Abstract
We conducted a qualitative metasummary of studies with qualitative findings from transgender and gender-diverse (TGD) child participants. We created this report as a resource that health care providers can use to improve and enhance the health care–related services that they offer to TGD children and the children’s accompanying parents. We used the qualitative metasummary method to identify relevant peer-reviewed articles with qualitative data collected from TGD children that address the topic of parental involvement in children’s health care experiences. Data collection resulted in 20 articles. Our data analysis resulted in three primary themes, three subthemes, and 18 total summary findings. The findings within this report offer useful information for health care providers to keep in consideration when serving TGD children and their accompanying parents.
Health care represents efforts performed by trained and licensed professionals to maintain, restore, or promote physical, mental, or emotional well-being (Merriam-Webster, 2024). Gender-affirming care is a specific type of health care, focused on a range of services (e.g., medical and mental health care) designed for transgender and non-binary people (Human Rights Campaign, 2023). The purpose of this report is to provide a resource that health care providers in the United States and Canada can use to enhance health care or gender-affirming care for transgender and gender-diverse (TGD) children, especially when providers engage TGD children with their parents.
Health care should protect vulnerable populations (e.g., American Medical Association, 2016), yet transgender individuals often face barriers when seeking to obtain health care. Barriers can include denial of insurance coverage (Bakko & Kattari, 2020), anticipated discrimination (Kcomt et al., 2020), and having to educate providers about trans people (Kattari et al., 2020). In fact, recent government policies minimize TGD children’s access to health care, support systems, and affirming school spaces and may also negatively impact TGD children’s mental health (The Trevor Project, 2022). Despite the onslaught of policies plainly designed to restrict transgender children’s access to health care, providers still serve TGD children and accompanying parents.
Because TGD children likely worry about being denied access to health care due to state-level policies (The Trevor Project, 2022), health care providers ought to consider this specific concern. Research reveals that transgender individuals who received gender-affirming medical care, for example, hormones or surgery, report lower levels of suicidal thoughts and attempts compared to transgender individuals who want, yet do not receive these treatments (Herman et al., 2019). Regarding mental health care, many transgender individuals benefit from the support of mental health providers (Dhejne et al., 2016), yet three out of five transgender and nonbinary youth report that they could not gain access to mental health care (The Trevor Project, 2022).
Even when medical and mental health care options are available to TGD children, many children will still not receive services, citing concerns such as gaining parental permission (The Trevor Project, 2022). Parental consent is often required for TGD children to receive treatment (Coleman et al., 2022), highlighting that parental involvement is critical for serving TGD children. Therefore, understanding TGD children’s health care experiences when parents are involved could yield new findings that support more positive outcomes from TGD children’s health.
Parental Involvement in Health Care
The World Professional Association for Transgender Health encourages involving parents in TGD children’s health care assessment and treatment processes (Coleman et al., 2022). Parental involvement in TGD children’s health care may be valuable to providers (Coleman et al., 2022) because parental support is linked with TGD children’s well-being (Gower et al., 2018) and is a protective factor for TGD children’s mental health outcomes (Grossman et al., 2019).
Previous research studies highlight challenges parents face when they attempt to access health care on behalf of their TGD children. For example, parents can face structural challenges, such as forced minimum age requirements or a lack of network providers willing to accept the parent’s insurance (Gridley et al., 2016). Even when parents gain access to health care services, many discover that their assigned providers are not confident in administering gender-specific treatments, for example, hormones/puberty blockers (Evans et al., 2017). Many parents seek providers who offer gender-affirming care (Gridley et al., 2016), have prior experience working with TGD children (S. L. Johnson & Benson, 2014), and do not use outdated terminology (Gridley et al., 2016).
In addition, parents want mental health care providers who reassure them of their child’s emerging gender identity (Pullen Sansfaçon et al., 2020), while not perpetuating the belief that their child needs treatment because of their gender identity (Menvielle & Hill, 2011). In general, parents want services with physicians, psychologists, and social workers working together on their child’s health care (D. Johnson et al., 2014), so that they can avoid taking on the responsibility of educating professionals while their child receives services (Pullen Sansfaçon et al., 2015).
