Sarah::

I feel like a boy. I’ve always felt this way. But now everything’s all wrong.

Sarah is 13 years old. In the waiting room sit Mum and Dad. In the last conversation, we all participated, but this developed into a loud, somewhat aggressive exchange that was hard to land in a good way. Now Sarah does not want them to be included. She is dressed like most teenagers in jeans and a hoody, but I sense all the same that her low-hanging jeans and oversize sweater are not accidental choices.

Sarah::

I’ve gotten breasts. I don’t want them. I see them in the mirror every day and cry. I’m so tired of not feeling good. Every time someone shouts my name, I feel sick. I don’t want to be called Sarah anymore, it’s not me. I’ve been born in the wrong body.

As she struggles to find words, I sense that this is important to say. When I ask how she wants things to be and how life could look then, she looks at me with a serious gaze and whispers:

Mum will never allow what I want. But I can’t stand to wait until I’m 18.

Throughout the past decade, gender identity has had considerable presence in the public debate. Questioning one’s gender, identifying as non-binary, agender or gender-fluid has become more usual. Though not a new phenomenon, there is now broader social acknowledgement, and this has produced challenges to our assumptions about nature and culture (Butler et al., 2022). People experiencing a different gender identity than that assigned to them at birth are today standing up and demanding their place in society. The contents of their demands range from what the health service should provide to which changing room they should be allowed to use. Over time, a space has opened in which increasing numbers of people grappling with feelings of incongruence between experienced gender identity and that assigned at birth have helped to raise this issue. They tell stories of desires and needs, about experiences of a narrow, gender-divided world in which they do not feel at home. Various institutions, from the Crown to the Church, from political leaders to schoolteachers have embraced the rainbow’s many colours to promote ideas of diversity, inclusion, the right to love whomever one wants and to decide who one is. In many ways, this has brought change and greater acceptance to areas of human life that previously were tabu. New knowledge has also changed professional and ethical thinking about children, youth and gender incongruence, and many boundaries have been moved. The most common understanding of the significant increase in youth choosing gender confirmative treatment is greater acceptance in many countries and those experiencing gender incongruence to a greater extent finding the strength and courage to promote their needs in fellowship (Coleman et al., 2022).

The view of trans identity as the desire to be “the opposite” gender has been challenged by increasing awareness of different non-binary identities (Butler, 2018). A quick internet search reveals many possible gender categories, and this list is expanding. While there has been an explosion in scientific research attempting to explain the increase in youths questioning their gender identities, there is less exploration of their lived experiences. It is the exception also in a therapeutic context to describe gender incongruence from the inside (Butler et al., 2022). Instead, these knowledge gaps are largely filled by information from social media and other internet platforms offering advice and guidance. The increasing openness about gender identity issues makes necessary an expansion of the conversational space with new ideas. The competence of the therapist regarding knowledge of gender attitudes and values is continuously on trial. We locate a pragmatic and culture-oriented perspective as the basis for understanding identities and concepts concerning gender. This involves the need to understand gender and gender understanding as phenomena that change over time, but that are stable enough in a cultural context to provide meaning and identity opportunities for people’s lives and life worlds (Andersen & Malterud, 2013). We recognize identities as changeable and made possible by culture and society. We also acknowledge that categories can help people understand themselves and cope with a complex reality and can function as stable dimensions that give meaning to people’s lives (see Chapter 4 and 6 about categorization).

Gender Incongruity

Traditional thinking about gender presents a two-gender model in which the child is categorized either as a boy or a girl. Narrow discourses about masculine and feminine gender roles are emphasized from the moment a child enters the world. Gendered codes place the new person within one category and thus communicate from the start (we believe) much about the child and the paths that will lead to a good life that fits what we can see with the naked eye. The child also enters life as a participant in culture already underway, in which opinions and concepts are negotiated and interpreted (Lock & Strong, 2010). Cultural ways of being, attitudes and values are woven into the personality through upbringing and normative expectations of acceptable development. To an extent, the child is “gendered” through clothes and toys, pronouns, comments and descriptions. Experience is thus a meaning-creating process, unique to the individual, but related to the world around us (Grasaasen, 2022). However, it is here that some children encounter difficulty because they feel something in themselves that does not resonate with what this world reflects. Just like culture, nature is diverse and rich in variation and expression (Coleman et al., 2022).

