Transgender and Gender Diverse Children: Considerations for Affirmative Social Work Practice

Abstract

Given growing public awareness about transgender and gender diverse identities, it is expected that greater numbers of children and families will seek mental health and social services, including transition-related services, from social workers and other mental health professionals. Transgender and gender diverse children have a range of transition-related needs which require the support of informed practitioners with transgender and gender diverse-specific knowledge and skills. Moreover, the needs and experiences of families and caregivers of transgender and gender diverse children will vary greatly. To date, research suggests a paucity of transgender and gender diverse-specific expertise among social workers and other mental health providers; this seems particularly evident with respect to the needs of transgender and gender diverse children. An affirmative practice framework to guide therapeutic work with transgender and gender diverse children and families is presented. In addition, key clinical practice considerations associated with engagement, assessment, psychoeducation, support and referral are provided. Finally, clinical examples illustrating use of the affirmative practice approach with transgender and gender diverse children are provided.

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Child Adolesc Soc Work J
DOI 10.1007/s10560-017-0507-3
Transgender andGender Diverse Children: Considerations
forAffirmative Social Work Practice
AshleyAustin1
© Springer Science+Business Media, LLC 2017
Introduction
With the advent of many high profile transgender indi-
viduals coming out and sharing their stories in the media
(e.g., Caitlyn Jenner, Jazz Jennings, Chris Mosier), public
awareness of transgender and gender diverse (TGD) iden-
tities and experiences has grown significantly in recent
years. However, understanding of contemporary transgen-
der experiences is neither nuanced nor comprehensive.
Rather, there remains a lack of awareness about transgen-
der-specific experiences among the general public, as well
as among social service, health, and mental health care
providers (Shipherd, Green, & Abromovitz, 2014). This is
particularly true with respect to TGD youth (Gridley etal.,
2016) seeking services. Given the disproportionate mental
health risks experiences by TGD youth (Cohen-Kettenis,
Owen, Kaijser, Bradley, & Zucker, 2003; Yunger, Carver,
& Perry, 2004) and the likelihood that affirmative inter-
ventions can mitigate these risks, it is critical that social
workers develop the knowledge and clinical skills to work
affirmatively with TGD youth. In this paper I will address
these gaps in the social work literature in the following
ways. I will present an overview of extant research contrib-
uting to our contemporary understanding of TGD identities
and experiences, as well as research defining best (affirma-
tive) practices for working with TGD children. I will then
offer practice recommendations for engaging in affirmative
social work practice with TGD children and their caregiv-
ers. Finally, clinical examples illustrating affirmative clini-
cal social work practice with TGD children with distinct
needs will be provided. I use the term TGD to refer to all
children whose gender identity or expression differs from
binary societal or cultural expectations associated with
assigned sex at birth. A conceptualization of gender that
Abstract Given growing public awareness about
transgender and gender diverse identities, it is expected that
greater numbers of children and families will seek men-
tal health and social services, including transition-related
services, from social workers and other mental health pro-
fessionals. Transgender and gender diverse children have
a range of transition-related needs which require the sup-
port of informed practitioners with transgender and gender
diverse-specific knowledge and skills. Moreover, the needs
and experiences of families and caregivers of transgen-
der and gender diverse children will vary greatly. To date,
research suggests a paucity of transgender and gender
diverse-specific expertise among social workers and other
mental health providers; this seems particularly evident
with respect to the needs of transgender and gender diverse
children. An affirmative practice framework to guide thera-
peutic work with transgender and gender diverse children
and families is presented. In addition, key clinical practice
considerations associated with engagement, assessment,
psychoeducation, support and referral are provided. Finally,
clinical examples illustrating use of the affirmative practice
approach with transgender and gender diverse children are
provided.
Keywords Transgender· Affirmative· Gender diverse·
Child· Transition· Health
* Ashley Austin
Aaustin@barry.edu
1 Barry University School ofSocial Work, 11300 NE 2nd
Avenue, MiamiShores, FL33161, USA

A.Austin
1 3
is multidimensional is recommended to replace current
binary conceptions of gender.
Transgender andGender Diverse Identities
inChildhood
The mental health and healthcare needs of TGD children
exists in a developmental context of emergent and fluid
experiences of gender and may vary considerably based
on many factors. A clear and considered understanding of
gender identity development including the range of gender
experiences among children, and associated terminology,
is a pre-requisite for informed discussions of TGD specific
health and social service needs. As such, I will provide a
brief overview of these concepts. Biological sex refers to
biological and physical anatomy and is used to assign gen-
der at birth while gender identity refers to the attitudes,
feelings, and behaviors that are associated with an individu-
als’ innermost sense of self as male, female, both or neither.
Most individuals develop a gender identity that aligns with
their biological sex, however for others, gender identity and
biological sex (sex assigned at birth) do not match.
It is becoming increasingly clear gender is not a binary
concept (either male or female). Recent data from the 2015
Report of the United States Transgender Survey (USTS),
the largest study to date of transgender adults (N = 27,715)
found that over one-third (36%) of participants embrace a
non-binary gender identity (James etal., 2016). Examples
of gender identities beyond the male/female binary include,
but are certainly not limited to, agender, bigender, gender-
queer, gender creative, genderfluid, gender expansive, gen-
der neutral, and transgender (see Austin etal., 2016 for a
glossary of terms). Terms such as genderfluid and gender
creative convey a broad, flexible range of gender expres-
sion. Individuals with these identities may have interests
and behave in a manner not limited by restrictive bounda-
ries of expectations of girls or boys. Moreover, genderfluid-
ity may suggest that individuals experience themselves as
both a boy and a girl at the same time. For these children
gender identity may vary from day to day or across circum-
stances and neither “boy” nor “girl” describes them accu-
rately (Ehrensaft, 2016; Graham etal., 2011).
