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Gender Affirmative Care

Gender Affirmative Care

Center for Discovery recognizes that honoring all patients’ self-defined gender is an evidence-based intervention for eating disorder and self-harm behaviors, as well as a form of suicide prevention for gender diverse people. We make every effort to affirm and support our patients throughout treatment, regardless of their gender identity, gender expression, sex assigned at birth, or stage in their social and/or medical gender journey.

We know that transgender, non-binary and all gender diverse people are much more likely to develop eating disorders, in large part due to oppression that we face. We know that in order to heal, your treatment must welcome, affirm and treat all of you. We, the Gender Affirmative Care (GAC) coordination team, are a group of providers with lived experience in the transgender community who serve as patient advocates to ensure that you are getting high quality care. We know that eating disorder treatment has historically not been set up to serve transgender patients, and we have been working hard for the last few years to change that. The GAC team is responsible for training staff, updating and creating inclusive policies and procedures, and providing direct patient care — all to help ensure your treatment with us is supportive and affirming.

During your treatment at Center for Discovery, you can choose to have a Gender Affirmative Care coordinator join one or more of your therapy sessions to dive deeper into topics related to your gender, including your exploration process; how your gender relates to your eating disorder; your relationship with your body; coming out; navigating family, friend and romantic connections; and/or transition steps. Your CFD treatment team will also work with our GAC team behind the scenes to get whatever support and knowledge they need to provide you with quality care. Our GAC team will always be available to you and your treatment team — we want you to have the best experience possible, so that you can focus on your recovery in an affirming, informed environment.

Meet the Gender Affirmative Care Coordinator

Emmy Johnson, MSW, LCSW

Coordinator, Gender Affirmative Care

Emmy Johnson, MSW, LCSW, (they/them) is a non-binary eating disorder professional working as a coordinator for Gender Affirmative Care. They have been with Center for Discovery since 2020 as a primary therapist before moving into the GAC role. They specialize in working with LGBTQ+ populations with eating disorders and trauma, and they love providing trainings and supporting clinicians who work with transgender clients. They have worked in transgender advocacy and support since 2015 and in the field of treatment of eating disorders since 2018. They received their master’s in social work – with internships at Carolina Partners (now MindPath) providing free outpatient therapy for trans adults, and Carolina House Center for Eating Disorder Treatment – and their BA in public policy and women and gender studies, both degrees earned at the University of North Carolina-Chapel Hill. They strive to be anti-racist, anti-oppression and Health At Every Size®/anti-sizeism oriented in all that they do. Outside of work, they love hiking with their dog Lyra and reading romance novels.

Frequently Asked Questions from Patients

Answered by Our Gender Affirmative Care Coordinators

We want to acknowledge that entering eating disorder treatment as a transgender, nonbinary or gender nonconforming person can feel like a scary, overwhelming process. We know that eating disorder treatment has historically not been set up to serve transgender patients, and we have been working hard for the last few years to change that.

The information below is intended to provide you with more information about how Center for Discovery addresses common concerns, and is not intended to be clinical recommendations for your individual situation. We’ve answered the questions below using evidence-based research, personal experience, and professional experience treating a large cross-section of transgender and nonbinary people with eating disorders. Your care at Center for Discovery will always be individualized.

We look forward to working with you.

Our philosophy at Center for Discovery is that supportive, affirming treatment is the gold standard for effective care. Center for Discovery has made great strides in our commitment to ensuring that all patients receive affirming care and feel safe in our facilities. Unfortunately, we know that change may not come all at once, so we have supports in place to assist your team in providing you with the best possible care. Your team will be augmented by a Gender Affirmative Care coordinator who can support you directly, as well as consult with and support your team throughout your treatment with us. You can reach a Gender Affirmative Care coordinator at any time by email at [email protected].

  • All outpatient (PHP and IOP) programs and all adolescent residential programs treat all genders.
  • Unfortunately, at this time, not all adult residential locations can accept all genders (for example, due to state licensing requirements). Your admissions coordinator will likely work with a Gender Affirmative Care coordinator to determine what location would be the best fit for you.

