Content uploaded by Randi Ettner
Author content
All content in this area was uploaded by Randi Ettner
Content may be subject to copyright.
Adjustment in Children
Word Count
Title [ 8 ]
Abstract [ 177 ]
Body [ 3154 ]
References [ 565 ]
1 Table and 2 Figures
Adaptation and Adjustment in Children of
Transsexual Parents
1,2 Tonya White, M.D.
3 Randi Ettner, Ph.D.
1 Division of Child and Adolescent Psychiatry
2 Center for Neurobehavioral Development
University of Minnesota
3 New Health Foundation
Evanston, Illinois
Abbreviated Title: Adjustment in Children
Corresponding Author__________________________________________
Tonya White, M.D.
Assistant Professor
Department of Psychiatry
University of Minnesota School of Medicine
2450 Riverside Ave F256/2B
Minneapolis, MN 55454
Tel. 612.273.9762
Fax. 612.273.9779
E-mail twhite@umn.edu
___________________________________________
Randi Ettner, Ph.D.
Director, New Health Foundation
1214 Lake St.
Evanston, IL 60201
(847) 328-3433
rettner@aol.com
- 1 -
Adjustment in Children
Abstract
It is a relatively uncommon event that children find themselves in a situation with
a parent who undergoes a transition from one sex to another. Unlike situations of
divorce or a parent with a medical or major psychiatric disorder, it is unlikely that
the children will know of other children who encounter similar situations. There is
very little literature that describes the adjustment of these children and the nature
of their relationships with their parents and peers. Such information would be
beneficial for clinicians assisting children and families in this situation. To better
delineate the adjustment of these children, we interviewed 27 parents of 55
children. The intervew took place on average six years after the gender transition.
The measures obtained included the parent and child relationships at present and
also at the time of the transition. We also inquired about academic function, peer
relationships and social stigma. The results found that children who were younger
at the time of the parent’s transition tended to have better relationships and less
adjustment difficulties. In addition, parental conflict that continues after the
transition period tends to reflect greater family conflict between the transitioned
parent and their child.
Key words: Children, Adolescents, Transsexual, Gender Identity Disorder,
Adjustment, Resilience
- 2 -
Adjustment in Children
Introduction
The process of physical and emotional development of children through
adolescence and adulthood is not always a smooth process. Events such as
divorce, encountered in upwards of 50% of families [12, 23], or a parent with a
medical or psychiatric disorder add additional challenges to a child’s typical
development. Numerous studies have evaluated the adjustment of children to
divorce [7, 8, 12] or parental illnesses [2, 6, 14, 24] and specific risk and
resiliency factors have been identified. There is some evidence to support that
these risk and protective factors generalize, applying also to the adjustment of
children with a parent who transitions from one sex to the other [25].
There is a qualitative difference for children who experience a parent
gender transition compared to parents who divorce or have physical or mental
illnesses. Not only is such a transition relatively uncommon, but it may also be
associated with considerable social stigma. The life events experienced by these
children during the period of time that a parent undergoes such changes may
include separation or divorce of their parents, considerable familial conflict, and
factors associated with such a dramatic change in one of their parents [21]. This is
a considerable series of life events in which the majority of children do not
discuss with their peers.
There is very little research on the adjustment of children whose parents
undergo a gender transition. Green et al. [11] reported that 37 children raised by
parents who were either homosexual or transsexual did not differ appreciably
- 3 -
Adjustment in Children
from those raised in more traditional settings. The majority of those raised with a
transsexual parent had witnessed the transition. The focus of Green’s work was
directed toward psychosexual development and identity formation, in contrast to
overall adaptation of the children. He found no difficulties in psychosexual or
identity development in these children.
We recently published a study in which we surveyed experienced
therapists who work with transgender patients and their families [25]. We
obtained information regarding the therapist’s experience with children’s
reactions to a parent who made a gender transition. The therapists identified a
number of factors that served as risk and protective factors for these children. In
addition, we found that there was an overall consensus that younger children
adjusted much better to the transition compared to adolescents and young adults.
