. 2022 Feb 14;7(1):7–29. doi: 10.1089/trgh.2020.0165

Table 1.

Articles on Family Therapy with Transgender and Gender Expansive Youth (Review 1)

Citation	Sample of interest	Treatment modalities	Outcome data/empirical support	Clinical strategies	Additional themes
Green et al.⁵⁶	“Very feminine young boys and their parents (n=4)	Behavior modification	Clinical observation of “reorientation” toward cisgender identification and expression after treatment in four case studies	• Develop a relationship of trust and affection between the male therapist and the boy. • Heightened parental concern about the problem so that parents begin to disapprove of feminine interests and no longer covertly encourage them. • Sensitize parents to the interpersonal difficulties that underlay the tendency of the mother to be overly close with the son and for the father to emotionally divorce himself from family. • Sensitize the child to “feminine” behaviors.	• Pathologizing and similar to conversion therapy. • Cisnormative/binary construction of masculinity, femininity, and gender identity development.
Higham⁵⁷	Children and adolescents with a “gender disorder” (n=4)	Rehabilitative approach	Clinical observation that the two older patients showed “improvement” (i.e., desistance).	• Sex role stereotypes, including choice of friends and activities, should be presented as social options rather than sex-linked imperatives. • Educate family and child with respect to sex differences (e.g., menstruation and gestation in women). • After initial investigation, consultations are as needed, with the long-term goals of achieving independence, a satisfying life work, and gratifying personal and sexual relationships for the child.	• Pathologizing (i.e., desistence from transgender identity conceptualized as a positive outcome).
Newman⁵⁸	“Extremely feminine boys” (trans and nonbinary AMAB children 5–12 years old) (n=5)	Weekly individual play therapy (psychoanalytic and behavioral) and weekly parental counseling	Anecdotal report of behavior and identity change based on four years of treatment with AMAB youth	• Pretreatment (assessment of major “pretranssexual” behavior) with parents and child. • Weekly individual child treatment and parental counseling. • Post-treatment follow-up focusing on family dynamic and marital relationship. • Address mother's ambivalence, dependence on son, father's absence and avoidance, and marital dissatisfaction.	• Pathologizing and similar to conversion therapy. • Cisnormative/binary construction of masculinity, femininity, and gender identity development. • Views gender diversity as aberration often caused by unhappy marriages and dependent mothers.
Wrate and Gulens⁵⁹	Transfeminine children of heterosexual parents	Systems family therapy	“Successful” reduction in feminine behavior observed by clinician in one family case study (one transfeminine child, two heterosexual parents)	• Increase parental emotional involvement. • Improve parents' behavioral control over children. • Increase parents' sense of achievement and satisfaction. • Increase emotional separation of child from mother. • Provide child a peer support group of those with behavioral disturbance.	• Pathologizing and similar to conversion therapy. • Addressing parental anxiety is key to youth's adjustment.
Bradley and Zucker⁶⁰	Children and adolescents with GID	Not specified	Not specified (recommendations derived from clinical experience)	• Have a strong alliance with parents to help them work through ambivalence toward treatment. • Have short-term goals of reducing social ostracism/conflict and alleviating associated psychopathology.	• Parental ambivalence toward treatment is more common when referral is from outside the family. • Intervention during childhood can lead to greater reduction in gender identity conflict than intervention in adolescence. • Long-term goal for treatment is prevention of “transsexualism”/homosexuality.
Sugar⁶¹	Children with GID	Psychoanalytic therapy	Single case example with 4-year-old AMAB child	• Treatment should consist of weekly psychoanalytic individual treatment, parent guidance sessions, and family/couples therapy (as needed). • History-taking should include details about daily routines, esp. on boundaries with parents. • Set limits for the child within the therapeutic context. • Encourage parents to set limits on cross-gender behavior at home and at school, especially regarding gender boundaries between child and mother.	• Takes a psychoanalytic approach to gender identity development and GID (psychosexual stages, castration anxiety, etc.). • GID can develop from improper limit-setting by the mother and passivity/absence of the father. • Reduction in cross-gender behavior seen as a positive treatment outcome.