Previous literature review studies explored the topic of transgender parents accessing health care for their children (Shields et al., 2012) and parents accessing health care for TGD children (Tyler et al., 2023). Yet, less is known about TGD children’s perspectives regarding their parents’ involvement in their health and mental health care. This literature review study outlines findings across qualitative studies with data collected from TGD participants. The participants included youth and also adult TGD children recalling past health care experiences with parents. We used the term child to represent a relational role rather than a developmental age. We created this report for researchers and providers who serve TGD children and parents.
Across countries, transgender individuals report varying levels of access to health care (Koch et al., 2020) and diverse experiences when receiving care from their providers (Falck & Bränström, 2023). We focused only on the United States and Canada, acknowledging that more research is needed to understand this topic within other geographical areas and global contexts. This study’s purpose is to create a report for researchers and providers in these two countries. This report accounts for both general health care and gender-affirming health care experiences.
Methods
To explore TGD child health care experiences with parental involvement, we conducted a qualitative metasummary (Sandelowski & Barroso, 2007). This method provides researchers with data collection strategies that they can employ to find articles linked to their topic. The purpose of a qualitative metasummary is to find relevant research reports and approximate the sum of findings across these reports (Sandelowski & Barroso, 2007). In contrast, researchers use the qualitative metasynthesis method to provide an interpretive analysis of qualitative reports. In this metasummary study, we share results that remain close to the findings, rather than provide an interpretative analysis to generate interpretive constructs that go beyond a basic summary of results. Metasummaries produce thematic reviews of qualitative findings, and the themes in this metasummary represent discoverable patterns across articles (Sandelowski & Barroso, 2007).
Data Collection
We searched for research articles that met these three inclusion criteria items: (a) studies with qualitative data from TGD children of various ages, (b) participants from the United States and/or Canada, and (c) findings that address parental involvement in TGD children’s health and mental health care. We conducted a qualitative metasummary to complete a comprehensive retrieval of relevant reports in a domain of inquiry (Sandelowski & Barroso, 2007). As a result, we sought studies with data collected from TGD participants at various ages, including research articles with younger TGD participants and older TGD participants recalling experiences in their youth. In this study, child represents a relational role, rather than a limited age group, for example, 1 to 18 years.
We searched databases, checked references, and scanned areas related to our topic. We used the following databases:
Family and Society Studies Worldwide
Family Studies Abstracts
MEDLINE
PsycINFO
Social Work Abstract
SocINDEX
We used the following search terms:
transgender OR transsexual OR gender varian* OR gender ident* OR gender queer OR gender fluid OR gender trans* OR gender non* OR gender exp*
AND disclos* OR coming out OR discover* OR aware* OR realiz*
AND parent OR caregiver OR guardian OR mom OR dad OR mother OR father
AND counseling OR treatment OR therap* OR support OR mental OR health
The first line includes terms that represent various gender identity labels. Before we began conducting official database searches, we first ran several practice searches testing various search terms. We discovered that age-specific search terms, such as “adolescent,” limited articles found with adult TGD child participants. We also found that relational role search terms, such as “offspring,” limited articles found with TGD children referred to with more general labels, such as “individual.” Our approach broadened our results, yielding a more comprehensive outcome while helping us to find research primarily on parent and TGD child health care experiences.
The second line outlines terms associated with how parents are introduced to their children’s gender identities. We made the decision to include these terms to provide the context that often proceeds parental involvement in accessing health care or mental health care for TGD children. For example, when parents sought health care on their child’s behalf after disclosure. The third line includes common labels used for parental figures. This line narrowed our scope to academic journal articles focused on parent–child relationships. The fourth line in our database search included terms associated with health care services and mental health services.
Next, we did reference checks, that is, backward chaining, with articles we found from database searches that met our inclusion criteria. This step involved reviewing each article’s reference section to identify new articles that also met our inclusion criteria. We continued this process of finding new articles and then checking their reference sections until we found no more new articles. For area scanning, we reviewed articles that did not meet inclusion criteria but were related to our topic. We reviewed these articles to see if they cited articles we could include. We identified 20 relevant articles. The PRISMA chart (Moher et al., 2009) offers more details (Figure 1). After we completed these strategies, we ended data collection in March 2023.