Adolescents had the greatest difficulties adjusting, as did young adults, this was
especially true when considerable family conflict was present.
The current study is an extension of the question of the adaptation of
children who are found in a situation of a parent who undergoes a transition
between genders. We were interested in further testing the hypothesis that
children who are younger at the time of the transition tend to have less difficulties
with adjustment. Thus, the study is developmental in nature, assessing and
comparing the children within different developmental stages. We also studied the
role of parent/parent and parent/child relationships on the adjustment of the
children. Finally, we were interested in studying the role of social stigma
encountered by the child.
- 4 -
Adjustment in Children
Methods
Subjects
Information was obtained from 27 parents with a history of TS who have
undergone a transition to the opposite biological sex. In most cases, the
information was acquired through a semi-structured interview with the
participant, however in 2 cases, the participants completed a questionnaire with
the same information. From these 27 parents, information was obtained on 55
offspring between the ages of 8 and 35 years. The interview systematically
covered a number of questions relating to the nature of the relationships around
the time of the transition. In addition, questions addressing the current
relationship with each parent, the child’s fear of being stigmatized by the
transition, social losses experienced by the child, academic performance, and
whether the child was willing to discuss the transition with their peers. Finally,
measures of temperament were collected for each family member. The participant
was given the opportunity to provide open-ended comments as to what they have
found either helpful or harmful in their child’s adjustment.
Statistical Analyses
Chi-square analyses were performed to assess the categorical data. Either
two-tailed T-tests or Pierson correlation coefficients were used to assess the
relationship between clinical measures. Finally, a backward stepwise linear
regression was utilized to determine which factors predicted a positive adjustment
- 5 -
Adjustment in Children
in the children of TS parents. All statistical analyses were performed using the
SAS statistical software package (Version 9.1, SAS Institute, Inc. Cary, NC,
USA).
Results
Characteristics of the Parents
The age of the 27 parents at the time of their participation ranged from 41
to 63 years (mean 50.0, SD 5.8 years). All but two of these parents underwent a
transition from male-to-female. The age at the time of transition ranged from 33
to 61 years (mean 43.6, SD 7.0). One participant was African American and the
remainder (97%) were Caucasian. The group tended to be highly educated, with
57% having a Masters or doctoral degree, 25% being college graduates, and 18%
with a high school or technical degree.
During the time of the transition, 7 families remained together, 12
divorced at or around the time of transition, and 8 were already divorced at the
time of the transition. At the time of the study, 6 of the families had remained
together, whereas 21 were divorced or separated. The average age at the time of
divorce was 40.7 (SD 7.6) years; with a range spanning from 20 to 50 years of
age.
Of the 27 parents, 23 have undergone sex reassignment surgery. The four
who have not had surgery have both hormonally and socially transitioned, and
were planning to have sex reassignment surgery. The average age at the time of
surgery was 44.9 years (SD 6.5). Thus, the information collected during this
- 6 -
Adjustment in Children
survey occurred on average six years following the transition and five years post-
surgery.
Characteristics of the Children
There were 55 offspring from the TS parents, 24 males and 31 females.
The age at interview of these children ranged from 8 to 35 (mean age 18.7, SD 6.3
years). Forty of the children (73%) were still attending school, with a mean
academic level of 10th grade (SD 4.5) and a range from 2nd grade to doctoral level
studies.
There was a wide range for the child’s age at the time of transition,
spanning from 1 to 25 years (mean age 12.9, SD 6.7 years). For parents who
separated or divorced, the average age of the children at the time of this event was
11.1 (SD 7.6) years. The majority of the children’s parents separated or divorced
within a year of the parent’s transition.
Elements of Disclosure
The average age that the TS parent disclosed their condition to their
spouse was 34.1 years (SD 9.3 years). Thus, there was an average duration of 9.5
years between the time of disclosure to the spouse and the transition. A longer
interval between disclosure and the transition did not improve the familial
relationships at the time of the transition. However, the level of conflict between
child and the transitioned parent was higher when there was a longer interval
between disclosure to the spouse and the transition (t = 2.44, DF 53, p < 0.02).
