Treating Family Members of Transgender and Gender-Nonconforming People: An Interview With Eric Yarbrough, M.D.
I am large, I contain multitudes.
—Walt Whitman
Question: What guidance would you provide to psychiatrists and other mental health professionals working with families of individuals in transition?
Transgender and gender-nonconforming (TGNC) individuals experience a period of increased stress and vulnerability during their coming-out process. While every coming-out experience is unique and influenced by biological, psychological, social, and cultural factors, family support or discrimination plays a critical role in the psychological resiliency or distress of TGNC individuals (1, 2). Furthermore, because of decreased access to social support services, employment discrimination, and increased health care costs, TGNC individuals often rely on their families for housing and financial support (2).
Gender transition can also be difficult for families. For example, whereas families attuned to a TGNC child’s gender expression can be assisted to foster a more affirming environment in which a child’s gender identity can be explored and supported, parental coaching may not provide the appropriate environment for parents to explore their own feelings in a compassionate and empathetic setting (3). There are distinct differences in the nature of the distress experienced by the adolescent children of transitioning parents, parents of transitioning adult children, and partners or ex-partners of transitioning adults (4). TGNC adults and their adult children experience similar levels of distress during transition (5).
Providing mental health treatment that addresses family relationships could have far-reaching consequences in improving health care outcomes for both TGNC individuals and their families (6). Psychotherapy and education may facilitate the restoration and strengthening of familial relationships and provide a receptive environment for exploration and identity integration for the TGNC individual, leading to improved mental health outcomes for all. To date, little published data exist to inform current best clinical practices in the treatment of family members of TGNC individuals. In this interview, we sought out an expert opinion to establish a framework for providing effective and compassionate therapeutic treatment with family members of TGNC individuals.
Expert Interview and Examples
Eric Yarbrough, M.D., is the author of Transgender Mental Health (7). In this interview, he discusses issues that emerge in the treatment of family members of people who are transgender, gender nonconforming, and gender diverse. Several illustrative clinical vignettes representing actual cases were presented to Dr. Yarbrough as well as questions about general treatment principles. Dr. Yarbrough’s responses are summarized. Identifying information in the cases has been changed to ensure confidentiality.
Case 1: A Supportive Parent of a Transitioning Adult Child
Stephanie is the mother of a 21-year-old transgender man, Greg, who had come out as a lesbian at age 15. Stephanie is a mental health administrator in a rural part of the Pacific Northwest who frequently interacts with psychiatrists but has never received mental health treatment. Greg’s chosen pronouns are now “he/him/his.” Greg had some difficulties with alcohol and cannabis use earlier in his life. Stephanie is a single mother; Greg’s father left the family when Greg was very young and is rarely in contact with him. Stephanie is, and has always been, very supportive of her son, including telling her own family of origin that they had to accept Greg’s gender transition. She read a recently published book on transgender mental health as well as Laura Erickson-Schroth’s book Trans Bodies, Trans Selves: A Resource for the Transgender Community (8) in a single sitting.
She does feel hurt that Greg “rejected” his birth-assigned name in favor of a more male-identified name. Greg appreciates his mother’s support but feels upset when he overhears her misgender him when talking to old friends about Greg’s childhood. He is in therapy but wishes he could find an LGBT clinician who “wouldn’t just talk about sexual orientation and gender,” as he is concerned about other areas of his life. He also wishes that his mother had sought therapy when he first came out. He feels that his mother fears that something about her mothering “made him trans.”
Interviewer: Dr. Yarbrough, what are your thoughts about their dynamic?
Dr. Yarborough: In this case, I’d work with Greg to encourage him to cut his mother some slack. She is being extremely supportive and has been doing a lot to understand and support his gender transition. One cannot expect people to be perfect, and her misgendering of Greg only occurs when talking about the past and with her old friends who are also misgendering him.
Case 2: Different Reactions in Parents of Transitioning Adult Child
Walter is the 55-year-old father of a 26-year-old transitioning gender-nonbinary person, Kevin, whose preferred pronouns are “they/them/their.” Identified male at birth, at the end of college, they seemed to suddenly develop great difficulty completing school and moving ahead with life. Depression and attention-deficit hyperactivity disorder were diagnosed and treated, and Kevin then came out, initially as a “demi-guy” and now as nonbinary. They have recently begun taking female hormones and are considering a name change. Kevin completed college and is working and continuing treatment. Both parents have been in individual long-term treatment with psychotherapy and medication. Both were initially shocked at their child’s gender changes. “Is this a phase?” the parents asked their individual clinicians. “Kevin never said anything to us about this before.” One parent has had more difficulty than the other in accepting Kevin’s transition, including pronoun changes.
