Conceptualizing Relationships among Transgender and Gender Diverse Youth and their Caregivers

Abstract

Family support and acceptance are protective for transgender and gender diverse (TGD) youths’ mental health and identity development. Although some studies have examined the role of supportive family relationships for TGD youth, prior research has not fully explored how TGD youth and their caregivers understand or characterize these relationships within the family system. In this qualitative study, we explored perspectives of TGD youth and their caregivers regarding youth-caregiver and caregiver-caregiver relationships within the family system. We recruited a community-based sample of 20 families (20 TGD youth, ages 7–18 years, and 34 caregivers) from across three U.S. geographic regions. TGD youth represented multiple gender identities; caregivers included mothers (n = 21), fathers (n = 12), and one grandmother. Each family member completed an individual, semi-structured interview which included questions about family relationships. Interviews were transcribed verbatim and transcripts were analyzed using thematic analysis. Analyses revealed complex bidirectional family relationships, highlighting five contextual factors influencing these relationships: school, community, workplace, religion, and extended family. TGD youths’ identity development is inextricably linked to how caregivers respond to, adjust to, and learn from their children, and how caregivers interact with one another. Findings illustrate how caregiver acceptance and family cohesion may be linked and how youth and caregivers identify shared contextual factors impacting the family system. This research highlights the importance of situating TGD youth and caregivers as equal partners in family-level approaches to affirm and support TGD identity development.

Although narratives of transgender and gender diverse (TGD) individuals are beginning to emerge globally, issues associated with this population’s health and well-being remain understudied. TGD individuals have a different gender identity than their assigned sex at birth, and may identify either within United States (U.S.) society’s binary construction of gender, as female/woman or male/man (e.g., trans girls/women: assigned male, identify as girl/woman; or trans boys/men: assigned female, identify as boy/man), or outside of the gender binary (e.g., gender nonbinary or gender diverse; Davidson, 2007). In contrast, cisgender individuals experience congruence between their gender identity and sex assigned at birth (e.g., assigned female, identify as girl/woman). Despite increasing discourse about the critical role of the family in TGD identity development, relatively little is known about how TGD youth understand their relationships with their caregivers and, conversely, how caregivers understand their relationships with their TGD youth. Even less is known about relationships between caregivers of TGD youth in multi-caregiver families.

The family system plays an important role in the development and well-being of youth. Individual caregivers (i.e., parents or other guardians) have a substantial influence on youths’ (i.e., children and adolescents) development and, consequently, how children make sense of the world (e.g., Bandura, 1978; Hutton et al., 2019; Kerr et al., 2019; Ong et al., 2018). Beyond this, the overall family system plays an important role. Family systems theory posits that family members rely on each other for social and emotional needs based on their relationships, and that the family is situated in a larger social context that can influence individuals as well as relationships between family members (e.g., Cox & Paley, 1997; Jaggers et al., 2015; Kerr & Bowen, 1988; Minuchin, 1985). Family connectedness is one of the key factors protecting youth from poor health outcomes (Viner et al., 2012). Parental supportiveness has also been identified as a mediating factor between youth-parent relationships and youths’ well-being (Hair, Moore, Garrett, Ling, & Cleveland, 2008). Youth who perceive their parents as more supportive are less likely to engage in risk behaviors (Parker & Benson, 2004). Beyond the dynamics of the youth-caregiver relationship, the relationships between caregivers also impacts youths’ well-being and development. Caregivers experiencing higher levels of parenting stress and inter-parental conflict are more likely to have children with behavioral issues (Chan, Brooks, Raboy, & Patterson, 1998; Chan, Raboy, & Patterson, 1998; Cummings & Davies, 2002), and children in high-conflict families—regardless of family structure—show lower levels of well-being across all outcomes (Goldberg & Carlson, 2014; Vandewater & Lansford, 1998). Conversely, children in families with higher levels of cohesion and well-being are less likely to report symptoms of anxiety and depression and to have substance use issues (Pilowsky, Wickramaratne, Nomura, & Weissman, 2006).

Although parental supportiveness contributes to the healthy development of all youth, it is particularly important for the health and well-being of lesbian, gay, bisexual, transgender, and queer (LGBTQ+) youth (Eisenberg & Resnick, 2006; McConnell, Birkett, & Mustanski, 2016; Ryan, Russell, Huebner, Diaz, & Sanchez, 2010). Associations between family support and youth’s well-being remain consistent in studies focused specifically on TGD individuals. Viewed through the lens of family systems theory, the entire family system is affected by the transition of a TGD youth from the gender associated with their sex assigned at birth to another gender (Alegria, 2018; MacNish & Gold-Peifer, 2014). This transition is not a single moment; rather, the caregivers and child mutually influence each other in an ongoing, iterative process (Katz-Wise et al., 2017; Tee & Abetz, 2020). Among TGD adults, family support is associated with higher employment, less homelessness, and fewer suicide attempts (James et al., 2016), and emotional closeness to the family system mitigates the impact of discrimination on psychological distress (Fuller & Riggs, 2018). Among TGD youth, family functioning and parental support for youths’ gender identity are associated with better mental health outcomes (Author; Olson, Durwood, DeMeules, & McLaughlin, 2016; Pariseau et al., 2019; Simons, Schrager, Clark, Belzer, & Olson, 2013). In contrast, lack of caregiver acceptance and support is associated with poorer health and well-being of TGD youth (e.g., lower life satisfaction, lower self-esteem, poorer mental health) (Bariola et al., 2015; Travers et al., 2012). It is important to note that caregivers of TGD youth play a critical role beyond the provision of emotional support: since they typically need to provide consent for their underage child, they are often also gatekeepers to accessing gender affirming services (Fuller & Riggs, 2018).