- 7 -
Adjustment in Children
The mean age that the child learned of their parents plan to transition was
11.9 (SD 6.4) years. There was a mean duration of 1.1 years between disclosure to
the child and the transition (range of 9 years before and 6 years following the
transition). There was not a significant relationship between the period of time
that the child was aware of the parent’s plans and the parent-child interaction.
Over half of the children (58%) did not reveal or discuss their parent’s
transition with their peers. Of those who did, the average age that they discussed
this with their peers was 13.9 (SD 4.4) years. There were no statistically
significant differences in peer disclosure between males (39% who disclosed) and
females (52% who disclosed). Seventeen percent of the children were felt to
suffer socially as a result of the transition. Those children who were embarrassed
by the transition were the same children who suffered socially as a result of the
transition (t = 3.31, DF = 45, p < 0.002).
Adjustment of the Children
Forty children (73%) did not exhibit any decline in academic performance
at the time of the parent’s transition. Thirteen children (23%) experienced a mild
to moderate decline in cognitive performance, and 2 children (4%) demonstrated a
severe decline in academic performance. In the case of severe decline, one parent
noted that it was difficult to tease apart the effects of the divorce from the gender
transition, since this child experienced significant parental conflict between the
transitioning and non-transitioning parent. There was not a significant correlation
- 8 -
Adjustment in Children
between the decline in academic performance and the parent/parent and
parent/child relationships.
For children attending school, there was not a relationship between age or
grade and academic decline. The children who demonstrated a decline in
academic performance were also the same children who perceived greater social
stigma as a result of the transition (t = -2.24, DF 39, p = 0.03).
Approximately one-third of the children continued to use the pre-transition
parental title in public settings (i.e., “dad” in a male-to-female transitioned
woman). One third of the children used their parent’s first name in public, and the
remainder either used a nickname (20%), aunt or uncle (2%), or a post-transition
congruent parental title (5%). Approximately 10% had no contact at all with their
child.
Psychopathology in the Children
Nineteen children (35%) were reported to have a psychiatric disorder. Of
these children, the disorder started prior to the parent’s transition in 12 children,
during the transition in one child, and post-transition in 6 children (See Table 1).
The sample tended to have a greater number of internalizing versus externalizing
disorders. Seven (13%) of the offspring had a history of depression, 3 (5%) an
eating disorder, 4 (7%) ADHD, and 2 (4%) a substance abuse disorder. In
addition, one child had learning disabilities, and another was mentally
handicapped. None of the children in the group were reported to have Gender
Identity Disorder.
- 9 -
Adjustment in Children
Factors Associated with Relationship between Child and Transitioned Parent
At the time of the transition, approximately 20% of the families
experienced high or extreme levels of conflict between parents, or alternatively,
no contact at all between the TS parent and child. This percentage of high conflict
relationships had dropped to approximately 15% after an average post-transition
interval of 6 years. This latter percentage is contrasted to 10% of the non-
transitioned parent and child having high or extreme levels of conflict.
Approximately 5% of the children (n=3) had no contact with their TS parent
during the transition, which increased to 10% (n=5) after six years post-transition.
There were several factors that predicted a positive relationship between
the transitioned parent and the child at the time of the interview. These included
less conflict at the time of the transition (F=12.07, p= 0.001) and less post-
transition conflict between the transitioned parent and the non-transitioned parent
(F=8.99, p<0.005). Interestingly, the level of conflict between the parents at the
time of the transition was not predictive of later relationship difficulties between
the children and the transitioned parent.
Children who were younger at both disclosure (t=4.15, DF 52, p=0.001)
and transition (t=3.76, DF 53, p=0.004) had significantly less conflict with the TS
parent at the time of the transition (Figure 1). This relationship for younger age of
the child at disclosure (t=2.47, DF 52, p<0.02) and age at transition (t=2.14, DF
53, p<0.04) also held true for the post-transition relationship between child and
TS parent. At the time of the transition, but not at the time of the study, children
- 10 -
Adjustment in Children
who were more embarrassed about the transition had higher levels of conflict with
the TS parent (t=4.44, DF 55, p<0.001). Finally, there tended to be a gradual
overall improvement in the relationship between the child and the TS parent over
time (Figure 2).
