“How in God’s Name Are We Going to Navigate This?”: Parent Support for Transgender Adolescents

The extant literature has clearly demonstrated that transgender and nonbinary adolescents (TNBA) face extreme stress related to navigating gender identity and expression across various social environments. Additionally, parents are perhaps the most critical aspect of support for TNBA, and research has repeatedly identified the benefits of parent support for adolescent mental health. However, few studies underscore how TNBA and parents within the same family perceive parent support after adolescents disclose that they are transgender or nonbinary. The present qualitative study uses a life history calendar (LHC) interview approach with 20 TNBA-parent dyads (40 individual interviews) to explore TNBA-parent perceptions of parent support and adjustment related to TNBA gender identity and affirmation. Findings yielded three main points regarding parental support for TNBA. First, the time between disclosure to a parent and puberty mattered for parental support and adjustment processes. Second, parents who stepped into their child’s gender journey during their child’s adolescence grappled with feelings of grief and loss as they were making decisions to support their child’s gender affirmation. For many of these families, stigma-related fears and adolescent distress impacted parent support for their child’s gender journey. Third, parents lacked a familiar and affirming roadmap in their own families and communities, and although parents connected with other parents of trans kids for support, for some, these supportive resources presented challenges. Continued research can further study the complex drivers of support and the potential impact of these support processes on adolescent and parental well-being. Life History Calendar qualitative interview approach to dyadic data collection with trans and nonbinary adolescents and one of their parents; Dyadic qualitative analysis; Findings underscore dyadic perspectives of parent support and adjustment to transgender and nonbinary adolescent gender identity and affirmation after TNBA disclosure of gender identity to parents. Life History Calendar qualitative interview approach to dyadic data collection with trans and nonbinary adolescents and one of their parents; Dyadic qualitative analysis; Findings underscore dyadic perspectives of parent support and adjustment to transgender and nonbinary adolescent gender identity and affirmation after TNBA disclosure of gender identity to parents.

Life History Calendar qualitative interview approach to dyadic data collection with trans and nonbinary adolescents and one of their parents; • Dyadic qualitative analysis; • Findings underscore dyadic perspectives of parent support and adjustment to transgender and nonbinary adolescent gender identity and affirmation after TNBA disclosure of gender identity to parents.
Most notably, family represents one critical system of both stress and support for all adolescents.Unlike peer relationships, the parent-child relationship is not voluntary, but rather tied by an emotional and legal bond constrained by societal expectations for harmony and comradeship (Becker & Useem, 1942).Misalignment in the parent-child relationship can result in adolescent distress and poor mental health (e.g., Collins et al., 1997;Dimler et al., 2016;Steinberg & Morris, 2001), whereas parent-adolescent trust, respect, and rapport buffer against behavioral health problems (Armsden & Greenberg, 1987;Ryan et al., 2010).For TNBA, rejection by parents or primary caregivers (hereafter referred to as "parents") has been linked to psychological distress (Bockting et al., 2016), whereas parental support appears to alleviate distress and strengthen selfconcept for all adolescents (Meadow, 2011;Ryan et al., 2009Ryan et al., 2010)).Expressing gender nonconformity or coming out as transgender often correlates with isolation from familial support systems that are unprepared to provide support (Burgess, 2000).This support is critical because high parental support protects against social stigma and psychological distress such as depression and anxiety (Bockting et al., 2016;Grossman et al., 2021;Simons et al., 2013), especially during the child's early (trans)gender identity development (Olson et al., 2016).Despite broad agreement that parental support is salient in the lives of TNBA, to date research on parental support has centered on functional aspects, such as using correct pronouns, providing access to medical care and other transition-related support (Hale et al., 2021;Johnson et al., 2020), educating themselves and others, providing emotional support, and expressing love and affection (Hale et al., 2021).
Indeed, all parents navigate parenting amid expectations set forth by their personal social support systems and cultural, religious, and social frameworks.Yet these contexts may present unique challenges for parents of TNBA as they try to also navigate their child's gender identity and affirmation in the face of cisgender social norms and expectations, without a clear roadmap to follow.Many parents of trans adolescents undergo stages of grief as they detach from their idea of who their child is and will become (McGuire et al., 2016;Meadows, 2011), perhaps even holding themselves responsible (Riley et al., 2011), while concurrently familiarizing themselves with and adjusting to their child's affirmed self (McGuire et al., 2016;Meadows, 2011;Olson et al., 2011).During this time, parents can feel isolated, excluded, ostracized, and harassed (Riley et al., 2011).Even as adolescents develop self-efficacy to challenge fixed assumptions connected to their gender, parents experience their own confusion and adjustment (Olson et al., 2011;Simons et al., 2013).However, little is known about how parents navigate parenting a transgender child and the factors that affect their ability to provide support, regardless of their best intentions.Understanding parental support and adjustment across social contexts is necessary as we strive to develop interventions that support not only TNBA but also their parents, who are arguably instrumental to TNBA well-being.

The Present Study
Most research on parent support for TNBA has focused on either parents or adolescents, but not both perspectives in the same family.The limited research available has separately explored a narrow set of topics, including (a) parents' initial reaction to their child's disclosure and adjustment (Alegría, 2018;Grossman et al., 2006Grossman et al., , 2021;;Sansfaçon et al., 2020); (b) youth's experiences with their parents' reactions (Meadow, 2011;Simons et al., 2013); or (c) supportive behaviors from the perspectives of adolescents and parents (Hale et al., 2021).Thus, the following gaps remain understudied: (a) TNBA and parental perceptions of parental support behaviors and processes in the same family, (b) parents' adjustment and motivators to support their TNBA, and (c) parents' support seeking after their child comes out as trans.Using a qualitative narrative research design and a life history calendar (LHC) approach to interviews, the present study sought to explore parental support from the perspectives of parents and trans adolescents in the same family.The following research questions guided the present exploratory study: (a) What does parent support for TNBA gender affirmation look like from the perspectives of trans adolescents and their parents?and (b) How do parents of TNBA navigate the path to supporting their trans adolescent child?This research has the potential to explain important family processes that can inform both future research and the development of theoretically grounded family-centered interventions.

Method
The present study used a narrative approach to dyadic data collection and analysis of individual and simultaneous LHC qualitative interviews with trans adolescents and their parents.Researchers define two people as a dyad "when intimate, face-to-face relations between them have persisted over a length of time sufficient for the establishment of a discernable pattern of interacting personalities" (Becker & Useem, 1942, p. 13).Data collection with parent-child dyads minimize subjectivity bias and enhances understanding through the collection of dual perspectives of a shared phenomenon (Thompson & Walker, 1982).Dyadic interviews provided an opportunity to deeply explore and understand TBNA and parents differing and overlapping perspectives regarding the phenomenon of parent support.Additionally, using two interviewers to conduct separate and simultaneous parent-adolescent interviews mitigated contamination from one dyadic member to the next and thus improved trustworthiness of our data.Within a narrative approach, we used the LHC interviews to explore context and important transitions of parent support processes during TNBAs' gender journey.