PRISMA Flow Diagram
Data Analysis
In the Handbook for Synthesizing Qualitative Research, Sandelowski and Barroso (2007) outline the five sequential steps for qualitative metasummary data analysis. We followed the five steps by (a) extracting finding statements from the results sections of dataset articles, (b) writing edited statements that simplify wording from the original finding statements, (c) placing edited statements across articles in a Word document and organizing statements into general categories, (d) engaging in the iterative process of refining categories into themes, subthemes, and findings, and (e) calculating manifest intensity effect sizes (Table 1) and frequency effect sizes (Table 2).
Cross-Study Display.
Note. TGD children often represented a smaller subsample in a larger sample.
Note. Some of the authors clarified specific information updated in this table.
Findings Report.
We employed several strategies outlined by Sandelowski and Barroso (2007) to optimize the validity of our literature review study. We created an ongoing audit trail to maintain a record of methodological decisions. We also consulted with an expert in research synthesis, with direct experience related to conducting qualitative metasummary studies. We invited a health science expert to join our research team specifically to help us identify articles essential to our dataset. We developed a team of interprofessional health care providers to offer us implication feedback. Multiple individuals conducted the database searches, and at least two researchers appraised each article for inclusion in our final dataset. We also held weekly scheduled research team meetings.
Results
We conducted a systematic literature review and analyzed qualitative findings in the research articles that we found. We identified three primary themes (health care engagement, mental health care, and recommendations), three subthemes (supportive parental involvement, unsupportive or unprepared parents, and parental influence on hormone therapy), and 18 total findings. We provide examples of study findings below (see Table 2 for the findings report).
Theme 1—Health Care Engagement
The first theme of health care engagement represents TGD children’s varying experiences of parental involvement and support associated with health care. Supportive parental involvement included attending appointments, acting as intermediaries, and offering guidance and resources. On the contrary, some parents were either unsupportive or unprepared, which seemed to create barriers to care, for example, restricted access to health care services due to financial constraints. The subthemes below present specific findings related to the theme of health care engagement.
Subtheme 1.1—Supportive Parental Involvement
Many TGD children said their parents attended their health care appointments. For example, one said their father took them to see an endocrinologist (Fahs, 2021). Another felt comforted when their parent joined their doctor’s appointment (Budge et al., 2018). Some parents acted as intermediaries between their child and health care systems. For example, one TGD child said that their mother used her credibility to help them access health care (Pullen Sansfaçon et al., 2018). Children recalled parents helping them address health care barriers (Clark et al., 2020). Some recalled when parents helped them identify health care–related resources, such as sexual health information (Andrzejewski et al., 2021) and online health resources (Evans et al., 2017). At times, parents provided helpful health-related guidance. Guidance included general health advice (Andrzejewski et al., 2021) and support when making decisions regarding health care interventions or making progress toward specific health care–related goals (Clark et al., 2020).
Subtheme 1.2—Unsupportive or Unprepared Parents
Some TGD children described times when parents represented a barrier between them and accessing health care. Children recalled parents attempting to restrict their access to gender-affirming services (Bhattacharya et al., 2021). One recalled his mother meeting with a second doctor only to then confront him about hormone and surgery-related risks (Pusch, 2005). Others found parents’ lack of financial resources represented a barrier to care (Clark et al., 2020; Fahs, 2021). Some children considered their parents as unsupportive of affirming care. Some described parents as unsupportive of their health goals, making discouraging remarks (Clark et al., 2020). Some children could access hormone therapy even without parental support (Clark et al., 2020).
Subtheme 1.3—Parental Influence on Hormone Therapy
Some TGD children said that their parents supported them in accessing hormone therapy, including receiving approval to begin gender-relate surgery, puberty blockers, and hormones (Katz-Wise et al., 2017). One TGD child said that their mother was initially reluctant, yet still agreed for the child to receive hormones (Fahs, 2021). In contrast, some parents did not support their children’s access to hormone therapy. Their reasons typically were that the child was too young (DiFulvio, 2015) or could wait (Tan & Weisbart, 2022). Several TGD children said parents required them to first turn 18 years old (DiFulvio, 2015; Fahs, 2021; Singh, 2013).