In society and professional contexts, attitudes show movement towards normalization and acceptance of gender diversity in human experience, expression and behaviour as a normal variant of sexual development (Coleman et al. 2022; Menvielle et al., 2010). The past several decades have brought new constructions of gender that, simply put, describe fluid boundaries. These new constructions include transwomen, transmen, non-binary and gender-rejecting (agender). One of the most significant developments affecting the quality of life of trans people is the change in the diagnostic manual of the World Health Organization (WHO; ICD) of diseases and health-related problems. In ICD-11 approved in 2019, trans-diagnoses were removed and replaced with “gender incongruity”. This condition is described as a lack of coherence between experienced gender or gender identity, and gender assigned at birth. It also encompasses those who define themselves neither as girl nor boy, but as having a non-binary gender identity (Coleman et al., 2022). In earlier ICD manuals, gender incongruence was classified as a psychological illness; now it is described in a chapter on issues and challenges concerning gender and sexual health. However, it is acknowledged that gender incongruence can bring discomfort, psychological pain and other forms of suffering. Related to this new recognition, it has become very clear how earlier use of terminology has been to categorize and define gender identities in negative ways. Gender incongruence is not, then, or now, a psychological illness, and linear explanations have had serious consequences for people finding themselves within the frame of this discourse.

When the non-binary came in, there were many who came out. (eepb 2022)

Gender Identity

Some young children, with great clarity and strength of conviction, refer to themselves as having a gender different from that assigned to them by their environment. Other children recognize another gender identity during or after puberty. Often, however, this point of recognition can be traced much farther back than that of self-declaration. For most trans people, gender identity concerns more the desire to move beyond an assigned box than to fit into a new one. Identity can be viewed as the experience of being the same over time, sometimes in contradiction to embodied experience, body image (how we dress and behave) and legal gender (Benestad, 2015). Experience of identity belongs to us as a subjective experience and is a feeling of being unique and independent. Therefore, gender identity has no external reference. It cannot be sensed by others but involves emotional experiences of gender that are not externally measurable. For secure gender identity to be established, others must perceive us as we perceive ourselves (Benestad, 2015; Benestad & Almaas, 2017). Secure gender belonging requires compliance between subjective experience of gender and its positive confirmation by our environment. Self-knowledge arises through interaction and relationship. We contribute continually to one another’s emerging identities and only become real living people when we are included through this interaction in a social world of significance and as part of society at large (Dallos & Draper, 2015).

Our understandings of phenomena are characterized by cultural themes. Constraints in the form of meta-narratives set the conditions that determine the stories that get highlighted and those that remain in the dark. Often narratives of what is usual are accommodated while those about what is more seldom are disavowed (Grasaasen, 2022). When a breach arises between the narrative images children and youth have of themselves and those they receive from their surroundings, they may attempt to resolve this by striving towards preferred cultural descriptions, driven by feelings of deviance and abnormality. Many children and youth do not feel at home in the external culture or in their own immediate environments because what they are unable to provide what is demanded of them. Difficulties in construction of a secure self-image and good quality of life therefore does not primarily concern their own gender experience but is shaped by the preconceptions of their surroundings and by social discrimination. The feeling of differentness can lead to lack of belonging and the feeling of outsider-ship. This can be understood from several perspectives. Adolescence is a vulnerable period in which development is learned in relationship with others. Youth travel in groups, arm-in-arm. At the same time, research shows that verbal harassment occurs frequently among adolescents, usually in the form of gendered words with negative connotations and steeped in traditional gender roles. The perceptions youth have of themselves are thus partially the result of linguistic and relational experiences (Grasaasen, 2019). However, these words also pull towards limited categories and block perception of different descriptions lying outside of these. Experiences leave traces. Research shows how children and youth with different gender affiliation who experience bullying can develop psychological problems, indulge in self-harm and substance abuse and have an increased risk of suicide (Eisenberg et al., 2017; Gower et al., 2018).

