Background: Previous research has suggested that gender diversity affects everyone in the family, with positive mental health and global outcomes for gender diverse youth reliant on receiving adequate family support and validation. Although the individual mental health, treatment and outcomes for gender diverse youth have received recent research attention, much less is known about a family perspective. Hence, a review of the literature exploring youth gender diversity from a family perspective is warranted.

Aims: To systematically identify, appraise and summarize all published literature primarily exploring gender diversity in young people under the age of 18 years, as well as selected literature pertaining to a family understanding.

Methods: Six electronic databases (CINAHL, MEDLINE, EMBASE, PsycINFO, SCOPUS, Web of Science) were searched for relevant literature pertaining to youth under the age of 18 years.

Results: Research evidence was consistently found to support the beneficial effects of a supportive family system for youth experiencing gender diversity, and a systemic understanding and approach for professionals. Conversely, lack of family support was found to lead to poorer mental health and adverse life outcomes. Few articles explored the experience of siblings under the age of 18 years.

Discussion: This literature review is the first to critically evaluate and summarize all published studies which adopted a family understanding of youth gender diversity. The review highlighted a lack of current research and the need for further targeted research, which utilizes a systemic clinical approach to guide support for gender diverse youth and family members.

Introduction

Many gender diverse children and adolescents experience a mismatch between their gender assigned at birth and their experienced or true gender self (Ehrensaft, 2011). Gender diversity is known to affect everyone in the family in varied, unexpected and often significant ways. Given that most gender diverse youth remain reliant on the family for varied forms of support in adolescence and beyond, a family understanding is merited. There has been a noticeable increase in coverage of youth gender diversity by academic journals and the media, and an increase in individuals presenting with gender-related issues (Deutsch, 2016; Goldberg, 2017; Katz-Wise et al., 2017; Reilly, Desousa, Garza-Flores, & Perrin, 2019; Turban & Ehrensaft, 2018). It has been estimated that up to 1.2% of young people of high school age identify as transgender (Clark et al., 2014). Incidentally, the number of referrals of children and adolescents wishing to pursue gender affirming medical and surgical treatments in Australia and elsewhere has been increasing exponentially (Aitken et al., 2015; Butler, De Graaf, Wren, & Carmichael, 2018; Spack et al., 2012; Telfer, Tollit, & Feldman, 2015; Wood et al., 2013). It is therefore imperative that service providers and professionals better understand the issues affecting these young people and their families. To date, few researchers have specifically examined individual family members’ experiences within a family context involving siblings (Coolhart, Ritenour, & Grodzinski, 2018; Norwood, 2012, 2013b; Zamboni, 2006).

Early understanding of self, others and the larger world is created within the context of the family system and associated relationships. It is already known that poorer family functioning can lead to increased mental health difficulties and worse psychosocial outcomes for children and young people generally (Ryan, Huebner, Diaz, & Sanchez, 2009; Umberson & Karas Montez, 2010). Conversely, family structures that provide essential nurture and protection from harm contribute to healthier individual functioning (Carr & Springer, 2010; Resnick et al., 1997; Umberson, Thomeer, & Williams, 2013). The family system can be conceptualized as an essential ‘psychological buffer’ to help children and young people navigate necessary developmental and social challenges (Telzer, Fuligni, Lieberman, & Galván, 2013; Walsh, 2002).

Several studies have confirmed the fundamental importance of family support for improving gender diverse youths’ mental health and fostering resilience (McConnell, Birkett, & Mustanski, 2016; Olson, Durwood, DeMeules, & McLaughlin, 2016; Sansfaçon et al., 2018; Sansfaçon, Robichaud, & Dumais-Michaud, 2015; Simons, Olson, Belzer, Clark, & Schrager, 2012; Simons, Schrager, Clark, Belzer, & Olson, 2013; Travers et al., 2012). Nonetheless, there seems to be little research that has adopted a family approach, encompassing all family member viewpoints. Importantly, the family can also be the source of “culturally imbued transphobia” (Ehrensaft, 2011, p. 530) and microaggressions from within (Gartner & Sterzing, 2018; Parker, Hirsch, Philbin, & Parker, 2018). Cultural beliefs, religion, social context and conceptual understandings of gender identity and expression may influence family member responses and acceptance. Consequently, the issues faced by families and individual family members of gender diverse young people can therefore be complex, multi-faceted and unique, and are worthy of investigation (Hill & Menvielle, 2009).

The literature review aimed to systematically identify, appraise and summarize all literature involving a family or systemic (pertaining to the family system and wider social systems) understanding of youth experiencing gender diversity under the age of 18 years. Furthermore, the literature review aimed to highlight and promote the importance of a systemic understanding and approach for all professionals working with gender diverse youth and their families.

Methods

Type and focus of review: the literature review broadly identified all published research literature relating to youth gender diversity (under 18 years) within a family context. The review followed a five-step process of literature search, identification, data evaluation, data analysis and presentation of integrated findings.

Protocol: Six chosen databases were searched in April 2019: CINAHL, MEDLINE, EMBASE, PsycINFO, SCOPUS and Web of Science. A range of search terms, synonyms and Boolean technique using AND/OR operators were used to ensure the different nomenclature captured relevant literature (see Tables 1 and 2) and adapted for each database. Searches were initially performed in the abstract or keyword domains. However, this was found to be ineffective; while the search terms were present, the primary focus of the articles retrieved were generally irrelevant to this literature review. Therefore, search terms were confined to the title domain. This process was repeated immediately prior to submission of this manuscript. To promote rigor, reference lists of retrieved articles were searched manually to identify additional articles of interest not captured by the search strategy. Each of the articles retrieved was assessed for relevance by reading the abstract and the whole article if necessary.

Table 1.

Search terms used within the six databases.

Gender diversity	gender divers* gender dysphoria gender varian* gender identity disorder transsexual* transgender* gender expansive gender creative gender nonconforming LGBT1* LGBTQ2* gender queer gender fluid gender independent gender minority
Child	child* adolescen* youth teen*
Family	family familial systemic parent* mother father caregiver carer* sibling* brother* sister*

¹Lesbian, Gay, Bisexual, Transgender.

