Abstract
Transgender youth are more likely than cisgender youth to report health risks related to violence victimization, substance use, mental health, and sexual health. Parental support may help foster resilience and better health outcomes among this population. However, limited research has characterized parental support among transgender youth. To address this gap, we conducted a thematic analysis of 33 in-depth interviews with transgender youth. We coded interviews using the dimensions of the social support framework (i.e., emotional, instrumental, appraisal, and informational) as well as inductive codes to identify emergent themes. Almost all participants described some form of general parental support (e.g., expressions of love, housing, advice, and affirmation). Parental support specific to gender identity was also noted (e.g., emotional support for coming out as transgender and chosen name and pronoun use) but was more limited. Parents may benefit from resources and programming to promote acceptance and gender-affirming behaviors.
Transgender youth (i.e., those whose sex assignment at birth differs from their gender identity) report more health risks related to violence victimization, substance use, sexual behavior, and mental health than cisgender (i.e., not transgender) youth (Johns et al., 2019); thus prevention strategies that include both risk reduction and health promotion are needed. Yet research with transgender youth traditionally focuses on dimensions of risk rather than protective factors that directly promote positive health outcomes or counteract risk (Johns et al., 2018). Despite more recent efforts to identify protective factors among transgender youth (Johns et al., 2018; Singh, 2013), there remains a need to understand how such factors operate and can be leveraged to improve overall health and well-being for this population.
Resilience theory provides a conceptual framework for understanding how risk and protective factors interact to affect health outcomes (Fergus & Zimmerman, 2005). Models of resilience emphasize the role of parental support in encouraging health-promoting behaviors and buffering against the risk effects of stressors for youth broadly (Fergus & Zimmerman, 2005) and transgender youth specifically (Watson & Veale, 2018). The protective influence of parental support is also documented empirically (DeVore & Ginsburg, 2005; Markham et al., 2010; Rohner & Britner, 2002). Among transgender youth, parental support appears to be protective for psychological distress, posttraumatic stress disorder, depression, suicide, eating disorders, condom use, quality of life, and perceived burden of being transgender (Bauer et al., 2015; Johns et al., 2018; Olson et al., 2016; Simons et al., 2013; Veale et al., 2017; Watson et al., 2017; Wilson et al., 2012; Wilson et al., 2016). Yet transgender youth report lower levels of parental support than cisgender youth (Eisenberg et al., 2017), and many face parental rejection related to their gender identity (Katz-Wise et al., 2016; Klein & Golub, 2016). While benefits of parental support for the health and well-being of transgender youth have been documented in the literature, descriptions of what ideal parental support for transgender youth looks like are lacking. The social support framework offers insights into potential types of support parents may provide, which are emotional (i.e., expression of “empathy, love, trust, and caring”), instrumental (i.e., “tangible aid and services”), appraisal (i.e. “constructive feedback and affirmation” useful for self-evaluation), and informational (i.e., “advice, suggestions, and information” for problem solving; Heaney & Israel, 2008); however, it is an outstanding question as to what unique forms of support related to their gender identity transgender youth may require.
Therefore, characterizing parental support for transgender youth and how it contributes to positive health is critical. Qualitative inquiry is one approach well suited for this objective, as it allows for in-depth exploration of parental support. Previous qualitative research has generally focused on the perspectives of parents of transgender youth (Alegría, 2018; Field & Mattson, 2016; Riley et al., 2011) and transgender adults (Riley et al., 2013), or included a predominately White sample (Katz-Wise, Budge, & Fugate, et al., 2017; Katz-Wise, Budge, Orovecz, et al., 2017). Research on parental support with transgender youth, particularly transgender youth of color, is warranted.
Accordingly, we conducted a thematic analysis of in-depth, qualitative interviews with a racially diverse sample of transgender youth in the Southeastern United States. Specifically, we identify key themes that characterize parental support in relation to different types of social support as described by the social support framework (Heaney & Israel, 2008), including emotional, instrumental, appraisal, and informational support. Understanding parental support in relation to these domains can inform efforts to bolster this protective factor for transgender youth and promote the health, well-being, and resilience of this population.
Method
Study Design
Data were collected as part of the Resilience and Transgender Youth Study, a formative study aiming to identify and understand protective factors that promote health and well-being for transgender youth. Between February and June of 2017, we conducted 33 one-on-one, in-depth interviews with transgender youth in a large Southeastern urban area. Study design and procedures were approved by the institutional review boards at the Centers for Disease Control and Prevention (CDC) and ICF.