Saeger⁶²	Transgender child and their parents	Family work and play therapy	Single case example	• Help parents practice supporting pronouns and appearance. • Collaborate with the child's school. • Meet with grandparents (and potentially include in treatment).	• Uses Lev's conceptualization of stages of adaptation to the child's gender.⁶³ • Discusses authenticity of identity vs. family dynamics.
Behan⁶⁴	Families with a transgender child/adolescent	Not specified	N/A	• Provide family with gender psychoeducation. • Sometimes advocacy with school is necessary. • Ask the transgender child to give their family time to process the transition. • Put families in contact with other families with trans youth (e.g., support groups) to create a feeling of “belonging.” • Delay in puberty should be provided to transgender adolescents who want it with consent of parents. • Provide positive and resilient images of transgender identities, rather than viewing it as a problem.	• Families often suffer at “losing the child they knew” and their imagined future. • Sometimes the family slows down the child's transition, which is often experienced as fast because of prior concealment of gender identity.
Butler⁶⁵	“SGM” individuals	SGMT and systemic practice	Not specified (recommendations derived from clinical experience)	• Self-reflect on how (sexual) identity influences work with clients (e.g., using CMM). • Therapist should engage in thoughtful disclosure that contributes to conversations. • Take a “not-knowing” approach to the clients' sexuality, etc. • Encourage connection with wider SGM communities and perspectives. • Resist applying principles extrapolated from work with non-SGM clients. • Link families to resources and support networks so they can share experiences. • Help family members reflect on range of emotional reactions. • Rehearse discussions of disclosure with those outside the family. • Help parents grieve the loss of the heterosexual child and associated expectations. • Assist parents to “come out” to combat homophobia and discrimination.	• A variety of identity-related factors can impact how families respond to their child's coming-out (religion, gender, race, etc.). • Focuses on LGB/sexual identity questions more than TGE/gender identity questions.
Lev⁶⁶	Lesbian parents with gender-expansive kids	Family therapy	Recommendations derived from literature and clinical experience	• Promote a home life where the child has flexibility and room to fully explore their gender. • Help families decenter heteronormativity/cisnormativity. • Help family members understand their own relationship to gender.	• Kids raised in queer homes have less rigid gender roles. • It might be easier for kids to come out as queer to queer parents.
Parker et al.⁶⁷	Families with GLBT youth	Family therapy, Kite in Flight model	Case example	• Promote personal empowerment and self-agency through dating relationships. • Increase differentiation through identity development in dating.	• Stresses importance of context and environmental influences, including race, ethnicity, rural/urban, SES, religion, etc. • Link between dating, romantic relationships, gender identity and family engagement not specifically made.
Malpas⁴³	Transgender and gender-nonconforming children and their families	MDFA	Case example and recommendations derived from clinical experience	• Assess parental acceptance, rejection, and knowledge of issues related to transgender children, and emphasize the critical role of parents in affirming the child's development and choices. • Through direct encounter with the child, assess the child's level of distress with their assigned sex at birth. • Offer multi-dimensional support, including: support groups for caregivers and youth, family therapy, parental coaching and child individual/family assessment. • Flexibility of modalities (individual, family and group). • Create thoughtful system of transfer of information between modalities and interventions.	• Coaching parents empowers them to serve as a resource for their child, facilitates resolution of marital and parental discord around the child's gender nonconformity, and guides them through difficult decisions (e.g., social and medical transition). • Family sessions help support a positive and functional family climate, repair the relational bond between parents and child, and mobilize collaborative problem-solving to negotiate gender expression in and out of the home. • Multi-family groups provide parent/children with a community of peers dealing with similar questions and a processing space to reflect on their own experiences.