Recruitment
Prior to the study, the PI spent a year with our three recruitment sites meeting with parents of trans young adults, trans young adults themselves, and clinicians to understand TNBA-parent needs and previous experiences with research and build rapport and trust.TNBA-parent dyads (N = 20 dyads) were purposively recruited from these three sites in Southern California: (a) a trans-specific child and adolescent health clinic, (b) a transgender family support group, and (c) an LGBTQ center.Study flyers were posted in case management offices at these sites and parent group facilitators approved and posted flyers online on their support group listservs.During our recruitment process, the principal investigator (PI) presented at the beginning of several adolescent and family support group meetings and during drop-in hours at a youth-specific LGBTQ center space to introduce the study and answer questions.Interested families and adolescents called, texted, or emailed the PI, and the PI conducted a brief screen to determine eligibility.The PI and parent-adolescent dyad scheduled a time to meet in a comfortable location of their choosing, either in the family's home (n = 16) or private university offices (n = 4) to conduct separate but simultaneous interviews.Interviews occurred between 2017 and 2019.

Procedures
The present study was approved by the UCLA North General Institutional Review Board (NGIRB).The PI and masters level trained social workers (MSW) conducted the separate and simultaneous interviews with dyads, with the PI and one MSW trained interviewer per dyadic interview.Recognizing that the researcher is a primary instrument in qualitative research, the PI would switch who they interviewed (parent or adolescent) for each dyadic interview to enhance trustworthiness and minimize potential interviewer bias.The PI separately interviewed both members of the dyad across two consecutive days for two families due to scheduling and availability of a second interviewer.For these two dyads, the PI could not control contamination from one member of the dyad to the other, however, the PI took in-depth field memos to be cognizant of and minimize any use of leading questions stemming from previous knowledge gleaned from the other dyadic member's interview.
Before the start of each interview, the two interviewers met with the dyad together for the verbal informed consent process with parents and adolescents.After we conducted the informed consent process with the dyad together, the PI and the interviewer separated into two individual spaces to conduct the separate and simultaneous interviews.Next, we completed verbal assent individually with each participant prior to the interview to give participants an opportunity to ask questions independently and choose whether or not they would like to individually participate.Each member of the dyads agreed to participate and be audio-recorded for the study.Immediately following the informed consent and assent, interviewers turned on an audio-recording device and conducted separate and simultaneous individual interviews with adolescents (n = 20) and their parents (n = 20).Interviews lasted between 90 min and 3 h.

Inclusion Criteria
Transgender adolescent participants were (a) aged 12-17 years old; (b) identified as transgender, nonbinary, or a gender different than the sex assigned to them at birth; and (c) had initiated puberty blockers or gender-affirming hormones within the last 12 months from the time of the interview.Parent refers to the caretaker primarily involved in the child's trans health and mental health care.The present study recruited parents primarily involved in their child's trans-specific medical care with the underlying assumption that these parents may have more knowledge of their child's gender-affirmation processes.In instances where both parents were involved in their child's transspecific care, fathers were encouraged to participate because throughout recruitment, more mothers than fathers selfselected into the study.All participants spoke English and provided verbal parental consent and youth assent.

Instrument
We relied upon a life history calendar (LHC) method to organize the interview processes (Baltes et al., 1980).In research, the life course orientation to studying human experiences and development can be applied to the entire lifespan or specific developmental periods such as adolescence (Baltes et al., 1980).Additionally, this life course perspective fit with our narrative approach to qualitative data collection and analysis because the LHC as a tool allowed us to explore adolescent gender affirmation and parent support as a series of intersecting events across time and occurring within a broad range of domains (for this study, primarily family, school, health care, and cultural community) (Yoshihama et al., 2005).Each LHC was tailored to the lifespan of the adolescent (from birth to current age).Our LHC interview questions assessed themes (e.g., disclosures, support, expression, affirmation, community connection) within each domain and these were also temporally organized by adolescent age and the academic calendar (fall to summer) (Yoshihama et al., 2005) as families tracked their experiences within domains more naturally using these temporal aspects of life.The present study's LHC was poster sized and laminated for writing during the interview (i.e., dry erase).Participants were invited to record events on the calendar during the interview to help visually and cognitively connect temporal and intersectional experiences (Freedman et al., 1988).
Each LHC interview started with a landmark or interviewerposed specific event question to initiate the interview.The interview-posed specific event question is a qualitative data collection strategy used to encourage participants to reflect on an emotional or memorable time of life (Fiese and Spagnola, 2005;Yoshihama et al., 2005).Interviewers started the main LHC interview with each participant using the same interviewposed specific event question, tailored slightly for adolescent and parent: "Thinking back to early childhood, what is an experience or memory you have that is more memorable for you?Some people think about a particular birthday or move or time in elementary school (or for parents, a time during pregnancy or when child came into their life).This can but does not have to be related to your (or your child's) gender.What comes to mind for you?".Interviewers used this early experience to ground the calendar in an early prominent memory, allowing interviewers to move fluidly forward and backward to understand development and changes throughout time from that early event.For the present study, using an LHC approach to understand TNBA and parental perspectives of adolescent gender identity and gender affirmation was important in two ways.First, it identified key processes in childhood informing experiences and perceptions during adolescence.Second, it allowed the interviewer to gather important information from two unique perspectives during adolescence that deepened our understanding of trans adolescent-parent stress, support, and well-being.

Individual qualitative analysis
The PI transcribed each of the 40 audio-recorded interviews word for word using Express Scribe transcription software.We used a narrative approach to understand lived experiences of TNBA and parents within the context of disclosure and gender affirmation.This approach was necessary as it helped us to connect narratives both temporally and in the context of meaningful phases in families' gender journey.First impression memos of transcribed audio files uploaded into ATLAS.ti8 provided critical information regarding initial thoughts about each interview (Creswell, 2013).Line-by-line inductive coding, including in vivo coding, paired with a priori deductive coding stemming from the LHC interview domains, guided the initial coding process of the first two dyadic interviews (four individual interviews).Codes were attached to text segments to understand how individuals experienced a phenomenon (Eisikovits & Koren, 2010).Intercoder checking and discussions between two independent coders and the PI with the first two dyadic transcripts were used to ensure rigor and trustworthiness.We used analytic memos, as described by Miles et al. (2014), to deepen interpretive understanding of codes and how they potentially grouped together.Following intercoder discussions, we developed a codebook with definitions and coding rules to use for the remaining transcripts.Additionally, as coding progressed, definitions of some codes changed slightly to account for additional phenomena.We revisited previous transcripts to determine if and how any newly defined codes applied to previously coded data and then checked for salience.
We used axial coding to determine salience and conceptual meaning of codes related to minority stress, parental support, and adolescent gender affirmation (Boyatzis, 1998;Malterud, 2001); codes were grouped into broader and more meaningful domains based on conceptual similarities and meaning.Our initial codebook yielded 222 codes and 15 analytic domains.Through our analysis process, our final codebook yielded 42 codes and 6 domains.Through the use of memos, these domains were grouped into salient themes that fit the data across transcripts and gave meaning to lived experiences across time (Creswell, 2013;Miles et al., 2014).