Although family support plays a crucial role in the mental health and well-being of TGD youth, few studies have examined the perspectives of caregivers of TGD youth (Westwater, Riley, & Peterson, 2019). One qualitative study examined the perspectives of mothers of transgender daughters, finding that, despite increases in parental acceptance over time, the shift towards acceptance was often a slower process for fathers (Kuvalanka, Weiner, & Mahan, 2014). In another qualitative study, parents of TGD children identified the educational environment, family and religion, and the health care system both as barriers and facilitators in parenting a TGD child (Capous-Desyllas & Barron, 2017). Finally, yet another qualitative study illustrated two approaches to parenting TGD children: rescuing the child from fear of stigma and hurt, or accepting gender variance and advocating for more tolerance (Gray, Sweeney, Randazzo, & Levitt, 2016).

These studies work together to lay a foundation for future research focused on the family systems of TGD youth. However, all of these studies enrolled a relatively small sample of caregivers of TGD children under age 13 years, and none investigated the relationships between TGD youth and their caregivers or between multiple caregivers of TGD youth. In particular, studies exploring the perspectives of TGD youths’ caregivers have primarily focused on mothers rather than fathers, which might reflect wider societal trends in cisgender parenting (Gray et al., 2016; Kuvalanka et al., 2014). These studies also lacked inclusion of the perspectives of TGD youth themselves (Westwater et al., 2019). Therefore, analyzing TGD youth and caregiver perspectives together would be a novel contribution to the literature and provide an important opportunity to understand complex interactions within the family system.

It is clear that family relationships impact the health and well-being of TGD youth. However, more work is needed to better understand how TGD youth and caregivers characterize the relationships they have with each other within the family system. To provide more insight on this topic, we used qualitative data from the Trans Youth Family Study, a multi-site mixed methods study of families with TGD youth, to conceptualize youth-caregiver and caregiver-caregiver relationships from the perspectives of those individuals. We sought to answer the following questions: (1) How do TGD youth and their caregivers characterize their relationships with each other within the family system? (2) How does parenting a TGD youth influence relationships between caregivers? (3) How do relationships outside the immediate family system shape both youth-caregiver and caregiver-caregiver relationships?

Method

Participants

Twenty families (N = 54 family members) participated in the Trans Youth Family Study (TYFS), including 20 TGD youth, ages 7–18 years, and 34 cisgender caregivers. Youth self-identified their current gender identity as trans boy (n = 11), trans girl (n = 7), and nonbinary/another gender identity (n = 2). Caregivers included mothers (n = 21), fathers (n = 12), and one grandmother. In 15 of the 20 families, two caregivers participated in the study; in the remaining 5 families, only one caregiver participated. Sample demographics appear in Table 1. We recruited participants from LGBTQ+ community organizations and support networks for families with TGD youth in the Midwestern, Northeastern, and Southern U.S., and via snowball sampling. Eligible youth were age 5–18 years and (a) identified with a different gender than their sex assigned at birth, or (b) were gender nonconforming. Caregivers were eligible to participate if they were guardians to a youth who met the inclusion criteria. Both the youth and at least one caregiver were required to participate in the study together.

Table 1.

Sample Demographics for Transgender and Gender Diverse Youth and Caregivers from the Trans Youth Family Study (N = 54)

Measure	Youth (N = 20)	Caregivers (N = 34)	Families (N = 20)
Age in years, M (SD)	12.30 (3.79)	47.29 (6.72)
Sex assigned at birth, % (n)
Female	55.00 (11)	64.71 (22)
Male	45.00 (9)	35.29 (12)
Current gender identity, % (n)
Cisgender woman		58.82 (20)
Cisgender man		35.29 (12)
Trans girl/girl	35.00 (7)
Trans boy/boy	55.00 (11)
Another gender identity	12.5 (2)	5.88 (2)
Race/ethnicity, % (n)
White	80.00 (16)	97.06 (33)
Hispanic/Latino		2.94 (1)
Multiracial/Another race/ethnicity	20 (4)
Education, % (n)
High school diploma/GED		5.88 (2)
Some college		8.82 (3)
College degree		47.06 (16)
Graduate degree		38.24 (13)
Individual income, % (n)
$10,000–30,000		8.82 (3)
$30,001–60,000		23.53 (8)
$60,001–100,000		29.41 (10)
≥ $100,001		35.29 (12)
Retired		2.94 (1)
County of origin, % (n)
U.S.		91.18 (31)
Non-U.S.		10.3 (3)
Sexual orientation, % (n)
Heterosexual/straight	30.00 (6)	85.29 (29)
Bisexual	10.00 (2)	5.88 (2)
Lesbian/gay	10.00 (2)	5.88 (2)
Pansexual	5.00 (1)
Unsure	20.00 (4)
N/A	25.00 (5)
Another sexual orientation		2.94 (1)
Relationship status, % (n)
Single		2.94 (1)
Married		73.53 (25)
Living with partner (unmarried)		8.82 (3)
Committed relationship without cohabitation		5.88 (2)
Separated/divorced		5.88 (2)
Widowed		2.94 (1)