According the American Pediatric Association (2015),
awareness of gender identity (e.g., male, female, other)
occurs relatively young, as children can typically identify
themselves as boys or girls by age 3 and gender identity is
generally stable by age 4. However, as a result of limited
and somewhat questionable data on TGD youth, there is
no consensus regarding stability of TGD identities among
children and teens. For instance, while some research has
suggested that a transgender identity did not persist for the
majority of children presenting for care associated with
gender non-conforming behaviors/identities (Levine, 2013;
Zucker, 2010). However, several factors suggest that this
research is flawed and may vastly underestimate the stabil-
ity of TGD identities among children and teens including
(1) skewed research processes, the likelihood that most
study participants did not actually have TGD identities at
the start of the study, as well as the possibility that par-
ticipants, as a result of the implicit and explicit pressure
to conform to gender-normative behavioral expectations
associated with biological sex, were reluctant to share per-
sisting experiences of gender dysphoria (Ehrensaft, 2016;
Olson, 2016; SAMHSA, 2015).
To date, the correlates of persisting (stability of TGD
identity into adolescence and adulthood) or desisting (TGD
feelings/experiences dissipate as a child approaches adoles-
cence) gender non-conformity remain unknown (Levine,
2013), but emerging research suggests a complex inter-
play between biological, environmental and psychological
factors (Steensma, Kreukels, deVries, & Cohen-Kettnis,
2013). Research suggests that stability of TGD identities
is more likely for children whose gender dysphoria (emo-
tional distress associated with a gender identity that is not
aligned with biological sex) is more severe and whose
cross-gender identity and expressions of self (e.g., play,
activities, appearance,) are insistent, persistent, and con-
sistent across time, circumstance, or developmental stage
(Forcier & Haddad, 2013). In addition, it appears that TGD
children who believe themselves to be the “other” gender
rather than wishing they were the “other” gender may dis-
tinguish persisters from desisters (Steensma, McGuire,
Kreukels, Beekman, & Cohen-Kettenis, 2013). Never-
theless, existing data suggests that gender dysphoria that
arises during childhood and intensifies during adolescence
is very unlikely to abate, and that TGD identification dur-
ing puberty (10–12 for natal females and 12–14 for natal
males) is likely to remain throughout the lifespan (Spack
et al., 2011; Steensma, Kreukels et al., 2013, Steensma,
McGuire etal., 2013).
Importantly, many studies have primarily focused on
TGD children with binary transgender experiences. Bur-
geoning clinical experience and research data suggest nota-
ble within-group diversity among TGD individuals (Ehren-
saft, 2016; James et al., 2016) highlighting the possibility
of an array of identity-related developmental trajectories
for TGD children and teens. As practitioners and theorists
continue to produce work which enriches our understand-
ing and knowledge about the emergence of gender identity
among children (Ehrensaft, 2016), it becomes clear that
existing frameworks for discussing gender awareness and
stability may not be adequate. Because existing frameworks
are rooted in cisgender, binary conceptions of gender, they
fail to account for the reality of non-binary, fluid and evolv-
ing experiences of gender identity and expression. This is

Transgender andGender Diverse Children: Considerations forAffirmative Social Work Practice
1 3
an area which requires further attention in research and
clinical practice with TGD children.
Considerations inTransition‑Related Care
forTGD Children
As the diversity of TGD identities and experiences is
acknowledged, along with the recognition that identity
emergence is an evolutionary process, it is important to
consider the corresponding variation in transition-related
needs among TGD youth across development phases. I
recommend that an inclusive and flexible understand-
ing of transition-related services should be embraced. For
instance, a useful definition of transitioning is: the pro-
cesses (social, legal, and/or physical) of modifying one’s
external indicators of gender (e.g., name, behavior, expres-
sion and/or body) to more accurately reflect one’s gender
identity. This conceptualization of transitioning focuses on
various processes associated with living authentically, cre-
ating room for both binary (e.g., male to female, female to
male) and non-binary (e.g., female to genderqueer, male to
gender creative) transitions. As such, for some non-binary
TGD children changing their name (e.g., Sabrina to Sam),
personal pronouns (e.g., she/her/hers to they/them/theirs),
hair and clothing (e.g., gender neutral style) may represent
a sufficient transition. For other TGD youth a transition
that includes physical changes (e.g., hair, clothing, acces-
sories), medical intervention (e.g., hormones and even-
tually surgery) as well as, legal components (e.g., name,
gender marker and document changes) may be necessary to
achieve a sense of alignment.
While the importance of transitioning for adults has
been recognized in activist, medical, mental health, and
social work communities for decades, mounting empiri-
cal research indicates the positive impact of social, medi-
cal, and legal aspects of transitioning on mental health and
overall wellbeing among transgender children (Ehrensaft,
2016; Olson, Durwood, DeMeules, & McLaughlin, 2016)
and teens (Simons, Schrager, Clark, Belzer, & Olson, 2013;
Tishelman etal., 2015). Olson et al. (2016) conducted the
first study of prepubescent, transgender children (n = 73)
who were supported in their social transitions and found
evidence of positive mental health outcomes similar to
those of their cisgender counterparts (n = 73). Similarly, a
study exploring parental support for TGD youths’ medical
transitions indicated that increased transition-related sup-
port was associated with lower rates of depression and bet-
ter quality of life among (Simons etal., 2013). Given previ-
ous research demonstrating elevated rates of mental health
problems among TGD youth (Cohen-Kettenis etal., 2003;
Yunger etal., 2004), these studies provide important sup-
port for transition-related care for TGD youth.