TGD children wanted parental approval for hormone therapy. One child recalled making a deal with his mother to get a job to pay for his own hormones (Fahs, 2021). Another said that their conversations with parents focused more on financial costs than on gaining approval for treatment (Fahs, 2021), yet children still declared their need to begin hormone therapy (Clark et al., 2020). Many anticipated that parents would say no. Some even delayed coming out because they believed their parents would say no to hormone therapy (Clark et al., 2020). One worried about whether their divorced parents would each permit them to receive hormones (Fahs, 2021).
Theme 2—Mental Health Care
The second theme of mental health care represents TGD children’s experiences with mental health care providers when their parents were involved. Some providers were supportive, affirming, and assisting the child toward feeling accepted and secure in their gender identities. In contrast, some children received services from unsupportive providers. Parents played a critical role in children’s mental health care experiences. We outlined specific findings related to this theme in the paragraphs below, including quotations from some qualitative study participants.
TGD children described various mental health provider experiences. Some described helpful providers. For example, one said their therapist “really helped me out because they fully accepted me and that helped me sort of be ok” (Budge et al., 2023, p. 14). Another said their mother postponed future psychiatrist meetings after one psychiatrist treated them negatively (Pullen Sansfaçon et al., 2018). Some TGD children disagreed with their parents regarding that specific providers were helpful (Budge et al., 2023). One believed their parent would respond differently to information from a psychologist versus from them (Tan & Weisbart, 2022).
Several TGD children recalled parents sending them to meet with mental health care providers. One participant remembered that their father requested for them to begin treatment after the child said they “might be a boy” (Fahs, 2021, p. 154). This participant recalled that their father brought them in for treatment because their father had a close friend with a gay son who committed suicide (Fahs, 2021). Another participant recalled their parents taking them to see a mental health therapist after they wore their sister’s underwear (Morgan & Stevens, 2012).
Children recalled parents impacting their mental health therapy experiences. Some parents responded affirmingly while attending appointments. For example, one participant recalled when his father joined his therapy sessions to find out how to best support him and help him feel more secure within his body and gender identity (Fahs, 2021). Another child recalled coming out to parents in therapy and the process going smoothly (Fahs, 2021). In contrast, some parents were less supportive. For example, one child disclosed to their parents that they “felt like a boy” and the mother said she wished that her child “had never been born” (Fahs, 2021, p. 155). This mother also shouted at the therapist saying that the therapist “put this into her head,” that is, encouraging the child’s gender identification (Fahs, 2021, p. 155). Afterward, the therapist told the child that it was “too traumatic” for the child to continue speaking with their mother if the mother responded harshly and negatively about the child’s gender identity (Fahs, 2021, p. 155). Another child’s counseling was impacted by his mother’s nonacceptance (King et al., 2020).
Theme 3—Recommendations
The third theme of recommendations represents specific health care recommendations shared by TGD children, especially the need for providers trained in supporting parent–child health care conversations. Participants seemed to value providers who confirmed their gender identities to parents and helped parents understand their gender health needs. Some preferred minimal parental involvement, wanting access to health care providers without the need for parental consent. Next, we outline specific findings related to the third theme of this study.
Some children implicitly shared health care recommendations. First, children seemed to want health care providers trained in supporting parent–child health care talk. Children said their relationship with their parents was particularly important in the context of them gaining access to gender-affirming health care services (Bhattacharya et al., 2021). Parental nonsupport of children’s health care seemed to strain parent and TGD child relationships (Clark et al., 2020). Children seemed to appreciate encouragement to share their feelings and strategies with parents about how to manage mental health (Andrzejewski et al., 2021). Children highlighted the value of having a provider who can help them and their parents navigate health care conversations.