Notes. Youth age range: 7–18 years. Caregiver age range: 34–63 years. All cisgender men were fathers. All cisgender women were mothers, apart from one grandmother. Other youth gender identities included gender-fluid and girlish boy, and were self-identified. Other caregiver gender identities included “female gender bender” and “mildly gender-variant female, and were self-identified. Frequencies for languages used at home, religion practiced at home, and relationship status were overlapping because participants could choose or write in multiple options. Race/ethnicity was collected as a demographic variable was assessed as an open-ended question (“What is your race/ethnicity? (please list all that apply)”) and thereafter categorized into the following categories for analysis: White, Black/African American, Hispanic/Latino, Asian American/Pacific Islander, American Indian, Other. Other youth race/ethnicity included multiracial White/Latina and White/Hispanic.

Researchers

The authors of this study represent a diversity of perspectives, shaped by life experiences related to their social positions and identities. All authors identified as cisgender and queer (non-heterosexual). Race/ethnicities of the authors included White and Indian American. Three authors specialize in LGBTQ+ health. Two authors are mental health clinicians. The authors were collectively trained in the following fields: public health, counseling psychology, clinical psychology, developmental psychology, and women and gender studies. Sabra L. Katz-Wise and Stephanie L. Budge are Co-PIs of TYFS. Nina Bhattacharya completed the data analysis, which was overseen by Sabra L. Katz-Wise and reviewed by Stephanie L. Budge. David W. Pantalone assisted with interpretation of the findings and implications for practice. Other members of the research team who conducted and transcribed interviews were graduate students in clinical and counseling psychology, public health, and human development.

Embarking on this analysis, we held several assumptions. First, we expected that TGD youth and caregivers would characterize their relationships differently based on how much time had passed since the youth disclosed their TGD identity. Second, we held the assumption that a majority of the caregivers in the study would be relatively supportive of their TGD child, since they agreed to participate in the study as a family. Third, we held the assumption that cisgender heterosexual women caregivers were more likely than cisgender heterosexual men caregivers to seek health care and information for TGD youth to demonstrate support, since previous research has demonstrated that cisgender women are more likely to seek and use health care than cisgender men (e.g, Vaidya, Partha, & Karmakar, 2012). Finally, we assumed that rejection experiences within relationships outside the immediate family, such as with teachers or religious institutions, would contribute stress to the family system.

Our assumptions were shaped in part by our own experiences. All of the authors are cisgender and, at the time of data collection and analysis, none of the authors were caregivers. As a result, there may be themes we did not identify, or that we identified differently, from a lack of direct personal experience negotiating familial relationships as a TGD person or caregiver of TGD youth. However, collectively, we have substantial research and clinical experience with this population, in addition to vicarious personal experiences through friends, colleagues, and trainees who are transgender. We hope that centering participant voices in this study has allowed us to characterize, to the best of our ability, the experiences of TGD youth and their caregivers.

Measures

The semi-structured interview protocols designed for this study included separate but similar protocols for TGD youth and their caregivers. We developed two interview protocols for TGD youth, each worded to be developmentally appropriate for youth ages 5–11 years or youth ages 12–18 years. Interview questions analyzed for this study addressed the effects of the youth’s gender identity on: (a) closeness or distance between caregivers and youth, (b) relationships between caregivers, and (c) relationships with people outside the immediate family (e.g., extended family, school, community, workplace, religious institutions). Other interview questions not analyzed for this study addressed TGD identity development, future perspectives, emotions and coping related to the youth’s gender identity, and support needs (Budge et al., 2018; Katz-Wise et al., 2017).

Procedures

The semi-structured interview protocols designed for this study included distinct but complementary protocols for TGN youth and caregivers. Interview questions assessed experiences related to the TGN youth’s identity development and expression, and the caregiver protocol also focused on the experience of parenting a TGN youth. Two protocols were developed for TGN youth, which were developmentally tailored for youth ages 5–11 years and youth ages 12–18 years. The research team conducted one-time, in-person, semi-structured interviews and quantitative surveys with TGD youth and caregivers between April and October 2013. The sessions occurred in the participants’ homes or at the researchers’ institutions, based on the family’s preference. Each youth and caregiver were interviewed separately. Interviews were conducted by members of the research team; all interviewers were trained and supervised by Sabra L. Katz-Wise and Stephanie L. Budge. Each participant gave written informed assent/consent prior to participation, and then completed an individual interview and paper survey in a private room with the interviewer. The interviews were completed between 30–90 minutes, and the survey was administered in 15–30 minutes. The interviews were digitally recorded and transcribed verbatim by undergraduate and graduate students from the researchers’ institutions. Participants were not offered compensation for participation; however, all participants received a comprehensive resource list at study visits. This study was approved by the Institutional Review Board at each study site.

