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. Author manuscript; available in PMC: 2023 Mar 1.
Published in final edited form as: Clin Pract Pediatr Psychol. 2021 Mar 4;10(1):1–8. doi: 10.1037/cpp0000384

Preliminary Factor Structure of the Parental Attitudes of Gender Expansiveness Scale for Parents (PAGES-P)

Vanessa Reguitti 1, Jonathan L Poquiz 2,3, Kathryn Jackson 1, Claire A Coyne 2,3,4, Marco A Hidalgo 5,6, Catherine Forbes 7, Diane Chen 2,3,4,8
PMCID: PMC9060209  NIHMSID: NIHMS1690262  PMID: 35509351

Abstract

Objective:

Parental acceptance and support are associated with positive psychosocial outcomes among transgender and gender expansive (TGE) adolescents. Understanding the degree of parental acceptance and support of gender identity and expression is an important component of gender affirmative pediatric assessment and can inform intervention. Although there are reliable measures assessing general family support, there are no existing parent self-report measures assessing acceptance and support of their gender expansive children. The present study examines the factor structure of the Parental Attitudes of Gender Expansiveness Scale for Parents (PAGES-P).

Methods:

Participants included 739 parents who completed the PAGES-P as standard-of-care during their child’s gender health clinic visit within a children’s hospital in the Midwestern United States. Principal Component Analysis (PCA) was used to identify subscales reflected in the PAGES-P.

Results:

PCA yielded four subscales reflecting the following domains: (1) support and affirmation, (2) guilt and loss, (3) gender concealment, and (4) pride.

Conclusions:

This study provides preliminary evidence of the factor structure of the PAGES-P. The resulting subscales lend insight into the thoughts and behaviors of parents of TGE youth and can inform clinical practice to facilitate parental support and promote overall well-being in TGE youth.

Keywords: transgender, gender diverse, youth, parental support, psychometric analysis

Preliminary Factor Structure of the Parental Attitudes of Gender Expansiveness Scale for Parents (PAGES-P) Date of Submission: October 22, 2020

Transgender and gender expansive (TGE) adolescents are at increased risk for anxiety, depression, self-harm, suicidal ideation, and suicide attempts compared to their cisgender peers (Reisner et al, 2015; Toomey et al., 2018). Disproportionate risk for poor mental health functioning among TGE adolescents is increasingly understood to result, in part, from minority stress experiences, including rejection due to gender identity and/or expression (Delozier et al., 2020; Hendricks & Testa, 2012; Toomey et al., 2014; Travers et al., 2012). Research shows that support from parents or caregivers (hereafter: parents) buffers against negative mental health outcomes in TGE youth (Pariseau et al., 2019; Simons et al., 2013; Travers et al., 2012). For instance, higher parental support predicts greater life satisfaction and lower depressive symptoms in TGE youth (Simons et al., 2013), whereas family rejection or non-affirmation of gender identity predicts greater depression, anxiety, and suicidality (Pariseau et al., 2019).

Limitations of current research on parental support and rejection in TGE youth include its primary reliance on general indicators of support (e.g., Simons et al., 2013; Travers et al., 2012), rather than support specific to gender identity and expression. Also, existing research that has examined gender-specific parental support and rejection uses complex coding systems of medical chart documentation that may not be easily employed in clinical settings (e.g., Pariseau et al., 2019). These are critical limitations as gender-specific parental support and rejection may be particularly salient to TGE youth. For instance, gender-specific parental rejection may be expressed in attempts to change the way a child expresses their gender (e.g., encouraging a child to wear clothing that stereotypically aligns with sex assigned at birth), refusing to use a child’s chosen name and/or pronouns, or expressing ambivalent behaviors such as not discussing gender-related topics with a child (Catalpa & McGuire, 2018). On the other hand, gender-specific parental support may be demonstrated by reacting positively to a child’s disclosure of a gender minority identity and supporting or advocating for a child to live authentically (e.g., supporting social and/or medical transition; working with schools to provide access to gender congruent restrooms; Hidalgo et al., 2017). It is notable that parental support and rejection are multifaceted and can potentially be expressed simultaneously (Khaleque & Rohner, 2002). For example, a parent may concurrently support a child’s gender transition by using chosen names and pronouns in the home but feel ambivalent about consenting for gender-affirming medical interventions. Therefore, it is critical for measures of gender-specific parental support and rejection to capture both spectra.