Dyadic qualitative analysis
We used the individual codebook and codes along with memos to develop a spreadsheet of descriptive and interpretive similarities and differences within and between dyads (Eisikovits & Koren, 2010).Then as a method to understand the dyad as a unit of analysis, we compared adolescent and parental perspectives regarding each domain and wrote interpretive and thematic memos.In each memo, we explored similarities and differences in perceptions of parental support across domains of life (Eisikovits & Koren, 2010).Themes were organized by timing (before and after puberty; before and after disclosure to parents).We also captured these experiences by three developmental periods (elementary, middle, and high school).We reviewed data-driven themes to determine the centrality of parental support and adolescent gender affirmation.The structure of the calendar provided an organized method of identifying specific support processes over time and identifying similarities and differences within dyads.Overlap and divergence within a dyad does not imply connection or disconnection between adolescents and parents (Eisikovits & Koren, 2010).Therefore, important attention was placed on how participants described and interpreted phenomena (Eisikovits & Koren, 2010).A narrative understanding of the findings included quotes from participants as a method of creating rich, descriptive stories of lived experiences (Miles et al., 2014).

Positionality Statement
The PI is a White, `educated, cisgender woman who is also a parent.The PI worked for over 15 years as a social worker and researcher with homeless youth, child and family mental health, LGBTQ youth, transgender youth, and young LGBT and pregnant women living with HIV.The MSW/LCSW trained interviewers all worked in the field of mental health (n = 4) and LGBTQA+ and transgender specific health and mental health (n = 3).As our lived experiences and identities influence our lens and representation, we felt it was important to note that the MSW/ LCSW interviewers were White (n = 3), cisgender (n = 2), transgender or nonbinary (n = 2), Black (n = 1), LGBTQA + (n = 3), and a parent (n = 1).One of the co-authors interviewed dyads and worked with the PI to analyze data for this particular paper.While our collective lenses and experiences informed our research questions, our methods informed how we understood and analyzed the interview data.We also used audit trails to provide transparency to these research methods (Creswell, 2013).To do this, the PI documented each step of the interview process, kept detailed field notes, maintained secure storage of transcribed interviews, and analytic memos.The co-authors met regularly to ensure analytic rigor of our dyadic analysis process and discussed how findings related to both theoretical and substantive knowledge.

Social Location of Families
Families who participated in this study lived in Southern California.All 20 parents in the current analysis previously gave consent for their child's gender-affirming health care including hormone blockers and/or gender-affirming hormones.Most parents interviewed for this study identified as White (65%, n = 13) and mothers (80%, n = 16).Among TNBA, 60% were transmasculine (n = 12), with 15% (n = 3) identifying as nonbinary (see Table 1).Participants discussed the importance of mental health care and educational systems as important components of TNBA-parent support systems.While most participants attended traditional public school (n = 11) or private school (n = 2), five In the context of this study, disclosure and puberty were two important milestones experienced by dyads.For five families, parents were aware that their child was trans by third grade, and all five were trans girls.The remaining 15 families included adolescents who disclosed to their parents that they were trans during puberty.Parent support occurred amid social norms and in community and family systems that didn't typically provide a path to understand adolescent gender variance as typical.We identified two themes that encompassed how TNBA and parents experienced parental support processes for adolescent gender affirmation (See Table 2): (1) Parent-adolescent knowledge and readiness gap; and (2) Parents (silently) adjust to their child's gender identity affirmation process while becoming (super) supporters.

