The Transgender Journey

What Role Should Therapists Play?

Magazine Issue
March/April 2016
Transgender Child

I’m a white Belgian American gay man. I was a gender-expansive child, and I now identify as a cisgender adult. My pronouns are he, him, and his. I’m an ally.

From the age of 2, I grew up going back and forth between my divorced parents’ houses. My father remarried a woman, while my mother repartnered with a woman for 15 years. She then repartnered with a man and identified as bisexual. Many of my mother’s friends were queer or lesbian-identified. My mother’s closest cousin was an effeminate gay man with the sharpest sense of humor. He taught me to laugh and properly lip-sync to Gloria Gaynor’s “I Will Survive”—all essential life skills, if you ask me.

I remember playing devotedly with my mother’s scarves and high-heeled shoes as a child. Anything soft, silky, perfumed, shiny, and glittery was a source of exquisite pleasure. I rarely cross-dressed, but when I did, I always did it alone and with an aftertaste of guilt and fear. Despite my mother’s queer friends and my father’s progressive attitude, I knew that this kind of play was “wrong”—something to enjoy only in secrecy. Although I knew my parents realized I was different and that they loved me, I was never quite sure their love would withstand my gender fluidity. An invisible line existed in my mind between what was okay and what wasn’t, and I was determined never to cross it.

Yet my body language and behaviors betrayed me constantly. All my friends were girls, and all my hobbies were considered feminine, like makeup and theater. At best, the boys in school ignored me; at worst, they insulted and made fun of me. Even before puberty, I knew I liked boys in a special way. But I also knew that while I liked boys, I never wanted to be a girl. Unlike transgender children who deeply want to transition, I was a feminine gay boy.

Fast forward 35 years later. On a sunny Sunday in June 2015, I’m walking in New York City’s Pride March on Fifth Avenue, a rainbow tutu adorning my jeans shorts. I’m also wearing a bright purple T-shirt that reads “Pride Is For Kids, Too.” It’s the slogan for the Ackerman Institute’s Gender & Family Project, a program I founded in 2010 to support families of gender-expansive children and families of transgender youth. The sidewalks are filled with cheering crowds—and right in front of us, a rainbow flag waves fiercely from the Flatiron Building.

Maria, the mother of Lila, a 12-year-old transgender girl, has been marching next to me in front of our float. As we wait to cross a street, she falls into my arms, tears streaming down her face. “I’m crying from joy,” she says. “I can’t believe I’m walking in the middle of New York City with my husband and my child, and everyone along the way is clapping for her. She’s happy and proud of who she is. And I’m not ashamed. I’m happy, too.”


I’m Lila

As I embraced Maria, I thought back to the remarkable journey she and her family had made since the more somber day, five years earlier, when I’d met them for our first session. Peruvian-born Maria was a teacher in the Bronx, while her husband, Ray, was a white computer programmer from the Midwest. They’d consulted me because their 7-year-old child, assigned male at birth and until then known as Leo, had long behaved and expressed himself in a traditionally feminine fashion, gravitating toward colors and activities usually associated with girls. As if born with an eye for design, Lila (as she now calls herself) turned bathrobes into dresses and towels into headpieces, stumbling from the bathroom to her bedroom in her mother’s shoes to sit on her bed and quietly arrange her stuffed animals and older sister’s dolls. She became obsessed with princesses when she discovered Disney characters in pre-K and openly preferred her girl-identified classmates in kindergarten. In many other ways, Lila was a typical child who loved physical activity and never missed a chance to romp in the backyard with cousins of both genders.

Both Maria and Ray were from conservative family backgrounds, but they were trying to make peace with the idea that Leo was probably going to be gay and enjoy a range of feminine and masculine things. But Lila had a whole other experience of herself, one that went beyond the question of gender stereotypes and expression. She wasn’t a feminine boy or a gay preteen. Her dilemma had to do with her deeply-felt gender identity. She felt like a girl trapped inside a boy’s body. Every night, she prayed for God to take Leo away and send Lila back to earth instead. A couple of years later, her parents found the diary she’d started in second grade. Page after page, Leo called himself “she” and “Lila.” “How can I ever tell them who I really am?” she wrote. “What if they stop loving me? What if God doesn’t want me in heaven?” Interwoven in these agonizing questions were thoughts of suicide, and the fear of losing their child was the catalyst to reach out for help.