It is a consequence in itself, that offensive words and expressions follow a traditional gender pattern that helps to maintain prejudices and stigmatizing attitudes. However, we wish to make clear that youth have their experiences along marked paths (Grasaasen, 2019). In a discursive perspective, gender and sexuality are not givens, nor stable, consistent quantities, but linguistic, appearing through historical, social and institutional practices (Foucault, 1998).

Family and Parenthood

Discourses of gender affect behaviour and development, mostly perhaps in relation to family relationships. Familial roles such as mother/father, daughter/son, brother/ sister and grandmother/grandfather are also delineated along gender-binary axes and come with sets of expectations for role performance. The family is a strong discourse founded on the idea that, despite its many and modern forms, it will remain important throughout life. It is the smallest, most fundamental and intimate context of life as well as a significant social institution. For most people, it will have great relational value from birth to death. The family creates a safe base for protection, development and learning in childhood—throughout the teen years and for many, throughout the lifespan. There are exceptions of course, but in crucial life phases and in life crises, it is those we view as our closest family who primarily and to the greatest extent are involved. When children and youth experience differentness, family support has been shown to function as a protective factor against negative consequences such as psychological problems and substance abuse (Gower et al., 2018).

Most parents want the best for their children and for them to have a good childhood and grow up to be independent adults with rewarding lives. However, parenthood is also discursively governed and strict norms exist for how best to perform it and what this should involve. Like the family, parenthood is a cultural construction undergoing continuous change. Recent decades have seen development of a discourse of “intensive parenthood” (Hays, 1998), in which children’s needs come first and significant time, energy and material resources are dedicated to their upbringing (Faircloth, 2014). The modern relationship between parents and children is largely borne through emotional bonds and independent of the extended family. Modern parenthood can be viewed as a relational project in which discourses of love define parent-child interaction in the family. The emphasis on care is also an expression of love and makes it visible. Parenthood is experienced as meaningful because of love and the parental role has personal value as a meaningful task. The cultural expectation of placing the child at the centre is the foundation for the practice of “child-led response” when children and youth show gender incongruity (Edwards-Leeper et al., 2016). Many parents express how their unconditional love for their child overrides a divergent gender identity. However, this also involves practical and emotional challenges for parents, siblings and close others (Wahlig, 2015). The family as a system is greater than itself; it is a composite of all the ideas, dreams, significances and expectations of its members and of one another. Parental decisions about how to support one another, also when this becomes difficult, will therefore be influenced by the implicit backdrop of cultural constructions of what it means to be a family and of good parenthood. It is from within this picture that some parents react strongly when their children “come out”. Parents can feel a sense of loss and confusion around their child’s new identity and role in the family. Many wonder how they will be treated by others and how life will be from now on. For some, this initiates a significant grief process. Parents describe also grieving the loss of family identity, especially if the child changes their first name, which usually has special meaning. They may also grieve over loss of the familial past, over how their child’s gender-related experience has not been authentic (Wahlig, 2015).

Some parents spend significant time finding out how to move from shock and grief through resistance to acceptance. Even though they want the best for their child, not all believe that a different gender path is the correct one. They can be afraid their child will be bullied or excluded. Some parents also have criticisms of a religious or political nature, or they have a value system that creates resistance (Zamboni, 2006). Other parents find it easier to support the child’s experience and development. They feel pride in the child who has the strength and courage to be seen, and they may experience a stronger bond to the child and within the family (Gonzalez et al., 2013). Family support is not, however, a one-dimensional or simple process, and stigma and marginalization within the environment will affect everyone in the family (Menvielle & Hill, 2010). All family members have their own processes to move through before they “come out” as siblings, parents or grandparents of a trans person. In addition, it can be stressful to have such a significant focus on the family system, and this may change relationships between members. This can result in changed relational attachment and poorer family function over shorter or longer periods (Westwater et al., 2019).

An Inclusive Conversational Space

Welcome!