Theme 1: Parent-Adolescent Knowledge and Readiness Gap
The knowledge and readiness gap refers to the gap in transrelated knowledge and readiness for adolescent gender affirmation between parents and adolescents after adolescents disclosed to parents that they were trans.Time between gender identity disclosure and puberty mattered in terms of the knowledge and readiness gap and ultimately, parental support processes.In this theme, we identified the following subthemes: (a) "Nobody gives you the book for this": parents trying to understand and catch up; (b) "I was just tired of listening to everyone": parents turn to familiar sources of knowledge and support; and (c) "People were noticing and they were doing something about it": benefits of having time.
"Nobody gives you the book for this": parents trying to understand and catch up For dyads with adolescents who disclosed during or after puberty, parents and TNBA were commonly at different starting points regarding TNBA's gender affirmation.For adolescents who disclosed in early childhood, before puberty, parent-TNBA dyads tended to navigate adolescent gender affirmation in unison.Adolescents who disclosed that they were trans to their parents during adolescence spent months to years before disclosure exploring their identity in terms of gender and sexuality, gaining transspecific knowledge, and connecting with familiar trans narratives online.Upon disclosure, parents of adolescents were unprepared, felt confused and afraid, expected rejection from other family and community members, and experienced a lack of knowledge on an unfamiliar path to supporting their child.
Adolescent G, a 16-year-old trans young woman, came out to her mom after her body started changing during puberty.Adolescent G's mom connected her child's dysphoria to her body development from male puberty and to the stress related to waiting to move from the East Coast to West Coast so that she could give her daughter an opportunity to transition.Here, the mother used male pronouns to refer to her daughter, which may have reflected her complex perceptions of and attachments to her daughter's assigned role as her son and now-affirmed role as her daughter."I told him to be patient and we had to talk, and I was like, "You know, we can move somewhere else and move to a whole new state and you could start living there as a woman.You could just start your life there as a girl."Adolescent G remembered her sense of urgency to progress with her gender affirmation and medical care and the distress connected to waiting.
Even though I came out now, I feel like I was too late.Because I wanted to do it before puberty.I didn't want to like, have my voice and big feet, big arms, like, I just didn't want any of that.But then as I grew, I got taller, I grew, I didn't want to grow.
Adolescent A, a 15-year-old trans young man, disclosed to his parents after his body started changing through his female puberty.Adolescent A's mom lacked a familiar roadmap regarding how to support her son's gender affirmation.
Nobody gives you the book for this, but all I know is that I want my kid to be happy, which is what any parent wants.I just want a living happy child.And you know I would rather have a happy living [Adolescent A] than a dead [Adolescent's birth name] any day.That has been the most for me, that has been my motto for every next step.And not that I am opposed but regardless of how I feel about the loss.This mother questioned how to support her child amid fears, feelings of loss, a lack of trans knowledge, and at the same time, she felt a sense of urgency to alleviate her son's dysphoria and protect him from being suicidal.Leading up to disclosure, Adolescent A had gained trans knowledge and felt ready to transition; thus, the gap in knowledge and readiness was prominent.
Yeah, I had done research before about this and when I finally had this come to terms, not come to terms with my parents, but by this point, I was surprised that they didn't know about this stuff.Because I had spent so much time by myself online that I just thought everyone would know about that.(Adolescent A) The mother of Adolescent E (14 years old, agender) discussed how her child's urgency to be affirmed further amplified the mother and father's uncertainty.They were simultaneously isolating from systems of support, trying to use new pronouns, and contemplating decisions to start hormones.Their initial distress as parents was compounded, in part, due to a lack of knowledge of gender affirming health care, their own experience of loss, and concerns that hormones would be a mistake.Like Adolescent G's mom, Adolescent E's mom used "she" pronouns, potentially reflecting her complex attachment to two genders that for her, represented her child: She would correct us constantly.And I said, "OK, we are trying, we are trying, trying."And it was just really hard.And of course, you don't tell anybody.I mean [husband's name] and I went through our own kind of three or four months of total depression ourselves and didn't talk to anybody.And everyone just kept saying [it takes] time and you guys got support.And then we just came to the conclusion to get over ourselves and it's not about us.It's about keeping our child safe and alive.
Lacking a familiar roadmap to help them understand and accept their child's gender journey, ultimately these parents' fear for their child's safety prompted them to take the initial step toward affirming their child's gender journey.At the same time, they had strong concerns about their child starting testosterone.Although they did provide consent for blockers to stop puberty from progressing, at the time of the interview, Parent E was questioning whether testosterone was the right next step in their child's life.
You know we will support him with whatever 100%.But for us we are a bit nervous, rushing into, because he says, "When can we see Dr. [name of gender doctor] again?" and "When can I get the T? When can we start?When can we start?"And we're like, "Just hold on."And then he starts getting depressed when we are not motoring with things.Because as parents we have to make sure because if this is wrong for whatever reason, then we can't reverse the testosterone.And then you are stuck with the deep voice and hair on the face.It's a big decision.And I know he's depressed and the dysphoria really is horrible; its horrendous, and we can't be like pushed as parents, we've got to be responsible.It's really tough.
Adolescent E initially felt relief from stopping his female puberty from progressing, and at the same time, he connected the delay in starting testosterone and thus male puberty to growing distress.
I have been hoping that my transition would go on a lot faster and get on T a lot quicker.Because I did start recently remembering how, like, when we had our first two appointments with Dr. [name of gender doctor], about blockers and testosterone and all that, we were originally planning on starting blockers and a very small dose of testosterone.But then we decided not to do that.It was kind of my parents convincing me out of starting testosterone immediately and starting it in a year's time.But I can't deal with not being on testosterone for a long time.It makes me really upset that I am not going through anything.
"I was just tired of listening to everyone": parents turn to familiar sources of support Parents discussed seeking support within their trusted community of family and friends to process their decisions and experiences navigating their child's social and medical gender affirmation.Yet some parents felt rejected, judged, and isolated within a close network of support whose presumed knowledge did not translate to empathy or openness for TNBA's social and medical gender affirmation processes.
The mother of Adolescent M (15-year-old young trans man) was a single mom and described her friends as knowledgeable but not understanding.
I get it from long-term friends, you know.I mean, people I am friends with are pretty knowledgeable, but no one really understands.They are like, "Are you sure?"The top surgery thing scares everyone, like, "Are you kidding?" Like, I get, "Are you joking?"You know, they don't understand that this is a health issue, it's not a social-it gets so squished into the social stigma part of it, where it's not what it is.I get a lot of negative, "You are a horrible mother."Her son, Adolescent M who was 15 years old and identified as a trans guy understood the impact of surgery and gender affirmation in terms of his wellbeing.He also acknowledged that while surgery would not cure his dysphoria, it would make a meaningful and positive difference to his wellbeing.I think I will always be dysphoric about some things.Like my height and eventually, I will have scars, but I don't think it will be unbearable, like it will just be a thing that I live with.I don't think it will be debilitating like it has been in the past.It will just be fine, you know.My therapist says that it [dysphoria] will be gone.I don't believe that.It will just be less.Adolescent M's mom had to defend the medical interventions she sought to ensure her son's health and alleviate his distress.Similarly, Adolescent G's mom questioned how to support her daughter's gender affirmation without a familiar roadmap to follow.Adolescent G's mother identified as lesbian, was a young single parent, and raised her children in a very intergenerationally connected Puerto Rican family.
And, my mom is so bias, you know."OK, you're a lesbian, it's OK.And if he would have been just a regular gay"-how she says, "Why can't he be a regular gay guy, you know, just a regular gay guy that dresses like a man but likes men?"And I'm like, "It's not, what kind of gay you want him to be.That's not his life."[Mom's mom would say], "He's too young, he doesn't know what he wants.They don't know what they want to be when they are teenagers.Wait till he gets older, and he can make that decision when he is 18 and an adult and he leaves the house."I was just tired of listening to everyone.Because at that point, I had so many regrets.I'm like, wow, if I would have listened to myself, he could have transitioned earlier, and he wouldn't have had to go through this stage of hating his body and maybe he wouldn't have all these male features that he hates about himself.You know, I regret it.I regret not thinking for myself.