Analytic Methodology

The process of developing the codebook was iterative, and blended two approaches to organizing and analyzing the data: immersion/crystallization (Borkan, 1999) and thematic analysis (Boyatzis, 1998). Both methods emphasize immersing oneself in the data, developing brief codes or notes, surfacing underlying themes, and iteratively refining these themes through judicious engagement with relevant literature throughout the analysis. Although the primary interview questions of interest for this current study explored the relationships between youth and caregivers, as well as the relationships between caregivers, each interview transcript was analyzed as a whole for themes related to relationships.

A sub-sample of 20 transcripts (4 trans girls; 2 trans boys; 1 gender-fluid boy; 8 cisgender mothers; and 5 cisgender fathers), representing approximately half of the total interview sample, was used to develop data-driven codes using thematic analysis (Boyatzis, 1998). We developed a single codebook that included content from both TGD youth and caregiver interviews to identify potential cross-cutting themes. After further revising the codebook, Nina Bhattacharya and Sabra L. Katz-Wise independently coded a subset of four interview transcripts (one trans girl, one trans boy, one father, and one mother), and then met to verify similar understandings and usages of the codes. After further refinement of the codebook, Nina Bhattacharya coded the remaining transcripts using the web-based qualitative data management program Dedoose. Nina Bhattacharya and Sabra L. Katz-Wise met biweekly to resolve issues that arose during coding. After all transcripts were coded, the team worked together to synthesize themes from the codes.

Results

Contextualizing Family Relationships

We identified 16 codes and 18 sub-codes from our thematic analysis of TGD youth and caregiver interview transcripts. To explicate the complex dynamics in youth and caregiver relationships, we organized the codes and sub-codes into five contextual factors influencing relationships within the family: school, community, workplace, religion, and extended family. Below, we discuss the codes that illustrate family relationships from the youths’ and caregivers’ perspectives.

Relationships Between TGD Youth and Caregivers

Closeness and “team spirit.”

Closeness was a theme across a majority of the interviews, wherein youth and caregivers alike described the TGD youth’s gender identity development as the catalyst for closer, more communicative relationships. A mother of a 9-year-old gender-fluid boy in the Northeast described the feeling she experienced with her child of working as a team as they navigated gender identity-related challenges together: “[T]here was a time when he was younger that I truly felt as though it was him and I against the world.”

A 15-year-old trans boy in the South noted that relationships with his caregivers shifted in different ways for each caregiver:

But [with] my mom, I think it’s gotten us a little closer, because we have deeper conversations and we talk more. But with my dad, it’s like there is a mini-elephant in the room. Not like a huge one but just a little one.

Youth described the youth-caregiver relationship as being particularly important in the context of needing to access gender affirming health care services. An 18-year-old trans boy from the Northeast described his mother’s role:

[S]he definitely helped me and supported me and even just helped me, just like, doing things… I would have absolutely no idea how to find a therapist… dealing with doctors… and dealing with the school, what should I do, who should I tell—could you tell this person for me? She’s really helpful with things like that…

Learning from youth.

As caregivers reported accepting their child’s gender identity, they also expressed learning from their child about TGD perspectives, their child’s gender identity development, and their child’s gender transition. A mother of a 9-year-old gender-fluid boy admitted, “I have learned. He has been my teacher. Absolutely.” She described how parenting her son opened her eyes to the experiences of other individuals who were struggling. A father of an 8-year-old trans girl from the Northeast explained that he and his wife looked to his daughter for cues: “[W]e haven’t necessarily tried to push her in any sort of way… we’ve tried to really be conscious of that… to let her sort of guide… her expression, [to be] who she is…” The father described one of the first times he followed his daughter’s guidance, adding how delighted she was when he let her wear a princess dress to her birthday party, as she requested.

Movement to acceptance.

Several caregivers, usually fathers, described an “adjustment period” after learning about their child’s gender identity, wherein the caregiver expressed movement from initial loss and/or not supporting their TGD youth’s gender identity or expression, to greater acceptance. A father of an 8-year-old girlish boy in the Northeast talked about renegotiating the gendered context of their relationship:

I think any parent would have to say there is some level of disappointment. I think you develop expectations of ‘this is what I want to do with my child’ and, again, there are stereotypical girl things, there are stereotypical boy things and wanting to share those with your child… You have to find different things that you can share together. So there is an adjustment period there and, probably, a continuing adjustment.

Caregivers stressed the varying length of time to acceptance of their child’s gender identity. Although almost all caregivers in the present study described an “adjustment period,” the length of time to acceptance was particularly vivid for caregivers of trans girls, as a father of a 7-year-old trans girl in the Northeast described:

I felt like I lost my son. It was such a strange feeling ‘cause I know that the child is still there and alive, but—the son that I had known for six years, I felt was an illusion. Gone. That’s how it felt. For weeks, months.