The timeline for transition-related medical care among
youth is often determined by developmental factors. For
example, while reversible pubertal suppression (i.e., hor-
mone blockers) is identified as an important and often criti-
cal medical intervention for TGD youth, this intervention
must be initiated during but not prior to onset of puberty
(Hembree et al., 2009; Spack et al., 2011). Importantly,
this often requires the development of relationships with
TGD competent mental health providers (to provide gender
assessments and letters of support) and pediatric endocri-
nologists well before the onset of puberty. For adolescents
interested in transitioning physically, hormone therapy
to regulate pubertal development of the desired gender
is often a primary need; this intervention can be initiated
during adolescence, but never prior to pubertal onset.
The recommended age for hormone initiation has been
16 years old (Edwards-Leeper & Spack, 2012; Hembree
etal., 2009), however this varies by provider. In fact, with
growing evidence demonstrating the positive mental health
impact of transition-related care for children and youth
(Olson etal., 2016) and the negative mental health conse-
quences of delaying transition-related treatment, including
pubertal blockers and subsequent cross-sex hormones (de
Vries, Doreleijers, Steensma, & Cohen-Kettenis, 2011),
providers are recognizing the importance of early interven-
tion (Forcier & Haddad, 2013). As such, social workers and
other mental health care providers must be prepared to pro-
vide the necessary support and services to TGD youth and
families in need of transition-related care.
The Practice Context forTGD Children
Barriers toAffirmative Care forTGD Children
While safe and identity-affirming clinical services can be
pivotal in supporting the long-term health and well-being
of TGD youth (Forcier & Haddad, 2013; Olson, 2016;
Simons et al., 2013), at present few eligible TGD youth
receive the support or transition-related care they need
(Gridley et al., 2016). In fact, research suggests multiple
and pervasive barriers to TGD affirmative care. Affirma-
tive care refers to a non-pathologizing approach to practice
which accepts and validates all (binary and non-binary)
experiences of gender. Providers engaging in affirmative
care support each child as they strive to openly express and
embody their authentic gender.
Barriers to affirming care may include overt bias, lack of
practitioner knowledge regarding TGD-specific healthcare
needs, and structural oppression toward TGD clients in
healthcare systems (Grant etal., 2011; Gridley etal., 2016;
James etal., 2016; Shipherd etal., 2014). A recent qualita-
tive study of TGD youth (n = 15) and caregivers (n = 50),

A.Austin
1 3
conducted by Gridley etal. (2016) found the following six
specific barriers to TGD affirmative care for youth: (1) few
accessible pediatric providers are trained in gender-affirm-
ing health care; (2) lack of consistently applied protocols;
(3) inconsistent use of chosen name/pronoun; (4) uncoor-
dinated care and gatekeeping; (5) limited/delayed access to
pubertal blockers and cross-sex hormones; and (6) insur-
ance exclusions.
These barriers likely reflect several factors. Knowledge
about and attention to TGD identities has grown exponen-
tially over the last decade, well after many practitioners
were trained. Moreover, evidence suggests graduate pro-
grams do not adequately train students to work affirma-
tively with TGD youth. For instance, research indicates
that social work programs dedicate very little attention to
transgender issues in their curricula (Austin, Craig, & McI-
nroy, 2016), resulting in graduating practitioners unpre-
pared to engage in affirmative practice. It is also important
to recognize that until 2013, when changes were made to
the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) (American Psychiatric Association, 2013), indi-
viduals of transgender experience were classified in the
DSM-IV with a mental disorder known as gender identity
disorder (American Psychiatric Association, 2000). This
pathologizing framework for understanding transgen-
der identities and engaging in clinical practice with TGD
individuals continues to impact TGD clients’ access to
informed and supportive care which facilitates (rather than
impedes) access to transition-related care.
Children with non-conforming experiences of gender
continue to be pathologized or have their experiences of
gender minimized by parents and providers. Children often
receive treatments which reject their true experience or
expression of gender, discouraging them from living in a
manner consistent with their gender identity. Instead TGD
children are often coerced to present and behave in a man-
ner consistent with binary gender norms associated with
their anatomical sex (Spiegel, 2008). In fact, the utilization
of pathologizing “reparative” approaches has been per-
petuated by some of the most well-known and widely cited
professionals working with TGD children (Spiegel, 2008;
Zucker, & Bradley, 2005). Such practices are contrary to
interdisciplinary practice guidelines (APA, 2000; NASW,
2015; SAMHSA, 2015) which repudiate all coercive men-
tal health and health care practices targeting sexual and
gender minority identity and expression among youth.
Furthermore, it should be noted that in 2015 Dr. Zucker
was dismissed from his position as the medical direc-
tor of Child Youth and Family Gender Identity Clinic in
Toronto as officials investigate and reconsider their recom-
mended practices (which have been equated with reparative
therapy) for intervening with TGD children (Beyer, 2015;
Singal, 2016). Although not without controversy, Zucker’s
dismissal and the clinic’s closure came as a relief to many
affirmative practitioners, researchers and transgender activ-
ists concerned about the wellbeing of TGD children (Beyer,
2015). At present six states in the U.S. (California, Illinois,
New Jersey, New Mexico, Oregon, Vermont) as well as the
District of Columbia have laws which ban conversion ther-
apy for minors and advocacy efforts aim to add more to this
list (Movement Advancement Project, 2017).