She turned to a familiar source of support, her mother, who rejected the idea that her grandchild was trans and old enough to know what she needed.Without access to transaffirming knowledge and support in her family and community, this mother was unclear about what steps to take to support her child.Ultimately, she moved across the country to provide her daughter a path to transition.Adolescent G felt her gender affirmation happened too late and at the same time, she understood the pressure her mom experienced regarding the process of support.I feel like it shouldn't be her fault because I didn't, it wasn't her job to do that, you know?But I felt likeoh my God, I'm going to cry but [cries]-I just don't want to make her feel it was her fault, me doing it so late.… She had kids at a young age, she had to drop out of school, she had to work three jobs.And I felt like that wasn't her fault.
Trans adolescents guided parents to support Whereas some support systems created roadblocks to parent support, others, such as TNBA themselves, provided a roadmap to support.Adolescent I was nonbinary, 16 years old, and used they/them pronouns during the interview but publicly and in their family used he/him pronouns.Adolescent I was raised in the United States, their mom was raised in another country, and their father was raised in the United States and passed away 3 years prior to this interview.Their mother's readiness to consent to testosterone was driven by the lack of easily available and culturally meaningful information about being transgender and gender-affirmation processes.
So, doctor prepare for the testosterone.I think October we went second time and I think [name of doctor] said, "So, are you ready to start?"And I was not.Doctor explained that because he is under the age, I have to sign."So, it's when you're ready, you can start it and I think it's healthy."And I said, "I can't do it this time, right now."In November, I was ready but it just, something [testosterone] he inject and, uh, it just scare me.I don't know.It's a medication but because it changes his body, I don't know.I told my therapist, like, "I almost there, but another 10%."I don't know, maybe if my husband be here, saying, "Let's go."I talked to my family and friends, but I think they do not understand it.(Parent I) Adolescent I feared their mom's hesitancy and confusion would be compounded if she knew her child was nonbinary.Performing a binary male gender was how Adolescent I guided mom toward consenting for testosterone.
Just like, with me being gender queer, like, in her trying to get to an understanding of what trans was and, like, why I feel like a guy, so I don't really tell her about those things because I don't want it to confuse her more.So, before I was on T, I didn't want to tell her about me feeling, like, in between the binary because it's like, oh, what if that makes her question, like, "Is T a good like path for you to go?"While this mother was questioning how to best support her child, she was managing conflicting advice from disparate trusted sources: (a) the medical provider who had trans-specific knowledge and felt her child was ready and that it was safe; (b) personal friends and family who represented her culture but were not perceived to be knowledgeable sources of trans-related information and support; and (c) Adolescent I, who was knowledgeable and whose suicidality and binary gender performance prompted her to support their gender affirmation.
Adolescent D, who was 15 and a trans young man, expected to immediately start testosterone upon disclosing to his mom that he was trans, but his mom was not ready for that step in his gender journey.
She wasn't entirely on board with the idea at first.Like she was just kinda like, "Oh, wait, what?We are going to look into this."It was frustrating because I just wanted the immediate things-like, I expected I would tell my parents and then tomorrow I would get my first testosterone shot.
Although he was clear about his gender, his mom struggled with ambiguity about her child being transgender.Without a familiar path, Parent of Adolescent D leaned on her son's process to guide her toward acceptance.
One of the things that struck me when I kind of knew this was true was the crying he did, and he's like, "If I had the choice, I wouldn't be transgender."And then when I heard that and started thinking, I was like, he is right, because at first, I thought he was making a choice.And that is what I have seen in the community and talking to other people about these things, they think they are making choices.But it's not a choice.
"People were noticing and they were doing something about it": the benefit of having time Families whose children were known to be transgender in early childhood (n = 5), were able to slowly adjust to parenting a trans child before adolescence.Three of the five adolescents (Adolescents B, N, and R) initially left their neighborhood or community setting to safely practice gender expression outside of their home before disclosing outside of the family.Before Adolescent N came out at school, her mom recalled vacation as a time to practice her gender.
I think we went to [name of U.S. city].I said, "If we go to [name of U.S. city], do you want to go as a girl or a boy?"She said, "As a girl."Well, like, "OK, you don't have any girl clothes.Let's go buy you just enough to get through this weekend."And we just bought a couple of outfits, and she didn't take any boy stuff for the weekend.She was girl all weekend.And then after that, it would be whenever she'd be home, she would be putting on these clothes.
Adolescent N did not mention her vacation and instead discussed her early gender expression through the lens of her parents' stories.
It was definitely before I remember.My parents have also told me I used she/her [pronouns] since [age] 5 or 6, but I started acting like I was a girl from age 3. I used to go in dresses, and my mom said that I would take her scarfs, her pretty scarfs, and played with them.
Although her mom remembered the time of her assigned gender as male, Adolescent N did not consciously remember socially transitioning because she always saw herself and had memories as a girl.On the other hand, Adolescent R remembered vacation as a time when she freely expressed her gender and her parents practiced adjusting to their child's gender identity development.
During the summer between first and second grade, my parents, they told me you can be whomever you want to be in [name of vacation town] and whoever that is, we can decide and think about it when we get back.And my mom allowed me to wear dresses.And then in second grade, it was a fresh start.Adolescent R's father discussed how he experienced his daughter's initial gender affirmation and the factors that contributed to his initial support processes as a parent.She came home from school [winter of first grade] and she was upset and crying, and she sat on the sofa and she said, 'I just don't know how to be a boy'.And that was pretty big.That was heartbreaking to see her so upset.She was so distraught.At that point, we didn't know what transgender was.And then we did research on the internet and stuff and got in touch with [name of gender therapist].And the thing that [therapist name] said to us was if you tell her she can't wear girls' clothes and be a girl, then you are telling her that who she is, is shameful.So, when school ended, in first grade, we were going to go to [name of country] and we asked her if she would like to try being a girl and we started asking her if she felt more like a girl and we explained to her that there was such a thing as transgender.
After disclosure, Adolescent B's mom recalled her daughter's therapist suggesting Adolescent B practice her feminine gender expression outside of the home in unfamiliar settings as a pathway to eventually expressing her gender in more familiar social environments such as school.
Then [the therapist] also suggested, you know, "[Adolescent B], if you want, where would you feel comfortable?I know not in your neighborhood, but where?"And [Adolescent B] was like, "Well, maybe if it's like 2 h away."So, we started like on a Saturday, driving 2 h away.
Adolescent B didn't discuss the long-distance trips to practice being a girl, but she described how she expressed being a girl within the social construction of how others perceived her gender, "I remember I would go to the hair salon and they would start judging me b/c I was a guy and I wanted my nails painted pink but I always got my toes done b/c nobody would see them" Adolescent Q's mom knew her child to be a girl when she was 3. By the time Adolescent Q was 6, she remembered seeing her medical provider and a therapist to support her anxiety and gender-affirmation process.
I was anxious when I was going to public school.I was always very anxious.My mom actually wanted me to see a therapist first.But uh, if I wanted to quit now, I couldn't because now [name of transgender doctor], while I have the blocker in my arm, is requiring me to stay with the therapist.
When Adolescent Q was six, mom began her own transition as a parent which entailed removing reminders of her daughter as a boy.
We transitioned her like literally overnight.Anything specifically boy we put everything away in boxes, anything that was specifically boy, we took down all her pictures, that was really hard for me, of her in boy clothes and put it all in boxes.I still sneak a couple of them around, but nowhere where anybody can see them.I have a boy box I keep which has boy stuff in it.The other thing that was hard was the pronouns.We had a gender jar for when we messed up and she kept the money from the gender jar.
This family initiated a social transition quickly and connected with a therapist and a medical provider years before Adolescent Q started her puberty blocker, speaking to the importance of time to prevent further exacerbation of distress and support gender affirmation early.During this time, mom secretly created a "boy box" of keepsakes to help her adjust to this transition and remember her daughter's early years when she was understood to be a boy.
Adolescent B, who had been open about being a girl to her parents since second grade, and her mom both spoke to the importance of being connected to their provider to prepare for puberty."I was 11.And I didn't show signs of anything.They just didn't want anything to start because they wanted to see if that would work better.And it did.Um, because it didn't start anything whatsoever" (Adolescent B).Whereas Adolescent B spoke to the significance of early access to care to prevent her male puberty, her mom remembered the extreme distress associated with her daughter expecting male puberty and the importance of being connected to gender-affirming care for support as they prepared for puberty blockers.
Like, you can't get the blocker until Tanner Stage 2 [a scale of physical development].So, there were freakouts all the time because there would be a hair and we would rush to [name of transgender health doctor] and she would say it's not time.It was the hardest thing.I am just surprised she didn't get hospitalized.I mean she would scream.She would destroy things.She would yell out, "Take me to the hospital!"She was in extreme distress.