²Lesbian, Gay, Bisexual, Transgender, Questioning.

Table 2.

Individual database searches and results.

Database: date of initial search	Terms/keywords with Boolean operators	Number of citations retrieved
PsycINFO 25/04/2019 No date limitations (1806-2019)	Gender dysphoria OR gender varian* OR gender identity disorder OR gender divers* or transsexual* OR transgender* OR gender expansive OR gender creative or gender nonconforming OR gender minority OR LGBT3* OR LGBTQ4* OR gender queer OR gender fluid OR gender independent	11535 (keyword) 5330 (title)
	AND child* OR youth OR teen* OR adolescen*	3160 (keyword) 782 (title)
	AND family OR parent* OR carer* OR caregiver OR systemic OR familial OR brother* OR sister* Or sibling* OR families OR systemic	1355-(keyword) 129-(title)
Web Of Science: 25/4/19 No date limitations (1945-2019)	Gender dysphoria OR gender varian* OR gender identity disorder OR gender divers* or transsexual* OR transgender* OR gender expansive OR gender creative or gender nonconforming OR gender minority OR LGBT* OR LGBTQ* OR gender queer OR gender fluid OR gender independent	80082 (topic) 6030 (title)
	AND child* OR youth OR teen* OR adolescen*	16581(topic) 691 (title)
	AND family OR parent* OR carer* OR caregiver OR systemic OR familial OR brother* OR sister* Or sibling* OR families OR systemic	5711 (topic) 87 (title)
Scopus: 25/4/19 (title) No date limitations (1966-2019) #1	Gender dysphoria OR gender varian* OR gender identity disorder OR gender divers* or transsexual* OR transgender* OR gender expansive OR gender creative or gender nonconforming OR gender minority OR LGBT* OR LGBTQ* OR gender queer OR gender fluid OR gender independent	30541 (title/abstract/key words) 1973 (title)
Scopus: 25/4/19 #2	AND child* OR youth OR teen* OR adolescen*	#1 AND #2 10115 (title/abstract/key words) 272 (title)
Scopus: 25/4/19 #3	AND family OR familial OR families OR parent* OR carer* OR caregiver OR sibling* OR brother* OR sister* OR systemic	(#1 AND #2) AND #3 3590 (title/abstract/key words) 23 (title)
CINAHL 25.4.19 #1 No date limitations (1986-2019)	Gender dysphoria OR gender varian* OR gender identity disorder OR gender divers* or transsexual* OR transgender* OR gender expansive OR gender creative or gender nonconforming OR gender minority OR LGBT* OR LGBTQ* OR gender queer OR gender fluid OR gender independent	5789 (abstract) 1243 (title)
CINAHL 25.4.19 #2	AND Child* OR youth OR teen* OR adolescen*	#1 AND #2 = 1228 (abstract) 227 (title)
CINAHL 25.4.19 #3	AND family OR families OR familial OR systemic OR parent* OR sibling* OR brother* OR sister* OR caregiver* OR carer* OR caregiver	(#1 AND #2) AND #3 = 475 (abstract) 39 (title)
MEDLINE via OVID 25.4.19 No date limitations (1946-2019)	Gender dysphoria OR gender varian* OR gender identity disorder OR gender divers* or transsexual* OR transgender* OR gender expansive OR gender creative or gender nonconforming OR gender minority OR LGBT* OR LGBTQ* OR gender queer OR gender fluid OR gender independent	9775 (keyword) 3825 (title)
MEDLINE via OVID 25.4.19	AND Child* OR youth OR teen* OR adolescen*	2887 (keyword) 446 (title)
MEDLINE via OVID 25.4.19	AND family OR families OR familial OR systemic OR parent* OR sibling* OR brother* OR sister* OR caregiver* OR carer* OR caregiver	729 (keyword) 45 (title)
EMBASE 25.4.19 No date limitations (1974-2019)	Gender dysphoria OR gender varian* OR gender identity disorder OR gender divers* or transsexual* OR transgender* OR gender expansive OR gender creative or gender nonconforming OR gender minority OR LGBT* OR LGBTQ* OR gender queer OR gender fluid OR gender independent	12159 (keyword) 5583 (title)
EMBASE 25.4.19	AND Child* OR youth OR teen* OR adolescen*	3390 (keyword) 738 (title)
EMBASE 25.4.19	AND family OR families OR familial OR systemic OR parent* OR sibling* OR brother* OR sister* OR caregiver* OR carer* OR caregiver	1133 (keyword) 76 (title)

³Lesbian, Gay, Bisexual, Transgender.

⁴Lesbian, Gay, Bisexual, Transgender, Questioning.

Eligibility criteria: search findings were limited to human research, peer reviewed journal articles in English, with no time limits imposed.

Inclusion and exclusion criteria: all research was included that involved gender diverse youth under the age of 18 years, their caregivers or parents, and siblings. In addition, research was included that involved gender diverse adults retrospectively reflecting on their adolescent years or current family circumstances, if deemed relevant. Articles including sexual minority youth LGBQ (lesbian, gay, bisexual, questioning) were included if considered relevant to gender diverse youth and their families. Unpublished theses, books and previous literature reviews were excluded, as were articles focusing specifically on causation, etiology or interventions for child or adolescent gender diversity. However, articles were included if specifically related to a family member perspective or experience.

Data extraction process and analysis: Each of the identified articles were read in full, with the main findings and themes summarized for the purposes of the literature review.

No formal ethical approval was required, given that no research participants were involved.