Sample and Recruitment
We recruited transgender youth through seven community-based organizations that serve transgender youth, distributing posters, flyers, and palm cards in person and online. Study participants were also given palm cards to share with friends. Eligible participants identified as a gender that did not align with their sex assignment at birth, were aged 15 to 24 years, and spoke fluent English. We employed purposive sampling to obtain a diverse sample in terms of sex assignment at birth and race/ethnicity. The final sample included 33 participants. Participants’ ages ranged from 16 to 25 years (M = 21.7 years; one participant turned 25 a few days before their interview). Fourteen participants identified as female or transgender women, 11 as male or transgender men, and eight as gender nonbinary, gender nonconforming, gender fluid, or agender. Over half (n = 18) identified as Black or African American, 13 as White, and two as multiracial. Two participants identified as Latinx.
Data Collection
Eight trained interviewers conducted face-to-face, individual interviews using a semistructured interview guide. Prior to data collection, all interviewers attended a half-day qualitative data collection training. Content included theories of qualitative data, techniques of data collection, and a practice interview session. Additionally, all interviewers completed one additional practice interview prior to entering the filed with the principal investigator to ensure consistency in data collection. The interview staff included three Black or African American cisgender women, three White cisgender women, one White transgender woman, and one White genderqueer person. Participants and interviewers were matched on at least one salient identity. Participants gave written consent (≥18 years) or assent (15–17 years); institutional review boards waived parental consent for participants <18 years. Participants received a $50 gift card after completing the interview, as reimbursement for their time and travel costs.
The interview guide focused on protective factors related to intrapersonal, interpersonal, community, and societal domains (McLeroy et al., 1988). Table 1 displays interview guide questions related to parents. During the interview, participants were asked about their relationship with their parents, including how, if at all, their parents supported them, and what, if anything, they wished their parents had done differently. We defined parents as primary caregivers, including biological parents, other family members, stepparents, foster parents, or chosen family. Interviews, which lasted between 37 and 150 minutes (Mdn = 52 minutes), were audiorecorded and transcribed verbatim. Field notes were documented by the interviewer and referenced by the study team as needed during analysis.
Semistructured Interview Guide Questions About Parents and Parental Support From the Resilience and Transgender Youth Study.
Note. Interviewers were instructed to skip Questions 3 through 6 if youth had no relationship with or experienced rejection from their parents.
Data Analysis
We used a multistage, thematic approach to code and analyze the data (Guest et al., 2011) in MAXQDA Version 12 (VERBI Software). First, we developed a codebook based on a priori research questions and preliminary examination of the data, which included a code for any reference to parents or caregivers along with codes for schools, health care, and sexual health education. Five coders refined the codebook by independently coding and discussing three transcripts. The remaining 30 transcripts, were then coded by a minimum of two of the five coders, reconciling discrepancies through discussion.
Second, we further analyzed the subset of data coded as “parents,” identifying themes using the process outlined by Braun and Clarke (2006). The first author developed a codebook for this specific analysis, including conceptual codes aligning with the social support framework (i.e., emotional, instrumental, appraisal, informational) and inductive codes (e.g., chosen name and pronouns, transition) that emerged through examination of the data. The codebook was reviewed by the study team, and two coders (JA and SP) independently coded six transcripts using this second codebook and resolved discrepancies through discussion. These same coders then each independently coded the remaining transcripts, periodically meeting to reconcile discrepancies. Codes were reviewed by the authors to generate themes, and the first author further organized coded content in tables to refine the themes and examine deviant cases.
Results
Almost all participants described the presence or absence of parental support, except one individual who declined to answer questions about her parents. Most participants (n = 31) indicated at least one parent was either a biological or adoptive parent. A few (n = 7) described their primary caregiver as another family member (e.g., sibling, grandparent); one characterized this person as a teacher and another as “[people] on the streets.” Table 2 provides an overview of our thematic findings. General parental support (i.e., dimensions of parental support relevant to all youth) was cited in relation to all four domains of social support—emotional, instrumental, appraisal, and informational. Some, albeit fewer, participants also described gender identity–specific support (i.e., support specific to transgender youth), noting in many cases that parents were in the process of becoming supportive. Gender identity–specific support was discussed primarily in relation to emotional and instrumental support, though examples of appraisal were also cited. Thematic findings in relation to each of the four types of social support are further described below, along with descriptions of general and gender identity–specific parental support. For each quote, we parenthetically provide the participant’s gender identity, as they described it, race/ethnicity, and age group (i.e., <20 or 20+).
Characteristics of Parental Support Described by Transgender Youth in the Resilience and Transgender Youth Study.