Offering an inclusive environment in which youth, parents and significant others can feel welcome, confirmed and seen is the prerequisite for family therapy to make a difference. The alliance can only be established if the relationship is experienced as equal and the conversational space a safe place for exploration. Non-verbal communication begins before the conversation starts. Use of context markers in the space enables us to declare awareness, interest and experience. These can be pictures, a pride flag or literature that indicate implicitly where we stand as safe conversational partners. Further, as systemic therapists, we are guests in their lives and should be respectful, informed by our knowledge of marginalization and social debate. Which pronoun do they want us to use? Her, hen, him, they, them, ze or perhaps a preferred name?

As family therapists we must also care for those around the child or youth, and it is important for a good exploratory process that therapists act as hopeful supporters for all involved. Parents can feel guilt and low self-confidence as parents. Therefore, we require knowledge of parental experiences when children are different; it is also imperative to understand what makes the family a good place to be throughout the exploration of the child’s gender identity (Wahlig, 2015). Other essential knowledge includes that of trans identities and a base understanding of central concepts of significance for conversations about gender. In this way, we avoid having to question children, youth and parents and prevent them from feeling that they must teach the therapist or explain themselves in an intimate way. We must help to locate hope and coping strategies that can make the future manageable. Knowing the terminology is the key to being able to confirm experiences and feelings, expand understanding and build bridges between people and ideas.

As therapists, we must not forget that we are also part of a family, a society and a culture and remain self-reflexively aware of our own constructions. We must continually reflect over our understanding of what we read in the social and academic debates and actively assess the extent to which these discourses interfere with our curiosity and ability to wonder. Our preconceptions usually lie implicitly as a confusing backdrop the effect of which is difficult to control. Before reflection can begin, it has already taken up a place, and we draw our prejudices with us into the professional conversation (Grasaasen, 2022). We must never believe that we know how another’s lifeworld is, but as far as possible take responsibility for remaining open to what the other needs.

The Conversations: Include All the Significant Others You Want

Usually, children and youth arrive at conversations with at least one parent, sometimes also with a sibling or grandparent. There is a saying that it takes a village to raise a child. Our slogan is include as many as you want among meaningful others. The entire system around a child is significant because all people need to experience belongingness to others to have a good life. The family is a system also surrounded by other systems of significance for the change process. For children and youth, these will include relatives, friends, teachers and other important persons from school and free time activities. They can act as buffers in meetings with challenges and be supporters of healthy development (Benestad, 2015; Benestad & Almaas, 2017; Eisenberg et al., 2017).

We have arranged with Sarah to speak with Mum and Dad without her present.

Mum::

Sarah has always been a bit special, but lately everything’s gotten so difficult. She says that she’s a boy. I just can’t believe that. I don’t understand it. What kind of an idea is that? That’s why we got in touch because I don’t believe in this thing about changing gender. I think she’s depressed and needs someone to talk to.

Just as strongly as we hear the despair in Sarah’s voice, we can hear it now in a grieving mother. Dad says little but shows his support with small gestures while Mum speaks. We acknowledge them for having sought help and emphasize the courage this takes. Being a parent is personal and private, and a role we like to believe we master. I ask if we can talk a little about Sarah in relation to what she experiences and says. When they think back on Sarah’s childhood and upbringing, how was she as a child?

Mum::

I don’t know what to say. I’ve got so many questions, but so few answers. Sarah has always been different from her sister, but they’ve been good friends and I know her sister has defended her when others have called her odd. As we’re talking now, I feel mostly how afraid I am for her. Children can be so nasty. What if she gets bullied? How will her life be now? What if we put in motion something she’ll regret? What if she won’t be able to have kids?

In describing how conversations with families about gender incongruence can be conducted, it is reductionistic to retell only one narrative in a landscape that is so multifaceted and dominated by tabus, resistance, denial, secrecy and shame. This is true especially for the child or youth, but also for parents and siblings who find gender incongruence difficult to understand and manage. Sarah and her parents can nevertheless illustrate the ambiguity that often appears, but which also makes gender incongruence possible to grasp and to talk about. On the reverse side of love, we find dread of not being enough, grief over losing the child they thought they had and fear of the unknown.