Results

The search yielded 46 relevant studies/papers (Figure 1), undertaken in eight countries: USA (35), UK (2), Canada (4), Germany (1), Australia (4), Ireland (1), Spain (1) and Belgium (1). Details of the publications can be found in Table 3. Four were discussion papers and did not include actual research participants but were felt to offer valuable insights to the literature review overall (Connolly, 2005; Ehrensaft, 2011; Emerson & Rosenfeld, 1996; Katz-Wise, Rosario, & Tsappis, 2016). Three studies were multi-centre: Spain and Belgium, USA and Canada, and Canada, Ireland and USA (Catalpa & McGuire, 2018; Dierckx & Platero, 2018; Mehus, Watson, Eisenberg, Corliss, & Porta, 2017). Studies included various participants: parents or caregivers (24), followed by youth experiencing gender diversity (18), adults experiencing gender diversity (4), siblings under 18 years (3), adult siblings (2) and professionals (1). Only seven studies involved more than one family member from the same family. The age of youth participants ranged from 5 to 26 years, while parent or caregiver responses related to children and youth between the ages of 4 and 22 years inclusive.

Figure 1.

PRISMA literature review flowchart.

Table 3.

Overview of included publications.

Study title, country, author and year	Design	Participants	Themes, findings and recommendations
Supporting families of transgender children/youth: parents speak on their experiences, identity and views. USA (Aramburu Alegria, 2018)	Longitudinal, qualitative study	14 parents of transgender children aged 6-17 years	Themes Role of religion Loss and grief Duality of gender Self-doubt Proactive, child focused, preemptive actions to prevent adverse outcomes Parental self-care Findings Best possibility for resilience and positive mental health when children receive affirmation and support from family Transgender issues as the family’s focus- enmeshment and ‘trans filter’ (everything viewed through this)
Transgressing the gendered norms in childhood: Understanding transgender children and their families. USA (Barron & Capous-Desyllas, 2017)	Qualitative case study and ethnographic techniques	4 families, involving all family members: parents, siblings aged 6-8 years, transgender children aged 5-8 years	Themes Children’s gender expression Transgender child ‘indicators and signifiers’ Transition process and social presentation of self Gendered activities Negative social experiences Family members’ understanding of the transition
Parent experiences of a child’s social transition: moving beyond the loss narrative. USA (Bull & D’Arrigo-Patrick, 2018)	Phenomenological study- analyzed data from hermeneutic perspective	8 parents, facilitated social transition for children 4-12 years	Themes Meaning making from an individual, social, relational perspective Small-t transition (ongoing changes) Large-t transition (name change)
Family Boundary ambiguity among transgender youth. USA, Ireland, Canada (Catalpa & McGuire, 2018)	Ethnographic content analysis, recruited from community centers, 10 cities across 3 countries	90 transgender youths aged 15-26 years	Themes Youths negotiated complex and ambiguous relationships Family boundary ambiguity- who is in or out Relational ambiguity Structural ambiguity Identity ambiguity Recommendations GPs, educators, policymakers urged to: Consider transgender resilience through lens of ambiguous loss; and Promote a gender-affirmative life-span approach
Experiences of gender minority stress in cisgender parents of transgender/gender-expansive prepubertal children: A qualitative approach. USA (Chen, Hidalgo, & Garofalo, 2017)	Qualitative study using focus groups	30 parents of transgender and gender expansive children less than 11 years	Finding Identified distal and proximal forms of minority stress, with notable impact on health and wellbeing
A process of change: The intersection of the GLBT5 individual and their family of origin. USA (Connolly, 2005)	Discussion paper		Finding GLBT experiences consist of familial and societal constraints that can impede and disrupt personal and relational health.
Experiences of ambiguous loss for parents of transgender male youth: A phenomenological exploration. USA (Coolhart, Ritenour and Grodzinski, 2018)	Interpretive phenomenological analysis	6 parents of youth aged 14-19 years	Themes Transformation of the child Coping Acknowledging parental needs Findings Some parents reported experience of loss and ambiguous loss Some parents did not report any experience of loss
The meaning of trans* in a family context. Spain and Belgium (Dierckx & Platero, 2018)	Qualitative, grounded theory study in Belgium and Spain, life stories- experiences of parents and children transitioning	15 transgender children 5-19 years 15 parents	Findings Transitioning is perceived as an individual or family process Social and family environment overlooked Children’s transition revealed important insights into parenting role Challenges to heteronormative expectations and family roles Need to deconstruct family relationships and build new ones Accepting family member’s gender identity is crucial Professionals criticized for lack of contextual support, understanding and family therapy Stigma relationship between trans families and health professionals
Boys will be girls, girls will be boys. Children affect parents as parents affect children in gender non-conformity. USA (Ehrensaft, 2011)	Discussion paper		Themes Transformational possibilities in the family Challenge to orthodox psychoanalytic thinking that gender non-conforming is the result of poor parenting, trauma or attachment disruptions Winnicott’s true gender self and false gender self Findings Three family types: ‘Transformers’ ‘Transphobic’ ‘Transporting’ Family as changing organism- gender is dialectical creation between organism and environment Culturally-imbued transphobia within the family
Stages of adjustment in family members of transgender individuals. USA (Emerson & Rosenfeld, 1996)	Discussion paper		Findings Five stages based on Kübler-Ross43 stages of grief: Denial stage Anger stage Bargaining stage Depression stage Acceptance Not linear and can be experienced in unique and diverse ways by individual family members
Parenting transgender children in PFLAG.6 USA (Field & Mattson, 2016)	14 interviews with parents, coded for themes	14 parents of individuals aged 10-49 years	Findings Parenting transgender child more difficult and isolating due to: Physical changes Lack of media representation Effect on their identity Tensions in public Parental isolation alleviated by: Adjustment to changes in appearance Process of grief and mourning Prioritize parental difficulties Fears of being a bad parent
Social ecological correlates of family-level interpersonal and environmental microaggressions toward sexual and gender minority adolescents. USA (Gartner & Sterzing, 2018)	Internet based anonymous survey using Likert scales	1,177 LGBTQ7 adolescents 14-19 years old	Findings First study to identify frequency of interpersonal and environmental microaggressions that occur within family systems. Higher frequency of microaggressions experienced by gender diverse youth Youth from higher religiosity families reported more microaggressions No microaggression association with race or ethnicity
The positive aspects of being the parent of an LGBTQ child. USA (Gonzalez et al., 2013)	Online Survey	142 parents of children/individuals aged 4-56 years	Findings Positive aspects reported: Personal growth Positive emotions Activism Social connection Closer relationships
Am I doing the right thing? Pathways to parenting a gender variant child. USA (Gray et al., 2016)	Ecological transactional approach - analyzed with grounded theory	11 parents of children aged 5-13 years	Themes Child within multi-level social ecologies (families, broader contexts) Findings Evolving journey to rescue or accept Parenting a transgender child impacts parenting self-efficacy and worry Changes relationships in whole family Struggle to create a normal childhood Social intolerance amplifies stressors Future uncertainty amplifies stressors