Emotional Support
Expressions of Love, Affection, Caring, and Trust
Participants generally felt that their parents loved and cared about them. Several participants described verbal expressions of love, while others described physical affection. For example, “My dad is a very huggy, touchy sort of person. His whole family is. Show affection easily, and I would say that’s been good for my health” (Female, non-Latinx White, 20+ years).
Empathy for Mental Illness
Several participants discussed their struggles with mental health and described how parents expressed empathy by sharing their own mental health challenges. As one participant remarked, “We can connect over having problems with mental illness in a way. I think that that’s been really helpful is having times when I can relate to him and talking to him about that” (Nonbinary, non-Latinx White, <20 years). This helped improve mental health by giving participants a space to discuss how they were feeling and allowing parents to share strategies to manage their health.
Communication About Emotions
Several participants emphasized the importance of their parents listening to them when they shared their feelings. For example, one participant remarked, “She really just listens to me like I’m her peer. I think that means a lot to me, and makes me feel really validated” (Nonbinary, non-Latinx White, <20 years). Parents communicating their emotions helped participants feel supported and comfortable sharing their own emotions. As one participant noted, I never knew my Dad’d get scared of somethin’ like—When he starts to let me know, it’s like, “Oh, I’m like that, too.” It kinda helps me out, cuz I know I don’t have to be—I thought I always had to be tough like my parents, but I know they have emotions, too, and they have fears and things, so I can be scared sometimes, and I can let people know. (Transgender female, non-Latinx Black, 20+ years)
Although a few youth indicated parents did not always know how to communicate emotional support, attempts to do so were received positively by participants.
When asked what they wish their parents had done differently, several participants expressed a desire for more communication with their parents specifically about gender, including listening to what the participants thought about gender. On the other hand, one participant was distressed by such conversations.
I don’t feel safe talking to them about most things. Oh, I wish they would not force me to talk to them about things I don’t want to talk about. Because they force me into conversations sometimes, that make me feel really uncomfortable and unsafe. Give me a lot of anxiety, and end up making me feel really terrible in the end. (Agender, non-Latinx White, 20+ years)
Emotional Support for Coming out as Transgender
Some participants described parents as accepting, caring, understanding or at the very least, respectful when they did come out as transgender. For example, I just never really opened up to her about emotional stuff. I did right before we moved, and right before her and my dad broke up, about feeling unhappy with how I look, or the whole trans thing. She was just really supportive. She cared enough to actually be like, “Is this something you wanna do? Do you need help?” She has always been really caring, and open, and understanding, and not just like, “Oh, you’re complaining.” (Trans male, Latinx mixed, <20 years)
Some parents were not comfortable with their child being transgender when they first came out, but progressively became more accepting and supportive. For example, She’s kinda getting used to my transition. At first, it was hard for her. Now she’s kinda getting used to it. Just our little time where we joke around. We have a day where it’s just me and her. We laugh and stuff. Just seeing her smile makes me like oh, good. (Transgender female, non-Latinx Black, 20+ years)
Instrumental Support
Financial Support and the Provision of Basic Needs
Financial support and the provision of basic needs such as food, housing, and health insurance were commonly cited. However, in some cases financial support was provided conditionally and used to impede transition. When asked if there was anything else she would like to do to live her gender, one participant remarked, Hormones. Getting a legal name change and getting my documents as in line as possible so I’m not constantly having to deadname
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myself, being deadnamed as I go through different interactions. Still at present financially dependent on my parents, which allows for a lot of coercion and policing of where I can be out and in what capacity I can be out, and a lot of need for hiding different things. Working toward more independence there. Those are the big things. [. . .] Just generally not necessarily things they did, but just being financially dependent on them has stopped me from doing a lot. (Trans woman, non-Latinx White, 20+ years)
Health Care
Parents also provided support accessing health care by helping youth find providers and attend appointments. For example, “She’s the one who found me a therapist when I need to see a therapist. Providing logistical things like that” (Nonbinary, non-Latinx White, <20 years). However, parents were not always supportive of medical gender affirmation services (e.g., puberty blockers, hormones). One participant remarked she wanted her parents to facilitate the initiation of gender affirming hormone therapies at a younger age, before the onset of secondary sex characteristics that caused the participant feelings of dysphoria (i.e., feelings of dissatisfaction, anxiety, or discomfort).