The possibility of having a gay child was already outside their comfort zone, but having to accept a transgender child was beyond their wildest imaginings. Like them, many parents of transgender kids experience the news as if hearing their child has a disability. After all, parental hopes and dreams are commonly tied up with their child’s gender and gender identity. So it makes a big difference to most parents whether their child is a boy or girl, simply because they express their love and envision future prospects for that child in the largely gendered terms society lays out for them. Rearranging that internal mind map requires tremendous effort and adjustment.

For Maria and Ray, the stakes were particularly high: they knew they had to get over their shock and grief if they wanted to keep their child alive. Initially, I met only with them, then with all three of them, and then with Leo alone. It was clear that everyone in the family needed support, but I alternated seeing Leo alone with sessions involving the entire family—which allowed me to adopt a pace and language that was sensitive to everyone.

I started my sessions with Leo by asking him how I could help and what name and pronoun he’d like me to use. He was quick to tell me that Lila, she, and her were what she wanted. I then asked things like what she knew about herself and when she started feeling that who she was inside didn’t quite match who she was expected to be. When I gave her crayons and paper, she drew herself as a beautiful girl in the past, present, and future, most often wearing purple and with very long hair. I could see that it was an enormous relief to find a space outside of her diary that reflected her sense of self.


Gender Diversity

Just as there are many ways of being a boy and many ways of being a girl, there are many ways of being transgender. Some kids, like Lila, know exactly that something isn’t right and can express it at a very early age. Other kids become aware of their transgender identity later in their teens. There’s also a third category of kids—those like I was—who don’t identify with the opposite gender but still feel great discomfort with the narrow pink and blue boxes of expected gender behavior. The little empirical research we have about gender nonconforming kids show that only about 30 percent of children who explore or question their gender identity before puberty will identify as transgender teenagers and seek social or medical transition as young adults. Research calls that group the “persisters” because their desire to transition endures over time. The remaining 70 percent are known as “desisters.” Of those, who will not identify as transgender as adults, two-thirds will be gay and lesbian adults and one-third will be heterosexual. However, nearly 100 percent of the children whose distress about their gender is intense, consistent in all areas of their lives, and persistent over time, will continue to identify as transgender adolescents and adults.

Lila belonged to these persisters. It wasn’t a phase, a minor concern, or a secondary reaction to another primary problem such as trauma or family dynamics. To the surprise of many folks who don’t experience a misalignment between their assigned sex at birth and their gender identity, children are able to identify their gender identity at a very young age. Research shows that a child as young as 3 or 4 years old can be very clear about their sense of themselves as a boy or a girl. It’s the same for transgender children. For Lila, kindergarten confirmed that she was on the wrong side of the class when her teacher told her to stand in the boys’ line.

In my initial sessions with Lila’s parents, Maria cried as if she were literally mourning the loss of her child, while Ray seemed shut down and puzzled. He wanted to support Maria and protect Leo. (I used this name in my early sessions with Maria and Ray.) To start, I asked them to give me a detailed account of Leo’s gender development and expression, from the expectations and hopes they had before birth to the most recent details of his life. Every now and then, we had to pause to allow them to express their overwhelming sense of powerlessness along with their anxiety about their child’s future: who will love him? Will he find a job? Should we change schools? Are there ways to prevent him from being transgender? Whom should we tell? Whom should we never tell?

Adequately supporting Maria and Ray was challenging. I had to be careful to stay right where they were in terms of how affirmative they could be while I expressed compassion and understanding. Now and then, when I sensed an opening, I cited psychoeducational facts that would help them put their experience in perspective. Indeed, they had a lot to discover about gender. “Gender identity is about who we each are, deep inside, as a boy, a girl, man or woman, both or neither,” I explained. “But it’s different from our biological sex and whether we’ve been assigned male or female at birth. It’s also different from whom we love and choose to have sex with as adults.”