When Adolescent N discussed puberty, she made it clear that she always saw herself as a girl, which made it challenging for her to talk about male puberty or transition.
During the interview, Adolescent N was asked: "Leading up to this part when you got blockers, what did you think about puberty?What thoughts would come to mind when you would just think about your body changing in that way?" Adolescent N replied: "I just think I am a girl, and I want to get it how I want."At the same time, her mom described the value of having time to emotionally adjust and gain knowledge for years, allowing them to anticipate puberty and plan for a medical transition.
If I look at this other kid who is now doing this in puberty, I'm like, "Oh my gosh.Thank God we did this at 5. Thank God we had enough time."What would that have looked like if at 14 all of a sudden, I am doing the paperwork, like, right away?Like, we all had years and years of living as a girl and then finally doing the paperwork.And then doing the puberty blockers.There was so much time for everybody to get used to this.Adolescent Q, who had been connected to both therapy and a trans medical provider since she was 6, felt distress connected to the anticipation of her male puberty and acknowledged the importance of planning with her provider for puberty blockers to stop male puberty.The thought of puberty was scary, but I went to my medical health care person, and she said it was time to get the blocker and block the male hormones from coming in.It was really nice.I was happy because everything was starting to happen, and people were noticing, and they were doing something about it.
Theme 2: Parents (Silently) Adjust to Their Child's Gender Identity Affirmation Process While Becoming (Super) Supporters All parents in the study had to navigate both familial and institutional barriers to their child's gender affirmation processes.We identified the following subthemes representing these experiences: (a) "Flip it once and I will flip it again": parental support was fierce and in the background; (b) "It's a mourning process for myself": parental support through grief; (c) "I still wanted someone to relate to me": Support groups were critical to their journey as parents, and (d) "The bottom line" of parent support.
"Flip it once and I will flip it again": parental support was fierce and in the background Many parents took steps to advocate for and protect their child in a world not structured for trans people to thrive.
Parent of Adolescent P, a 14-year-old trans young man, talked about how emotionally hard it was to allow her son to navigate public spaces such as restrooms and how she provided support in the background to ensure his safety.
One time he went to the bathroom in [name of grocery store], and I was hanging out close by, not that I was hovering but just-it was taking forever, like, 15 min had gone by and he wasn't coming out.I'm texting [name of father] like, "Do I go in there?"Like, I'm about to burst the door open and I'm seeing all these men go in and out.And I'm like, what the hell?So anxious.I was about literally to break through the door and then he texted me, "Sorry, the line's long," so I'm like, OK, no problem, no big deal [takes deep breath, sighs, and laughs], I'm just here, you know.Some parents gave their family members an ultimatum and instilled norms and rules in the family early to ensure their child felt supported and affirmed.Parents were clear about this boundary, and some "drew a line in the sand" regarding support and affirmation.The mother of Adolescent H (a 13-year-old trans young man) described the discrimination and social stigma her brother and sisterin-law directed toward her about her son and her parenting.
My sister-in-law and I had lunch in August.It was 2 h of her preaching to me about how what I am doing is hurting my kid and this was wrong and here's why and there's a guidebook for life and it's called the Bible.And, you know, she was like, "What does this mean moving forward?Like, we can't be together?"I said, "Well, I am not going to put my child in a room full of people where he is not going to feel accepted."… So, the rest of my family has been nothing but supportive of us and [Adolescent H], and they don't invite my brother, my sister-in-law, and their kids to any holiday events and anything.It's like, they all drew a line in the sand.Adolescent H's mom's emotional labor to hide family rejection represented a hidden support process to protect her son.When asked more about the support from his mom, he said: "I don't really like talking about it [re: being trans].I don't really need support".For Adolescent H, mom's support was important but existed in the larger and perhaps more salient and impactful context of his dad's rejection.: "My mom is really understanding.And my dad just doesn't care… when I was like, 12, that's when I said, "hey dad, I think I'm a guy."And he's like oh that's stupid".When asked what he wishes were different, he said, "my dad to not be in my life".
The mother of Adolescent C (17 years old and a young trans woman) who disclosed to parents when she was 16, was the parent who primarily emotionally and logistically supported the early time of her child's gender affirmation.This mother drew a line in the sand with father, setting a boundary that subsequently motivated her father to support his daughter's gender identity.
I told him if he wasn't gonna get on board with this, I was going to leave him.Uh, so we just kind of held that tension because he wasn't ready to do things differently.And then the next [trans] family group came again, and I don't remember why but I could not go and said, "You have to drive her.And if you don't go in there and show up, like-"; I don't know what I said, but like, I made it clear that this was going to be a major decision point for me.This father's lack of readiness to support his daughter motivated the mother to threaten to leave her husband so that he would show up for a support group.After she disclosed to her parents that she 'cross-dressed', Adolescent C described that her father initially tried to connect with her as a man: "And actually, [dad] did a lot of work with me to go through manhood ceremonies.I was like a part of like boys' groups and did a lot of like just work to become a man with him."Ultimately, Adolescent C perceived both parents to be supportive which may speak to the efforts of mom behind the scenes to encourage dad's support.I think accepting me, um as my gender being different was actually very easy because all they really had to do was support me in me being happier.Um like they could see there was light in my face.They used the pronouns.It was easy, and they knew about it, they were educated about it.
On the other hand, Adolescent F, a 13-year-old young trans man, reflected on the impact of one rejecting parent.He's not like really a big part of my life.I mean, he is supposed to be.I mean, he lives in the same house as me, he does everything for me really, but I feel selfish for saying that, but I don't feel like he supports me that much.… I can hear them [parents] arguing sometimes.They are specific to me.Like, specific about my transition.Like, my dad is like, "I don't think [Adolescent F] is trans."And my mom's like, "But he said multiple times," and he's like, "I don't think-"; … he doesn't see me being a guy.So, my mom and other grownups say it's pretty hard to lose a baby girl, I should understand that.But I don't anymore.
Parent rejection had the potential to thwart adolescents' gender-affirmation process entirely.Adolescent F's mom used her puberty and trans-related medical knowledge to instill a sense of urgency so the father would consent to gender-affirming medical care, even if the father failed to see and validate his child's gender.I think having one supportive parent has helped a lot.But I think it's very hard for [Adolescent F].He [father] is very slow to adapt to new situations.I think just even the idea of it, I think he was doubtful.And I think he thought it was just a phase we were going through.Um, didn't want to start blockers or testosterone.Um, and after speaking with [transgender physician name] and being in group, you know, I said, "Look, the realization is that [Adolescent F] started puberty very early at age 9, his plates are going to close soon, and if we don't move now, this could be something detrimental."He [father] had very reluctantly agreed.
The mother of Adolescent L (a 13-year-old trans young man) anticipated harassment at her child's public middle school, and that fear motivated her to consolidate support early.
I was anticipating, "Here's a kid who doesn't fit the norm, and is he going to get bullied?"Then starting in sixth grade, which is middle school, we knew about PE and the locker rooms, and I met with the counselor ahead of time to make sure he had an alternate place to get changed, because I knew he wasn't going to be comfortable in the girls locker room.
When asked about middle school, Adolescent L described their experience with more ease.It has been fine, it's been great.I haven't had any problems with it at all.And everything has been relatively easy.The teachers, a lot of them are very nice.Um, and like, the administrators are really nice.The students, most of them are nice and some of them are kind of jerks.But I knew the teachers would be accepting and the students just didn't care, like, it wasn't a problem.
Although parents may have limited control over the social climate of nonacceptance, they did what they could to ensure accommodations.Other parents, like the mother of Adolescent N, acknowledged that both their child's persistence and their steadfast support as a parent created the path for the child's gender affirmation.
It is really just trying to make the world OK for [Adolescent N].And everyone would always say, "Well, what if she transitions back?What if she doesn't agree?Other kids have decided to."Enough.Flip the world again.Flip it once and I will flip it again.I will make it OK.It was the best I can for her."It's a mourning process for myself": parental support through grief Some parents engaged in supportive behaviors and at the same time, struggled with their adjustment.For Adolescent O, who was 15 and transmasculine, ambiguous acceptance represented the dichotomy between his parents' high involvement in support groups and community advocacy and their continued struggle to adjust and accept their child as trans.Adolescent O discussed his parents' affinity with family support groups and the support he felt as they took steps toward a medical transition alongside him.At the same time, he continued to feel invisible as he perceived his mom as struggling with "losing a daughter." My mom was kind of difficult.She would say, "I'm still mourning the death of my daughter," and OK, go to the funeral, come back.Like, I gave them the time and everything, and my mom still gets sensitive about it.… They're big support group people.They go to every single one.