At Center for Discovery, we know that eating disorders do not exist in a vacuum. Eating disorders are complex and can function as coping mechanisms for the stressors of life. We also know that trans, nonbinary and gender-questioning people are much more likely to develop eating disorders than our cisgender peers, likely due to the oppression we face and our potentially complex relationships with our bodies. In order to most effectively treat your eating disorder, we want to make sure that together we recognize the whole picture of who you are and what is going on for you.

  • No. You get to choose how much or how little you talk about your gender. Your treatment is your own. We hope to provide a space where you can safely explore your gender and how it relates to your eating disorder and your life more broadly, if that is relevant and appropriate to you and your treatment.
  • At admission, the treatment team will ask all patients a few questions about gender identity. You can choose how much to share at that point, or you can choose to share more once you get to know your treatment team better.
  • If you disclose that you are transgender, non-binary, genderfluid, agender, questioning/exploring your gender or self-define as another gender diverse identity, your therapist will ask you some follow-up questions and explain our policies to ensure you receive high-quality affirming care.
  • It is your choice to decide who you want to be out to. Your gender identity is protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). We will support your choice and protect your information.
  • If you decide to be out to other patients, we will support you and affirm you. We expect all patients to address each other respectfully, which includes using the appropriate names and pronouns for peers.
  • At Center for Discovery, it is our policy that all staff will use the name and pronouns that are affirming to you. Regardless of whether you have legally changed your name, we honor that you are the person who determines the name you are called.
  • Your legal name may need to appear on your chart and documentation for legal and insurance reasons.
  • Center for Discovery is a large company with many providers. It is possible that people will make errors or be less affirming than our policy states. We have been hard at work making sure our entire staff is trained and ready to be affirming, and we know that change can come slowly. We, CFD’s dedicated team of Gender Affirmative Care coordinators, are here to make sure you are affirmed in your identity and receive high-quality care. If you have concerns at any time, you can reach us at [email protected].
  • Center for Discovery strives to never disclose a patient’s gender identity without the patient’s permission. Your gender identity is private information to share with others if and when you choose to.
  • If you are an adult: your gender identity and/or questioning is protected under the Health Insurance Portability and Accountability Act (HIPAA). Center for Discovery does not have the legal authority to tell your loved ones anything about your identity without your consent. Your team will ask you questions about how you would like us to navigate situations that may involve your loved ones (e.g., therapy session, visiting/calling, medical records and paperwork).
  • If you are under the age of 18 and not living in the state of Washington, your parents/guardians may legally be able to access your medical records. However, due to the sensitivity and importance of this topic, Center for Discovery does our best to protect your privacy. Please talk to your treatment team and/or email us at [email protected] about your concerns, as we can offer a variety of options that may help you feel more comfortable discussing your gender identity while in treatment. If you are over the age of 12 and live in Washington State, you are granted additional confidentiality by state laws; therefore, information cannot be shared with parents/guardians without your explicit consent.
  • Your team will take a variety of measures to protect your privacy, including informing all staff about who you do and do not want to know about your gender, and reminding staff of the importance of protecting your privacy.
  • While Center for Discovery aspires to fully protect your privacy, because mistakes can happen, including potentially at the insurance provider level, some patients prefer for their treatment team to intentionally mis-gender them in certain situations and in medical records. If a mistake were to happen, at any level, your Gender Affirmative Care coordinator and treatment team would help you navigate and offer accountability.
  • All patients are encouraged to participate in family therapy and you can discuss with your therapist beforehand how you would like them to refer to you in these sessions. We define “family” broadly, including biological, legal and/or chosen family, and anyone who can support you in your recovery who you would like to invite to participate, such as roommates, coaches and friends.
  • All patients are encouraged to participate in family/support system therapy.
  • We define “family” broadly, including biological, legal and/or chosen family, and anyone who can support you in your recovery who you would like to invite to participate is welcome, such as roommates, coaches and friends.
  • During family therapy, your therapist can support conversations with your loved ones by guiding conversation, pausing conversation appropriately and debriefing with you afterwards.
  • If you would like a GAC coordinator to be present during your family session(s), you may request this at any time.
  • In individual sessions or GAC sessions, your therapist or GAC coordinator can support you in brainstorming, scripting or practicing what you would like to say to your loved ones. We can also support you in processing any emotions that come up before or after talking to loved ones.
  • The GAC team maintains a list of resources, including resources for loved ones. You or your therapist can request those resources to give to your loved ones.