In between sessions, they worked hard to educate themselves on the issue and kept arriving with new questions. Gradually, they began to make sense of Lila by understanding the fundamental differences between the body she was born in (biological sex), who she felt she was on the inside (gender identity), what she showed the world (gender expression), and whom she’d one day love and desire (sexual orientation). They even learned to give themselves a new name, cisgender, which applies to those whose biological sex is aligned with their gender identity. The prefix cis means “on this side” and can be thought of as referring to being aligned with something. When there’s a discrepancy among our biological sex, our culturally assigned gender role, and our gender identity, we can call ourselves transgender.

For Maria and Ray, taking in and accepting this information was far from a calm, linear process. Sometimes, they seemed eager for knowledge and willing to understand Lila for who she was; at other times, the whole idea was too much, too scary, and their child was still Leo.


The Path to Acceptance

For Maria and Ray, joining the Gender & Family Project’s parent support group—and acquiring a community of peers, caregivers, and family members who shared the experience of parenting a transgender child—was transformative. It normalized their situation, widened their resources, and allowed them to get to know other parents who were also struggling with a sense of loss, fear, and helplessness. While Leo connected with other kids in the program and was affirmed as Lila in the playgroup, her parents could cry, laugh, and find relief with other loving parents who were trying to figure out their next steps.

Each group session provided material for discussions with me during their individual sessions. One day Maria sat down and announced, “I couldn’t believe how relieved I felt when the other mom said, ‘I’d love my child to be just gay.’ I’ve been secretly saying that to myself for months. And there she was saying it out loud! But it got me thinking too. Why is it more difficult to accept Lila as a transgender girl than Leo as a gay boy? I don’t know. As a straight and cis . . . how do you call it again? Cisgender, right! As a straight and cisgender parent, you always just assume your kid is going to be like you.”

Over time, Maria and Ray began to see that the world is made of unique individuals who are all over the gender spectrum. They became avid readers of the topic of transgender kids and were soon more up to date than me on the visibility of the transgender community.

“Did you see Laverne Cox on the cover of Time?!” Ray asked one day.

“Of course, it’s a big deal! What do you think of it?” I responded.

“It’s good, I guess,” Ray said hesitantly, then added, “I’m glad Lila can see that there are other healthy and successful girls of color like her out there. She’s not only transgender, she’s also interracial. She needs that to feel strong and hopeful.”

Maria squeezed his hand hard, smiling. Together, they were no longer thinking about Lila’s identity as a tragedy. They were envisioning a future and they wanted it to be bright.

These days, I often reflect on what allowed Maria and Ray to change. At the beginning, meeting with me alone gave them space for their grief and to trust that I could see things from their perspective. As we progressed, a gradual sense of surrender to reality emerged. Maria and Ray understood deep down that they didn’t have a choice: they couldn’t make or break their child’s gender identity. They could make it harder for Lila to be herself, but they’d also make it likelier for Lila to feel bad about who she is and internalize their fears and rejection.

They’d once believed that being protective meant refuting Lila’s deep feelings about her gender, but they now realized that it was the other way around. Accepting Lila was the best way to protect her. With that new sense of purpose and agency, bolstered by a community of parents who were cisgender allies, they felt ready to take on the big challenges ahead.

Of course, not every family, nor every child, is that lucky. Many families lack the resources, time, and access to a validating community that can help them integrate this perspective. Some parents flat-out reject their children’s identity, experiencing gender diversity as an irreparable rupture. Some even kick their child out of the home. Another group of parents is more ambivalent, caught in a dilemma between unconditional love and cultural or religious values that reject the notion of self-determined gender identity. And yet another group of parents is more readily on board but still overwhelmed by questions and fears: should I affirm my child’s identity, or is it just a phase? Should I help my son understand that there are many ways of being a boy? Should I help my daughter realize it’s okay to be a tomboy and that she doesn’t need to see herself as a man? At what point should my child be in therapy or medical care? If I do nothing, could I make it worse?


The Roots of Rejection

I’ve worked with several parents who left our program, most often at their child’s expense. Erik, a wealthy, white dentist, was the father of two children he parented on his own after their mom remarried and relocated to Europe. Nineteen-year-old Tom identified as a cisgender boy and had just left for college. Patricia, Erik’s youngest child, had been assigned female at birth and had always been a tomboy. A year ago, at the age of 15, she came out as a transgender man. Since then, she’d fiercely advocated to be called Pat and for a change of pronoun from she to he.