His dad, on the other hand, discussed the distress he and Adolescent O's mom experienced in relation to their child being trans.Both parents attended support groups regularly and simultaneously struggled with their internalized trans negativity, which created barriers to acceptance.Upon disclosure, the father discussed expecting an amalgamation of stigmatizing experiences for them and their child.
I think for [adolescent mom], it was a little bit deeper.She was raised pretty devout Catholic, and I think generally deep inside, she knew her parents weren't going to be accepting.So, there was shame involved.There was hiding involved.There was embarrassment involved.There was feeling of lack of acceptance.I mean, I could fill up the whole board with the adjectives.So, it just kind of strikes fear into you that our entire world is going to get turned upside down.And if that was the case, how in God's name are we going to navigate this?Adolescent O saw how his parents personally benefited from their involvement in support groups and simultaneously, he continued to experience their lack of connection to him as their son.Adolescent O's parents often hid their stress and struggles from their child to protect and support him, yet at the same time, they became super advocates in support group.
Intersecting experiences of loss magnified the experience of loss for some parents.Adolescent D's mom who had previously described her grief of losing her son also described her tenuous connection with her faith and peer communities through her son's gender affirmation journey.
We would go to church regularly, they went through um classes.After he had come out, he showed me a thing about Pope Francis and what he was talking through a crowd and he said "can you believe parents let their kid choose their gender?"And he showed me that speech and at that point I was like Oh.So, we don't go to church much.I still have my faith, I do believe that God is fair and kind.Its just hard when you hear that.I want to be on the kid's side.It's isolating (crying) because nobody kind of really knows what it's like (crying) and the church and its like OK, well, can't support that either.
Many adolescents in this study understood that parental adjustment was a factor in their support and acceptance.Adolescent G discussed his mom's emotional response when looking at pictures from when she was known to be a boy: "She keeps that to herself.I feel like she keeps more emotion to herself.Like she doesn't express it as much to me.Because she feels like she doesn't want to let me down".Her mom, described her emotional adjustment to her daughter's gender affirmation process: "I would just like to speak to a mother who is going through this.And, obviously, that whole time, there are days that I would just cry because, I mean, yea, I am accepting and I'm open but at the same time, I lost my son, [crying], you know." Similarly, Adolescent A understood that his mom likely continues to hold on to the idea of a daughter.I feel like my family has much more of a connection to her than I do.I mean, I have some fond memories and stuff like that.My parents remember all of this [from his childhood], but because of their supporter attitude and role, they wouldn't bring any of this up.Adolescent A's mom supported the steps of her child's gender-affirmation process and at the same time, she felt grief attached to the ambiguous loss of her child's sex assigned at birth.Additionally, although support groups provided a space to connect with similar others and develop a sense of community and pride, it was not always a space where parents felt safe discussing their grief and questioning.
So, when I go to the support group, I am like, "Yeah, hooray!"But privately [cries], I hold a lot in because I don't want [Adolescent A] to see [cries] the struggle that I have.It's not for who he is, but the loss for who I knew him to be when he was [child's birth name; cries].Anyway, I recently come to the understanding for myself that its mourning.It's a mourning process for myself.But it's something I will never tell [Adolescent A], how much I am struggling with this [cries].
"I still wanted someone to relate to me": support groups were lifesaving but not always accessible Parents largely lacked access to other parents in their social environment who had trans children; thus, most families felt like nobody related to them.While some parents did not feel support group was a place to question gender affirmation processes or grieve, many parents found solace in trans parent groups.Having access to a support group with other trans parents was, for many, a lifeline.Adolescent B's mom described how her sister was accepting but her support felt disconnected from what she needed.
My sister has five kids and four are boys.[She would say,] "Oh my God, she is going to have four boys to choose from because you know I am going to make them all have to take her to prom or whatever and it's going to be great.We are going to be taking pictures, don't you worry."That sounds like the person is being an empathetic person, but to me it was like, the worst thing anyone could say.But I couldn't say that to her, like "God, shut up.Your consolation is your kids, like her cousins?"So, I didn't go there but where I could go was support groups.I went to [name of family support group].I went to PFLAG.And just hearingmaybe I wouldn't even share.But hearing other parents and knowing they were going through the same thing.Because no one that I knew, you know; she is the only one at the school, no families-no one knows what I go through every single day.Adolescent P's mom started looking online once she realized her child was embracing a masculine gender expression.
When I saw the outward expression like fully masculine, that's when a lightbulb went on for me.I got online and went crazy and googling it and found genderspectrum.org,thank God, and found [name of transgender family support group] and like, OK, there's like a whole world here for us.
Similarly, the father of Adolescent O reflected on the importance of education to their journey as parents, and at the same time, described his and his wife's continued emotional adjustment and perhaps shame despite their transrelated education through support group.
Fear. [Name of mom] used the word "shame."A lot.I don't have shame over it.It's not something I've chosen.I don't think I have to have shame over it.I don't feel shame that my child was born in the wrong body.Nobody did anything wrong, it's just an unfortunate incident.Which we are just trying to be productive and make the best of it.I want to be supportive and so, we started going to [name of support group] meeting.And, I'll never forget, we left this meeting, and I could tell my wife was very emotional over it.We stopped at a red light.And she looked at me and said, "Please God, tell us that is not our path.I'll take anything other than that."So, we just decided to get very involved in the transgender community … and just got educated real fast.So, it sounds really simple and it's not, because it's very convoluted and complicated and emotional.But if you think about it in the most macro sense, it is pretty simple.You just have to be supportive of your kid when you are in their presence.
For Adolescent O's father and Adolescent A's mother, connecting to a support group helped them gain knowledge and learn how to support their child's gender affirmation, yet they continued to struggle to emotionally adjust, navigate ambiguous loss, and cope with shame.The mom of Adolescent H was a single parent and found formal sources of support with providers and other parents of trans kids to be a pivotal part of her journey and support as a parent.
All it takes is one parent.You just have to find one parent who is in this situation, and they will give you all the information you need and the resources you need.Um, going online helped a little bit, too.Um, the support group has been pivotal for all of us.Um, having access to doctors.[Name of transgender doctor] is phenomenal.She spent an hour on the phone with me the week I found out about all of this.And this is a busy person.She spent an hour on the phone explaining everything to me, which was amazing.
For most parents, support group provided validation and a path to support their child's gender affirmation process.Despite the knowledge gained within groups, some parents experienced structural barriers to accessing and connecting within these groups.Adolescent J's mom's cultural lens is informed by her upbringing and support system which is within another country outside the U.S.She discussed this dissonance between perceptions and pressure from her own cultural community to wait until her son was 18 and that of the support group who questioned why she would wait till 18 to start gender affirming care.
It was stressful.Yea, for a while.And uh, at least my family [group meeting].Because [Adolescent name's] aunt say, "why don't you wait till 18 when he decide."We already know he is going to be 18, so then you know go to meeting and why I wait till 18? Adolescent G's mother, a single parent, did not initially have access to knowledge resources or other parents of transgender children in her East Coast community before moving to the West Coast.
When he started telling me stuff, I started looking up support groups for, like, me or for him and programs, and there was none.This was in eighth grade, when he started becoming more of a girl to me.It was just overwhelming because even though [partner's name] was so supportive, I still wanted someone to relate to me.I feel there should be more to help parents going through it.Because a lot of parents are struggling.I suffered a lot because I was alone.
While Adolescent K's father found support groups to be a lifesaver, he recognized the challenges for families who did not have access to this support.
And I think if you're in a small town or if you're removed from access to those kind of groups, I can't imagine how tough it is not having groups like that.You can read stuff online or books but its still not the same as having other actual people because the best thing to do is to ask a question and then 30 people are there who can fill it in for you.