Our highest goal is that you are placed in a room where you feel safe, affirmed and able to focus on your treatment. Our rooming policy is to room people based on gender identity, rather than assigned sex. When you arrive, you will be asked about your preferences for rooming. Your treatment team will use that information and their clinical judgment to decide where you will room. Because of laws and codes of ethics related to patient privacy, staff cannot share your gender identity with any other patient, nor disclose your roommate’s gender identity to you.

  • At our residential facilities, CFD has all-gender bathrooms just like you would find in someone’s home. Locations include: Alexandria RTC (VA), Bellevue RTC (WA), Chicago RTC (IL), Cypress RTC (TX), Danville RTC (CA), Del Mar RTC (CA), Dunwoody RTC (GA), East Quogue RTC (NY), Edmonds RTC (WA), Fairfax RTC (VA), Fairfield RTC (CT), Fremont RTC (CA), Glenview RTC (IL), Granite Bay RTC (CA), Houston RTC (TX), La Habra RTC (CA), La Jolla RTC (CA), Lakewood RTC (CA), McLean RTC (VA), Menlo Park RTC (CA), Mesa RTC (AZ), Montverde RTC (FL), Plano RTC (TX), Rancho Palos Verdes RTC (CA), Southport RTC (CT) and Thousand Oaks RTC (CA).
  • At our outpatient (IOP and PHP) facilities, CFD may have all-gender restrooms or may be in a larger building that unfortunately has gendered bathrooms. The specifics for each facility will be different. The following outpatient programs have all-gender bathrooms: Columbia Outpatient (MD),  Southport Outpatient (CT), Tacoma Outpatient (WA) and Tampa Outpatient (FL).
  • Yes, your team will work with you to continue your current medications and collaborate with your prescribing doctors if changes need to be made. A number of outside factors could impact your access to GAHT while in treatment, so please let your team know about prescription refills/changes as soon as possible. Examples of outside factors that can delay your medications include controlled substances regulations, insurance verification, pharmacy inventory and/or medication change requests.
  • If you already have surgery scheduled, your team will work with you to make sure you are mentally and physically stable enough to have a successful surgery and recovery process. Generally speaking, patients receiving electrolysis are often able to continue this process while at PHP & IOP programs, and generally need to pause these procedures while in residential treatment.

Center for Discovery currently does not have providers who will initiate gender affirmative hormone therapy (GAHT), nor does CFD have surgeons on staff. We would be happy to assist you in getting referrals to outside providers who specialize in these areas of gender affirmative care.

