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Transgender and Gender Nonconforming Youth
What Does It Mean to Be Transgender or Gender Nonconforming (TGNC)?
People who identify as TGNC experience their gender as something different than what is stereotypically associated with their sex assigned at birth. For some people, their experience of their gender fits in what is known as the gender binary, and they may identify as male or female. For other people, their experience of their gender does not fit in the gender binary, and they may identify as genderqueer, gender fluid, or use one of many other labels for diverse gender identities.
Identifying as TGNC is not a psychological disorder. Although researchers are still working to understand the biological and developmental components of TGNC identities, they can be best understood as natural variations in human gender expression.
However, people who identify as TGNC can experience significant distress associated with the incongruence between their gender and their sex assigned at birth. When this distress leads to problems in everyday functioning (e.g., interpersonal, academic, work) it is called Gender Dysphoria, which is currently listed in the Diagnostic and Statistical Manual of Mental Disorders-5 by the American Psychiatric Association. Therapists would use this diagnosis to treat the anxiety, depression, and stress that TGNC youth might experience.
Affirmative Care for TGNC Youth
Historically, clinicians and health care providers have used a variety of treatment approaches in working with TGNC youth. Experts in the treatment and care of TGNC youth are increasingly using a framework known as the affirmative care model. In this model, clinicians support and affirm a youth’s expressed gender. And, while validating that a youth’s understanding and expression of their gender in any moment is true, clinicians also recognize that gender identity development is complex and that youths’ understanding of their gender may change over time. Importantly, the affirmative care model recognizes that the care of TGNC youth is highly complex and requires an individualized and interdisciplinary approach. What this means is that there is no single treatment plan or transition process that will work for all TGNC youth. Mental and physical health care providers will work together to make recommendations based on each individual’s unique situation and needs.
Information for Parents of TGNC Youth
Parents of TGNC youth have the opportunity to provide crucial support and affirmation of their child’s identity. Research has shown that support and acceptance from parents and families is a strong protective factor against many of the challenges faced by TGNC youth. Parents of TGNC youth also act as their primary advocate when interacting with school administrators, health care providers, and other adults in their child’s life to navigate the unique circumstances associated with a TGNC identity.
TGNC youth could benefit from seeking support from a psychologist who has appropriate training and experience working with TGNC individuals. Primarily, psychologists can help TGNC youth to explore their gender identity in a supportive and affirming environment. TGNC youth can also learn cognitive and behavioral skills in therapy that can help them cope with stressors in their life. Stigma and discrimination associated with TGNC identities can add additional stress to the lives of TGNC youth on top of the typical stressors experienced by all children and adolescents.
Although the body of research on TGNC youth is still relatively small, it appears that, as a result of these additional stressors, TGNC youth may be at a higher risk for depression, anxiety, and suicidality. Additionally, they may be more likely to be the victims of verbal, physical, or sexual harassment or abuse. In light of TGNC youth’s elevated risk for suicidality or abuse, it is important that youth have a parent, psychologist, or other trusted adult that they feel comfortable talking to if, or when, they feel unsafe.
Individuals can begin to recognize, understand, and share their TGNC identity at any age, and for many this occurs during childhood or adolescence. The current limited data on TGNC children suggests that from 12% to 50% of children who express a TGNC identity in childhood will continue to express that identity after they reach puberty. Researchers and clinicians currently cannot predict which children will persist in their TGNC identity and which will not, but it appears that children who experience more intense gender dysphoria (i.e., those who are more distressed by the incongruence between their gender and their sex assigned at birth) are more likely to persist in their TGNC identification.
TGNC children and their parents might consider what is called socially transitioning, which can help children live more comfortably as their affirmed gender. A social transition can include steps such as the child using a new name and different pronouns, wearing different clothes, or getting a new haircut. Some TGNC children fully socially transition in all areas of their lives, and others choose to partially transition (e.g., wearing gender affirming clothes but using the same name/pronouns, socially transitioning at home but not at school). Psychologists can help support families in making decisions about whether and when a social transition would be appropriate for TGNC children. This decision process is unique to each family, and it should take into account factors such as the child’s safety and where the child is in their gender identity development. Medical interventions to support gender transitions are not recommended for prepubertal TGNC children.
Once TGNC youth reach puberty, they and their families have additional transition options to consider beyond socially transitioning. If TGNC youth are interested in medical interventions to support their transition, health care providers may request that a readiness assessment be conducted by a mental health care professional who has specialized training in working with TGNC youth. The purpose of this comprehensive assessment is to provide TGNC youth with the best care possible. Readiness assessments typically include an evaluation of the youth’s gender identity development history, their current physical and psychological functioning, their family and other social support, and the youth’s understanding of the implications of transitioning. It is important that TGNC youth have the support of a psychologist before beginning a medical transition, as well as throughout the transition process.
Medical interventions for TGNC adolescents might include puberty-suppressing medications, gender-affirming hormone treatment, and possibly gender-affirming surgical interventions. Puberty-suppressing medications, also known as puberty blockers, are a reversible intervention that provide TGNC youth with additional time to explore their gender identity without experiencing the irreversible and potentially highly distressing development of their biological secondary sex characteristics. The administration of gender- affirming hormones (i.e., testosterone or estrogen) results in physical changes for TGNC youth such as changes in voice pitch, muscle mass, body and facial hair, and body fat redistribution, among others. Surgical interventions can be used to alter primary or secondary sex characteristics, but are typically not recommended until at least late adolescence. TGNC youth should talk with their parents, psychologists, and physicians about the implications of medical interventions, including the implications for their future fertility.
Outlook for TGNC Youth
TGNC youth are a diverse and resilient population. Family support and acceptance can help TGNC youth to succeed in a world that is still growing in its understanding and acceptance of gender diversity. Moreover, affirmative care from psychologists and physicians can help TGNC youth explore and live a fulfilling life as their authentic selves. Researchers are working to expand our empirical knowledge of TGNC youth and the development of diverse gender identities in order to develop and provide the best possible affirmative mental and physical health care for TGNC youth.
Please also see the American Psychological Association’s Guidelines for Psychological Practice with Transgender and Gender Nonconforming People: http://www.apa.org/practice/guidelines/transgender.pdf.
You might find the book The Transgender Child, by Brill & Pepper, and published by Cleis Press, useful.
Professionals might find the following article of use: Edwards-Leeper, L., Leibowitz, S, & Sangganjanavanich, F. (2016). Affirmative Practice with Transgender and Gender Nonconforming Youth: Expanding the Model. Psychology of Sexual Orientation and Gender Diversity, 3, 165-172.