Interviewer: Dr. Yarbrough, as the father’s psychiatrist, how can I best deal with his questions of whether the wish to transition is “just a phase” and can the wish be genuine if it was not at all apparent in childhood or adolescence? Also, what is the best way to work with differences in the responses of my patient and his spouse?
Dr. Yarbrough: Parents can worry (as can spouses, partners, and siblings): “Did I cause this?” “Is this a phase?” “Is it real?” There may be feelings of sadness, loss, grief, even outright hostility and anger. Sometimes, family members are extremely supportive, as is Stephanie in Case 1. We hear about strain in parents in both Cases 1 and 2 with changes in pronouns and names, as well as with choices about gender-affirming hormones and surgery. If the family member patient asks, “Is it just a phase?” ask how long their relative has been in this “phase.” Once a family member told me that a relative had been going through “a phase” for 40 years! Then one can discuss the range of gender identities (bigender, gender fluid, nonbinary, etc.) and explain how people can move between identities over time. Family members can also be reassured that their actions do not cause their relative to become TGNC, but their support can make their transition process easier.
Case 3: Feelings of Grief in Family Members of Transitioning Individuals
Lynn (a 60-year-old woman in integrated psychotherapy and psychopharmacological treatment for chronic depression and migraines) is the aunt of 24-year-old Olivia. Olivia’s mother died when Olivia was very young, and Lynn became a mother figure to her. Olivia began identifying as a lesbian in college and has long been interested in issues of gender and social justice. Recently, Olivia began taking testosterone and adopted “they/them/their” as preferred pronouns. They asked only their father and his girlfriend to use these pronouns, however, and have not specifically asked Lynn or their grandmother to do so. Lynn expresses profound feelings of loss, grief, and sadness at this transition. She also expresses disbelief, asking, “Isn’t it just because her mother died and she never got the attention she needed from her father that she is doing this?”
Interviewer: Dr. Yarbrough, here is a patient with a deep sense of loss and sadness about her family member’s transition, as well as a theory that there is a psychodynamic explanation for it. How can these feelings best be dealt with in her treatment?
Dr. Yarbrough: Lynn insightfully acknowledges her feelings, a good first prognostic sign. We see that she feels sorrow at Olivia’s early bereavement and theorizes that that is part of her decision to transition. I often wonder how much of what unfolds in families is due to pre-existing dynamics versus how much is about transitioning per se. It is not uncommon for parents (or parent figures, in Lynn’s case) to go through a grieving process as their children grow up: Perhaps a child did not follow in their career footsteps, or changed religions, or chose a partner or spouse of whom the parents do not approve. It is worthwhile asking family members to imagine alternative scenarios like these and consider whether in those cases they might respond similarly to their child.
Case 4: Grandmother Responds With Hostility
Elizabeth is the 74-year-old widowed maternal grandmother of two young teenage girls who live in another country with their parents. Elizabeth has been seeing a psychiatrist episodically for several decades for medication treatment of anxiety and depression. She told him that she was outraged and upset that the older of the two grandchildren had announced that she would be transitioning to be a boy and asked the parents (but not Elizabeth) to use “he/him/his” as pronouns when referring to him. Elizabeth is worried about her upcoming annual trip to visit them and angrily says: “I’m losing my grandchild!” She takes the transition as a personal affront and, after two appointments with her psychiatrist, is unwilling to continue treatment. If the transition could not be stopped, she did not see what good individual treatment could do for her.
Interviewer: Dr. Yarbrough, what can be done to help the angry family member?
Dr. Yarbrough: In this case, I would initially avoid correcting the grandmother’s pronoun usage. She is feeling angry and unaccepting, and the important place to begin the work is in exploring the source(s) of her anger. Of course, if Elizabeth were to express opinions that were factually incorrect (e.g., gender identity is a choice), I would gently correct her. It is worth noting that in neither Case 3 nor Case 4 have the transitioning individuals yet asked their grandparents to switch pronouns for them.
Stephanie, the parent in Case 1, and Elizabeth, the grandparent in this case, also illustrate what I think of as a spectrum of support by family members for their TGNC relatives. Elizabeth is on the hostile and rejecting end, whereas Stephanie can come across as almost too supportive. I sometimes see families propelling their child through an idealized transition, which prevents the child from following their own decisions, choices, and timing. This can leave a child of any age confused. A related issue is families automatically assuming that their TGNC relative who is coming out will automatically or immediately take hormones and undergo surgery. It is important to explain in psychoeducation with families that not everyone chooses these options or follows a formulaic process and that pressuring a transitioning relative to do so can be harmful to that relative and to their relationship.