When families seek help, this may be because the situation has become so stuck that constructive communication has become impossible, more often, however, they seek guidance and support to assist the child- or adolescents process towards belongingness. Facilitating family conversations thus involves creating a direction in which all participants come into position to speak and listen to one another. Sometimes, it may be necessary to have conversations with family members on their own. Parents and others who feel guilt can benefit from opportunities to express uncertainty, grief and discomfort without their child or youth present. Just as important is having one-to-one conversations with the child or youth. The goal of the conversation is to support the child’s exploration such that they can feel secure and self-sufficient using their own expressions, standing on their own two feet. The reactions of parents and close others will influence how the child or youth thinks about themselves. Parents are usually the first to experience the child’s attempts to create agreement between inner and outer self-images. They also have some power to determine the extent to which the child or youth is allowed to express their gender identity through clothing, pronouns and name. Denial from them can limit space for action and make the child invisible. Further, the child can turn frustration inward and blame themselves for their differentness (Eisenberg et al., 2017).

I hear Mum’s uncertainty about how to handle Sarah’s experiences and how to think about the future. I ask how they as parents talk about this at home?

Dad::

It’s difficult because we think quite differently. I’m also worried about Sarah, but right now I can’t get concerned about her adult life or what other people think. I want her to feel better right now. What can I do for her? She’s a fantastic child having a hard time. I agree that she’s always been different, but I’ve been a bit proud of that, and thought that it’s sort of cool to have a child who’s so independent and unconcerned with being like everyone else. At the same time, I understand that this must have cost Sarah more than what I’ve understood, and I feel guilty for overlooking what she’s tried to tell us. I wonder what she thinks about me. As her dad, I should probably have known her as well as she knows herself?

To generalize, I choose to conventionalize his question (Bruner, 2003) as reflecting ideas he probably shares with many other parents of children the same age. I refer to Sarah’s independence as well. In what way has he contributed to this quality Sarah is certainly happy to have now?

In gender incongruence, family support has been shown to be particularly protective of psychological health of children and youth (Abreu et al., 2022). Unfortunately, it also happens that parents refuse to acknowledge their child’s gender identity and the family becomes divided. Occasionally, we see that youth break with those closest to them to establish themselves in another family or within a network in which they can feel at home. It is then even more important for the therapist to acknowledge the unique needs of the youth and act as an allied party (Eisenberg, 2017).

From Different to Talented

The power of language becomes extra clear when those we speak with have marginal voices (Moscheta & Rasera, 2021). When children and families feel excluded and different, the use of inclusive language can make a big difference. The goal of professional conversations is to create change. We must, therefore, inspire by being unprejudiced and resourceful and use the language of co-creative action. We must speak in a way that gives hope, pride, meaning and movement towards the new and better. Maturana and Varela (1987) describe three fundamental elements that together and reciprocally stimulate opportunities for growth, development and change: love, external guidance and time for reflection. Therapists can support the family by investigating, deconstructing and reshaping cultural and familial discourses around gender and transgender identities. Through reflective processes, we can actively search out several perspectives, new understandings and other ways of communicating.

Sarah is lucky. In their own individual ways, Mum and Dad talk about great love for a loved child. She has one parent most concerned about what is happening now, while the other is thinking about the future. Together, this yields a difference that is both complementary, double and provides space for two thoughts at the same time. What do they think when I summarize what they have said in this way?

Mum::

That sounds much better but it’s difficult as well because it continues to give us different roles. Dad as always, is the nice one and understanding, while I’m the difficult one asking questions. We need to learn to talk about this in a way that makes Sarah understand that we’re cooperating, and that we’re afraid of doing something now that might be wrong later on.

Connotations have significant place in systemic conversations and can be defined as the meaning a word or action receives through how it is coloured or presented with a positive or negative nuance. Positive connotation is an active reformulation in which we seek ways to give words and phenomena additional, attractive meaning. This is an active change of awareness and a skill the therapist can employ to show the significance complexity and avoid oversimplified and linear descriptions. When we bring a positive connotation to the negative this puts Yin and Yang together to form a whole (Hoffman, 1981). As an example, we raise the expression, “born in the wrong body”, one Sarah uses about herself. The expression has become widespread among those it describes, in the media and in public discussions. It is used as a personal narrative, a description of other people’s experience, and by health professionals speaking about gender incongruence. As a metaphor it has temporary meaning but for several reasons, we do not find the expressions well-connoted. Firstly, no one is born in the wrong body because no body is wrong. Secondly, no one can exchange their body for another, and if Sarah had been born in another body, she would have been someone else. On the contrary, we can believe that people are born with different talents, also for gender. We can positively connote a youth’s experiences and call this trans talent or talent for gender (Benestad & Almaas, 2017). It will also make a big difference in conversations with Sarah and her parents if instead of describing her as odd and different, she is called courageous and talented. The goal can also be to get the parents to place Sarah’s experience into a framework that is easier to relate to. Movement towards a more appropriate understanding can occur if the conversation can be led towards resources over faults and deficiencies. In the same way, we can construe the term “trans-aesthetic” to make it easier for all to see the beautiful in the androgynous.