Emotional labor.

TGD youth articulated a nuanced understanding of this “adjustment period” in their caregivers’ experience. A 16-year-old trans boy from the Midwest observed that his father “struggle[d] with it more because he’s a very black-and-white or ‘there is, there isn’t’ person, so it was a lot harder for him to understand” a transgender identity. An 11-year-old trans girl in the Midwest reflected, “[M]aybe [my parents] thought of [my gender expression as a] phase but, when they started to realize it wasn’t one, they accepted me.” TGD youth also reported managing caregivers’ emotions associated with the youth’s gender identity development or affirmation. A mother of an 18-year-old trans boy from the Northeast recalled an early conversation with her child, who carefully modulated the information he shared with her:

And we talked about a name and I said, ‘Do you know what you want to call yourself?’ [He said] ‘Yeah, I do.’ And I said, ‘What is it?’ [He said] ‘You’re not ready for that. I [will] give you a little bit of information, and you go and deal with your emotions. And then I [will] give you a little bit more information.’

Conflict.

Participants described conflict in the youth-caregiver relationship arising in contexts in which the caregiver attempted to “police” the TGD youth’s gender presentation (e.g., hair or clothes) or restrict access to gender affirming services. A 14-year-old trans girl in the Northeast talked about experiencing how she went through a difficult period with her mother because “she didn’t want me to have hormone blockers.” Another TGD youth, a 16-year-old trans boy from the Midwest, talked about how his father was initially uncomfortable with him purchasing boys’ clothes:

I went to the men’s area to buy a tank top and he [father] was like, ‘I told you, no boys clothes!’ And I [said], ‘Dad, come on. It’s just a tank top; it’ll be fine.’ And he [father] was like, ‘Here, let me see what it looks like on you first.’

Participants reported that this type of conflict typically became less of an issue over time for caregivers who accepted the TGD youth’s gender identity. However, when caregivers failed to accept the TGD youth’s identity over time, it caused critical roadblocks in the TGD youth’s access to gender affirming services. An 18-year-old trans boy from the Northeast described this situation: “[P]eople would ask me, oh, are you on testosterone? And I’d have to explain to them, no, my dad doesn’t accept [my gender identity].”

Relationships Between Caregivers

Proactivity between caregivers.

In families of mothers and fathers, mothers were more proactive than fathers about accessing gender affirming services for their child. One mother of a 16-year-old trans boy in the Midwest explained:

I’m still more proactive… I’m the one who did the name change, went to court. We [mother and father] both had to show up for the actual change, [I] took him for his social security card. So, none of that would be done had it been left to my husband but, again, to me, that’s just kind of the man-woman thing. I don’t know, I just take charge.

Discordance in parenting.

Differences in parenting emerged when one caregiver was prepared to affirm the TGD youth’s gender identity, while the other caregiver was still adjusting to the identity disclosure. One father of a 7-year-old trans girl in the Northeast said that his relationship with his wife felt more stressful because “she came to terms with the gender thing long before” he did, and they “[h]ave differences of opinion… [about] how to handle behavioral issues, and things like going about a name change now… or should we wait a while [to] see how things pan out.” A mother of a gender-fluid 9-year-old boy in the Northeast described how the lack of a parenting “guidebook” for raising a TGD child caused discordance in the caregiver-caregiver relationship:

[A]t the time, my husband and I had very different ideas on how to raise a child like this… It was one opinion against another opinion. As easy as that. That became very troublesome for many different reasons… We weren’t giving each other support because we didn’t believe what the other one thought we should do, and so we were at constant odds [about] how to even address a child like this.

Sometimes, a caregiver’s emotional response to the disclosure of their child’s gender identity differed from that of their partner. A mother of a 15-year-old trans boy in the South “[c]alled in the troops,” telling her close circle of friends that she was “[i]n a situation here that I really need help [with].” Although this mother found support, her husband “[d]idn’t tell anybody, he didn’t tell any of his friends,” and both partners independently acknowledged the subsequent discordance in their relationship. The child’s mother described one particularly significant conversation: “Without question, for me, the hardest part was that day when my husband said to me, ‘that child is dead to me’.” The child’s father told the interviewer that he was “embarrassed” by his comments, which were “very painful” for him to think or talk about.

Closeness and support.

Over time, as caregivers adjusted to their child’s gender identity, relational stress between caregivers also abated. A father of an 18-year-old trans boy from the Northeast talked about his admiration for his wife’s advocacy work on behalf of their TGD child:

[T]he biggest thing is, I have a lot of respect for [my wife]. And, if we didn’t go through all this, it probably wouldn’t be as deep. She’s been really amazing with her advocacy and just everything she’s done for [our child]. You know, just writing letters and talking to people and going out there…

Caregivers also relied on each other for support, especially in disclosing their child’s gender identity to extended family members. A mother of an 8-year-old trans girl in the Northeast recalled:

We would be going to see my family, and I would be freaking out. I’d get real stressed out and worried, like, ‘What is this gonna be like? How is this gonna go?’ And that’s where [my husband] would come and support me, and help me through it, and try to see my way through it.