Understanding the experience of parents of pre-pubescent children with gender identity issues. UK (Gregor, Hingley-Jones, & Davidson, 2015)	Free association narrative interviews- constructivist version of grounded theory	8 parents of children aged 6-10 years	Themes Five themes related to mourning: Loss Uncertainty Ambivalence Being unable to think Acceptance Finding Parents felt poorly understood by professionals
Parents’ reactions to transgender youths’ gender nonconforming expression and identity. USA (Grossman et al., 2005)	Individual interviews and questionnaires	55 transgender youth aged 15-21 years	Findings Majority of parents react negatively More gender non-conformity led to more negative reactions
You have to give them a place where they feel protected and safe and loved: the views of parents. USA (Hill & Menvielle, 2009)	Telephone interviews	42 parents of 31 transgender youth aged 4-17.5 years (over half adopted).	Findings Parents reported: No family discord, or issues with child or marriage 43% identified as having unconventional gender beliefs One parent typically less involved 50% unconditional acceptance 38% thought passing phase initially 60% policing gender choices 60% fear for child, 40% fear for future 50% interpreted as homosexual 40% child had taught lessons Paths to acceptance varied Issues are multiple, complex and not easily reducible Pursuit of contradictory goals
Communication of acceptance and support in families who have gender-variant youth. USA (Libby at al., 2019)	Qualitative study using grounded theory analysis	5 parent-adolescent dyads. Adolescents aged 14-20 years	Findings Collaboration between parent and adolescent Family environment of openness and tolerance Being accepted enhanced youth self-efficacy
Lesbian, Gay, bisexual, and Transgender youth and family acceptance. USA (Katz-Wise, Rosario, & Tsappis, 2016)	Discussion paper		Recommendations Health care providers should address issues of family acceptance and rejection during clinical visits More research needed to determine impact of parental acceptance/rejection on health of transgender youth Finding Family acceptance and rejection important in understanding the youth’s experience of minority stress
Transactional pathways of transgender identity development in transgender and gender-nonconforming youth and caregiver perspectives from the Trans Youth Family Study. USA (Katz-Wise et al., 2017)	Qualitative interviews using respondent narratives	16 transgender youth aged 7-18 years 29 caregivers	Themes Seven overarching themes of transgender identity development, organized into a conceptual model: Trans identity development Sociocultural influences/societal discourse Biological influences Family adjustment/impact Stigma/cisnormativity Support/resources Gender affirmation/actualization
Family functioning and mental health of transgender and gender-nonconforming youth in the trans teen and family narratives project. USA (Katz-Wise et al., 2018)	Longitudinal study Measured family communication/family satisfaction of transgender youth, parents, siblings using (FACES IV) Family Adaptability and Cohesion Evaluation Scales- recruited from community-based resources	33 transgender youth 13-17 years, 15 siblings 14-24 years, 48 parents	Findings Better family functioning led to improved individual health Mental health outcomes associated with minority stress, associated with stigma Transgender youth’s own perceptions of the family should inform interventions to improve family functioning Parent and sibling views not correlated with mental health Siblings only partially completed questionnaires, therefore conclusions limited
Child, Family, and Community Transformations: Findings from Interviews with Mothers of Transgender Girls. USA (Kuvalanka, Weiner, & Mahan, 2014)	Individual interviews, inductive thematic analysis	5 mothers of transgender girls 8-11 years	Themes Child transformation Family transformation Initial reaction Mothers becoming experts and advocates Fathers took longer to adjust Siblings Extended families Community transformation Majority professionals uneducated
Risk factors for psychological functioning in German adolescents with gender dysphoria: poor peer relations and general family functioning. Germany (Levitan et al., 2019)	Cross-sectional, questionnaire-based, single-subject study design using youth self-report, McMasters Family Assessment Device (MFAD)	180 adolescents, mean age 15.5 years	Findings Poorer family functioning (less acceptance) and peer relations led to worse psychological outcomes
Families matter: social supports and mental health trajectories among lesbian, gay, bisexual, and transgender youth. USA (McConnell, Birkett, & Mustanski, 2016)	Longitudinal study over 5.5 years, using rating scales	232 LGBT youth aged 16-20 years	Findings Family support for lesbian, gay, bisexual, transgender youth influences mental health outcomes
‘Deep down where the music plays’: How parents account for childhood gender variance. USA (Meadow, 2011)	Qualitative interviews	49 parents of children aged 4-18 years	Findings Majority of parents favored single explanation- biological, psychological or spiritual 25% believed a benign form of variation, 40% biomedical explanation Parents undertook a “deeply personal, cognitive and emotional project” to understand and consolidate their ideas of child gender diversity
Living as an LGBTQ adolescent and a parent’s child: Overlapping or separate experiences. USA and Canada (Mehus et al., 2017)	Qualitative using open ended questions	66 LGBTQ adolescents aged 14-19 years	Findings Comparison of youths’ LGBTQ experience outside the home mirroring parent-youth experiences within the family
Transitioning meanings? Family members communicative struggles surrounding transgender identity. USA (Norwood, 2012)	Analysis of online postings re transgender identity and transition- using relational dialectics approach - struggle between different meanings	63 individuals (age over 18)	Themes Three “sites of struggle”: presence vs absence (grief related) sameness vs difference (grief related) self vs other (support related) Findings Family members struggle with meaning making 21% of posts referred to a sibling relationship
Grieving gender: Trans-identities, Transition, and Ambiguous loss. USA (Norwood, 2013)	Relational dialectics- social world system of competing discourses	37 interviews – parents, siblings, children of transgender persons (no age specified, although likely adults)	Themes Negotiation of meaning Concepts of replacement, revision, evolution, removal Findings Meaning making for family members related to ambiguous loss Endure, avoid or overcome grief associated with transition
Meaning matters: framing trans identity in the context of family relationships. USA (Norwood, 2013)	Qualitative, dialogic analysis, using ‘authoring’	Telephone interview of 35 family members of trans individuals	Themes How trans identity functions as family stressors Constructed trans identity as a medical condition, natural nuance of gender identity, a lifestyle choice Meanings assigned to transgender identities
Experiences regarding coming out to parents among African American, Hispanic, and white gay, lesbian, bisexual, transgender, and questioning adolescents. USA (Potoczniak, Crosbie-Burnett, & Saltzburg, 2009)	Qualitative study using focus groups, grounded theory and naturalistic enquiry	LGBT adolescents aged 14-18 years	Themes Fear of emotional/physical rejection Parental shock leading to acceptance Importance of social support for adolescents Religion/culture-based responses Varied attitudes towards mental health professionals