Assessing gender-specific parental support and rejection is critical to identifying parents that may benefit from clinical intervention to increase support and improve understanding of their child’s gender expansiveness. However, few such measures exist. (Hidalgo et al., 2017) developed the Parental Attitudes of Gender Expansiveness Scale for Youth (PAGES-Y; Hidalgo et al., 2017), a 14-item self-report measure assessing youth perceptions of their parents’ support of their gender diversity. The PAGES-Y yields two subscales, parental acceptance and parental non-affirmation, reflecting the multifaceted parental response to gender expansiveness from youths’ perspectives (Hidalgo et al., 2017). Recognizing the importance of multi-informant measures, a parent-report version of the PAGES-Y, the Parental Attitudes of Gender Expansiveness Scale for Parents (PAGES-P), was developed to assess parental perceptions of their own level of support of their child’s gender diversity. Utilizing analogous measures of youth- and parent-reported perceptions of parental support of gender expansiveness may aid in establishing an overall picture of parental support, detecting points of disagreement between informants, and identifying targets for clinical intervention. The PAGES-Y was found to be a reliable and valid measure of youth-reported parental support and non-affirmation (Hidalgo et al., 2017), but the factor structure of the PAGES-P has not yet been examined.

Current Study

Research evidence emphasizes the importance of parental support to promote positive outcomes among TGE youth (e.g., Simons et al., 2013). However, to our knowledge, there are no established parent self-report measures of gender-specific acceptance and support. To address this gap, the current study examined the underlying factor structure of the PAGES-P, a parent-report version of a reliable and valid measure of youths’ perceptions of their parents’ support of gender expansiveness (PAGES-Y; Hidalgo et al., 2017). Establishing psychometric support for a measure of parental perceptions of support for their child’s gender expansiveness can provide clinicians with an assessment tool and inform clinical recommendations to facilitate positive outcomes for TGE youth.

Method

Participants

Participants were 739 parents who completed standard-of-care psychosocial measures during their child’s initial appointment within a gender health clinic housed in a pediatric academic medical center in the Midwestern United States. These measures assessed their child’s emotional and behavioral functioning, gender-specific experiences, and included youth- and parent-reported parental support (see Chen et al., 2016 for more information about the standard assessment battery). Some youth had two parents present for their clinic visit (n=416). In this case, two copies of the PAGES-P were completed and denoted “Parent A” and “Parent B” via self-selection. In this study, Parent B responses were not included to avoid paired data.

Procedures

Demographic and clinical data from parents of adolescents ages 12-17 years seen between August 2013 and July 2019 were extracted from patient charts. This study was conducted as a retrospective chart review and received approval from the Institutional Review Board (IRB#: 2017-744) of Ann & Robert H. Lurie Children’s Hospital of Chicago.

Measure

Parental Attitudes of Gender Expansiveness Scale for Parents (PAGES-P).

The PAGES-P was developed alongside the PAGES-Y (Hidalgo et al., 2017) as an analogous measure with input from two subject matter experts (SMEs): a gender expansive young adult and a cisgender female licensed clinical psychologist. SMEs collaboratively developed items based on existing research, input from personal experience and TGE communities, and clinical and professional experiences. The development of the PAGES-P was completed in 2012.

The PAGES-P consists of 18 items assessing the degree to which parents perceive themselves as supportive and affirming of their child’s gender identity and/or expression. Using a 5-point Likert scale ranging from “strongly disagree” to “strongly agree,” parents responded to items such as “I am supportive of my child’s gender transition,” “I try to hide my child’s gender identity,” and “I protect my child and defend my child against others’ prejudice against gender-nonconforming/transgender people.” Values of 1 – 5 were assigned to each item, such that a higher sum score was indicative of greater parental support and affirmation.

Data Analytic Plan

All statistics were performed using R (“R Core Team,” 2017). Data analyses occurred in two phases. First, bivariate correlations were used to evaluate suitability of the 18-item scale for factor analysis (Yong & Pearce, 2013). Items that correlated poorly (i.e., below 0.3) with other scale items were dropped. Missing cases were also dropped from analysis. Second, we examined the presence of any underlying factor structure using principal components analysis (PCA). PCA is a commonly used statistical technique that measures the relationship between variables; using PCA with rotation eases interpretation of the factor structure (Hidalgo et al., 2017; Rattray & Jones, 2005). We used oblimin rotation as we expected the factors to have some relationship with each other (Rattray & Jones, 2005). We estimated the number of components through a scree plot test and by identifying factors with eigenvalues >1 (Rattray & Jones, 2005).