  • Yes, they do! Please let them know when it is scheduled and sign a Release of Information for your surgeon. The whole team — including your Gender Affirmative Care coordinator and you — will discuss what will need to happen to make sure you are ready for surgery.
  • Your team’s top priorities are to help you live the life you want, including safely undergo surgery and heal appropriately to achieve the best possible surgical outcomes. Eating disorder behaviors can get in the way — particularly by depriving your body of the nutrients needed to heal — so it’s your treatment team’s job to help you recover so that you can achieve your goals.
      • Resilient Fat Goddexx’s Peer Support Groups for fat trans folks in recovery from an eating disorder
      • Many LGBT centers offer support groups, events, and social gatherings in person and virtually. You can search for an LGBT center in your area through CenterLink.
      • Eating Disorder Foundation – LGBTQ+ Support Group every Wednesday 4:30-5:30pm PST. This support group is ideal for lesbian, gay, bisexual, transgender, queer and gender non-conforming individuals at least 18 years old to discuss struggles with disordered eating, body image and identity.
      • Eating Disorder Foundation – Trans+ and Nonbinary Support Group every Thursday 3:00-4:00pm PST. This support group is ideal for individuals at least 18 years of age who identify as trans+, gender nonconforming, intersex, and gender diverse, struggling with eating disorders, disordered eating, body dysmorphia and body image. (The Wednesday LGBTQ+ group is for those who identify anywhere within the LGBTQ+ community. The Trans+ & Nonbinary support group is specifically for those who identify as trans+, gender nonconforming, intersex, and gender diverse.])
    • Help lines:
    • Resource websites:
      • Harvard Law School’s LGBTQ+ Advocacy Clinic’s Trans Youth Handbook  – Legal resource guide that covers the rights of trans youth across such a wide spectrum of situations, including identity documents, school, health care, non-affirming care environments and work.
      • National Center for Transgender Equality’s Know Your Rights website
    • Nonfiction books:
      • Gender Outlaws: The Next Generation by Kate Bornstein and S. Bear Bergman
      • The Queer and Transgender Resilience Workbook by Anneliese Singh
      • Trans Bodies, Trans Selves: A Resource by and for Transgender Communities edited by Laura Erickson-Schroth
      • The Body Is Not an Apology, Second Edition: The Power of Radical Self-Love by Sonya Renee Taylor
      • You and Your Gender Identity by Dara Hoffman-Fox
      • Mindful Masculinity Workbook: A Practical Guide to Healthy Masculinity edited by Rocco Kayiatos
      • Gender Failure by Rae Spoon and Ivan E. Coyote
    • Fiction Books with Trans Representation:
      • Birthday by Meredith Russo (YA romance, trigger warnings for violence, transphobia, suicidality, substance use, abuse)

      • If I Was Your Girl by Meredith Russo (YA romance, trigger warnings for violence, transphobia/hate crimes, suicidality, substance use, sexual violence)

      • Magical Princess Harriet by Leiah Moser (middle grades, trigger warnings for transphobia)

      • Felix Ever After by Kacen Callender (YA romance, trigger warnings for transphobia, bullying, substance use)

      • Dreadnought by April Daniels (YA fantasy superhero, trigger warnings for transphobia, emotional abuse, violence)

      • Cemetery Boys by Aidan Thomas (YA fantasy/romance, trigger warnings for transphobia, blood, death)

      • The Prince and the Dressmaker by Jen Wang (YA romance graphic novel, trigger warnings for transphobia and outing)

      • Upright Women Wanted by Sarah Gailey (YA dystopian action/adventure, trigger warnings for homophobia/transphobia, gun violence, death, misogyny)

      • PET by Akwaeke Emezi (middle grades/YA fantasy, trigger warning: sexual violence, child abuse)

      • The Mermaid, the Witch and the Sea by Maggie Tokuda-Hall (YA fantasy/romance, trigger warnings for torture, violence, blood, sexual violence, substance use)

Frequently Asked Questions from Parents, Caregivers and Loved Ones

Answered by Our Gender Affirmative Care Coordinators

Dear Parents, Caregivers and Loved Ones:

Thank you for being here. Your support for your loved one is essential in their recovery and well-being, and we appreciate the work you are putting into learning and understanding. 

We want to acknowledge that you know your loved one. And, your loved one knows themselves best, which is why our philosophy is to listen and follow their lead while exploring identity.  

The question of “what is gender affirmative care” is answered in detail below, but we want to emphasize that the majority of this work is about exploration and support. We view our role as being present with your loved one as they explore new territory. We want to create space for them to safely feel emotions that are scary to be felt alone and to safely try out possibilities with the intention of establishing a long-term, sustainable trust in themselves and their recovery.   

The information below is intended to enhance your understanding of this complex subject, rather than to speak to the specific clinical recommendations for your individual family. We’ve answered the questions below using evidence-based research, personal experience, and professional experience treating a large cross-section of transgender and nonbinary people with eating disorders. The care of your loved one at Center for Discovery will always be individualized.  

We look forward to working with you. 