The gender binary meets the gender variant child: parent’s negotiations with childhood gender variance. USA (Rahilly, 2015)	Qualitative interviews using Foucault’s nation of ‘truth regime’ to conceptualize the gender binary	24 parents of youth 5-19 years	Themes ‘Gender hedging’- attempting to curb gender diversity ‘Playing along’- with others outside of home ‘Gender literacy’- talking back to gender binary Help parents come to an awareness of the gender binary as a limited cultural ideology or ‘truth regime’
Support experiences and attitudes of Australian parents of gender variant children. Australia (Riggs & Due, 2015)	Scoping study, mixed methods, using internet survey	61 parents of children 4-18 years	Findings Parents receive conflicting evidence - reparative or affirmative Diagnosis facilitates support inside and outside of family Mixed experiences with healthcare professionals Fathers less supportive
The needs of gender-variant children and their parents: A parent survey. Australia (Riley at al., 2011)	Internet survey- content analysis and reflective-interpretive process	31 parents of children <12 years	Themes Identification of child’s gender variance - need for info and research Parents and family’s response Seeking emotional support Dealing with negative responses from others and fears about safety Seeking medical support Seeking political, government and legislative support
Recognising the needs of gender-variant children and their parents. Australia (Riley et al., 2013)	Online survey Grounded theory and content/thematic analysis	31 parents of children <12 years, 29 professionals and 110 transgender adults	Findings Children’s needs according to parents: Access to information Being loved unconditionally Accepted Respected Issues prioritized Given own choice Using preferred pronouns Peer and school support Learning skills to make friends and deal with bullies Being safe Needs identified similar for transgender adult and professional participants HAPPINESS acronym: Heard Accepted Professional access and support Peer contact Information Not to be bullied, blamed, punished Expressive freedom Safe Support
Surviving a gender variant childhood: the views of transgender adults on the needs of gender variant children and their parents. Australia (Riley et al., 2013)	Semi-structured, qualitative internet survey- analyzed by content and thematic coding	110 transgender adults	Findings Needs as children: Education programs in schools and society Acceptance and support to discuss gender variance Freedom of identity expression Validation Recognition Needs of parents: Access to information Education to increase others’ awareness Peer support Access to educated professionals
“Family support would have been like amazing”: LGBTQ youth experiences with parental and family Support. USA (Roe, 2017)	Phenomenological analysis of individual interviews	7 LGB adolescents 16-18 years	Findings Coming out was necessary Initial parent reactions were not supportive LGBTQ youth view religion as a barrier to support from parents LGBTQ youth want explicit support from parents
Family acceptance in adolescence and the health of LGBT adults. USA (Ryan et al., 2010)	Quantitative study 9% transgender participants 21-25 years	245 participants aged 21-25 years, reflecting on age 13-19 years	Findings Family acceptance predicts: Greater self-esteem Social support General health status Protects against depression, substance abuse, suicidal ideation and behaviors
Examining the Family Transition: How parents of gender-diverse youth develop trans affirming attitudes. USA (Ryan, 2017)	Guided by Ridgeway’s theory of gender primarily organizing social life	36 parents, in-depth interviews of preschool children	Themes Gender as primary frame for organizing life within the family Parents’ ability to challenge hegemonic beliefs Competing demands of raising ‘proper’ children or prioritizing childhood happiness Findings Making space for gender diversity taken on almost exclusively by mothers
The experience of parents who support their children’s gender variance. Canada (Sansfacon, Robichaud, & Dumais-Michaud, 2015)	Qualitative action research, using grounded theory	14 parents of children aged 4-13 years	Themes Understanding nature of childhood gender variance Labeling of gender variance Invisibility and stigma Unique and fluid experience Importance of accepting child’s true gender identity Emotional rollercoaster of support Protecting children from outside world
Youth and caregiver experiences of gender identity transition: a qualitative study. USA (Schimmel-Bristow et al., 2018)	Qualitative, semi-structured interview or focus group discussion	15 transgender youth aged 14-22 years 18 caregivers of transgender youth 22 years or younger	Findings All youth and caregivers initially lacked language and knowledge to describe feelings of gender confusion. Youth experienced both positive and negative experiences; however, all described transitioning as rewarding and vital Many needed mental healthcare support, but experienced barriers First study of in-depth recall of transitioning process for youth and caregivers
The relationship between parental support and depression and suicidality in transgender adolescents. USA (Simons et al., 2012)	Computer based survey using Beck Depression Inventory (BDI), suicidality and support questionnaires	28 transgender adolescents aged 15-24 years	Finding Parental support protective of depression, although not related to severity of suicidality
Parental support and mental health among transgender adolescents. USA (Simons et al., 2013)	Used family subscale of multidimensional scale of perceived social support, linear regression analysis	66 transgender youth 12-24 years presenting for care LA children’s hospital	Findings First study to document associations between parental support, mental health and quality of life in transgender youth Parental support led to higher life satisfaction, lower perceived burden of being transgender and less depression An intervention that promotes parental support may significantly affect the mental health of transgender youth
Impacts of strong parental support for trans youth: a report prepared for the children’s Aid society of Toronto. Canada (Travers et al., 2012)	Internet survey	84 socially transitioned youth aged 16-24 years	Findings Strong parental support led to: Higher life satisfaction Higher self-esteem Better mental health Adequate housing Study findings were limited by broad definition of ‘trans’
Family matters: transgender and gender-diverse people’s experience with family when they transition. Australia (von Doussa, Power, & Riggs, 2017)	Qualitative- interviews	13 transgender adults	Findings Protecting family relationships occurred at expense of transitioning Participants were concerned with protecting family life Found low levels of support from health services for family members at the time of transition (particularly conversations about impact on family unit)
Understanding more about how young people make sense of their siblings changing gender identity: How this might affect their relationships with their gender-diverse siblings and their experiences. UK (Wheeler et al, 2019)	Qualitative semi-structured interviews	8 siblings, aged 11-25 years, of gender diverse youth aged 8-18 years	Themes Confusion finding out about sibling’s gender diversity Achieving clarity through social transition Managing their gender diverse sibling’s two identities Deepening empathy over time Increased knowledge over time, enhanced relationship Overall experience a process of adjustment
‘I can accept my child is transsexual, but if ever see him in a dress I’ll hit him’: dilemmas in parenting a transgender adolescent. USA (Wren, 2002)	Qualitative study analyzed using grounded theory	11 families of gender diverse youth aged 14-19 years, no siblings	Themes Communication between parent and adolescent Non-acceptance Accepting and understanding- an iterative process How accepting and non-accepting parents cope