When analyzing the components themselves, several measures of fit were used. Correlations below 0.70 indicated that the components were not too highly correlated and thus were measuring distinct aspects of parental support. A root mean square of 0.08 or less was considered acceptable, and smaller χ2 values were indicative of better model fit (Hu & Bentler, 1999). Cronbach’s α, a measure of internal consistency, was calculated for the items used in the PCA as well as for each subscale of the final four-factor model. A Cronbach’s α > 0.7 is considered acceptable and α > 0.8 is considered good. Of note, Cronbach’s α is influenced by scale length; thus, we expect subscales comprising fewer items to have smaller α’s.

Results

Of the 739 parents that completed the PAGES-P, the majority were female (85.1%). Their children were between the ages of 12-17 years [M(SD) = 15.4 (1.5) years] and the majority were White (69.5%), assigned female at birth (73.3%), and identified their gender as boy/man/masculine spectrum gender identity (63.2%). See Table 1 for parent and youth demographics.

Table 1.

Parent and Child Demographic Characteristics (N=739)

Parent Gender n %
Female 542 85.1%
Male 95 14.9%
No Response 102
Child Age
Range 12.0 – 17.9
Mean 15.4
SD 1.51
Child Race/Ethnicity n %
White 489 69.5
African American 25 3.5
Hispanic/Latinx 100 14.2
Asian 29 4.1
Other 11 1.6
Multi-Racial 50 7.1
No Response 35
Child Sex Assigned at Birth n %
Female 542 73.3
Male 197 26.7
Child Gender n %
Boy/Man/Masculine Spectrum 467 63.2
Girl/Woman/Feminine Spectrum 169 22.9
Non-Binary 66 8.9
Questioning 35 4.7
Unknown 2 0.3
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The majority of the 18 items were correlated above 0.30 with all other PAGES-P items. Two items—“My religious beliefs help me be supportive of my gender-nonconforming/transgender child,” and “I am afraid of the physical effects of gender transitioning,” correlated poorly with all other scale items and thus were dropped from further analysis. These two items overlapped with items dropped from the PCA analysis of the PAGES-Y (Hidalgo et al., 2017).

The remaining 16 items were used in the PCA analysis. Cronbach’s α = 0.87, and the average inter-item correlation was 0.36. Visual analysis of the scree plot showed a break at two factors; however, four factors had eigenvalues > 1. For the PCA, both a two- and four-factor model were run. The two-factor model (Model 1) yielded two components explaining 23% and 22% of the variance, respectively (total of 45% variance explained). The components were positively correlated (r = 0.5). This model also had a root mean square of 0.07 with a χ2 = 967.29. The oblimin rotation solution showed 15 items loading substantially onto one of the two components (Table 2). One item (i.e., “I use toys, treats or other rewards to pressure my child not to gender transition and to live as his or her birth-assigned gender”) did not load onto either component. Conceptually, items loading onto the first component reflect parental acceptance and affirmation. Items included “I advocate for the rights of my child” and “I am supportive of my child’s gender transition.” Items loading onto the second component reflect affective responses to children’s gender expansiveness. Items included “I feel like I am losing a son/daughter, or as if my child were dead” and “I am ashamed of my child”.

Table 2.

Item Loadings for Principal Components Analysis Comparing a Two Factor Model to a Four Factor Model