  • Transgender, sometimes shortened to trans, is an umbrella term for anyone who does not consistently identify with their sex/gender assigned at birth 
  • The term transgender is an umbrella term that can encompass a wide variety of identities and experiences, including male, female, non-binary, transmasculine, transfeminine, genderqueer, genderfluid, agender, etc.  
  • Some two-spirit people identify as transgender and/or non-binary; some do not. 
  • It is important to note that people self-define their gender identity (rather than being labeled by others) and have their own definition/meaning of these terms; many of the terms mentioned above are not interchangeable. We recommend that you ask your loved one about what their identity language means to them 

Cisgender, sometimes shortened to cis, is a term for anyone who consistently identifies with their sex/gender assigned at birth.

Two-spirit is a modern umbrella term used by Native American Indigenous people who are considered neither men nor women, and generally occupy a distinct gender status. In many tribes, two-spirit people historically filled special religious roles as healers, shamans and ceremonial leaders. Most Indigenous communities have specific terms in their own languages for the gender-diverse people in their communities, and with over 500 surviving Native American cultures, attitudes about sex and gender vary widely.  

  • Nonbinary is an umbrella term referring to anyone who does not identify within the man/woman or male/female binary.  
  • Some nonbinary people identify as transgender, some do not. These two terms are not mutually exclusive, but rather have large areas of overlap in gender diverse communities. 
    • Gender dysphoria describes the distress that someone may feel when their body and/or social experience does not reflect their gender 
    • Gender dysphoria is also a DSM V diagnosis (Diagnostic and Statistical Manual, 5th Edition), defined as “a marked incongruence between one’s experienced/expressed gender and assigned gender” which requires clinically significant distress to be diagnosed. 
    • Dysphoria is treatable, largely with appropriate social and/or medical transition to assist with alignment, as well as coping strategies to alleviate distress when dysphoria arises. 
    • Not every trans person experiences gender dysphoria; gender dysphoria is not a requirement to be trans. Dysphoria may wax and wane over moments, days or years. 
    • Trans people can also experience gender euphoria, or the joy and sense of rightness that someone might feel when they are aligned with their body and/or social experience. Colloquially thought of as the opposite, non-pathologizing experience of dysphoria, gender euphoria is used by many transgender & non-binary people to guide their gender journey.  
  • Transgender people are much more likely to develop eating disorders than cisgender people, with studies estimating that 16% of trans young people have been diagnosed with an eating disorder nationally, roughly 8x more often than their cisgender peers (Diemer et al., 2015). Evidence suggests that this disparity may be due to:
    • Minority stress (the stress that someone may experience due to being part of a minority, marginalized, or oppressed group); 
    • Potentially complicated relationships trans people may have to their bodies, such as discomfort or distress within their bodies; 
    • A desire to suppress secondary sex characteristics, such as breasts or muscle growth, via malnourishment; 
    • And/or a need to find soothing in unsupportive, confusing or closeted situations.  
  • Studies that examine the treatment of eating disorders in trans individuals show that access to gender-affirming care improves outcomes (Donaldson et al., 2018; Jones et al., 2016; Jones et al., 2018; Nowaskie et al. 2021; Testa et al., 2017).  
  • We want to ensure we are treating the whole person. Eating disorders do not exist in a vacuum, nor can they be separated from the complexity of a human being. For many of our transgender and nonbinary patients, gender identity is an important piece of that complexity and exploring gender becomes a major theme of eating disorder recovery. 
  • For all of our patients — cis, trans and questioning — this can include:  
    • Imagining their life is worth living 
    • Noticing their own preferences 
    • Identifying and expressing their emotions 
    • Trying on different identities, appearances, preferences, activities, etc. 
    • Exploring their values 
    • Developing self-awareness and self-trust.  
  • We share your desire to help your loved one recover from their eating disorder. In treatment, we focus on whatever we need to focus on to facilitate recovery. For some people, this is a strict focus on their eating disorder. For most people, there’s something underlying the eating disorder that keeps them stuck in the eating disorder, so we need to address that underlying issue to support full recovery 
  • Eating disorders are often coping mechanisms or ways to hide parts of ourselves. If someone is using their eating disorder to cope with dysphoria or using their eating disorder to hide parts of themselves that feels unwelcome, confusing or dangerous, then we need to support them in exploring their identity, creating safety, becoming comfortable in uncertainty and coping with dysphoria in other ways. 
