The evolution of mainstream society and the influx of social media are greatly influencing the visibility of the transgender community. As new terms for pronouns, gender identities and affection orientations are being constructed, our teenage (and middle school) clients are certainly keeping us updated on the constantly changing labels. Working specifically with transgender teenage clients is a unique subset to the umbrella acronym of LGBTQ+ community because it blends gender equality AND sexuality—two intrinsically critical aspects of the developing self. The exploration of gender and sexuality within the teenage population is overlaid with the general maturation process. Indeed, these clients are transitioning from children to teenagers—a process that generally is not easy even for cis-gendered, heterosexual teens. Someone whose gender identity matches the sex they were assigned at birth is considered cis-gender.

How does a therapist who has never worked with the transgender population navigate gender within the therapeutic relationship? It begins with being very real. Transgender teens are likely to be reluctant to share feelings about their gender dysphoria with a person they perceive as a cis-gendered therapist. Therefore, the first session is absolutely critical for establishing trust and transparency. This begins with the therapist. Given the current statistics of transgender-identified persons, the therapist most probably identifies as cis-gendered. Therefore, it is important that the therapist come out to their teen client. A brief statement such as “I am very interested in working with you to navigate your transgender journey of self-exploration. I feel it is important for you to know I am cis-gendered and while I have knowledge of what a transgender journey may look like, every journey is different and I am most interested in learning about your specific experience.” However, we are NOT looking to our transgender clients to educate us about what it means to be transgender. We should do our due diligence as professionals to become educated through consultation and additional trainings.

Open-ended questions allow for the teen client’s story of their gender identity to be revealed. I suggest starting with a very broad question. This allows the therapist to observe where the client starts their narrative, whether it is chronological, situational, somatic, or something else. The question can be as simple as “what is it like to be in your body?” or “what is it like to be at home or at school?” The client’s response is a source of information on their family of origin, their history of anxiety/depression, somatic symptoms, anatomical dysphoria, family and social support (or lack thereof). Their response also reveals the client’s level of self-awareness, their capacity for communication, and a plethora of other relevant information. It becomes the launchpad for further exploration.

Lean in to approach the uncomfortable. When they meet with a therapist, transgender teens possibly have already disclosed at least a limited amount of their discomfort to their family of origin. However, the therapist—an adult professional—will likely be the first adult outside of their family to hear the depths of their transgender exploration. Discussions that include dysphoria about genitalia, desire for or fantasies of being in the other gender, grief about the medical process taking too long or for being misgendered in public, are simply a few of those tough topics. To preface a potentially sensitive question, I suggest saying “I would like to ask you a very personal question that you may or may not have thought about before. I am thinking that it may be helpful to explore it here in this safe place. If once I ask you feel uncomfortable, just say so and we can discuss something else.”

Although it may be challenging to admit not knowing, it is important to do so for the client. As therapists, we will never be well-versed in all possible life circumstances that our clients share with us. Within the bounds of personal non-disclosure, we may give ourselves permission to be vulnerable with our clients. We certainly do not expect our clients to have all of the answers about their journey either, so in a lighthearted (and possibly playful) way, we can say “you brought up an interesting perspective, one that I will need to ponder and learn more about.” We may even verbalize thoughts by sharing “you know, when I am not sure about something, sometimes I need to reflect on it and possibly seek other opinions. I do not always have the answer right away either. I certainly do not expect you to know all about your gender today, next week, or even next year. Gender is always in flux and our opinion of it evolves as well.”

There could be a medical component to a teenager’s transgender exploration, including hormone blockers, hormone replacement, top surgery, electrolysis, and others. If working with the transgender population is not a specialty area of your practice, I suggest becoming connected with local medical care providers who support this population. In parallel, it is very helpful to ask the teenage client to share what they know about the medical process. This gives the therapist insight into the teen’s knowledge, its source, and the accuracy of the information. Most importantly, it exposes the gap areas in that very knowledge. It gives the therapist the opportunity to step in and help to educate, challenge, and further explore the process with the client.

Supporting a teenage client through their transgender journey is a wonderfully unique experience. It is filled with the inevitable highs and lows of any life experience including increased communication skills, establishment of close friendships and family ties, building self-confidence through gender expression (clothing, hair, accessories), formalizing a legal name and/or gender change, and change in pronouns. It is crucial to remember that our role as clinicians is to be present, curious, thoughtful, and a beacon of support to the client and their family. Bearing witness to transformation—in this case gender—is a life-altering experience for both the client and the clinician.

For further resources, consultation, or questions about working with transgender clients, Sean Garcia may be reached at www.seangarciatherapy.com.

Sean Garcia is an associate marriage and family therapist who has worked in a variety of settings including clinical, educational, and is now in private practice. As one of a handful of trans-identified clinicians in silicon valley, Sean is extremely passionate about supporting transgender people and their families. This population is the primary focus of his practice and he is currently expanding his clinical influence by developing and facilitating transgender sexual wellness programs for teens, a Trans Brotherhood adult support group, and a transgender tween support group. Sean is actively involved as a speaker and facilitator for educational training and enrichment for parents, staff, and students at local high schools.