Items Two Factor Model Four Factor Model
Factor 1 Factor 2 Factor 1 Factor 2 Factor 3 Factor 4
1. I am proud of my child 0.35 0.28 0.20 0.12 0.08 0.69
2. I am ashamed of my child 0.23 0.50 0.16 0.39 0.01 0.53
3. I try to hide my child’s gender identity 0.41 0.36 0.27 0.27 0.41 −0.10
4. My child can be him- or herself around me 0.71 0.04 0.79 0.09 −0.12 0.02
5. I advocate for the rights of my child 0.76 −0.08 0.67 −0.15 0.07 0.33
6. I protect my child and defend my child against others’ prejudice against gender-nonconforming/transgender people 0.81 −0.10 0.81 −0.09 0.04 0.02
7. I have problems with my child’s gender expression 0.47 0.44 0.44 0.42 0.25 −0.23
8. I encourage my child to wear clothing and accessories consistent with their birth-assigned gender 0.35 0.15 0.00 −0.08 0.79 −0.04
9. I use toys, treats or other rewards to pressure my child not to gender transition and to live as his or her birth-assigned gender 0.29 0.19 −0.09 −0.07 0.77 0.13
10. My child can talk about romantic relationships and dating 0.62 −0.05 0.61 −0.06 −0.02 0.15
11. I worry about how my child’s gender identity will affect our family’s image 0.35 0.51 0.20 0.41 0.42 −0.06
12. I feel like a bad parent because I have a child that is gender-nonconforming/transgender 0.00 0.83 −0.01 0.78 0.09 0.11
13. I think my child is gender-nonconforming/transgender because of something I did wrong −0.14 0.87 −0.07 0.86 −0.08 0.14
14. I feel like I am losing a son/daughter, or as if my child were dead −0.02 0.60 0.10 0.66 −0.08 −0.16
15. I am supportive of my child’s gender transition 0.55 0.27 0.55 0.28 0.17 −0.22
16. I am worried that my child’s gender identity is a bad influence on my other children 0.14 0.49 −0.05 0.31 0.30 0.41
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The four-factor model (Model 2) yielded four components explaining 20%, 18%, 13%, and 8% of the variance, respectively (total of 59% variance explained). The components were positively correlated with each other, with component 1 correlating with both components 2 and 3 at r = 0.4. Components 2 and 3 correlated at r = 0.3, and components 1, 2, and 3 correlated with component 4 at values ranging from r = 0.11 - 0.18. The four-factor model had a root mean square of 0.07 with a χ2 = 891.63. The oblimin rotation solution showed all 16 items loading substantially on one of the four components (Table 2). Conceptually, the four components reflect: (1) support and affirmation (items 4, 5, 6, 7, 10, and 15; α = 0.80), (2) guilt and loss (items 12, 13, and 14; α = 0.71), (3) gender concealment (items 3, 8, 9, and 11; α = 0.67), and (4) pride (1, 2, and 16; α = 0.62). Given that all 16 items loaded substantially, greater variance was explained, and the χ2 value decreased when comparing the four-factor model to the two-factor model, the four-factor model was chosen as our final solution.

Two of the four PAGES-P subscales are positive in valence (i.e., support and affirmation; pride) and two are negative in valence (i.e., guilt and loss; gender concealment). Thus, in finalizing scoring for the PAGES-P, all 16 items were initially anchored “strongly disagree” = 1 to “strongly agree” = 5, and the three items for which item valence did not correspond with scale valence (i.e., items 2, 7, and 16) were reversed scored so that “strongly disagree” = 5 to “strongly agree = 1”. Higher sum scores for each subscale are indicative of each domain. See Supplemental Materials for the final PAGES-P.

Discussion

This study examined the underlying factor structure of a brief parent self-report questionnaire assessing attitudes toward their children’s gender expansiveness. The 18 items were developed by two SMEs with personal, clinical, and community-level experience with parental challenges in supporting and affirming gender expansive identity and expression. Based on data from 739 parents of TGE adolescents, our analyses resulted in a 16-item scale with four moderately correlated subscales reflecting: (1) support and affirmation, (2) guilt and loss, (3) gender concealment, and (4) pride. These subscales reflect our clinical and theoretical understanding of parental responses to gender diversity and emphasize that parental support and rejection are not mutually exclusive, but rather are multifaceted and can co-occur (Khaleque & Rohner, 2002).

Consistent with previous research (Hidalgo et al., 2017; Khaleque & Rohner, 2002), the emergence of four separate components suggests parental responses to a child’s gender identity and expression may be nuanced. Indeed, parents may exhibit behaviors that explicitly support their child’s gender expansive identity, and yet still maintain internalized feelings of grief, loss, or fears of social consequences related to raising a gender expansive child (e.g., discrimination). Recent research suggests that parents of TGE youth encounter a number of stressors on account of their child’s gender identity and expression (Hidalgo & Chen, 2019). Qualitative findings highlight parents’ fears of disclosing their child’s gender identity to extended family members and worries about how to handle social encounters in which their child is misgendered in public (Hidalgo & Chen, 2019). Other studies emphasize parents’ negative expectations for their TGE child’s future. For example, parents of TGE youth frequently worried about their child’s physical and emotional safety (Katz-Wise et al., 2017; Kolbuck et al., 2017). Thus, even parents who are supportive of their child’s gender expansiveness may feel pressure to conceal their child’s gender history in misguided effort to protect them from harm.