When Erik and Pat entered the Gender & Family Project, Pat wanted to start testosterone to masculinize his body. They engaged in family therapy and joined support groups. Pat went to the teen space, and Erik joined the group for parents of adolescents. While Pat loved meeting the other young people, Erik attended the parent group reluctantly. He thought his daughter was acting out to get attention. “She wants me to pay attention to her and provokes me with this trendy and incendiary stuff,” he said.

While Erik had a valid point about not taking every gender declaration as a permanent fact, he had great difficulty accepting that Pat had been struggling with his gender identity for years. From the time he’d entered puberty, he’d desperately wanted to avoid menstrual periods and their painful reminder of his female body. Since Erik refused to buy him proper binders for his breasts, he used undersized sports bras instead. Despite my efforts to acknowledge Erik’s feelings in individual sessions, and to move slowly, Erik wouldn’t consider hormone blockers to put puberty development on hold, the medical treatment Pat was begging for. While a young person’s emotional, cognitive, and social development continues, blockers keep the body from developing secondary sexual characteristics typical of the assigned sex at birth.

Our team faced a complex dilemma: Erik clearly needed more time to get on board, but Pat’s emotional health was quickly deteriorating. He was now avoiding school, abusing drugs, and caught up in a deep despair that included thoughts of suicide. Aware of the significant suicidal risk that trans youth present, we began to feel that we had to do something. Professional standards of care indicate that preventing children’s access to affirmative care such as therapy, evaluation, and a safe educational environment is not only dangerous, but can be a form of parental neglect or even abuse. While parents are absolutely allowed to struggle and feel deep grief and anger about their child’s identity, they can’t unilaterally increase their child’s chance for self-harm because of a difference of opinion. With deep sadness, we referred the case to Child Protective Services.

As we all know, such a step rarely brings prompt resolution. We lost access to the family: Erik was furious with us, and Pat dropped out of the teen group. I often think about why things didn’t work out better. Clearly, Erik had struggled to shift the way Maria and Ray had. Did he lack his own support? Did we push him too far too fast, not allowing him enough time to grapple with his own fears? These are all possibilities. Another crucial difference is that by the time Pat came out to his dad as a teen and joined our program, he’d been in great distress for years and couldn’t afford to give his dad much time to come around. The more his dad resisted, the harder Pat pushed. I dearly hope they’ve found a way to move forward together.

Sometimes cultural and religious dilemmas can lead parents to lose their relationship with their child rather than accept their gender identity. One day I received a call from a social worker about Billy, an 11-year-old African American boy who’d been hospitalized eight times over the past year. The provider insisted that I take on the case, since the family seemed to be severely challenged by their son’s feminine identity and gender expression.

In our first session, Sonia, Billy’s mother, said, “I don’t really think my son is a girl, but I just need some help to make him understand that he needs to calm down and figure himself out. He doesn’t get that it’s dangerous to be a person like him in our neighborhood. He has to be careful.”

I wondered what she meant by “a person like him.” Did she think of him as a young gay boy? Or was she alluding to his gender expression and identity? My cotherapists and I made a note to return to these questions but first wanted to gather a bit of information from Billy’s parents, who were both black, devout Christians working in retail and con­struction, respectively. Sean, Billy’s father, described the exhausting marathon of challenges they’d faced since Billy had been a child, from temper tantrums to school trouble to physical aggression. A year ago, in fact, Billy became violent with Sonia, who called the police and voluntarily placed Billy under the care of Child Protective Services.

When my team and I met Billy for the first time with his parents, he shared some striking insights. “My mom just doesn’t understand who I am. She says I need to wait to be 18 years old to be me. I say that’s too late! It’s already happened. I’m already me!” Tilting his head as if posing for a sassy photo shoot, he added, “I think my mom is struggling with me being a princess. But she’s a princess, too. That’s why we’re here.”

“What kind of language is that, Billy?!” erupted Sonia. “You see, that’s exactly what I have to deal with and why he gets in trouble everywhere.” Clearly, Billy was an exuberant and expressive child, and those qualities made Sonia anxious for him and his future.