Bernal and Coolhart⁶⁸	Transgender children and youth and families	Family therapy	Case example	• Clinician serves in clinical assessment/gatekeeping role. • Advocate for children with family, school, and other providers. • Be knowledgeable of standards of care and medical intervention options to effectively counsel families (including risks and benefits, consent and custody issues, etc.).	• Four areas of competencies for ethical treatment of trans youth and families: (1) Standards of care, letter writing, and GI development; (2) Community resources (groups, peers, providers); (3) Advocacy and sensitivity training in larger systems (incl. School training); (4) Updated research and sociopolitical context. • Informed consent and transparency of the opinion of the therapist are essential.
Coolhart et al.⁶⁹	TGNC youth and their families	Individual youth, parental and family counseling	Not specified (recommendations derived from clinical experience)	• Support parents struggling with social transition and gender-neutral language with psychoeducation on family acceptance and blockers. • Connect families to support systems, groups, advocacy orgs, etc. • Connect youth to community and support resources beyond the family and school. • Use combinations of sessions with family together, youth alone, parents alone, and extended family. • Family assessment should include gathering information about the child's gender development, early childhood, etc. and assessing family attitudes and behaviors. • Therapist should play an active role in the school context by training and capacity-building.	• Working with parents alone is particularly important if parents are rejecting or struggling to accept. • Article describes an assessment tool for youth readiness for medical treatment.
Harvey and Stone Fish⁷⁰	Queer youth and families	Intersectional systemic treatment	Three clinical case examples	• Hold complexity and multiple aspects of youth and family experience, including homophobia and need for love, and empathy. • Provide psychoeducation and guidance regarding coming out and social issues. • Connection families to community and resources for queer youth. • Facilitate a safe space that can provide honesty and compassion while tolerating difference. • Maintain awareness of the effects of multiple cultural contexts and identities. • Maintain awareness of the effects of power dynamics and oppression. • Help parents in accepting and integrating queerness into the family by providing an expanded vision of family life.	• Takes an intersectional and queer-affirmative approach. • Honors hidden resiliency and the “gift of queerness.”
Giammattei⁷¹	TGNC families	Not specified	Not specified (recommendations derived from clinical experience)	• Ask clients their name, pronoun, and gender description, and use these when interacting with the family. • Share research with parents showing positive effects of family support and role models on transgender youth. • Give parents a space to discuss and grieve for lost hopes and dreams for their child (support groups can help with this). • Couples therapy and parent coaching may be warranted if parents differ in support.	• Parents may need to reconcile beliefs, understand fears, and grieve loss of dreams they had for child before they can truly support their transgender child. • Families may need tremendous support in navigating social transition. • Parents may particularly struggle with nonbinary gender identities. • Model of family therapy is less important than for the treatment to be affirming of clients' identities.
Wahlig⁷²	Transgender children and their parents	Not specified	Not specified	• Be knowledgeable of multiple models of loss to better support the variety of family member reactions to transition. • Guide families to label the ambiguous loss as a major source of stress. • Meet with multiple family members so that individual perspective can be expressed and heard by others. • Provide psychoeducation regarding transition and normalize grief responses. • Direct families to other peer and professional resources (e.g., parent support groups). • Provide a safe space for parents to find meaning in their loss. • Explore role changes and potential renegotiations with families.	• Parents may experience both types of ambiguous loss—psychological presence and physical absence, and physical presence and psychological absence. • Treatment goal is to develop a greater ability to tolerate the ambiguity of the “loss,”⁷³ which can be impacted by the family's cultural beliefs and values. • Both physical and psychological connection of the family can be a source of resilience. • Some parents may not experience loss or may be more equipped to handle its ambiguity.