Participants also observed that closeness between caregivers facilitated closeness or acceptance within the youth-caregiver relationship as well. A mother of a gender-fluid 9-year-old boy in the Northeast explained:

Now, we’ve made steps to kind of come closer together. It’s a lot easier for him [her husband] now that [our child] outwardly dresses like a boy. It’s just like, ‘phew.’ His dad can deal with that. It takes people different times to accept things, and it’s just taken [his dad] a little bit longer, but he’s definitely come full-circle. I think—I hope—[our child] would say he has the support of both of us.

Conflict.

In some cases, however, one caregiver blamed the other for the youth’s TGD identity. A mother of an 18-year-old trans boy from the Northeast described how her ex-husband blamed their divorce for their child’s gender transition:

[H]is dad absolutely believes that the divorce caused it… If that was the case—60% of the population is divorced—don’t you think there’d be billions and trillions of…everybody’d be transgender, for crying out loud! But he thinks that [being transgender is] a choice and that the divorce definitely had something to do with it.

Contextual Factors Influencing Youth-Caregiver Relationships

Families identified five extra-family factors that influenced intra-family relationships: school, extended family reactions, community support, religion, and the workplace. Each factor was coded as a facilitator or a barrier, depending on how it affected the family’s relationships related to the TGD youth’s gender identity and expression. When a contextual factor acted as a support or facilitator, it typically eased relational stress within the family system. Conversely, when a contextual factor acted as a source of stigma or a barrier, it exacerbated relational stress within the family system. Each family described the role of these factors differently; some influences that were sources of support for one family were sources of stigma for another.

School.

One father of an 18-year-old trans boy from the Northeast talked about the critical role played by staff at his child’s school in the early days of his child’s transition: “They were really, really supportive. And I think that helped a lot, even in the first month or two. They just set the tone.” Conversely, a mother of an 11-year-old trans girl from the Midwest discussed challenges that her child faced at school that were particularly frustrating: “We offered a lot of professionals to come to the school, and offered things to other parents, if they were curious. We offered things to the teachers, and our school was just absolutely not supportive in that.”

Extended family.

Relationships with extended family were a contextual factor for both TGD youth and caregivers. One 15-year-old trans girl in the Northeast expressed that even when “there was like a slip up here or there [in terms of correct pronoun usage], they always apologized, and it was really nice to have the support of my family.” On the other hand, for caregivers who had to navigate adult family relationships on behalf of their child, experiences with discrimination and hostility from extended family contributed to increased tension at home. A mother of an 8-year-old girlish boy from the Northeast described that she had the “biggest fight” of her life with her own father, the child’s grandfather, about her child’s gender identity:

My dad…said, ‘I just don’t understand, at what point are you going to make him play with gender-appropriate toys?’ So, I just lost it. And I just said, ‘This is who he is, this is what he likes to play with, and I’m not going to tell him that it’s wrong.’ …My husband said to me, ‘I’ve never heard you yell at anyone like that! I’ve never seen you have a fight.’ It was the biggest fight of my life.

A grandmother of a 10-year-old trans boy from the South, who co-resided with her daughter and grandchild, described the pain she experienced when one of her other daughters rejected her grandchild: “[T]his fall was especially hard because both [the cousins] had birthdays and [TGD youth] was not invited to the birthday parties. So, that was incredibly tough.”

Community.

Community support outside of the extended family was another contextual factor described by youth and caregivers. Many TGD youth talked about learning to respond to misconceptions espoused by members of their broader community, or individuals who discriminated against them overtly. A 13-year-old trans girl in the Northeast said, “I just taught myself to not care, ‘cause I figure that’s what I have to do,” and took a similarly patient approach with her relationships with caregivers. A 16-year-old trans boy from the Midwest said, “I tolerate a lot of misconceptions because I think that people being uneducated isn’t necessarily their fault—so I usually provide information.”

Many caregivers identified individuals from the community as important sources of support while adjusting to their child’s disclosure of their gender identity. For example, a mother of a 13-year-old trans girl in the Northeast described the relief she experienced after a particularly affirming experience when her child was in the hospital. She had been worried that the staff on duty would not know how to respond:

The nurse says, ‘Can you shut the door and come in here?’ [A]s I came, she says, ‘I just want to let you know that I’m the parent of a trans son.’ I went, ‘What?! This couldn’t have been any better!’

Religion.

Several TGD youth identified religion as an influence in their lives. For a 17-year-old trans boy from the Northeast, his religious community provided support after the social transition to his gender identity. Recalling a positive experience at weekend conferences with his faith community, he said: “The kids that go to them, they kind of practice… radical acceptance, ‘Oh my gosh, you’re different, that’s the best thing ever!’” His caregivers, also part of the same faith community, expressed appreciation for their religious institution’s support for the entire family during the youth’s social transition. On the other hand, religion also was a source of relationship tension for this TGD youth’s former romantic partner, whom he met in youth group: “[O]ne of the reasons I broke up with him is because his parents were so unaccepting. [T]hey wanted to send him to conversion therapy.”