Gender Map

The gender map is a therapeutic and educational tool developed by Silje-Håvard Bolstad (2019), based on a way of thinking about gender developed by Almaas and Benestad (2017). It is a visual picture that can be used as an aid in conversations with slightly older children, youth, adults, parents and networks. The idea is that it is open and only roughly refers to categories of gender without presenting uniform answers. We find it of great usefulness, not least because it provides children and youth with a seamless opportunity to set their own “brand” on the map and enable them to move it again at a later point. This permits reflection over feelings and experiences they have had, before and now, related to development and age. Defining gender as fluid means that the idea of who one is can change over time and that is fine. An important feature of map use is that gender is not thought of in terms of opposites. The opposite of a girl is not a boy, but a non-girl, and a boy is not the opposite of a girl, but non-boy (Fig. 3.1).

Fig. 3.1
An illustration of a gender map. It has 4 circles in the 4 equal segments of a square. Labels include 0 and 100% boy in the bottom-up order on the left, and 100% girl on the bottom circle on the right.

Gender map (reproduced by the authors, based on Bolstad, 2019) (www.gendermap.no)

Full size image

The farther to the right a child or youth moves on the map, in every vertical axis is the extent to which they feel like a girl and the farther up along all horizontal axes, the extent to which they feel like a boy. This means that in the right-hand corner they feel both very girl and very boy—an example of the non-binary experience. Feeling a pure girl identity or pure boy identity is an experience of finding oneself, respectively, in the lower right and upper left corners. There are few children and youth who place themselves in the one-dimensional corners, and those who do are often on a desperate hunt to be their experienced gender. They experience themselves as binary and find their place in the upper right portion of the map or in the lower left portion. Close by these placements we usually find those who experience themselves either as transwomen or transmen. Down in the left corner, a youth has no experience of being a gender, a different, but also non-binary experience. Those who place themselves here have the greatest challenges, because as a society, we still find it difficult to find space for such (gender) expression. In this context, we see constructions of types of dress, makeup and beards.

There is a wide space outside the binary boxes, and this provides the opportunity to locate oneself in multiple places, wherever one wishes along the spectrum. Those who find their place in the map often want to alter their lives, outward appearance and sometimes their bodies to harmonize as well as possible with their gender identities. The map can also open to conversations about narrow discourses of masculinity and femininity to expand the image of what is common. In this way, we can be challenged to think in new ways about narrow gender roles and what is required for children and youth to feel at home in themselves, with the gender they experience.

An Inclusive Professional Community

While changes are occurring that reveal more inclusive images of children, youth and gender incongruity, we continue to inhabit a professional landscape with divergent opinions and significant disagreement. The power of academic positions is still used to promote some ideas and suppress others in ways that create division. This in turn affects development of and opportunities for locating help. Along with a sharpened social debate this can alienate those children, youth and parents experiencing gender incongruity seeking acknowledgement of their needs. Within a social constructionist perspective, we view previous practice as a collective construction in which most recognized knowledge has been shaped within a categorizing and discriminative tradition (Moscheta & Rasera, 2021). We believe that a relational and social constructionist approach to family conversations can be helpful and make a difference. We also believe in dialogue and in the opportunities that can appear if we seek a multiverse in which opinions produce expansion instead of restriction. Then we can address the importance of the power and influence of the environment, acknowledge the rights of all children and youth to live in a healthy milieu, turn narratives of difference around and promote what is beautiful on the other side of difficult experiences.