I wish they would have put me on estrogen, and I wish they were a little more open minded to it when I was younger. Cuz I wish that had all started when I was 13, 14. I would never have to deal with the shoulders or the back or certain aspects of my body that I have to deal with now. If they had put me on estrogen when I was younger and hormone blockers, it would a been so much easier. (Female, non-Latinx multiracial, 20+ years)
Social and Legal Transition Related Support
Some parents provided instrumental support related to transitioning, such as help with makeup, clothing, jewelry, and hair. For example, one participant noted, [. . .] my stepmom put my first weave in my head at 16. You get what I’m saying? Before that, I was already wearing girls’ jewelry. I was already getting my nails done. You get what I’m saying? I wasn’t wearing makeup, but my eyebrows was already arched. It was just common. I didn’t even notice it was—then, she just put weave in my head, and it was over. (Female, non-Latinx Black, 20+ years)
In other cases, parents helped with paperwork for changing names and gender markers on government documents. In one case specifically, this allowed the participant to feel supported while waiting to pursue medical gender affirmation.
He’s the guy who’s in charge of the label stuff, like changing the ID stuff, so he’s helped me that way too. Even though I feel impatient about the surgery part and stuff, I’m being patient cuz as long as he’s helping me it’s good. (Male, non-Latinx White, 20+ years)
Appraisal
Feedback
Participants received feedback from their parents that helped them assess whether or not they were “doing a good job,” or if they should make additional efforts in relation to school, taking care of themselves, or life in general. In one case, even when the participant felt he failed, his father reminded him that he did achieve something. “Whenever I fail, reminding me, ‘Hey, this is not the end. At least you did that. You can get back up and do something else’” (Male, non-Latinx Black, 20+ years).
Affirmation, Motivation, and Encouragement
Participants described affirmations, motivations, and encouragement they received from their parents, at times describing their parents as “pushing them to do things.” This type of affirmational support helped participants achieve more than they otherwise would have. For example, Ultimately, my dad, he pushed me to do a lotta things. [. . .] Every time he would say, “It would be hard for you to do that,” I’d go and do it. Just to prove that, “Hey, I did it.” I think at the same time, hearing him trying to point out how hard it would be to do certain things, he was rooting for me to actually go and do it, if that’s what I really wanted to do. Because even after saying it, he was like, “But if that’s you wanna do, I’m behind you all the way.” (Male, non-Latinx Black, 20+ years)
Chosen Name and Pronoun Use
Some participants described parents’ use of their chosen name and pronouns as affirming and validating their gender identity, a gender identity–specific form of appraisal or affirmation. While some parents were “working on” using the correct name and pronouns, parents who did so contributed positively to their child’s well-being. For example, “My dad, he is in my life as far as like, he’s more supportive than anybody on his side of my family. He calls me his daughter, so he’s opened up to me being who I am” (Woman, non-Latinx Black, 20+ years). Most participants wanted their parents to use the name and pronouns that matched their current gender identity. However, one participant felt it was unfair to expect her parents to use her chosen name and pronouns.
Because I feel like my biggest thing is when transgenders [sic] want their parents to switch over to calling them their daughter rather than their son, or their son rather than their daughter or etcetera. It’s not fair. (Female, non-Latinx multiracial, 20+ years)
Informational Support
Advice
Several participants stated that their parents gave them health advice and tips for problem solving. One participant receiving health information stated, “They will listen to what I have going on, and they’ll give me advice about what they think I should do, and where I can go to get certain resources” (Gender-fluid transmasculine, non-Latinx White, 20+ years). Other health information received from youth’s parents included topics like sexual health (which was asked about in relation to school experiences) and nutrition. In certain instances, parents were filling in information gaps from school-based health education. For example, Well, personally my mom took the reins in all that. [. . .] By the time I was in seventh grade and she found out that we weren’t being taught anything about sex ed, she was like okay, well here’s the T [truth]. (Gender nonconforming, non-Latinx Black, 20+ years)
Discussion
Nearly every participant in our sample of transgender youth in the Southeastern United States described some form of parental support. These findings extend previous research that emphasized transgender youth’s need for emotional and instrumental support (Katz-Wise, Budge, & Fugate, et al., 2017; Riley et al., 2011; Riley et al., 2013) by highlighting multiple dimensions of social support and the important role they play in the health and well-being of transgender youth. In particular, transgender youth described experiencing the types of emotional, instrumental, appraisal, or informational support from parents that general adolescent samples report (McNeely & Barber, 2010). This consistency underscores the relevance of these dimensions of social support, regardless of gender identity. For example, participants described parental empathy related to mental health issues and aid with accessing mental health care. Parents can listen to youth about mental health problems, provide strategies for addressing these problems, and help youth access mental health care services. This type of general support may be particularly important given its connection to preventing depression and suicide among transgender youth (Wilson et al., 2016), and the extent to which transgender youth experience suicide risk (Johns et al., 2019).