Case 5: Spouse Questions Own Identity When Partner Transitions
Pam, a 37-year-old cisgender married woman, was referred to a psychiatrist by her psychotherapist for the continuation of medication for her chronic anxiety and depression. She and her spouse had recently moved from a distant state and are looking for work. While reviewing her history, she reported that her spouse is currently transitioning gender. Raised as male from birth, Pam’s spouse had several surgical procedures very early in life and had felt himself to be a fairly feminine man. At 34, Dennis, now Deena (chosen pronouns are now “she/her”), was told by her parents that she was, in fact, born intersex. She decided to transition and has begun hormonal treatments and presenting as a woman, very happily. Pam, however, reports feeling unmoored. “My husband is now my wife, and I never thought of myself as a lesbian,” she said. The couple remains together, and they are working with their psychotherapist on all of these issues.
Interviewer: Dr. Yarbrough, how can we best understand the position of a spouse of a person who transitions in adult life? How do we best approach the challenges that a couple may be facing? This couple is childless, but can you address how to handle the subject of a parent’s transition with children?
Dr. Yarbrough: If you are treating a long-term partner of someone transitioning, the patient may question their own sexual orientation and/or gender identity. They may ask: “Should I have known?” “Did I cause this to happen?” There may be questions about whether the couple should stay together. My bias is prorelationship and prointimacy, so I encourage some ongoing connection. In couples who have young children, questions may also come up on how to discuss a parent’s transition with them. Each child, and each family, is unique; there is no single right time to talk to children about the transition. Children will react differently, and reactions may include excitement, support, fear, confusion, anger, grief, and other feelings. Older children will react differently than younger children, particularly in how they disclose the transition to their peers. Both parents may need help not only to navigate the changes in the dynamics of the relationship but also on how to best support their children in an open, patient, loving, and developmentally appropriate way.
In these vignettes, we also see that gender diversity is not simply about male or female, male to female or female to male, he or she. The paths are not linear and include many possible variations in gender identity, gender expression, treatment choices, family involvement, sexual orientation, and relationship choices.
Interviewer: What guiding principles for treatment should be kept in mind as an increasing number of family members of TGNC individuals appear in our practices, hospitals, and clinics?
Dr. Yarbrough: It is important to start with the basics. First, determine whether everyone involved understands gender diversity (i.e., gender is on a spectrum and is not limited to male and female). Then, determine whether everyone respects each other and whether there is a willingness to use appropriate names, pronouns, and gender identities. If these basics are not established, or if there is active hostility, it is important to start with psychoeducation until they are in place.
As the basics of respect are established, the next step is to align and develop a rapport with the patient(s). As in all other therapies, building a strong relationship with one’s patient is essential for them to work through their difficulties. Reacting to a loved one’s transition may be only one of the issues that brings a patient to treatment.
It is important to learn about the family’s background and internal dynamics. Clinicians may either consider an outside referral for family therapy or work themselves with the family of their transitioning patient, if appropriate. In the latter case, prepare carefully for any family meeting, including being respectful of and attending to any details that the patient who is being seen individually would not feel comfortable discussing in the family setting.
Also consider the appropriateness of suggesting external resources to patients. These include PFLAG (https://pflag.org), which has support groups and excellent brochures for families; books, such as those read by Stephanie in case 1; and online resources such as the Family Acceptance Project (https://familyproject.sfsu.edu).
When families ask questions about the medical treatments that their transitioning family members may be starting, to the degree that you feel informed, include education about risks and possible complications. In this way, family members will not be surprised in cases of adverse outcomes.
Interviewer: What skills or qualities does a psychiatrist or other mental health professional working with family members of TGNC people need to be effective?
Dr. Yarbrough: The one irreplaceable quality is to listen with an open mind and align yourself with your patient. One does not need to completely understand the nuances of anyone’s gender identity to be an excellent psychiatrist for their relatives. We use our well-honed skills with each patient and approach each from an affirming place. If there is something that you are not yet familiar with, simply say so. As always, be aware of your own areas of identification and of your own reactions, and endeavor to understand and tolerate your feelings. Understand that there is internalized transphobia just as there is internalized homophobia. Take a breath and remember that, as with each person we see, you do not have to know everything; just approach each person with an open mind.
Again, remember the two basic starting points as you see family members: gender is on a continuum and may evolve over time, and respect (including names and pronouns) is crucial. One last suggestion if you would like to expand your own fluency with current shifts in pronoun usage: whenever possible in your nonclinical endeavors, substitute “they/them/their” for the “she/he” binary.
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