The Role ofSocial Workers inPromoting TGD
Affirmative Care
Affirmative approaches to social work with TGD children,
teens, and adults are markedly different than damaging and
unethical practices which try to change sexual orientation
and gender identity. Affirmative practices, which support
and validate the identities, strengths, and experiences of
TGD populations are increasingly important in the provider
landscape (Craig & Austin, 2017; Ehrensaft, 2016; Seve-
lius, 2013). Such interventions can counter experiences of
transphobic stigma and/or bullying and promote the health
and wellbeing of TGD individuals (Austin & Craig, 2015;
Craig, Austin, & Alessi, 2012; Crisp & McCave, 2007).
Moreover, a TGD affirmative framework is consistent with
core social work values, in particular those which foster
integrity, uphold dignity and worth of the person, and pro-
mote social justice (NASW, 2008). In addition to embrac-
ing an overarching approach to TGD identities that is vali-
dating, inclusive, and supportive, TGD affirmative practice
requires TGD-specific competency in areas of particular
relevance to TGD youth wellbeing, specifically, engage-
ment, clinical assessment, support, and linkage.
Creating aTGD Affirming Clinical Context
A social worker may be among the first points of contact
for families as they attempt to identify and understand their
children’s TGD identities and experiences. As such, the
adoption of an affirming clinical position which acknowl-
edges the diversity of gender and provides unconditional
positive regard for all gender identities and expressions is
critical (Austin & Craig, 2015). Affirmative social work
practice must acknowledge and counter the oppressive
contexts in which children and families may have previ-
ously experienced services by creating an affirmative cul-
ture at the onset of the clinical relationship (Craig et al.,
2012; Craig & Austin, 2017). At the organizational level,
attending to structural and policy-related components of
the therapeutic environment is necessary. Social work prac-
titioners should consider creating visibly affirming offices
by including posters, brochures, and children’s and parents’
books that embrace diverse TGD identities. In addition,
the use of inclusive intake/referral forms that allow for the

Transgender andGender Diverse Children: Considerations forAffirmative Social Work Practice
1 3
use of chosen names, as well as, a diverse and inclusive
range of gender identity options is recommended (Levine,
2013). Practitioners should ensure that TGD youth can take
part in programming based on gender identity rather than
assigned sex at birth (e.g., support groups consistent with
gender identity). Similarly, practitioners should replace sex
segregated spaces with gender inclusive spaces whenever
possible (e.g., gender neutral restrooms). Finally, adopting
agency and organizational policies that prohibit identity-
based discrimination against clients and staff contributes to
an organizational culture that values and supports affirma-
tive care.
At the clinical practice level an important first step
toward helping children and families overcome reticence
or distrust is to establish a gender inclusive stance dur-
ing the first session. Doing so in clear, uncertain terms is
important. Table1 provides examples for TGD affirmative
communication with both TGD children and their caregiv-
ers. Allowing children to self-identify is important to estab-
lishing an affirmative context and building rapport early
on. Clearly explaining the social work practitioner’s role as
collaborator, rather than driver of the therapeutic process
and resulting outcomes, can empower TGD children and
families and increase their trust. Finally, demonstrating a
client-centered approach that acknowledges the child as the
expert of her/his/their own experiences of gender is a key to
creating a safe and affirming therapeutic setting (Ehrensaft,
2016). This approach has been described as facilitating
“the child’s authentic gender journey” (Ehrensaft, 2012,
p.339), allowing the child to drive the process of identity
emergence and expression in a manner consistent with
their developmental stage (early childhood, pre-puberty,
adolescence). The benefits of a client-centered approach to
TGD affirmative practice for promoting child wellbeing are
deftly described in the ensuing quote by Ehrensaft (2012).
Repeatedly, the children I work with tell me, in words
and actions, that when allowed to express their gen-
der as they feel it rather than as others dictate it, they
become enlivened and engaged; when prohibited
from that expression, they show symptoms of anxiety,
stress, distress, anger, and depression (p.338).
Conducting aTGD Affirmative Assessment
Explore Gender Experiences The DSM-5 (American
Psychiatric Association, 2013) provides for an overarching
diagnosis of gender dysphoria with specific criteria for chil-
dren that differ from the criteria for adolescents and adults
(See Table2). While a diagnosis of gender dysphoria may
be important for guiding some aspects of care (e.g., making
decisions about social and/or medical transitioning) and/or
getting services covered by insurance, it is not designed to
elucidate the full array of gender diverse experiences among
children. As such, I recommend engaging in a comprehen-
sive gender assessment aimed at gathering a complete and
nuanced understanding of each TGD child’s unique experi-
ence.
Assessments for TGD children include careful and
thorough exploration of a range of gender identity related
experiences. Screening questions should be developmen-
tally appropriate for exploring TGD identity and experi-
ences among children of all ages (Sherer, Baum, Ehren-
saft, & Rosenthal, 2015). As some children, particularly
those younger in age, communicate better through drawing
or art (Landreth, 2012; Oaklander, 1988), it may be help-
ful to integrate art into the gender assessment process as
well. Verbal responses, as well as pictures can be used to
facilitate understanding of each child’s gender identity and
gender-related experiences in the world. In Table 3 I pro-
vide examples of important assessment domains, as well as
sample questions associated with each domain.
Flexibly employing methods that facilitate client expres-
sion and articulation of gender experiences, practitioners
should assess gender identity across several dimensions.