  • That makes sense! Your loved one exploring or expressing a different gender than what you thought they were is a big deal. You may feel lost, confused, scared, guilty, angry, ashamed, hurt or a wide variety of other emotions, perhaps at the same time as feeling proud, relieved or clarity. This may be outside of your past experiences, maybe outside of the experiences of everyone you know. You may be concerned about what this means for your loved one’s life — you’ve probably heard a lot of scary reports and statistics about how hard it is to be transgender in many communities. This is all so valid and understandable. 
  • They want you to know them. It’s a big deal that they chose to share this with you. They have chosen to let you into this piece of them, saying that they want you to know them better. 
  • Lead with love. You love your loved one, that is abundantly clear just by the fact that you’re reading this right now. We encourage you to notice all your other emotions and seek support, while keeping your love for them central in all your communication and decision making. What your loved one needs to hear and see from you most is your love for them.  
  • Process your feelings. We want you to have space to process these emotions, perhaps with the support of other family/community members going through the same thing, religious or spiritual community, and/or mental health professionals. We recommend contacting your local PFLAG chapter or other organizations with support groups and experience supporting family members like you, such as Trans Families and Gender Spectrum (see the resources question below).  
  • This is a wonderful area to focus your support on immediately. Using your loved one’s name and pronouns is hugely important and we have evidence that being supportive in this way is a protective factor for better mental health outcomes (Durwood, McLaughlin, and Olson, 2017; Sevelius et al., 2020). 
  • Practice! When you’re driving alone in the car or doing dishes, talk out loud about your loved one, using their name and pronouns.  
  • Correct yourself. If you make a mistake, correct yourself, briefly apologize and move on. 
  • If your loved one is out to others, then correct others to help them improve their use of your loved one’s pronouns and name. Corrections can be as simple as briefly interrupting to state the correct name or pronoun when you hear errors.  
  • Making progress on names and pronouns can be something you work on in family therapy. Your child’s therapist can help correct you during session, and family therapy is a space to explore how your child experiences misgendering (being referred to as the wrong gender, the wrong name or wrong pronoun). 
  • We all go through phases — that’s part of life. In adolescence and young adulthood, we explore our identities, and as part of that exploration process, we may “try on” different ways of being. For most people, being trans is not a phase.  
  • The evidence suggests that the vast majority of adolescents and adults who do not feel at home in their gender assigned at birth will continue to identify differently than their gender assigned at birth (de Vries et al., 2012), though they may move around under the trans umbrella as they continue to explore and come to a deeper understanding of their gender.  
  • Whether or not your loved one identifies in a different way later, your support of their identity exploration and who they are will help them feel safe and loved 
  • Sexual and gender exploration is normal at all phases of life. We all continue to grow and explore as a lifelong process. There is no right or wrong age to question gender, to come out, or to begin taking steps to align gender identity with body/social experience. Gender exploration is very individual. 
  • Gender identification, or the ability to identify they have a gender and participate in cultural gender norms, begins for most children around ages 2-3. Some children voice experiences of gender incongruence at this young age. Some transgender people realize there is something different about their experience of gender as compared to their peers later in childhood as they navigate gender separated groups. 
  • For many transgender adolescents the onset of puberty often creates significant distress as their body begins to display secondary sex characteristics, leading them to start questioning their gender, identifying as trans, or talking about their gender experiences around puberty. 
  • Our job is to help your loved one find a sense of peace, clarity, and happiness. In mental health care, we are often responding to a person’s distress, and helping them move from a place of distress to a place of peace, affirmation, clarity, and joy. This is a miraculous and transformative process, regardless of the age it happens. 
  • Our society has taught us that gender identity is innate and static, never changing but most peoples’ experience of gender is complex and evolving. Many of the stories in the media about transgender people fit into that narrative, saying that trans people are “born in the wrong body” and “always knew” they were a different gender than they were assigned. Some people fit this narrative. Many do not. 
  • Some family members feel surprised when their child comes out as transgender, nonbinary, or questioning of their gender, and family members may look back to their loved one’s childhood to try to process what their child is telling them. For some families, they can find memories that help them feel that their child coming out makes sense. For others, they find it difficult to reconcile how they experienced their loved one in childhood with what their loved one is telling them now.  