Factors Associated with Relationship between Child and Non-Transitioned
Parent
Approximately 10% of the families had high or extreme levels of conflict
between the child and the non-transitioning parent. There were several factors that
predicted a positive relationship between the non-transitioned parent and the child
at the time of the interview. These included less post-transition conflict between
the parents (F=11.55, p= 0.001) and less conflict currently between the
transitioned parent and the child (F=7.32, p<0.01). Individuals who transitioned
at a younger age had a better relationship with the non-transitioned spouse. Also,
children who were younger at the time of the transition were reported to have a
better post-transition relationship with the non-TS parent (t=3.47, DF 53,
p=0.001).
Factors Associated with Sex of the Child
There was a significant difference between the sex of the child and their
age at the time of transition (t=3.46, DF 53, p=0.001). The mean age of the girls at
the time of transition was 15.4, compared to 9.6 for the boys. Boys were informed
of the transition younger than girls (t=3.56, DF 52, p<0.001), and boys also had
- 11 -
Adjustment in Children
younger TS parents than girls at the time of the transition (t=3.46, DF 53,
p=0.001). There were no sex differences in level of conflict, academic decline,
embarrassment about the transition, or social stigma.
Discussion
There were two primary factors that predicted a healthier, or less
conflicted relationship between the child and the transitioning and non-
transitioning parent. These factors included a younger age of the child at the time
of the transition (Figure 1) and a positive relationship between the two parents. As
is true in children of divorce, children who experience considerable parental
conflict tend to have greater difficulties in adjustment [12, 23]. In addition, a 10-
year follow up of children of divorce showed that children who were younger at
the time of the divorce fared better than older children [22]. Since the current
study did not have a comparison group of children of divorce, it is not possible to
tease apart the effects of the transition versus the effects of the divorce.
For the transitioning parent, the nature of the relationship at the time of the
transition was highly predictive of a better longer term relationship. Comparing
the relationship between the child and transitioned parent during the transition and
at the time of the interview, there was a tendency toward an overall improvement
in the relationship. However, what is most striking is the stability of the
parent/child relationship over time (Figure 2). Only three children went from the
most extreme levels of conflict during the transition to minimal or no conflict at
the time of the study, whereas a swing in the opposite direction did not occur.
- 12 -
Adjustment in Children
A higher level of conflict between the parents at the time of the transition
did not predict longer term parent/child conflict. Thus an initial reaction with high
conflict between parents does not necessarily negate a longer term positive
relationship between the child and the transitioned parent. It is possible that the
parents are able to protect their children from the parental conflict at the time of
the transition. The time of the transition is often very stressful for the parents, and
thus the key appears to be not that there is considerable conflict during this
stressful period, but rather the evolution of the relationship over time. Those
parents who are able to build healthier relationships between themselves, are also
able to develop healthier relationships with their children.
One measure of childhood adjustment that is common to all children is
academic performance. Children and adolescents who experience greater stress
tend to have greater difficulties in academic performance [9, 20]. Whereas in
divorce there is a relationship between decline in academic performance and level
of family conflict [10], such a relationship was not found for this population. The
majority of children did not have a decline in academic performance during the
transition. Although time spent with each parent was not measured in this study,
few children had no contact with the transitioned parent. It’s possible that both
parents spending time with their child offered some protection from a decline in
academic performance of the children [3].
Rather than the extent of family conflict impairing academic performance,
social stigma served as a factor more related to those children who demonstrated a
decline in academic performance. The adverse consequences of stigma have been
- 13 -
Adjustment in Children
a source of recent research [16] and since stigma is most felt for children within
the school setting, this may account for this relationship. One decision that
families face is what name to use for the parent post-transition, and one third of
the children continue to use the pre-transition gender specific identifier (i.e.,
‘mom’ for a female-to-male transsexual). Interestingly, those children who use the
pre-transition parent identifier, or those who have no contact with their parent, are
those who are most embarrassed by the transition. Children who are not
embarrassed by the transition adopt either their parent’s first name, a neutral
nickname, or a post-transition gender congruent title (i.e., mom or dad). The small
number of parents who were referred to as either aunt or uncle (2%) may reflect a
desire to not alter the nature of the parental relationship.