Whyatt-Sames⁷⁴	Transgender children in foster care	Gender-affirmative model²⁵ and MDFA⁴³	Single case study	• Maintain a nonjudgmental stance and allow the child to guide social transition. • Assess pros/cons of social transition with the child. • Identify necessary changes for social transition, develop a timeline, and utilize role-play to anticipate changes. • Utilize multiple treatment approaches (e.g., parents alone, child alone, family together). • Regularly assess progress. • Identify and engage all stakeholders (i.e., family members). • Have families use local support resources (e.g., LGBT groups).	• Treatment recommendations based on the gender-affirmative model and the MDFA.^25,43
Coolhart and Shipman⁷⁵	Families of TGNC youths	Gender-affirming family therapy	Not specified (recommendations derived from clinical experience)	• Two-stage model of treatment: (1) Assessing and increasing family attunement; and (2) Exploring and supporting gender expression and transition. • Assessment should evaluate whether the child's gender is persistent, consistent, and insistent. • Utilize different modalities for treating families (i.e., treat family together and subsystems separately) • Provide group treatment for families. • Involve multiple generations in treatment. • Provide psychoeducation on gender and treatment to families.	• “Both/and” approach involves being attuned to parents' reactions while affirming/protecting the child • Goal is to help families understand, become attuned to, and become advocates for their child. • Advocacy is important in care as well as in larger social contexts (e.g., school). • Flexibility is important in treatment pace and clinical configuration. • Alliance with parents is key to success in treatment.
Ehrensaft et al.⁴²	Trans youth and their families	Not specified	Not specified (recommendations derived from clinical experience)	• Link youth and families with peer support resources. • Provide families with psychoeducation on gender identity and TGE family issues. • Promote parent engagement as a risk prevention strategy. • Emphasize the importance of professional and peer support for family acceptance. • For social transition, differentiate gender identity from expression, balance affirmation with safety, and consider affirmation as nonbinary.	• Families can socially transition their child well without family therapy or help of professionals. • Clinical approaches of (prepubertal) gender-expansive children fall under three categories: reparative, watchful waiting, and affirmative. • Mental health providers are particularly important before puberty because medical treatment is not necessary at this stage.
Bull and D'Arrigo-Patrick⁷⁶	Parents of transgender children who are transitioning	Not specified	Phenomenological methodology, face to face interviews (n=8)	• Hold the loss narrative loosely and engage with curiosity. • Frame social transition as family-level event (i.e., “big T” vs. “little t” transition). • Explore intersecting identities (race/ethnicity, religion, etc.). • Explore the parents' relationship to records of youth (e.g., photos) from pretransition and what purpose they serve. • Connect families to resources in their communities.	• Stands out because using a certain form of technology, centers parents experience (as opposed to whomever created the questions)
Coolhart et al.⁷⁷	Transgender male youth (n=6 families of trans male youth)	Not specified	Not specified (recommendations derived from clinical experience)	• Help parents verbalize array of feelings (including ambiguous loss). • Identify positive, useful, and relevant coping strategies. • Use therapy as a space for parents to tell stories of the child they feel they are losing and listen to other family members' experiences. • Connect parents with other parents of trans youth to share experiences. • Explore the dynamics of family's gender and how this impacts experiences of the child's transition.	• Ambiguous loss encompasses physical absence and psychological presence, as well as physical presence and psychological absence.
Abreu et al.⁷⁸	Transgender and gender diverse children and their parents	Not specified	Systematic literature review	• Acknowledge and normalize negative family reactions to the child's coming out. • Help families to increase cognitive flexibility, develop affirming values, cultivate positive meaning-making, and create narratives of strength and hope for the TGE child.	• Family members experience trans-related stigma by empathizing with TGE youth, which can increase risk for mental health problems in family members.
Ashley⁷⁹	Transgender and gender creative youth	Not specified	Not specified	• Be attentive to potential of being over supportive of binary transgender identity (which can lead to perception that child will only be accepted if trans, and hamper development of nonconforming gender expressions). • Respect (and help families respect) the child's wishes for social transition. • Be aware of potential clinical biases before treating and maintain critical openness to being wrong about assessments of treatment readiness due to these biases. • Integrate the work of trans communities and scholars into clinical work. • Seek to understand how/why families struggle with their child's gender and support parents in their difficulties with their child's gender by working alongside support groups for parents of trans youth.	• Social transition facilitates, rather than inhibits, gender exploration. • Clinical hesitancy for puberty blocking treatment is unjustified. • Goal should not be to assess the child's gender, but rather to provide them with the tools to explore their gender.