Participants also described parental support in relation to gender identity, although not all parents provided this more tailored dimension of support. Gender identity–specific support primarily involved emotional support for coming out. Some participants reported instrumental support for transitioning and appraisal support related to use of chosen names and pronouns. The overall level of gender identity–specific support reported here differs slightly from previous work with lesbian, gay, bisexual and transgender (LGBT) students, which documented a general absence of support related to gender identity and sexual orientation nearly two decades ago (Mufioz-Plaza et al., 2002).
Findings also suggest that parental support specific to gender identity can be strengthened. For example, some participants described their parents as initially unsupportive (e.g., resisting use of chosen name and pronouns), but more supportive over time, similar to descriptions from sexual minority youth (Nesmith et al., 1999). Instrumental support, particularly in relation to gender affirming medical care, was also limited. Notably, participants did not describe informational support related to gender identity despite desiring this type of communication with their parents from young ages. Some participants noted parental discomfort and lack of knowledge on this topic, highlighting the need for parental education. Notably, in some cases, the provision of general support in the absence of gender identity–specific support appeared to be harmful. For example, one participant described the use of financial support as a form of coercion to impede her ability to be out and transition. Future research might further explore this finding.
Health care providers, health educators, and other public health professionals may be able to bolster gender identity–specific parental support by providing parents educational resources to increase their understanding of gender diversity, as well as specific supportive practices. For example, materials that explain to parents of transgender youth options and outcomes for medical gender affirmation services could enable them to more effectively support their children through these processes. While professional organizations have created standards of medical care for transgender youth (Coleman et al., 2012), the extent to which this informational is accessible and understandable to parents is unclear. Communication materials that explain to parents of transgender youth the options and outcomes for medical gender affirmation services could increase their knowledge of and comfort with such options.
Other parent- and family-based interventions may improve parental support of transgender youth, but have not yet been thoroughly evaluated (Newcomb et al., 2019). As a specific example, the Family Acceptance Project is an intervention delivered to parents, youth, and providers to promote the health of sexual and gender minority youth (Ryan, 2010). Additionally, group therapy sessions with other parents of transgender youth could serve as a resource to facilitate parental support (Menvielle & Rodnan, 2011). As these interventions are further developed, evaluated, and brought to scale, lessons learned from other parenting programs on sensitive topics, such as sexual health, may be useful (Widman et al., 2019; Wight & Fullerton, 2013). Finally, not all youth have a safe, stable, and supportive relationship with their parents, and for these youth, bolstering individual resilience and other sources of social support may be most useful (Allen et al., 2019; Shelton et al., 2018).
Limitations
A central limitation of this analysis is that the findings are not widely transferable to transgender youth who are Latinx, younger, or live outside the Southeastern United States. Although we recruited a diverse sample of transgender youth, only two participants identified as Latinx and most participants were older than 21 years. Therefore, these findings may not fully reflect the experiences of Latinx youth or transgender youth younger than 16 years. All participants resided in the Southeast; however, this fact is also a strength of this study, given the lack of research with transgender youth in this region.
Although participants provided rich descriptions of parental support, few discussed this support directly in relation to health outcomes, limiting our ability to characterize specific ways in which parental support improved health. This analysis also focused on characterizing parental support rather than documenting the lack of support, perhaps giving the impression that parents of transgender youth are only supportive. This is certainly not the case, and future work is needed to address barriers to parental support for transgender youth. Nonetheless, in this particular context, many parents of transgender youth from diverse backgrounds wanted to be and are supportive of their transgender children, and practitioners and health educators can build on such existing intent.
Conclusion
Youth in this study described various dimensions of parental support, both generally and specifically in relation to their gender identity. However, not all parents were able to offer gender identity–specific support. Ideally, gender identity–specific support would include diverse types of support aligning with the social support framework, including emotional, instrumental, appraisal, and informational support. Future research should investigate which types of parental support relate to specific health outcomes and the mechanisms by which they improve transgender youths’ health. Health care providers and health educators should be aware that parents of transgender youth may be at different stages of being supportive and help parents to move along a continuum of support. More work is needed to develop interventions that improve provision of gender identity–specific parental support and gender-affirming parenting behaviors. These interventions might directly target parents or address educators and health care providers who can serve as resources for parents of transgender youth. Strengthening parental support has the potential improve overall health and well-being of transgender youth.
Footnotes
Authors’ Note
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this study was provided, in part, by the Centers for Disease Control and Prevention’s Division of Adolescent and School Health to ICF under contract HHSD-200-2013-M53944B, task order 200-2014-F-59670. Jack Andrzejewski is supported by the National Institute of Drug Abuse (NIDA), National Institutes of Health (NIH) under Award Number T32DA023356 (the funder/sponsor did not participate in the work).