“There are many princesses in my family, and not just girls!” Billy said when his parents were out of the room. We threw a large piece of paper on the rug and a bunch of colored sharpies and offered to draw a family tree with him. “My mother, my aunt, my grandmother, and my grandfather on my mother’s side are all princesses in different ways,” he began. “They’re strong people and they know what they want. But my aunt is the most fabulous. I love her dresses!”

Billy was proudly referring to his family’s resilience and strength. He associated femininity with power, and he believed that men could be princesses, forces to be reckoned with in this world. In contrast, Sonia and Sean explained that for them, princess was a pejorative word, and an 11-year old boy shouldn’t be calling himself one. They also felt that Billy’s behavior was overly sexual and he needed to “keep it a little cooler.”

In the following session, we tried to convey Sonia’s dilemma to Billy. “Do you think she might be able to accept you for who you are if you reassure her a little bit?” I asked. “She knows you’re passionate about dancing and pop music and strong women, but she’s afraid you could get in trouble and that things could be unsafe for you. Maybe if she felt you respected her advice as a mom, she’d be able to hear your requests a bit better?”

Billy paused for a moment to consider it then declared, “If she gives me ‘accept,’ I’ll give her ‘respect.’”

Again, we seemed stuck in a pattern of escalation where neither parent nor child was willing to take the one-down position. To Sonia and Sean, raising a strong black man included teaching appropriate respect for authority and an urgent fear of racist or transphobic violence, both inside and outside their community. For his part, Billy could only see parents who didn’t understand him and his joyful femininity. Sadly, he shared with us that he wanted to leave home. “I want to be placed outside,” he said. “At least there I can be me.”

A couple of weeks later, Sonia called to cancel our next session. Billy had been placed in a residential home. “I think it’s probably better for all of us,” she said, sounding exhausted and resigned. As in Erik and Pat’s situation, the combination of parental resistance and a child’s escalating urgency had made it impossible to shift from conflict to connection.


Parents Speak

Last September, I facilitated the first parent group of the school year. Forming an enormous circle in the Ackerman Institute’s largest meeting space, 45 parents of gender-expansive or transgender preteens assembled. Looking around the room, I saw all ages, races, genders, and sexual orientations. Many longtime members were noisily and happily reconnecting with old friends, while others were warmly greeting wide-eyed newcomers.

“Welcome, everyone!” I shouted over the din. “Since our group is welcoming quite a few new families today, I thought we’d go around the circle and introduce ourselves. Maybe say a word about what brings you here, or something about what this community means to you.”

The room went silent. Then, to my pleasant surprise, Ray spoke up. “Well, I’m gonna start with a contradiction,” he said. “In a way, this space has helped me understand that it’s all about me, and at the same time, that it’s not about me at all.” He took a breath. “It’s all about me because I’m a father of a transgender girl and I discovered that I had to develop my own gender identity as a cisgender dad to be able to help her. But it’s not about me because the most important lesson I’ve learned is that I can’t make or break my child’s gender identity.”

Many heads nodded in recognition. “That was the hardest part for me,” he continued. “I really thought I’d done something wrong, that it was my fault or that it’d be totally irresponsible to let Lila dress as a girl and transition at school. I just couldn’t accept it. To be honest, I feared I might not be able to come around and would have to leave Maria and Lila. What was I going to do? Accept my daughter and throw her into a life of hardship? Repress her and watch her suffer until she could leave us? I felt like every option was doomed. And then I read an article about a young trans woman who’d committed suicide. She’d left home at 14 because her parents hadn’t accepted her. It just stopped me in my tracks. “I thought, no, no, this is not going to happen to Lila. I’m not gonna be that dad!” Ray’s voice broke.

Maria took her husband’s hand. “It’s not in my control who Lila is and who she’s going to be,” she said. “But I’m still her mother, and I still need to make decisions and protect her. She’s almost 13 now, and if it was up to her, she’d be wearing gowns instead of skirts to school. No, thank you! She still needs some guidance!” A wave of laughter erupted. “But she guided us first to know who she was.”