⁵Gay, Lesbian, Bisexual, Transgender.

⁶Parents and Friends of Lesbians and Gays.

⁷Lesbian, Gay, Bisexual, Transgender, Questioning.

Despite geographical, cultural and healthcare differences, research themes and findings were largely consistent. For ease, retrieved studies will be discussed according to study participants and main themes identified, although several studies included more than one family member or theme.

Parent or caregiver experiences

In total, 16 studies involving between 5 to 142 parent or caregiver participants were found that focused solely on the experiences of parents or carers of gender diverse young people, between the ages of 4 to 19 years (Aramburu Alegría, 2018; Bull & D’Arrigo-Patrick, 2018; Coolhart et al., 2018; Field & Mattson, 2016; Gonzalez, Rostosky, Odom, & Riggle, 2013; Gray, Sweeney, Randazzo, & Levitt, 2016; Gregor, Hingley-Jones, & Davidson, 2015; Hidalgo & Chen, 2019; Hill & Menvielle, 2009; Kuvalanka, Weiner, & Mahan, 2014; Meadow, 2011; Rahilly, 2015; Riggs & Due, 2015; Riley, Sitharthan, Clemson, & Diamond, 2011; Ryan, 2017; Sansfaçon et al., 2015). However, studies by Gonzalez et al. (2013) and Field and Mattson (2016) additionally included parental experiences of gender diverse individuals spanning from childhood to adulthood. A variety of methodologies were used, including qualitative thematic analysis, mixed methods, phenomenology, free association narrative and grounded theory. In-depth individual interviews were the most frequently used way of exploring experiences, either in person or by telephone, followed by online surveys, used to gather data from the largest sample of 142 parents.

Gender diverse youth experiences

Eleven studies, ranging from 7 to 1177 youth participants, were found that specifically focused on gender diverse youths’ experiences between the ages of 12–26 years, using various methodologies: ethnographic content analysis, phenomenological analysis, quantitative approaches and internet surveys (Catalpa & McGuire, 2018; Gartner & Sterzing, 2018; Grossman, D'Augelli, Howell, & Hubbard, 2005; Levitan, Barkmann, Richter-Appelt, Schulte-Markwort, & Becker-Hebly, 2019; McConnell et al., 2016; Mehus et al., 2017; Potoczniak, Crosbie-Burnett, & Saltzburg, 2009; Roe, 2017; Simons et al., 2012; Simons et al., 2013; Travers et al., 2012). Themes emerged of acceptance versus rejection, changing identity and relationships, adjustment within the family and the need for family support.

Sibling experiences

One study was found that concentrated exclusively on siblings: 8 siblings with a gender diverse sibling were asked their experiences (Wheeler, Langton, Lidster, & Dallos, 2019). This study sought sibling opinions of the research questions in advance, utilizing an LGBTQ (Lesbian, Gay, Bisexual, Transgender, Questioning) charity as part of the research design. Themes of confusion, role ambiguity, adjustment and enhanced sibling relationship were identified.

Parent and youth experiences

5 studies combined 5-29 parent or caregiver views and the views of gender diverse youth aged 7-22 years (Dierckx & Platero, 2018; Katz-Wise et al., 2017; Libby, Miller, Regan, Gruschow, & Hawkins, 2019; Schimmel-Bristow et al., 2018; Wren, 2002) using grounded theory analysis and qualitative interviewing. Indeed, Schimmel-Bristow et al. (2018) was the first in-depth study of caregiver and youth experiences, using responses from 18 caregivers and 15 gender diverse youth aged 14 -22 years.