Workplace.

Caregivers identified workplace relationships as causing stress at home, particularly in terms of insurance access and time off from work. A mother of a 14-year-old trans girl in the Northeast described negotiating relationships with her employer as “tricky”:

They’ve been pretty intense about [insurance]… they [the human resources department] claimed… I was the first one to claim a same-sex spouse on insurance in the company. And they had to go to all this extra work to figure out how to tax it. So they already had their eye out on me.

For other caregivers, the workplace relationships were a source of understanding and support while adjusting to their child’s gender identity. One parent of an 8-year-old girlish boy described a conversation with a supervisor at her workplace. She had anticipated her supervisor would be reluctant to allow her to leave work to take her child to doctor’s appointments. However, rather than receiving pushback, the supervisor said: “Oh, that’s fine, we don’t care.” To her surprise, after more research, she learned that her workplace had a policy for TGD individuals that she described as “second-to-none.”

Discussion

In this study, we examined how TGD youth and caregivers characterized their relationships with each other within the family system, and identified factors outside the family system that they identified as having shaped those familial relationships. Our findings illustrate how emotional labor is shared by both youth and caregivers in two primary ways: (a) how caregiver acceptance and family cohesion may be linked, and (b) how youth and caregivers identify shared contextual factors impacting the family system.

Emotional Labor Within the Family System

The bidirectionality of the youth-caregiver relationship was an important theme that emerged across families within descriptions of the emotional management of caregivers. Just as caregivers considered the emotional well-being of their child, youth of all ages considered and negotiated the well-being of their caregivers. This experience was reflected not only in TGD youth’s decisions about disclosing their gender identity to caregivers, but also in how and when TGD youth corrected caregiver missteps (e.g., using incorrect pronouns). Other research has found similar bidirectional influences between TGD youth and caregivers related to the TGD youth’s identity development (e.g., Katz-Wise et al., 2017; Tee & Abetz, 2020). The current study expands this concept to the relational aspect of emotion management. Our findings indicate that it is essential to acknowledge the crucial role of TGD youth as active agents in their familial relationships.

To better understand the implications of TGD youth’s emotional labor, looking to the body of literature on language brokers—children of immigrants who translate and interpret for family using their heritage language and English—may be instructive. Like the emotional labor observed in this study, language brokering is a dynamic interactional process that asks children navigate complex social contexts and institutions and make potentially stressful decisions for caregivers that may not be developmentally appropriate (Tse, 1995). The quality of the relationships within the family system, specifically between caregiver and language brokering youth, influences whether or not youth perceive this labor as a burden, and, in turn, the magnitude of internalizing behaviors, substance use, and general effect on health and well-being (Kam & Lazarevic, 2013; Weisskirch, 2013; Wu & Kim, 2008). Within the context of this study, understanding if and how this emotional labor within the family system affects the health and well-being of TGD youth performing it, warrants future research.

Another key finding relates to the gendered nature of parenting. With cisgender men and women in heterosexual relationships who become parents, they tend to become differentiated in their work and family roles along more traditional, gendered lines (Author). This differentiation manifests primarily through housework, such that women are more likely to perform the larger share of household labor compared to men (Duncan, Edwards, Reynolds, & Alldred, 2003; Author). Findings from our study echo this division, e.g., mothers with cisgender male partners sustained the majority of the day-to-day parenting duties, including navigating access to gender-affirming services and initiating conversations with school and health care providers about their child’s needs. Beyond day-to-day parenting, mothers in cisgender heterosexual relationships also tend to perform the greater share of emotional labor within the home and focus on the emotional aspect of their child’s past experiences (Fivush, Brotman, Buckner, & Goodman, 2000), based on ingrained social constructs that imply women are better suited for this emotional work (Erickson, 2005). These previous findings are consistent with data from our study—even in a family of two mothers within our sample—with mothers often describing emotions associated with different junctures of their child’s social transition. Heterosexually-identified mothers in the present study frequently discussed performing greater emotional labor by conducting online research, calling health professionals, and initiating conversations about gender identity with the child’s father.

Caregiver Acceptance and Family Closeness

Parenting is also shaped by the gender of the child; in recent research, parents of TGD children reported that their child’s assigned sex at birth influenced their parental identity because of the gendered roadmap of parenting it implied (Field & Mattson, 2016). Many caregivers in the present study expressed a shift in their parental identity in relation to their child’s gender identity, referencing an “adjustment period” in which they acclimated to parenting a child of a different gender than they had anticipated. Many of the fathers in this study expressed taking longer than mothers to understand and accept their children’s gender identity, much like the fathers described in previous research (Kuvalanka et al., 2014). The caregivers in our study reiterated a theme appearing in previous research, that caregiver acceptance of TGD youth is an evolving process that does not occur overnight (Gray et al., 2016; Hill & Menvielle, 2009; Pullen Sansfacon, Robichaud, & Dumais-Michaud, 2015).