Edwards et al.⁸⁰	Transgender people and their families	Ecological Systems Theory⁸¹	Not specified	• Assess family resilience, strengths, and available sources of support. • Reflect on one's own power/privilege and how one's identity affects the therapeutic relationship. • Consider family's' experiences through an intersectional lens. • Prioritize the child's expressed goals. • Maintain lists of current and affirming medical and community resources for families (including support groups and advocacy organizations) and connect families to broader LGBTQ community. • Support all family members through transition and reorganization of family structures, while emphasizing flexibility. • Ensure clinic environment is affirming (e.g., inclusive materials, all-gender bathrooms). • Promote laws supporting transgender families and visibly advocate for the community by attending advocacy events.	• Framework was adapted from Ecological Systems Theory,⁸¹ which views human development as an interaction between the individual and multiple nested systems (relational, community, and societal) at a particular time. • Article speaks about transgender individuals of all ages but recommendations not particularly applying to youth and their families.
Hidalgo and Chen⁸²	Families with transgender/gender-expansive prepubertal children	MDFA-based treatment⁴³	Results of qualitative research with cisgender parents on experiences of gender minority stress	• Use parent psychoeducation and coaching to help parents build gender-affirming capacity. • Cognitive-behavioral approaches (e.g., cognitive restructuring) can be used to target parents' negative future expectations regarding their child. • Parental coaching builds off psychoeducation by promoting parents as resources and decision-makers for issues related to child's well-being. • Consider integrating mindfulness and acceptance strategies with parents.	• Topics for psychoeducation can include gender development, research findings, pediatric gender dysphoria, and importance of parental acceptance and advocacy. • Nonaffirming family members may be more amenable to acceptance than rejecting family members.
Golden and Oransky⁸³	Transgender adolescents and their families	Gender-affirmative family therapy	Four case studies	• Challenge own assumptions about identities and treat families as experts in their own identities and experiences.⁸⁴ • Provide youth-focused individual and group therapy to address family and societal rejection, as well as resulting psychopathology. • Use parent individual therapy and support groups to help them understand how intersecting identities influence reactions to their child's gender (including understanding parental identities). • Explore risks the adolescent may face that may be compounded by other identities. • Work with families to understand how their identities support/restrict their ability to affirm their child.	• Incorporate tenets of intersectionality.⁸⁵ • Family reactions to the child's gender are often embedded in the context of other aspects of identity, and support is best accessed when placed in the context of these identities. • Families return to therapy together once they gain psychological and social resources that have validated their identities and understood their point of view.
Miller and Davidson⁸⁶	Young people with diverse gender identifications and their families	CMM	Two case studies	• The first meeting can provide an opportunity for the clinician to discover families' stories and hopes for treatment. • When there is disagreement within families, have members collaborate and consider if it's possible to move forward while holding different perspectives. • Use circular questioning to make connections between family's stories, meanings, and different contexts. • Consider different aspects of family members' identities and how they may impact how they define and conceptualize their gender. • Meet with schools and other extra-familial networks to negotiate supportive outcomes, while supporting the perspectives of all parties. • Use “both/and” approach to understand reciprocal influence of individual and social contexts on understanding of gender and foster nonjudgmental acceptance of gender identity issues. • Collaborate with professionals from different specialties (e.g., pediatric endocrinologist). • Allow mourning processes to occur • Foster hope in youth and their families.	• Therapeutic aims derived from Di Ceglie.⁸⁷ • Three principles of CMM: (1) there are multiple social worlds, (2) social worlds are made in interactions and through conversations with others, and (3) we are all active agents in the making of social worlds.⁸⁸ • Conceptualization of gender fits well within a social constructionist paradigm. • CMM facilitates collaborative relationships and having families “constructing gender together.”