Beatrice, the mother of a 10-year-old transgender boy, spoke up. “You all have also helped me accept that being transgender isn’t a disease,” she said. “When I came here two years ago, I thought we needed treatment to fix Troy. But the group helped me understand that Troy was actually doing great. I was the one in crisis!” She rolled her eyes a little and smiled.

“As a lesbian woman and a mother,” Cindy followed, “I’ve always known there were many possible identities in life, right? But Peter, my 6-year-old gender-fluid son, reminds me every day that even gender is this web, this spectrum of different ways to be human. It’s ironic, really. As a pretty butch person myself, I kinda know this, but Peter really brought the point home.”

I was observing the tone of the group. The longtime members had clearly started on a light note, creating a sense of cohesion and making sure not to scare the newcomers. I also knew this celebratory mood was sure to shift.

“Yeah, I get that intellectually,” responded Mark, a member since 2010. “We’re all different and gender is diverse and all that.” He looked pained. “When we got here five years ago, we were in crisis. All of a sudden, my 14-year-old boy was a girl and needed hormones and a dress, and I hate to say this, but I was freaked out. I didn’t recognize my child. I felt like I had to get to know a stranger all over again.”

More heads nodded quietly. “Thank you, Mark, for keeping us real here,” I said. “When I think about when each of you initially entered the project, I’d say that many of your families were going through a crisis of belonging. As a family, we feel that we belong together. And one of the ways we do it is based on this assumption that we share a lot in common, including being cisgender. Gender diversity brings in a sense of otherness that we have to become acquainted with, become less afraid of.” I looked around the circle. “Does that make sense?”

“It does,” said Laura, the mother of a 12-year-old boy who’d socially transitioned last year. “I felt like my family had been broken, but I couldn’t say it to anyone. I felt so unequipped to raise a child I didn’t understand. I was like, ‘How am I gonna keep my child safe and know what to do? My ex-husband and I were fighting about it, and I felt so lonely,” she said. “And then I came here and began to get to know my child again through your stories, through recognizing my fears in your fears. I needed to talk to other folks and make mistakes, learn the language, and know what I could do as a mom—as an ally, really.”

Most of these parents had arrived here as pioneers, some never having heard the word transgender or cisgender before, all of them hacking their way through a wilderness of confusion, panic, and shame. As we worked together, they slowly began to understand—and act on—what we’ve found to be three essential elements of healing. First, follow your child’s lead. If your daughter says, “I’m a boy” persistently, you’ve heard the truth. For many parents, understanding this comes as an enormous relief. The endless inner questions—What should I do? Try to change him? Hope she’ll grow out of it? Refuse to talk about it at all?—fall away. The work is acceptance.

Second, there’s no pathology here. Your child isn’t disordered, doesn’t have a disability, doesn’t need treatment for being transgender. However, your child may need therapeutic support for anxiety, depression, or other difficulties that come with the challenges of trying to live outside prescribed pink and blue boxes. As a parent, you may need professional support, too. But there’s no underlying condition to treat. Fundamentally, your child is fine. So are you.

Third, we need each other. Gender-diverse kids and their parents need to belong to a community of folks who truly get who we are, share some of our struggles, and genuinely care for us. By now, “community” as a cultural prescription has become so familiar that it’s in danger of losing its meaning. We need to wake up and hear it freshly. Especially for those who are wrongly made to feel deviant and repugnant for who they are, a validating peer group is more than just a helpful accompaniment to therapy: it’s a first-line, essential element of healing.

As I looked around the circle to see who wanted to speak next, I flashed on a photo of me as a kid, wearing a blanket on my head to pretend I had long hair. I’m deeply moved by these parents’ devotion and their commitment to becoming their children’s allies so they won’t have to face the challenges that lie ahead on their own. The 5-year-old boy inside me is in awe. He never imagined it possible to feel free to express his forbidden feelings about gender fluidity outside the dark closet of secrecy, let alone be surrounded by a whole tribe of friends and allies. At this moment, I realize that what was once unimaginable is now happening right in front of me.


Jean Malpas

Jean Malpas, LMFT, LMHC, is the director of the Gender & Family Project and director of international training at the Ackerman Institute for the Family. He maintains a private practice in New York City. Visit his website.