Parent, youth and sibling experiences

Two studies were found that combined all immediate family member responses; sibling experiences under the age of 18 years with parents and youth experiencing gender diversity. In their longitudinal study, Katz-Wise, Ehrensaft, Vetters, Forcier, and Austin (2018) included 15 siblings aged 14-24 years, parents and gender diverse youth aged 13-17 years, using responses from the FACES-IV (Family adaptability and cohesion evaluation scale-IV) questionnaire. However, the research findings were limited by siblings only completing one subscale, as opposed to two. Moreover, sibling viewpoints were not found to have any correlation to the mental health of their gender diverse sibling; however, better family functioning was. A further qualitative case study using ethnographic techniques by Barron and Capous-Desyllas (2017) included two cisgender siblings aged six and eight years, whose gender diverse sibling was aged eight and five years respectively.

Family support and acceptance

Two studies explored the impact of parental support on the health and wellbeing of between 66 and 84 gender diverse youth respectively, aged 12-24 years, using quantitative questionnaires and an internet survey (Simons et al., 2013; Travers et al., 2012). Sansfaçon et al. (2015) instead explored the experience of parents who support their children’s gender variance and identified various themes ranging from facilitating understanding to experiencing invisibility and stigma. In their landmark study, Simons et al. (2013) asked 66 transgender youth their experience of parental support and documented associations between parental support, mental health and the quality of life of gender diverse youth. Parental support led to higher life satisfaction, lower perceived burden of being gender diverse and less depression. The role religion plays in coming out and whether the family is accepting or rejecting was identified by youth in three studies (Gartner & Sterzing, 2018; Potoczniak et al., 2009; Roe, 2017). In a further study focusing on family acceptance for gender diverse adolescents between 13-19 years, Ryan, Russell, Huebner, Diaz, and Sanchez (2010) used adult transgender (age 21-25 years) participants’ recollections, concluding that greater family acceptance leads to improved self-esteem, social support, general health status and is protective against depression, substance abuse and suicidal ideation and behaviors. Katz-Wise et al. (2016) conclude that more research is needed to determine the impact of parental acceptance or rejection on the health of gender diverse youth.

Collective family system experiences/interpretation

Three papers discussed potential changes within the family system as a whole, with particular reference to how parents or carers react to youth gender diversity and the bi-directional interplay of youth gender diversity on family dynamics and the wider social system (Connolly, 2005; Ehrensaft, 2011; Emerson & Rosenfeld, 1996). Indeed, Emerson and Rosenfeld (1996) were amongst the first scholars who sought to explain family member reactions using a five-stage grief paradigm model (Kübler-Ross, 1973).

Meaning making

Five studies explored ‘meaning making’ of youth gender diversity using various conceptual ‘lenses’, including ambiguous loss, whereby other family members often experience gender transition from a grief and loss perspective (Boss, 1999). Meaning making was primarily explored from a caregiver perspective, incorporating relational and individual factors. Furthermore, etiological causation was explored and collectively found to be reducible to an interplay of biological, sociocultural and normative identity development by a variety of researchers (Bull & D’Arrigo-Patrick, 2018; Katz-Wise et al., 2017; Norwood, 2012, 2013a, 2013b).

Family needs of gender diverse youth

Three online studies using qualitative (grounded theory) internet surveys focused on the needs of gender diverse children (less than 12 years) and their parents, using a non-linear approach (asking about the feelings or needs of another); 31 parents, 29 professionals and 110 transgender adults were asked about the needs of gender diverse youth and parents (Riley, Clemson, Sitharthan, & Diamond, 2013; Riley et al., 2011; Riley, Sitharthan, Clemson, & Diamond, 2013). Gender diverse youths’ needs were summarized using a HAPPINESS acronym: Heard and accepted, Professional access and support, Peer contact, Information, Not to be bullied, Expressive freedom, Safety and Support.

Studies involving research participants with gender diversity over 18 years

Five studies were included that involved adult participants, as findings were considered applicable to a youth context. In an Australian study, von Doussa, Power, and Riggs (2017) explored how gender diverse individuals experience transition within the family, while three further studies explored meaning making and loss related to trans identity within the family (Norwood, 2012, 2013a, 2013b). Riley, Clemson, et al. (2013) uniquely adopted a circular and lived approach (Selvini, Boscolo, Cecchin, & Prata, 1980) in that transgender adults were asked to think about the needs of gender diverse children and their parents, using their own lived experience.

Discussion

This review summarizes and synthesizes the available literature of youth gender diversity understood from a family or systemic context. It needs to be borne in mind that there was a noticeable absence of any literature from anywhere other than Europe, North America and Australia. This suggests that the results summarized are not necessarily comparable to family systems and cultures in Asia, Africa, The Middle East or elsewhere. This could therefore be a focus for future research. Two studies were included where the age of family member participants was unclear (Norwood, 2013a, 2013b). The literature retrieved identified consistent themes and findings in relation to youth gender diversity. Researchers attempted to understand individual family member experiences from a systemic perspective, considering the immediate and wider family context. Overarching themes identified were meaning making, carer or parental responses, lack of professional understanding or support, loss and grief, a family system understanding and family support. It is evident from the research that youth gender diversity may become both the focus and stressor for the family system, and interpersonal relationships, and the ‘filter’ through which family life is viewed (Aramburu Alegría, 2018; Gray et al., 2016; Ryan, 2017). Gender diversity affects all members of the family in unique, highly personal and diverse ways, not always readily apparent to others. Several authors focused on the same themes. Bull and D’Arrigo-Patrick (2018) discussed meaning making in relation to individual, societal and relational perspectives and distinguished small-t transition (ongoing transitional issues) and large-t transitions (definitive changes such as name change). Similarly, Connolly (2005) viewed youth gender diversity through familial and societal constraints lenses. Individual family members variably understood gender transition as a medical condition, a natural nuance of gender identity or a lifestyle choice, although individual meaning making was generally a complex and highly individualized endeavor (Hill & Menvielle, 2009; Norwood, 2012, 2013b). Moreover, Schimmel-Bristow et al. (2018) highlighted deficits of appropriate language and knowledge to describe initial feelings of gender confusion for both youth and caregivers. Several authors sought to describe and understand caregiver responses within the immediate context of the family. Ehrensaft (2011) categorized parents as ‘transformers, transphobic or transporting’: ‘transformers’ provide attuned emotional support for young people to live in their chosen gender and can usually overcome any potential internalized transphobia. ‘Transphobic’ parents, by contrast, are described as insecure in their own gender authenticity, struggle to provide support to their child and are rejecting. ‘Transporting’ parents are described as insidious and incongruent in presentation, meaning that their initial and subsequent reactions are not always predictable. Rahilly (2015) instead postulated ‘gender-hedging’ (attempting to curb gender diversity), ‘playing along’ with the child’s gender expression (when confronted by others) and ‘gender literacy’, or parents talking back to the gender binary. Unhelpful historical assumptions in relation to attributing blame to caregivers or the family system were challenged by the findings of Hill and Menvielle (2009) who found no evidence of family discord, child or parent issues in all 42 parents interviewed; however, they note that over half of the children in the study were adopted. Furthermore, Ehrensaft (2011) strongly contests orthodox and psychoanalytic interpretations of the cause of childhood gender diversity, and instead clearly situates gender diversity and creativity within a normal developmental paradigm.