Okrey-Anderson and McGuire⁸⁹	Gender minority youth and their families	Not specified	Not specified	• Support families that worry that support for their gender minority child will lead to ostracism from their religious or social community. • Be careful with unsolicited psychoeducation, which may result in defensiveness and resistance in conservative or religious families. • Establish rapport, foster trust, and assist families to navigate relationships without condemning families or affirming transphobic attitudes • Seek opportunities to increase competency in working affirmingly with gender minority youth and their families.	• Selective positioning and value-based referrals are ineffective, because religious practitioners may need to treat a religious family with a gender minority child. • Advising partial or conditional support can negatively impact the child and family. • Cognitive flexibility can lead to closer and more stable relationships with gender minority youth through the coming out process. • Feelings of ambiguous loss are more likely to occur in conservative religious families where there is strong emphasis on traditional gender roles. • Families may need to distance themselves from strict theology and family expectations to develop resilience, cognitive flexibility, and stronger relationships with their gender minority child.
Oransky et al.⁹⁰	TGNC adolescents and young adults	Family therapy drawing from MDFA⁴³ and Family Acceptance Project⁹¹	Case example	• Intervene (or have child do so on their own behalf) in transphobic discrimination by educating school personnel on rights of TGNC students and the impact of discrimination on their mental health. Remove barriers to care (treating those without insurance, provide multiple avenues for program entry, etc.) and connect with legal experts who can help with name/gender changes on documentation. • Ensure staff/clinicians, forms and clinic environment are affirming and welcoming • Coordinate care with other health providers ( medical doctors, social workers, etc.). • Provide early psychoeducation regarding effects of transphobia and the importance of an affirmative approach to care. • Utilize a variety of treatment modalities (parental coaching, child therapy, family therapy, parent support groups, etc.). • Explore caregivers' assigned meaning to gender and validate their fears and concerns. • Use DBT/CBT approaches adapted for use with TGNC populations.	• Encourage use of group treatment for TGNC youth to foster community support and peer education in responding to minority stress.
Reilly et al.⁹²	Young children with gender nonconforming behaviors and preferences	Not specified	Not specified (recommendations derived from clinical experience)	• Resist prematurely predicting the child's path in terms of gender identity development. • Have parents explicitly tell the child they're exploring together “what feels right,” and that the family will support any outcome (i.e., “follow the child's lead”). • Have families consider an open social transition rather than “going stealth.” • Acknowledge to parents that the child's gender nonconformity represents a deviation from their envisioned child.	• Parent support groups can help families navigate the complexities of gender dysphoria/transition. • It is preferable to have families open about the child's gender nonconformity with extended family, community, and school. • Families may experience child's gender nonconformity as a loss of the child they dreamed of and initially had.
Wren⁹³	Gender diverse children and adolescents	Not specified	Not specified (recommendations derived from clinical experience)	• Build with families a shared understanding of the child's gender identity development. • Assess for current/past distress and make sense of its associations with gender conflict and desire for bodily change. • Explore with child motivations for seeking gender-related treatment. • Consider the meaning of sexual intimacy and fertility for the developing young person. • Communicate to families at all stages the known/unknown benefits/drawbacks of proposed interventions. • Assess youth for capacity for consent and scaffold such discussions appropriately. • Acknowledge how social, personal, and professional locations lead to certain biases. • Work with other stakeholders to build affirming public attitudes toward gender nonconforming youth.	• Clinicians should be aware if the treatment given is in the best interest of the child

CMM, Coordinated Management of Meaning; DBT/CBT, dialectical behavior therapy/cognitive behavioral therapy; GID, gender identity disorder; GLBT, gay, lesbian, bisexual, and transgender; LGB, lesbian, gay, and bisexual; MDFA, Multi-Dimensional Family Approach; N/A, not applicable; SGM, sexual and gender minority; SGMT, sexual and gender minority therapy; TGE, transgender and gender expansive; TGNC, transgender or gender nonconforming.