Although there was a high rate of psychopathology in the children (35%),
the rates did not greatly exceed rates found in the general population. Rates of
depression in adolescence have been found to be as high as 33% in a community
study [15]. The rates of ADHD vary by studies, but the current study is in
agreement with a population based incidence of 7% [1]. This study does have a
higher rate of individuals with eating disorders compared with population based
studies [13]. Three of the four children with eating disorders were female,
whereas one male had a disorder of increased intake and was obese. Since factors
associated with gender role have been shown to be related to eating disorders [4,
18], the higher rate of eating disorders in this population may reflect the child’s
adaptation to the transition.
- 14 -
Adjustment in Children
There are a number of limitations to this study. The major limitation of the
study was that the children were evaluated through the report of the transitioned
parent, rather than through an actual interview with the child or through a report
of the non-transitioned parent. In general, parents are reasonable informants on
adjustment or clinical symptoms in children, although parents are better at
reporting externalizing disorders than internalizing disorders, especially in
adolescents [5, 17, 19]. The study would be significantly strengthened by
obtaining collateral information to augment the parental reports. These include
reports from teachers and other family members (i.e., grandparents, aunts and
uncles). Obtaining information from sources such as peers may be challenging,
however, the information would be very helpful, especially in the adolescent age
range. In addition, evaluations such as teacher reports, report cards, and school,
medical, and/or therapists records would also be beneficial to complement the
parents report. Finally, following children during the period that encompasses pre-
and post-transition would assist in better delineating the longitudinal adaptation of
children of a transitioning parent.
In summary, children whose parents transition between genders are placed
in a unique situation. Those children who experience greater conflict during the
transition tend to have greater conflict years later. As was demonstrated in our
earlier study [25], children who are younger at the time of the transition tend to
adapt better and maintain healthier relationships with both parents over time.
Finally, although there may be considerable conflict between the parents at the
- 15 -
Adjustment in Children
time of the transition, this does not negatively impact the child, unless the conflict
persists over time.
- 16 -
Adjustment in Children
Table 1 – Psychiatric Disorders in the Children of Transitioned Parents
Onset of the Disorder Internalizing Disorders Externalizing Disorders
Pre-Transition Depression (n=3)
Obsessive Compulsive D/O (n=1)
Anxiety D/O (n=1)
Post-Traumatic Stress D/O (n=1)
Binge Eating Disorder (n=1)
ADHD (n=3)
Substance Abuse (n=2)
Gambling Addiction (n=1)
During the Transition Eating Disorder (n=1)
Post-Transition Depression (n=4)
Eating Disorder (n=1)
Bipolar Affective Disorder (n=1)
ADHD (n=1)
- 17 -
Adjustment in Children
Figure 1 – Age of the Child at the Time of Transition Versus the Level of
Conflict with the Transitioned Parent. Measurements include both Relationship at
the time of the Transition and the Time of the Study (1 = no conflict, 5 = Extreme
level of conflict).
0
0.5
1
1.5
2
2.5
3
3.5
4
Young Child
School Age
Young Adolescent
Older Adolescent
Young Adult
Level of Conflict
Transition
Current
- 18 -
Adjustment in Children
Figure 2 – Change in the Level of Conflict Between the TS Parent and the Child
(y-axis) Versus the Time Since the Transition (x-axis). There is a general change
toward less conflict over time.