Specifically, practitioners need to: tune in to each child’s
articulation of their gender identity (non-binary and binary
expressions); listen for the child’s expressions of being
versus wishing (e.g. I am a girl versus I wish I was a girl
because things would be easier); attend to distinctions
between cross-gender interests and play (e.g., liking boy
toys and games) versus TGD identification (e.g., I play with
boy toys because I am a boy); evaluate for the existence of
gender dysphoria using DSM-5 criteria; explore the ways in
which the child would like to present to others (be seen and
recognized by); and note the importance of being perceived
“accurately” by others for the child (Bockting, Knudson, &
Goldberg, 2006; Forcier & Haddad, 2013). It is critical to
recognize that there is no typical or single way in which
a child presents as TGD, so an affirming an comprehen-
sive assessment should focus on trying to understand each
child’s authentic experience of gender as well as what each
child needs to feel supported and affirmed in that identity.
Explore Experiences of Transphobic Stigma and/or Bul‑
lying Assessment clarifies the client’s needs and experi-
ences, as well as informs the direction of the therapeutic
work. Considering the deleterious impact of anti-transgen-
der discrimination and the accompanying minority stress on
mental health outcomes (D’Augelli, Grossman, & Starks,
2006; Goldblum et al., 2012; Toomey, Ryan, Diaz, Card,
& Russell, 2010), it is imperative that social work practi-
tioners assess for discrimination and anti-TGD messaging in
the lives of TGD individuals (Austin & Craig, 2015; Austin,
Craig, & Alessi, 2017; Craig etal., 2012; Langdridge, 2007).
Instead of waiting for TGD youth to disclose experiences of

A.Austin
1 3
Table 1 TGD Affirmative communication with children and caregivers
Topic Child Caregiver
Create a welcoming and gender inclusive context during the
first session
Welcome, I want to let you know that we work with many
children here, including some children who feel a little bit
different than other boys or girls their age. For example,
some kids feel like girls, boys, both, or something else. What
would you like me to know about you?
Welcome, I want to let you know that we work with children
across the spectrum of gender identities, expressions and
experiences. What is important that I know and understand
about your child?
Encouraging self-identification Hello, my name is Dr. Ashley Austin, but I like to be called
Ashley, what would you like me to call you during our time
together
It is important that your child feel as comfortable as possible
while in these sessions, part of that includes being called the
name and gender pronouns that fit for them
Adopt and share a TGD affirming clinical position I want you to know that I believe that any way that you experi-
ence being a girl, boy, or something else is absolutely ok.
Everyone experiences their gender in unique and special
ways. I will not pressure you to act in any way that is not
comfortable to you
Like many children, your child is still understanding their own
identities around gender. It is best to remain open to these
explorations and the evolution of their emerging identity.
If you find this difficult to do, I can provide support and
resources that you might find helpful
Clearly explaining the practitioner’s role As your practitioner, I am here to learn more about you so that
I can help you to feel more safe and comfortable expressing
yourself—as a boy, girl, both, or something else. Part of this
might include helping the grown-ups in your life, parents,
grandparents, teachers, doctors, learn how to support you
better
As your child’s practitioner, I am here to learn more about
your child so that I can help them feel safe and comfort-
able identifying and expressing their gender identity—as a
boy, girl, both, or something else. Part of this process might
include helping you navigate this journey, as well as providing
any necessary advocacy related to garnering support from the
other folks in your child’s life (e.g., grandparents, teachers,
doctors)
Demonstrating a client-centered approach that acknowledges
the child as the expert of her/his/their own life and experi-
ences
I have worked with many kids and families, and everyone is
different. You are the expert on your own feelings and expe-
riences. The more I learn about your unique experiences and
needs, the better I will be able to help you
While I have worked with many kids and families, every child
is different. You and your child are the experts on your own
family’s needs and experiences. The more I learn about your
child’s unique experiences of gender and their expressed
needs, as well as your needs as parents, the better able I will
be to provide the specific guidance and services necessary to
support each of you through this process
Encourage open expression of identity-based discrimination
and/or negative messages about being TGD
Sometimes kids I work with hear people say things that are
not very nice about TGD people (or about people who dress
or behave in a way that may be different than what they are
used to). That can make us feel pretty upset. Have you heard
anyone say things like this? If so, would you mind telling me
a little bit about it?
Sometimes families of TGD children are exposed to anti-
transgender attitudes, beliefs, and behaviors from individuals
in their personal, social, religious, and work lives which can
be very difficult. Is this something you have had to deal with?

Transgender andGender Diverse Children: Considerations forAffirmative Social Work Practice
1 3
victimization, bullying or marginalization, these should be
standardized components of a TGD affirmative assessment
(See Table3). As with other components of assessment, it
may be helpful to allow younger clients to use art to express
their experiences with bullying. Part of affirmative assess-
ment is validating clients’ self-reported experiences of dis-
crimination. For example, when a child reports an incident
of discrimination, the practitioner should not automatically
universalize it (e.g., all kids have a hard time getting along
with their classmates), search for alternative reasons for
the bully’s behavior (e.g., doesn’t he tease everyone?), or
blame the child (e.g., perhaps you are being overly sensi-
tive). Instead, an affirming and validating response should
be provided (e.g., he is using your old name to tease you; it
really hurts). It is critical to not dismiss the discrimination
or accept it. It is important to let the child know that you are
sorry it is happening and they are not to blame.