  • If your loved one is telling you that their gender questioning or gender identity is something they have had for a long time, it might be that your loved one was skilled at hiding their questioning from everyone and this helped them protect themselves. Children pick up early on what the expectations are for their assigned gender, and they learn early that if they do not follow those expectations, bad things may happen. They may have learned that they needed to act as their assigned gender in order to be loved, to be safe, and to survive.  
  • It is also common for people’s relationship with gender to change over time. Many children don’t have any discomfort in their body and assigned gender before puberty, and the changes of puberty are when discomfort starts. For some people, their assigned gender fits well enough to not have excessive distress, but later they found other gender options that fit better. For others, their gender changed as they grew and changed, much the way that their personality, values, interests or other aspects of their identity might change. 
  • It is normal to look for answers and certainty, but that isn’t always possible right away. It is normal to feel confused and distressed if you don’t find answers and certainty. We encourage you to find support as you work through any feelings that arise for you as your loved one explores their identity.
  • If you are reading this question, it is likely that your child has let you know that they need to start one or more transition steps (steps to align their body and/or social experience to their gender). It is understandable that you may want to wait for your child to be old enough to legally make their own decisions, for you to be more comfortable with the steps they want to take, or to see if they change their mind.  
  • When someone is in significant psychological distress, we need to take steps to alleviate that distress. When a person lets us know that they need to take transition steps, it usually means that they are experiencing significant distress with their current situation. You may have noticed this distress, through their words, emotions and/or behavior, including eating disorder behaviors, substance use behaviors, self-harm behaviors or suicidal behaviors. We want to alleviate that distress. Talk with your loved one and their treatment team to get individualized recommendations about how ongoing gender affirmation through social transition, medical transition and/or legal document updates could improve their mental health struggles. 
  • Everyone has a different path and each person needs different support to alleviate their distress. Many people will need to experiment, start and stop interventions, or continue to course-correct as they assess what the right decisions are for them. It’s valuable to focus on increasing joy and decreasing distress, at a pace set by your loved one, rather than adherence to any particular path or destination.
  • Many family members have concerns that their loved one may later regret transition steps that they take. It is normal and understandable to have concerns about your loved one’s well-being and how choices they make now will affect their life going forward.  
  • Rates of regret are very low, with current estimates ranging between less than 1% and 3.8%. That means that there is a 96.2-99.5% chance that your child will not regret these transition steps. 
  • Most transition steps are completely or partially reversible. If your loved one needs to make a different decision later, they can do so. 
  • As Myles Marcotte, ASW, discusses in his training, Normalizing Complex Grief in Transition, it is often assumed that if someone transitions and then later wants to transition back/again, they will feel regret about having transitioned in the first place, and that this regret will cause suffering. However, neither regret nor suffering are inevitable. We all make decisions throughout our lives, and when we move onto a different path, we can view the paths we have been on as growing and learning experiences.  
    • If we do regret past choices, we can process that with therapists, family and friends, and work towards acceptance and forgiveness of our past and present. This is the work all people, regardless of gender identity, do throughout our lives, for all sorts of decisions.  
  • Rapid Onset Gender Dysphoria (ROGD) was a concept proposed by one researcher in a survey of parents in 2017; this concept has been widely challenged by experts in the field of transgender care. In the survey, parents reported being surprised by their children coming out, and talked about their caregiver perspective that their child’s gender dysphoria or transgender identification appeared suddenly. As other parents and some providers recognized their experiences in this paper, this theory of ROGD circulated more and more widely. 
  • A fear that many parents have is that who their children spend time with will determine who their child is, and it’s true that peer groups influence who we become. However, the theory that being trans is based on peer pressure and popularity has no scientific evidence base (see: What about Rapid Onset Gender Dysphoria?).  