The PAGES-P has important clinical implications as it assesses varying aspects of parental attitudes and responses to a child’s gender diversity in order to identify parents and families in need of additional support. For example, parents who report high levels of guilt and loss or gender identity concealment may benefit from family- or parent-focused supports that provide education on gender diversity or individualized space for parents to express and process beliefs that may be contributing to difficulties accepting and supporting their children. Additionally, use of the PAGES-P may be beneficial in tracking therapeutic change over time and assist clinicians in identifying potential treatment targets to promote positive change. For example, the pride subscale may provide fruitful information as pride can be considered the foundation for further positive action such as activism or supporting other parents of gender diverse children (Alegría, 2018). Also, in families with two parents, the PAGES-P may help identify differences in support between parents that affect family discussions and decision-making about gender transition interventions.

Although youth-report measures such as the PAGES-Y may capture youths’ perceptions of their parents’ explicit and observable behaviors of support or rejection, there are limitations in solely relying on youth-report in understanding parental support. Past research has identified discordance in parents’ and youth’s reports of parenting behaviors and recommend multi-informant assessment to obtain an accurate assessment (e.g., Hou et al., 2020). Findings from the current study provide preliminary support of the use of the PAGES-P in assessing parental support of gender diversity from parents’ perspectives. Using the PAGES-P along with the PAGES-Y can help clinicians integrate parent and youth perspectives in understanding of the experiences of support and rejection and inform clinical conceptualization. Analyzing youth mental health outcomes along with informant agreement between PAGES-P and PAGES-Y is also an important future direction for research.

Limitations

Our study has limitations. Because the PAGES-P was given as a standard-of-care clinical measure, there was no secondary measure of general parental support to examine convergent validity. In addition, our analysis sample included predominately female parents. While we would not necessarily expect the factor structure of the PAGES-P to be different for male parents, conducting a confirmatory factor analysis on a more balanced sample of male and female parents or a male-only parent sample would help establish measurement invariance of the PAGES-P by parent gender. This will be an important step prior to examining potential differences between parents on PAGES-P subscales and exploring associations with patient outcomes. Additionally, our sample included predominately White parents drawn from a large metropolitan area and its surrounding suburbs; thus, the PAGES-P factor structure should also be further examined in more racially/ethnically diverse populations and among parents living in more rural areas. Last, minors are required to have parental consent to access clinical services within our program, thus implying a certain level of family support and suggesting that the experiences of the most unsupportive parents—those who would not seek services at a gender-affirming clinic—are not represented in our data.

Conclusions

Study findings provide preliminary evidence for the factor structure of the Parental Attitudes of Gender Expansiveness Scale for Parents (PAGES-P). The four subscales include: (1) support and affirmation, (2) guilt and loss, (3) gender concealment, and (4) pride. Each subscale reflects an aspect of caring for TGE youth that is important to assess from a clinical perspective. Understanding a parent’s perspective can better aid clinicians in identifying parents who would benefit from further supports and intervention. Future research on the psychometric properties of the PAGES-P should examine convergent and discriminant validity, assess measurement invariance by parent gender and in more racially/ethnically diverse samples of parents, and explore whether a similar factor structure exists when using the PAGES-P with parents of younger TGE children (i.e., ages 11 and younger). More substantively, the PAGES-P can help facilitate research examining differences in levels of support and affirmation, guilt and loss, gender concealment, and pride between parents and explore whether parent gender or youths’ sex assigned at birth is differentially associated with parental support for gender diversity, as has been reported in recent research (Grossman, Park, Frank, & Russell, 2019).

Supplementary Material

Supplementary Material

Implications for Impact.

The Parental Attitudes of Gender Expansiveness Scale for Parents (PAGES-P) includes four subscales: (1) support and affirmation, (2) guilt and loss, (3) gender concealment, and (4) pride. This questionnaire can be used clinically to identify parents who may benefit from intervention to better support their transgender and gender expansive children.

Acknowledgments

Research reported in this publication was supported, in part, by the National Institutes of Health’s National Center for Advancing Translational Sciences, Grant Number UL1TR001422, awarded to the Northwestern University Clinical and Translational Sciences Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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