Identify Needs forTransition‑Related Care Given the
range of transition-related services (social, medical,
and legal) that may be relevant and necessary for TGD
youth, it is important that the social worker be able to
adequately explore the child’s individual needs as well as
the family’s level of awareness about and understanding
of these services. It is important that assessment ques-
tions be asked in a normalizing and nonjudgmental man-
ner. TGD children and their family members may inter-
face with many health care providers (e.g., primary care,
school nurse, endocrinologist) and other professionals
(e.g., school administrators, religious leaders) with vary-
Table 2 DSM 5 criteria for a
diagnosis of gender dysphoria
in children
A gender dysphoria diagnosis for children requires at least six of the above criteria and an associated sig-
nificant impairment in function, lasting a minimum of 6months
1 A strong desire to be of the other gender or an insistence that one is the other gender
2 A strong preference for wearing clothes typical of the opposite gender
3 A strong preference for cross-gender roles in make-believe play or fantasy play
4 A strong preference for the toys, games or activities stereotypically used or engaged in
by the other gender
5 A strong preference for playmates of the other gender
6 A strong rejection of toys, games and activities typical of one’s assigned gender
7 A strong dislike of one’s sexual anatomy
8 A strong desire for the physical sex characteristics that match one’s experienced gender
Table 3 TGD affirmative assessment domains
Topic Examples
Explore TGD identity and experiences 1. Some clients wonder if they are more like a girl or boy or something else on
the inside. What has it been like for you?
2. Do you ever feel the people around you have got it wrong about you being a
boy?/girl? Can you tell me about that?
3. Can you draw/paint a picture of how you see yourself?
Explore how TGD clients would like to be perceived by others 1. How would you like other people (family, friends, teachers, strangers) to see
you?
2. Can you draw a picture/paint of how you would like to be seen by others?
Explore preferences for clothing and hairstyle 1. What kinds of clothes or outfits do you like? Do you have a favorite outfit?
What’s so special about it?
2. How do you like to wear your hair? Do you like it now? Or do you wish it
were different in some way? How?
Explore play preferences 1. What kinds of games do you like to play?
2. When you play pretend, who is your favorite character to play?
3. Can you draw me a picture of you playing with your favorite toys?
Explore thoughts and/or hopes about future self 1. What do you imagine you will be like when you grow up?
2. When you imagine your future, what do you hope it will be like?
3. Can you draw me a picture of yourself in the future?
Explore experiences with stigma or discrimination related to
expressed gender identity
1. Has anyone made fun you for the clothes you like to wear or the games you
like to play? Can you tell me about this?
2. Some clients tell me about other kids or adults who bully or pick on them. Is
this something that has ever happened to you?
3. Can you draw me a picture of what it was like for you that day?
4. Can you draw a picture of how that experience made feel?

A.Austin
1 3
ing levels of trans-specific knowledge and compassion.
Having an informed social worker serve as an affirma-
tive source of support while exploring and/or processing
challenging experiences is beneficial.
With younger children, the social transition is often
the most immediate area of concern. The assessment
may include an exploration of the following issues (both
what is happening currently and how they wish things
could be): clothing, hairstyle, pronouns, name, bedroom
and toys, as well as extracurricular activities (e.g., bal-
let versus football, or playing on the girls’ soccer team
versus the boys’ soccer team). Once the child has been
able to express their needs, it is important to explore any
caregiver ambivalence about the child’s social transi-
tion, as well as needs for advocacy (e.g., working with
the school to ensure a safe and supportive climate for the
client; family sessions with grandparents to help them
understand the needs of TGD children).
Exploring the child’s and family’s feelings about and/
or plans related to legally changing the child’s name is
another important area of assessment. This may also be
an opportunity for psychoeducation. While not all fami-
lies will be ready to take this step during childhood (ver-
sus adolescence or adulthood), some will. Legal name
changes are often important to children who have already
socially transitioned and are living as their authentic
gender across all spheres of life. Legally changing a
child’s name to match his/her/their identity and gender
presentation can often make the child more comfortable
in school, recreation and medical settings where legal
names are documented and often called aloud. The use
of a child’s legal name and/or the incorrect pronouns
may feel like an emotional assault to TGD children and
can be a source of notable anxiety and distress.
Puberty can be a particularly distressing time for TGD
youth who may feel that their bodies are betraying them
by developing in the “wrong” direction. As puberty is
occurring earlier than ever (in some instances in children
as young as 7 or 8years old) (Sherer etal., 2015), it is
important that social workers explore transition-related
medical needs with young children and their caregiv-
ers. When exploring a child’s transition-related medi-
cal needs, it is important that the social worker be aware
of the developmental considerations (discussed above)
associated with various aspects of medically transition-
ing, the reversible (pubertal blockers) and non-reversi-
ble aspects of medically transitioning (e.g., hormone
therapy, surgeries) as well as current research associated
with medical transition-related care for children. More-
over, social workers should have a list of appropriate,
affirming medical providers (e.g., pediatric endocrinolo-
gists) to share with the family.
Providing TGD Affirming Family Education andSupport
Family acceptance and support for TGD identities and
transition-related care are increasingly recognized as key
contributing factors to positive development among TGD
children and teens (Olson et al., 2016; Ryan, Huebner,
Diaz, & Sanchez, 2009; Ryan, Russell, Huebner, Diaz,
& Sanchez, 2010; Simons et al., 2013). However, it is
well-established that many parents struggle (especially
initially) with their child’s TGD identity (Menvielle
& Rodnan, 2011) and are often ill informed regarding
best practices (Riley, Sitharthan, Clemson, & Diamond,
2013). As such, providing psychoeducational information
to parents is an integral component of helping families to
better accept and understand their children (Ryan et al.,
2009, 2010). Specifically, affirmative education might
include information about TGD identity development,
the spectrum of TGD identities, transition-related options
and resources, and the impact of family acceptance and
support on health outcomes (Riley et al., 2013; Ryan
etal., 2009, 2010). Exploring parents’ feelings of confu-
sion, shame, guilt, fear, and/or anger about their child’s
TGD identity and correcting any misconceptions are also
important tasks (Forcier & Haddad, 2013; Menvielle, &
Rodnan, 2011).