Many children want providers to confirm their gender identities to their parents. They respect providers who helped parents understand their gender health needs (Clark et al., 2020). Some want providers to minimize the need for parental permission, and others view provider-imposed requirements to involve parents as problematic and as a systemic barrier (Clark et al., 2020). Others felt they should be able to meet directly with providers and not worry about the providers then sharing this information with the child’s parents (Tan & Weisbart, 2022). Finally, TGD children want resources to help them deal with family members after they decide to come out (Bith-Melander et al., 2010) and resources to help them support their parents (Tyler, 2015).
Discussion
This study focused on a specific topic area within current academic literature: TGD children’s interactions with their parents as these experiences relate to accessing health care. We conducted this literature review to summarize available related qualitative research and make this information available to health care providers. In this section, we present practice implications for health care providers to consider when serving TGD children and their accompanying parents.
Implications for Practice
On many occasions, parents attended health care appointments with their TGD children. Sometimes parents set up the appointments (e.g., Fahs, 2021), and children felt comforted when their parents accompanied them to health care appointments (e.g., Budge et al., 2018). Providers may consider consulting with TGD children to understand their preferences regarding parental involvement in health care appointments. Parents often provide children with health insurance to make the appointments possible, yet consulting with children and allowing them to have a say about parental involvement may yield more supportive and collaborative care experiences. Health care providers may consider assisting parents with finding out-of-network private practice providers. Providers may also ask parents if they are willing to approve of their children meeting alone with the provider if doing so will make the child feel more comfortable to speak openly.
A few parents acted as intermediaries between their child and their child’s health care. Some even used their credibility and knowledge to support their TGD children (e.g., Pullen Sansfaçon et al., 2018), yet what happens when parents lack a basic understanding of gender-affirming care to advocate for their TGD children? Providers may offer resources to parents or schedule meetings with them to review possible treatment timelines and discuss expectations for various gender-affirming treatments, for example, puberty blockers. Educating parents may lead to more positive health outcomes for TGD children and also strengthen their parent-child relationships.
Health care providers can encourage parents to recognize that they are in a unique position to provide a safe space for their TGD children to authentically explore their gender identity.
Parents tried to restrict children’s access to gender-affirming care (e.g., Bhattacharya et al., 2021). Some children recalled parents seeking a second opinion to counter their first (e.g., Pusch, 2005). As legal guardians, parents often oversee their children’s health care decisions. Providers can demystify the process of gender-affirming care by sharing potential outcomes to help parents maintain realistic expectations when making decisions about their child’s care.
We learned that one type of treatment that parents seemed most involved in was children receiving hormone therapy (e.g., Fahs, 2021). Some parents considered their children too young to make this decision, wanting their child to first turn 18 years old before receiving hormone therapy (e.g., DiFulvio, 2015). Health care providers can provide information to TGD children and their parents to weigh out the pros and cons of beginning hormone therapy at various ages, such as adolescence and early adulthood. Providing realistic expectations may increase parents’ confidence about this topic while inviting children to play an active role in their own care.
Providers may offer psychoeducation to help parents develop realistic expectations for their child’s treatment outcomes. Providers can encourage parents to consider the possibility that delaying gender-affirming care could also delay the child’s gender and social development.
Affordability of hormone therapy and parental financial support are both important topics of conversation for TGD children and their parents. One TGD child voiced a willingness to make money to pay for their own hormone therapy (e.g., Fahs, 2021). Limited insurance coverage and expensive out-of-pocket costs may still prevent children from beginning hormone therapy, even when parents voice support for their children to eventually receive treatment and a willingness to pay for it. Health care providers working within health systems may connect TGD children and parents with financing options or other sources of financial support if resources are available.
TGD children had various reviews for mental health care providers. Some found them helpful yet others did not (e.g., Budge et al., 2023). Parents seem to have various motivations when scheduling appointments for their children to meet with mental health therapists. Some wanted to support their child, some were concerned for their child’s safety, and others seemed motivated to problematize their child’s gender identity. Providers may consider speaking with parents to understand their motivations for wanting their children to receive mental health care. Health care providers can address when parents’ motivations and their goals are not aligned.