Their child’s gender identity, in other words, disrupted caregivers’ gendered social and emotional map to parenting, and in turn, shaped the emotional dynamics of the family system when one caregiver adjusted sooner than another. These differences in the length of the “adjustment period” were at times described by the participants as “parenting tension.” Many youth observed that, although their caregivers were not always understanding soon after their coming out, the journey of navigating access to gender affirming services typically resulted in increased closeness between youth and caregivers. A strength of this study is that it included both caregivers and youth with a variety of gender identity development experiences, and in different stages of the gender affirmation process. The diversity of narratives helps illustrate that, despite caregivers’ initial difficulty in adjusting to their child’s gender identity, the process of doing so hand-in-hand with youth has potential to strengthen interconnectedness within the family system.

Shared Contextual Factors

Both TGD youth and caregivers identified common contextual factors (e.g., school, extended family) that either eased or exacerbated relational stress among caregivers or between caregivers and TGD youth. In other words, factors outside the family system shaped dynamics within the family system. This finding is consistent with prior research highlighting these factors as relevant to TGD youth’s gender identity development (Capous-Desyllas & Barron, 2017; Gray et al., 2016; Kuvalanka et al., 2014; Pullen Sansfacon et al., 2018). The present study also adds to previously published research identifying the caregiver’s workplace as an additional site which influenced family dynamics through health insurance coverage for gender affirming services.

Limitations

There are limitations to consider in interpreting the results. Participants were primarily recruited through LGBTQ+ community organizations and support networks for families with TGD youth. Thus, our findings may over-represent the experiences of supportive families, and under-represent the experiences of TGD youth with less supportive families. Future research should examine whether the contextual factors we identified reflect the experiences of families who are less supportive of TGD youth, or family relationships that include non-kin or chosen family (vs. biological family; Weston, 1991). Another limitation was the lack of financial compensation for study participants, due to funding constraints. The majority of families in this study were White, included heterosexual caregivers, were upper-middle class in socioeconomic status, and based in the Northeastern U.S. Providing compensation may have encouraged more economically disadvantaged families to participate and diversified the sample. As such, our findings may not capture the experiences of families of color, sexual minority-led families beyond those with two mothers, families from lower socioeconomic backgrounds, or families residing in other geographic regions, both inside and outside of the U.S. Knowing that TGD individuals of color in the U.S. are more likely to experience discrimination and violence than their White counterparts (James et al., 2016) may shape relationships in TGD families of color. In addition, in this study, we interviewed only primary caregivers and TGD youth; to develop a more holistic understanding of the bidirectional relationships between caregivers and youth, and to understand relationships among other core family members, it would be helpful to expand the definition of “family” to include siblings or other co-residing relatives.

Implications for Practice

Our findings build on the literature calling for the needs for increased access to gender affirming health and mental health services for younger TGD children (Durwood, McLaughlin, & Olson, 2017; Olson et al., 2016). Younger TGD youth in the present study (ages 7–11 years) were just as aware as older TGD youth (ages 12–18 years) about how others stigmatized their identity. TGD youth in both age categories could clearly identify and describe relationships at home, within the community, or at school that did and did not affirm their identity. Moreover, caregivers of younger TGD youth expressed a desire for formal support programs targeted to their children, who are often considered too young to access medical affirmation options. Therefore, our findings highlight a need to develop or expand existing services for TGD youth in younger age groups—an approach that may also alleviate relational stress within the family.

Findings from the present study also highlight how gendered norms about heterosexual parenting interact with a TGD youth’s gender identity development and affirmation processes. Counseling approaches that use a feminist lens and respond to the unequal distribution of work, and engage male partners in the emotional labor across caregiver relationships, might alleviate stress within caregiver-youth and caregiver-caregiver relationships (Worell & Remer, 1992).

Mental health providers working with TGD youth and families may wish to consider cultural differences based on region. Although caregivers from the Southern U.S. represented only 18% of our sample’s caregivers, several Southern participants referenced a broader, conservative “community culture” that made it challenging for families to process feelings related to their child’s gender identity. For example, parents noted difficulty talking to others about TGD issues, and highlighted the physical distance from health care facilities overall as a specific barrier to accessing gender-affirming services. We recommend that mental health clinicians apply for social justice-focused funding and that those with expertise in affirmative approaches provide family support groups or workshops in their communities to increase awareness of resources or pooling together energy to generate ideas for resource-building.

Conclusions

In sum, our findings provide insight into the relationships of TGD youth and caregivers, as described in their own words, and by considering both youth-caregiver and caregiver-caregiver relationships. This research can help families of TGD youth understand they are not alone in navigating the complicated family dynamics that can emerge during the child’s gender identity development and gender affirmation processes. These findings present a call to identify TGD youth as equal partners—and experts in their own experience—when designing family-centered policies and programs to address TGD young people’s health and well-being. Our research also echoes previously published work that calls for increased formal supports for younger TGD youth within the healthcare and educational systems, as these children are already aware of the social impact of their gender, are providing emotional labor to their caregivers, and are not served by current systems. The bidirectional relationships between youth and their caregivers are shaped by the larger social context in which they exist, providing insight on how to support families tasked with ensuring they nurture TGD youth who are affirmed and supported in their gender identity.