Many families can benefit from being connected with
others navigating similar experiences (Riley etal., 2013).
As such, social work practitioners should be aware of
local and national resources that offer support. Connect-
ing families with local chapters of the national advocacy
and support organizations PFLAG and Trans Youth Fam-
ily Allies can enable family members to learn from oth-
ers how to better support their child. Encouraging fami-
lies to find online information and support may also be
beneficial, such as directing parents of TGD children to
YouTube videos that document (1) stories of families
with TGD children (e.g., Whittington Family), (2) expe-
riences of TGD young people with a range of identities
and who fall within various stages of the transition pro-
cess (e.g., pre-hormone replacement therapy, changes
related to hormone usage, post-surgery), as well as (3)
narratives of nonbinary or agender youth. There are also
transgender specific websites and conferences that spe-
cifically provide support to family members of TGD chil-
dren (e.g., Genderspectrum, Gender Odyssey Family).
Research suggests that providing advocacy for families
is also an important role for the trans-affirmative social
worker, including offering support for families navigating
transition-related health services (Gridley etal., 2016) as
well as schools and other community organizations, such
as sports leagues, dance studios, or camps (Riley etal.,
2013).

Transgender andGender Diverse Children: Considerations forAffirmative Social Work Practice
1 3
Clinical Examples
There are several factors to attend to when striving to
engage in competent and affirmative clinical care with
TGD children and their families. When assessing a TGD
child’s clinical needs, it is important to consider the client’s
age and developmental stage, the persistence and consist-
ence of experiences of gender non-conformity, as well as
any social, cultural, or familial pressures to conform to
the behaviors, attitudes, and expressions associated with
assigned sex at birth. Moreover, TGD affirming practition-
ers must be aware of the importance of practicing from
a framework that acknowledges and affirms non-binary
experiences of gender, and helps adults support children’s
non-binary, fluid, and/or evolving expressions of gender
(Ehrehnsaft, 2016). The following clinical examples were
developed from a constellation of experiences of TGD chil-
dren/parents who were seeking transgender-specific thera-
peutic services in a private practice setting. As such the
examples do not reflect the experience of any single client,
rather they highlight several salient clinical considerations
that may be relevant to providing affirming care to TGD
children in a variety of social work practice settings.
Taylor
Taylor is a 9-year old who was assigned female at birth
and expresses a gender identity that is non-binary and
fluctuates. Taylor is brought in for therapeutic services by
her single mother who is “confused” by Taylor’s shifting
expressions of gender and wants support to help Taylor
get through “this phase”. An in-depth gender assessment
reveals that Taylor has preferred wearing gender non-con-
forming clothing (e.g., clothing more typical of biological
male children) since a relatively young age (3-years old),
although there are still many instances where Taylor likes
to wear stereotypically feminine clothing (e.g., t-shirts with
glitter, sparkly shoes) and play with stereotypically female
toys (e.g., dolls, baking) even at home alone. From a young
age, Taylor begged to wear her hair short, and if it was long
would always wear it pulled back in a low ponytail. While
Taylor generally prefers a physical gender presentation that
is more typical of a young boy (e.g., short hair, baseball
caps), unlike some transgender children Taylor has never
stated “I am a boy”. Rather, when Taylor is asked about
gender identity (e.g., how do the words boy or girl fit for
you?), Taylor describes it as follows: I mostly feel like a
boy, but not always. Sometimes I like to be girly too. Maybe
I am two things—boy and sometimes girl. Taylor appears
to have little dysphoria associated with sex organs (e.g., no
expressions of distress, disgust, or shame about having a
vagina, although she has stated that she would rather not
grow breasts). Taylor is not bothered by female pronouns
(which are used at both school and at home), but is also
comfortable with male pronouns (which often happens in
public places). Taylor does express significant distress over
being teased by kids about being gender non-conforming or
stared at in public (which reportedly happens while shop-
ping for clothes or toys). These experiences are very upset-
ting for both Taylor and her mother. Because Taylor does
not explicitly reject her female identity or exclusively claim
a male identity, feels little gender dysphoria associated with
her body, and demonstrates some gender fluidity, Taylor’s
experience of gender appears to be non-binary and one that
may further evolve as she approaches puberty.
Given existing research on identity emergence and best
practices, the specific strategies necessary to support Taylor
should focus on supporting Taylor’s current and potentially
evolving experiences of gender, provide psychoeducation
to facilitate her mother’s ability to understand, affirm and
support Taylor’s non-binary experience of gender, pro-
vide resources (e.g., coping skills, support services) and/or
advocacy to Taylor and her mother to address the impacts
of bullying and stigma associated with negative attitudes
and responses to Taylor’s gender nonconformity. It is
important to validate and support Taylor’s mother’s efforts
to get her the care and services she needs, while simulta-
neously educating her about: (1) non-binary experiences of
gender; (2) research regarding the evolution of gender iden-
tity and experiences for some children/teens; and (3) age/
developmentally appropriate intervention strategies that
can support Taylor’s authentic expression of self. In addi-
tion to psychoeducational interventions, supportive inter-
ventions may be important for youth and family members
dealing with stigmatizing experiences associated with TGD
identities. For instance, Taylor may benefit from supportive
individual or group counseling if she is teased or ostracized
at school, while her mother may need support from a prac-
titioner when trying to help family and friends understand
that Taylor is not confused about her gender identity, but
rather that her sense of gender is more fluid or diverse than
some.