Mental health care providers can share gender identity-related information with parents. Some children perceived their parents were actually more willing to accept the same information from a provider than them (e.g., Tan & Weisbart, 2022). Providers need to be thoughtful when sharing assessment information with parents, especially when doing so may influence the parent to further accept or reject their child’s gender identity. Providers may also meet one-on-one with parents to hear specific concerns without the child present and also to increase parental support.
In addition, children explicitly or implicitly voiced that they want providers to help them navigate times when parents are involved in their gender-affirming care. Unsupportive parents may prevent access to care and further strain parent–child relationships (e.g., Bhattacharya et al., 2021). Providers can make an exerted effort to encourage parent–child perspective taking in and outside of their office. Supporting parent–child dialogue may improve parent–child relationships. Parental support represents a protective factor for TGD children’s well-being (Ryan et al., 2010). By supporting parent–child communication, providers can support TGD children’s well-being. In contrast, providers may encourage children with abusive parents to avoid communication.
When parents disregard their TGD children’s disclosure and believe the child’s gender identity is only a phase (e.g., Catalpa & McGuire, 2018), children may ask providers to confirm the authenticity of their gender identity and health care needs to parents (e.g., Clark et al., 2020). After hearing directly from providers, parental perspectives may change, resulting in additional parental support. When applicable, providers can confirm the child’s gender identity directly to their parents. Providers can also provide evidence-based literature to inform parents’ decisions.
Some children sought to minimize provider-imposed requirements for parent permission at each step of the process (e.g., Clark et al., 2020). For legal reasons, providers may not be able to remove specific requirements. Yet, providers can encourage TGD children to engage in open conversations about when and how parents will be involved in the treatment decisions for their TGD child. Providers may also seek broader policy changes if deemed necessary. In principle, exploring parent and TGD child expectations may enhance mutual relational understanding.
Limitations
First, our study focused on participants residing in the United States or Canada, yet in other areas, transgender health care also remains limited, for example, United Kingdom (Wareham, 2021). We encourage future studies that explore geographically diverse experiences related to children accessing health care with parental involvement, including nonsupportive parents. Second, we selected search terms to create a dataset inclusive of children’s accounts of seeking medical and mental health care with their parents, yet a future metasummary study may include different search terms to produce metasummary findings with other results, for example, hormone blockers. In addition, we included search terms related to disclosure to focus generally on postdisclosure health care–related experiences. A future literature review study could employ different terms.
Third, we found only a few studies exploring TGD children’s perceptions of parental concerns related to financial costs associated with gender-affirming care. Canada and the United States maintain different health care systems in terms of consumer costs. Medical costs in the United States fluctuate and recently approved government policies negatively impact families seeking gender-affirming care (Redfield et al., 2023). Additional research is needed to explore parental experiences of seeking, financing, and attending appointments with TGD children.
Fourth, we searched for studies with a broad age range of TGD participants. This methodological decision permitted us to include studies with youth and adult participants (Boguszewski et al., 2022), studies that did not include the exact ages of all participants (Bith-Melander et al., 2010), and studies with adult participants’ recalling childhood experiences (Morgan & Stevens, 2012). In the future, researchers may conduct a similar literature review focused only on studies with qualitative data collected from TGD participants younger than 18 years, or only studies with participants 18 years and older recalling past health care experiences. A future review can explore health care experiences aligned with specific developmental stages.
Conclusion
The results of this metasummary highlight challenges and complexity providers may encounter when supporting TGD children and their parent–child relationship, especially when both relational parties maintain misaligned views about the child’s health care. We encourage providers to review this report to inform the services they offer to members of the TGD community, especially children with parents involved in their health care.
Footnotes
Acknowledgements
The authors thanks the following authors for their contributions toward this study: Renee Baker, Julie Barroso, Monica Coulter, Steffanie Grossman, Melanie C. Maine, Rebekka Ouer, Faye Reimers, Kimber Shelton, Amanda Swartz, LaShonda Thomas, and Danuelle “Danni” Williams.
Disposition editor: Cristina Mogro-Wilson
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a grant from the TCU Research and Creative Activities Fund.
