Supporting transgender and gender-expansive youth

July 2022

Transgender and gender-expansive (TGE) children and youth continue to experience marginalization, as institutions across the United States institute new oppressive policies that challenge and, in many cases, altogether prevent access to gender-affirming health care. TGE children and youth include young people between ages 3 and 17 whose gender identity is different from the sex designated at birth; the label “transgender” implies alignment with the gender binary (e.g., “I was designated female at birth and am a transgender man”), whereas gender-expansive identities do not align with the gender binary (e.g., “I was designated female at birth and am nonbinary — meaning that I am not a girl or boy”).

The realities of living as a TGE child or youth in today’s social, legal, educational and health-related environments are harrowing. Every day, new policies and legislation are introduced regarding TGE youth’s rights to access medically necessary gender-affirming health care, present as their authentic self at school, participate in extracurricular programs and sports, and have their appropriate name and pronouns honored in educational spaces.

As the parent of an incredible 12-year-old TGE child, my tolerance for the headlines is waning. I wake up each morning and check the latest news, and suddenly, I feel anxiety rising in my chest. I feel breathless and sick to my stomach. I have to put down my device and find a comforting television show or familiar rerun to watch before continuing with my day.

But we can do something about it. As helping professionals, we have an ethical obligation to support members of this community, as well as their caregivers and loved ones, and to advocate for dissolution of oppressive policies and legislation.

The current crisis

Despite over a decade of research and clear medical guidance supporting the efficacy of affirming social and medical interventions, several state and local governments across the United States have initiated anti-TGE legislation. In April 2022 alone, more than 20 pieces of legislation targeting the rights of TGE persons were introduced across the country.

On April 20, the Florida Department of Health released guidance on the treatment of gender dysphoria for children and adolescents, which states: “social gender transition should not be a treatment option for children or adolescents” and “anyone under 18 should not be prescribed puberty blockers or hormone therapy.” Alabama enacted a similar prohibition on affirming health care, but with more severe consequences for providers who violate the ban. The Vulnerable Child Compassion and Protection Act, which took effect May 8, states that health providers who provide gender-affirming puberty blockers or hormones will be charged with a Class C felony. Sanctions for violating the ban could include 10 years in prison or $15,000 in fines.

Standards of practice from the American Academy of Pediatrics and World Professional Association for Transgender Health, however, continue to support social and medical transition as a necessary option for the health and well-being for many TGE youth.

Earlier this year, Texas Attorney General Ken Paxton issued an opinion stating that gender-affirming medical interventions, referred to as “elective sex changes,” are part of a “novel trend” and “constitute child abuse.” The fact that this opinion equates gender-affirming care with “child abuse” is of particular importance for helping professionals because this means credentialed providers are legally obligated to notify child protective services within 48 hours of learning that a minor is receiving gender-affirming medical care.

Many families and caregivers of TGE youth in Texas are now unable to access medically necessary gender-affirming interventions, such as puberty blockers and hormone replacement therapy. In addition, major TGE advocacy organizations are encouraging families and caregivers of TGE youth to maintain a “safe folder” — a collection of documentation that debunks the “affirming care is abuse” myth. The folder includes “carry letters,” which are documents written by licensed counselors, helping professionals and/or pediatricians who have worked with the youth. These letters contain the professional’s credentials, their relationship to the youth, a statement from the American Academy of Pediatrics supporting gender-affirming medical interventions as evidence-based and best practice, and an overview of the youth’s gender identity development process.

A call for advocacy

I share these current events not to stir your compassion but to make a request: Please act and advocate for TGE youth. You can pursue positive change in whatever realm you hold power, privilege or space. As a professional, I wear many hats, including assistant professor, mental health and substance use counselor, rehabilitation counselor, training facilitator and advocate. These professional roles provide a space for me to channel my anxieties and distress over these recent oppressive policies targeting TGE youth and work toward positive change.

For me, advocating for this population serves as a source of nourishment and a way to derive meaning from what feels like hopeless circumstances, and I hope that engaging in this work may do the same for my colleagues. Here are some ways helping professionals can better support the advocacy efforts for the TGE community:

• Use a humanistic lens when working with TGE children and youth and recognize the client as the expert on their own experience.
• Get to know the standards of care and research regarding evidence-based care with TGE youth. And make sure the research you consume and the information you share with others all come from prominent and reliable scholarly sources.
• Elevate the voices of TGE youth. If you work with this population, know what prominent TGE community organizations provide safe and brave spaces for TGE youth, and be prepared to share this information with your clients. If you facilitate trainings or educational opportunities for responsive and competent practice with the TGE community, and you yourself are not a member of this community, use panels of TGE folx to share their experiences and expertise.
• Inform people that gender-affirming social and medical interventions are medically necessary and are a key component of suicide prevention. According to a 2009 report by Caitlin Ryan, the director of the Family Acceptance Project, TGE children experiencing caregiver or family rejection are more than eight times as likely to have attempted suicide and nearly six times as likely to report high levels of depression than TGE youth who were not or only slightly rejected by their parents and caregivers. This report also found that TGE youth who were in accepting homes, with caregivers who supported social and/or medical affirming interventions, had rates of anxiety, depression, and suicidal ideation and attempts similar to their cisgender peers.
• Advocate with and on behalf of these youth in their living environments, schools and greater communities; this may include educating others about the role of affirming health care in preventing suicide and improving TGE youth’s overall health and well-being, testifying against oppressive anti-TGE legislation, or supporting affirming legislation.
• Honor the history of TGE communities by acknowledging the role of colonization and historical trauma in the erasure of histories of gender diversity. Recognize the systemic influence of adverse experiences in health care, schools, the legal system and other institutions on TGE individual’s ability to trust institutions. This history along with the major influential events in the lesbian, gay, bisexual, transgender and queer (LGBTQ+) rights movement are key to understanding the intergenerational trauma and resilience of members of TGE communities.
• Keep learning! Developing one’s ability to provide culturally responsive care requires lifelong education and reflective practice. Sign up for workshops and continuing education regarding serving TGE individuals. And join consultation and supervision groups that focus on providing care to this population.
• Connect and advocate. Connect with a local TGE advocacy organization and volunteer to support their efforts; if time does not allow for this level of engagement, consider donating to these causes to support their advocacy work.

As LGBTQ+ advocate, actress and film producer Laverne Cox once stated, “Each and every one of us has the capacity to be an oppressor. I want to encourage each and everyone of us to interrogate how we might be an oppressor and how we might be able to become liberators for ourselves and for each other.” At this point in history, it is critical that we as helping professionals identify how our actions contribute to the oppression of our TGE clients and do better. The health and well-being of an entire generation of TGE youth need helping professionals who are willing to use their power and privilege to elevate their voices and serve as liberators.  

Cortny Stark (she/her/hers) is an assistant professor and the substance use and recovery counseling program coordinator in the Department of Counseling and Human Services at the University of Colorado, Colorado Springs. She is also a telehealth therapist with the Trauma Treatment Center and Research Facility, where she provides trauma reprocessing and integration, clinical services for substance use and process addictions, and support for transgender and gender-expansive youth. Her research focuses on LGBTQQIA+ issues in counseling, integrative approaches to trauma reprocessing and integration, and substance use and recovery.

The views expressed in Counseling Today are those of the authors and contributors and may not reflect the official policies or positions of the editors or the American Counseling Association.