  • Your child’s friends may have encouraged your child to question and explore their gender — this isn’t a bad thing! Regardless of the outcome of the exploration, questioning their gender will result in your child knowing themselves better. It is a beneficial, lifelong skill to be able to question yourself and explore who you are. 
  • This is a complicated question that everyone will navigate differently. We can’t tell you how to navigate your personal relationship with spirituality and faith, nor how to navigate your relationship with any religious institutions you belong to.  
  • We encourage you to talk with your loved one about how they feel about their faith institutions and what the teachings are. You might listen to their emotions about it and consider their opinions about the course to take. You might be able to explore options for next steps together, whether that be navigating your current faith tradition, advocating for change or changing faith traditions. 
  • Some ideas that have been helpful to some people during this process include: 
    • Check in with your own belief system and connection to your higher power. Some people struggle due to their internal, “gut” feeling about what is right being at odds with the religious teachings they follow. It can be helpful to reflect on some of the variety of perspectives you may uncover from prayer and meditation, from your own upbringing, from religious leadership and from your personal relationship with your higher power.
    • Access resources from those who have come before you. There are groups of people, organizations and other supports for many major religions and groups within religions. There are also books written by parents and other family members navigating religion as their loved one comes out as transgender.
    • Know that there are histories in your religion, which may include previous positions that have changed or been reinterpreted. It can be useful to notice that your religious teachings continue to evolve over time, often in response to cultural context.
    • You may consider talking to your faith leader and faith community, including advocating for change. We have heard and witnessed faith communities changing due to one of their community members coming out.
    • There can be a great deal of loss in losing faith communities and structures due to being transgender or having a transgender loved on. You may be in a position to be your loved one’s spiritual guide or spiritual elder and to help them navigate their own relationship with faith or their higher power in the context of being their authentic self. 
  • We have no evidence that trauma causes transgender and/or nonbinary identity 
    • While transgender people have high rates of trauma, this has been linked to discrimination and many trans folks report questioning their gender prior to trauma occurring (James et al., 2016).  
    • There are many people who experience trauma who are not transgender/nonbinary, and there are many people who are transgender/nonbinary who have not experienced trauma. 
  • If trauma were to influence gender identity, it does not follow that trauma recovery would result in a change “back.” Trauma recovery does not return someone to who they were prior to trauma; it helps them move forward in their life, integrating the trauma as part of their story but not all of their story.  
  • If someone’s identity does change, that’s OK! We have no attachment to the outcome of someone’s gender journey. Whether or not your loved one identifies in a different way later, support of their identity exploration and their healing process will help them feel safe and supported. 
  • A large part of the trauma recovery process is re-learning to trust yourself. To that end, an essential part of trauma therapy is for clinicians to believe patients and support patients in believing themselves, including their ability to trust what they know about their identity, life decisions and interpersonal relationships.  
  • No, transgender and nonbinary identities have existed for all of human history and the focus on trans and nonbinary issues in the political arena has come and gone several times over the history of the United States. 
  • Some people welcome the discussion into the political sphere, viewing it as an opportunity to increase access for transgender and nonbinary people to human rights and legal protection from discrimination. Others note that the increased focus has increased danger and bullying, with politicians using this as an opportunity to say harmful things about transgender people and present legislation that harms transgender and nonbinary people.  
  • It is difficult to have your identity be the center of a political discussion; it can feel dehumanizing. The political discussions tend to be about whether transgender and nonbinary people should have access to the rights and privileges that all participants in U.S. society have — access to public restrooms, access to sports teams and educational institutions, access to healthcare, etc. As you support your loved one in navigating this topic, consider discussing with them what it’s like for them to see this legislation being proposed and passed. Note that they may find it too distressing to talk about.  
  • Challenging gender identity is not a recommended form of treatment and the evidence that we have suggests that it is harmful. We use evidence-based treatments and always work to be up-to-date to ensure the best outcomes.  
  • Here are some books we like for family members: 

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