The conceptual frameworks and ‘lenses’ of grief, loss and ambiguous loss related to youth gender diversity within a family context were utilized by several authors (Aramburu Alegría, 2018; Catalpa & McGuire, 2018; Coolhart et al., 2018; Emerson & Rosenfeld, 1996; Gregor et al., 2015; Norwood, 2013a). In their multi-centre ethnographic study of 90 transgender youth, Catalpa and McGuire (2018) adopted a systemic understanding using the concept of ‘family boundary ambiguity’, referring to who is ‘in or out’ of the family. Boss (1999, p. 4) defined ambiguous loss as “not knowing whether a loved person is absent or present, dead or alive” and described this as one of the most debilitating and difficult losses to resolve. Norwood (2013a) continues with the theme of grief and discusses how family members endure, avoid or overcome grief associated with transition and conceptualized the transitional process as encompassing consecutive stages of replacement, revision, evolution and removal.

Both Emerson and Rosenfeld (1996) and Gregor et al. (2015) instead postulated a 5-stage grief model, with denial and loss being experienced respectively, leading to acceptance. Field and Mattson (2016) attempted to differentiate the LGBT (Lesbian, Gay, Bisexual, Transgender) cohort grouping and found parenting a transgender child was more difficult and isolative compared with parenting a lesbian, gay or bisexual child. In contrast, Gonzalez et al. (2013) discussed the positive experiences of parenting an LGBT child, including personal growth, positive emotions, activism, social connection and closer relationships.

Definitive evidence was found by several authors in terms of the positive and negative effects of parental support, or lack thereof, on the mental health, resilience and quality of life of gender diverse youth (Aramburu Alegría, 2018; Katz-Wise et al., 2018; Ryan et al., 2010; Simons et al., 2013; Travers et al., 2012). Numerous authors highlighted the need for, or lack of, professional support and understanding of youth and families experiencing gender diversity (Dierckx & Platero, 2018; Gregor et al., 2015; Riggs & Due, 2015; Riley et al., 2011; Schimmel-Bristow et al., 2018; von Doussa et al., 2017). Indeed, Katz-Wise et al. (2016) went so far as to suggest that health professionals should address issues of family acceptance and rejection during routine clinical visits. Literature was generally excluded if not directly referring to youth experiences. However, adult transgender experiences in relation to the family system will share common characteristics to those of children and young people, which some authors have already demonstrated (Riley, Sitharthan, et al., 2013). Nonetheless, the literature review findings are limited by the relatively small numbers of research participants and ungeneralisable sampling techniques. This is however understandable within the context of studying a minority and stigmatized population, and studies predominantly using a qualitative methodological approach. Fathers and male caregivers were under-represented, and caregiving of gender diverse youth was commonly found to be a solo endeavor. Some of the included literature subjugated transgender youth participants with lesbian, gay and bisexual youth, which although similar in many respects, are a unique and distinct research cohort. Only three studies could be found that included sibling experiences under the age of 18 years (Barron & Capous-Desyllas, 2017; Katz-Wise et al., 2018; Wheeler et al., 2019) and no studies could be found that primarily adopted a non-linear or circular line of enquiry (asking someone in the family how someone else might be feeling) involving caregivers, youth and siblings. Furthermore, although frequently mentioned in the research literature, no studies could be found describing how family functioning or individual family member viewpoints are currently explored in routine or specialist clinical care.

The importance and merit of understanding youth gender diversity within a family or systemic context is supported by the collective research findings. Frequent and compelling themes of meaning making for individual family members, adjustment, acceptance, professional understanding and improving youth mental health and quality of life, were found in the literature. Nevertheless, several authors highlighted a dearth of current research using a systemic perspective and the need for future research to incorporate findings into routine clinical care and to better understand and improve outcomes for young people and their families. The research findings consistently highlighted either a need for, or a lack of, professional knowledge, coupled with unsatisfactory healthcare experiences for young people experiencing gender diversity and other family members. Furthermore, future research should strategically target siblings and male caregivers to address a clear gap in the research literature.

The following recommendations are made to contribute to an enhanced understanding of individual and collective family member experiences, to inform current clinical practice and improve management guidelines and outcomes for gender diverse young people:

1. explore existing specialist assessment protocols to determine whether a comprehensive family approach is utilized;

2. explore professional viewpoints in relation to the value of a systemic approach in assessment and treatment;

3. include and integrate all family member viewpoints using a circular line of enquiry (asking one family member how another family member might be thinking or feeling) to reveal potentially unknown family member opinions, with a view to addressing unhelpful or pejorative assumptions to promote family acceptance; (Brown, 1997; Cecchin, 1987; Selvini et al., 1980); and

4. use future research results to inform professionals, educators, therapeutic approaches and treatment guidelines.

Declaration of interest

The authors report no conflict of interest. The authors alone are responsible for the content and writing of this paper.