- 19 -
Adjustment in Children
References
1. Barbaresi WJ, Katusic SK, Colligan RC, Pankratz VS, Weaver AL, Weber
KJ, Mrazek DA, Jacobsen SJ (2002) How common is attention-
deficit/hyperactivity disorder? Incidence in a population-based birth
cohort in Rochester, Minn. Arch Pediatr Adolesc Med 156:217-224
2. Barbin JM, Williamson DA, Stewart TM, Reas DL, Thaw JM, Guarda AS
(2002) Psychological adjustment in the children of mothers with a history
of eating disorders. Eat Weight Disord 7:32-38
3. Bisnaire LM, Firestone P, Rynard D (1990) Factors associated with
academic achievement in children following parental separation. Am J
Orthopsychiatry 60:67-76
4. Cantrell PJ, Ellis JB (1991) Gender role and risk patterns for eating
disorders in men and women. J Clin Psychol 47:53-57
5. Chang PC, Yeh CH (2005) Agreement between child self-report and
parent proxy-report to evaluate quality of life in children with cancer.
Psychooncology 14:125-134
6. De Judicibus MA, McCabe MP (2004) The impact of parental multiple
sclerosis on the adjustment of children and adolescents. Adolescence
39:551-569
7. Dong Q, Wang Y, Ollendick TH (2002) Consequences of divorce on the
adjustment of children in China. J Clin Child Adolesc Psychol 31:101-110
- 20 -
Adjustment in Children
8. Felner RD, Ginter MA, Boike MF, Cowen EL (1981) Parental death or
divorce and the school adjustment of young children. Am J Community
Psychol 9:181-191
9. Felsten G, Wilcox K (1992) Influences of stress and situation-specific
mastery beliefs and satisfaction with social support on well-being and
academic performance. Psychol Rep 70:291-303
10. Gottman JM (1998) Psychology and the study of marital processes. Annu
Rev Psychol 49:169-197
11. Green R (1978) Sexual identity of 37 children raised by homosexual or
transsexual parents. Am J Psychiatry 135:692-697
12. Hetherington EM (2005) Divorce and the adjustment of children. Pediatr
Rev 26:163-169
13. Hoek HW, van Hoeken D (2003) Review of the prevalence and incidence
of eating disorders. Int J Eat Disord 34:383-396
14. Hoke LA (2001) Psychosocial adjustment in children of mothers with
breast cancer. Psychooncology 10:361-369
15. Lewinsohn PM, Hops H, Roberts RE, Seeley JR, Andrews JA (1993)
Adolescent psychopathology: I. Prevalence and incidence of depression
and other DSM-III-R disorders in high school students. J Abnorm Psychol
102:133-144
16. Major B, O'Brien LT (2005) The social psychology of stigma. Annu Rev
Psychol 56:393-421
- 21 -
Adjustment in Children
17. Moretti MM, Fine S, Haley G, Marriage K (1985) Childhood and
adolescent depression: child-report versus parent-report information. J Am
Acad Child Psychiatry 24:298-302
18. Murnen SK, Smolak L (1997) Femininity, masculinity, and disordered
eating: a meta-analytic review. Int J Eat Disord 22:231-242
19. Nauta MH, Scholing A, Rapee RM, Abbott M, Spence SH, Waters A
(2004) A parent-report measure of children's anxiety: psychometric
properties and comparison with child-report in a clinic and normal sample.
Behav Res Ther 42:813-839
20. Ng V, Koh D, Chia SE (2003) Examination stress, salivary cortisol, and
academic performance. Psychol Rep 93:1133-1134
21. Sales J (1995) Children of a transsexual father: a successful intervention.
Eur Child Adolesc Psychiatry 4:136-139
22. Wallerstein JS (1984) Children of divorce: preliminary report of a ten-year
follow-up of young children. Am J Orthopsychiatry 54:444-458
23. Wallerstein JS (1991) The long-term effects of divorce on children: a
review. J Am Acad Child Adolesc Psychiatry 30:349-360
24. Welch AS, Wadsworth ME, Compas BE (1996) Adjustment of children
and adolescents to parental cancer. Parents' and children's perspectives.
Cancer 77:1409-1418
25. White T, Ettner R (2004) Children of parents who make a gender
transition: disclosure, risks, and protrective factors. J Gay Lesbian
Psychotherapy 8:129-145
- 22 -
Adjustment in Children
- 23 -