Madison
Madison is a 6-year old child assigned male at birth whose
expressed gender identity is female. Madison’s father is
Non-Hispanic White and her mother was born in the United
States but is of Cuban descent. Madison is the client’s cho-
sen name (although it has not yet been legally changed) and
she experiences notable distress when her legal name Rod-
rigo (a clearly masculine name) is used by others. When
asked about this, she said “it embarrasses me”, and “makes
me really sad”. “It makes me feel like I’m not who I am”.
Madison has expressed attitudes, behaviors, play and pref-
erences for toys and clothing typical of female children

A.Austin
1 3
since she was 2years old. As soon as she was able to speak
she began emphatically and consistently expressing “I am a
girl” to her parents. Her mother and father initially rejected
these claims, but as Madison did not stop, and instead grew
more insistent about her gender identity, her parents have
been allowing her to dress in female clothes and use her
preferred name at home. Her parents indicate that this is
helpful, but acknowledge that it does not seem to be suf-
ficient. An in-depth assessment with Madison indicates that
she knows she is a girl and cannot wait to begin to grow her
hair long like Princess Jasmine’s and wear her dresses and
sparkle shoes to school. Madison expressed notable distress
about her penis and said she wants it to go away. She also
indicated that something that really scares her is the idea
of getting a beard or mustache. Madison indicated that at
school her best friends are girls but she gets very sad when
the class lines up because there is a boys’ line and a girls’
line and they make her go in the boys’ line. She indicated
that sometimes she cries or doesn’t want to go to school.
Madison expresses very clearly that she would like to grow
up to be a beautiful woman. Madison’s parents would like
to learn to support Madison, although they are not sure
how. They face a great deal of pressure from Madison’s
grandparents and some of their friends at church to put a
stop to what others see as Madison’s outrageous and atten-
tion seeking behavior.
Best practice strategies for working with Madison and
her family should be rooted in the existing research which
points to the importance of insistent, persistent, and con-
sistent expressions of gender dysphoria as indicators for
a transgender identity that remains through adolescence
and adulthood, as well as research illustrating the pro-
tective impact of transition-related care and parents who
support and facilitate this process (Olson et al., 2016;
Simons etal., 2013) There are specific strategies neces-
sary to support Madison. One important step is to affirm
Madison’s identity and work with the family to help cre-
ate safe and affirming spaces for Madison outside of the
home and clinical setting. In addition, the practitioner
should offer psychoeducation focused on developmen-
tally relevant transition-related care and research on the
protective impact of family support. While puberty is not
rapidly approaching for Madison and medical interven-
tions associated with transitioning (e.g., hormone block-
ers) are premature at this developmental stage, it may be
helpful for the provider to help the family plan for the
future by locating and establishing a relationship with a
TGD-friendly endocrinologist. As a result of the paucity
of TGD affirmative healthcare providers, this can often
be a complex process. Supportive interventions may be
important for Taylor and her family given that they are
experiencing rejection and hostility from their extended
family and their church family. Providing referrals to
TGD specific support groups and/or conferences (e.g.,
PFLAG, Gender Odyssey) may help Madison and her
family manage these stressors and teach her parents to
become effective advocates.
Finally, practitioners may want to provide the fami-
lies of both children with various advocacy oriented
resources aimed at ensuring that the children are sup-
ported in school. Such resources might include linkages
to local, state or national organizations that support TGD
students in school (See Schools in Transition: A Guide
for Supporting Transgender Students in K-2 Education);
resources that help parents support and advocate for their
children (e.g., Genderspectrum); or local, regional, or
national legal support aimed at creating safe school cli-
mates for TGD children and adolescents (e.g., Human
Rights Campaign: Welcoming Schools, Lambda Legal,
National Center for Transgender Equality).
Conclusion
As TGD children have a range of gender experiences that
may evolve over time, corresponding clinical support
and transition-related needs will also vary widely. TGD
affirmative practitioners must be capable and prepared to
play several distinct roles depending on each client and
family’s unique set of needs and circumstances. Practi-
tioners should develop the TGD-specific knowledge and
expertise required to engage in a comprehensive gender
assessment, offer psychoeducation, refer clients to local
and online resources, competently discuss developmen-
tally relevant transition-related care options, and provide
affirmative therapeutic support. Moreover, when neces-
sary, TGD affirmative practitioners should be able and
willing to support TGD children and families through
advocacy efforts targeting schools, other providers, as
well as the community at large. Practitioners must have
the ability to offer affirmative support to each child as
they navigate their unique gender journey. This requires
embracing an open and inclusive stance toward gen-
der diversity and the recognition that a child’s ability to
authentically express and inhabit his/her/their true gender
may evolve over time. Finally, social workers’ practice
must be rooted in a TGD affirmative framework, a clini-
cal stance which honors and supports the integrity, diver-
sity, and worth of each child as well as the right of all
individuals to live authentically.
Acknowledgements I extend sincere and heartfelt gratitude to all
of the transgender and gender diverse children, teens, and adults who
have deepened my understanding of and compassion for gender diver-
sity in all of its beauty.

Transgender andGender Diverse Children: Considerations forAffirmative Social Work Practice
1 3
Compliance with Ethical Standards
Conflict of interest The author declares that the author has no con-
flict of interest.
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