"The bottom line" of parent support
Although some parents continued to grieve or feel unsure, at the end of the interviews, all parents discussed wanting their child to be happy, feel secure, develop intimate relationships, and build a life for themselves.Parents also looked up to their children and felt their experiences parenting a transgender child were transformative.The mothers of Adolescents G and P expressed gratitude for their process as parents and reaffirmed the importance of their support for their child: "I'm definitely more compassionate.She's done that for me.I honestly just go through life so differently now" (Parent G). "I'm just grateful that we had the experience we had and that he is doing so good.That means a lot.That is the most affirming thing for us as parents, is to see him happy and so, that's the bottom line" (Parent P).Adolescents reflected on their gender affirmation in the context of the support they received from their parents.Adolescent L reflected on the meaning of his parents support."I think it is pretty important to know that I had it a lot better than most people and my transition went a lot smoother given that my parents are accepting, and they were able to push and get everything quickly, and I think that is the only thing."

Discussion
A family's gender journey is complex with varied cooccurring interpersonal and structural factors contributing to parental support.We interviewed families within adolescents' first 12 months of starting blockers and/or hormones.Most dyads, regardless of when parents knew their child to be trans, confronted proximal stress related to negative expectations and internalized stigma, and distal stress related to discrimination, rejection (Goldbach & Gibbs, 2017;Meyer, 2003), and non-affirmation (Testa et al., 2015) within their community and social support systems.We interviewed families during a unique time when transgender community rights and social policy were being explicitly confronted and reversed-representing a powerful, vocal, and hostile community climate targeting transgender people (Jones, 2018).Jones's work, examining transnational progress related to the Trump-era reversal of transgender civil rights and powerful groups vilifying transgender "others", found that these narratives have contributed to a hostile climate towards the trans community within the United States (Jones, 2018) and is currently enacted through legislative policies blocking legal access to medically necessary gender affirming care for children and adolescents across the United States.Importantly, our interviews occurred in a state where trans rights are protected, yet families still experienced social stigma, isolation, and barriers to support, acceptance, and care.Using a minority stress lens helped us understand the complexity of parent support for trans adolescents within this current social landscape.Thus, our findings are embedded in this context and yielded three main points regarding the unique experience parental support for TNBA.First, the time between disclosure to a parent and puberty mattered for parental support and adjustment processes.Second, for parents who stepped into their child's gender journey during adolescence, ambiguous loss uniquely impacted adjustment and support.Third, parents lacked a familiar and affirming roadmap in their families and communities and thus, connecting to other parents of trans kids was a lifeline.These points are further expanded upon below.

Time Between Disclosure to a Parent and Puberty Mattered for Parental Support
Families whose TNBA children disclosed in early childhood navigated their gender journey for years before medical intervention, whereas other families learned their child was trans and then were immediately making decisions regarding gender affirmation processes.Parent support reflected complex and intersecting drivers that impacted the knowledge and readiness gap within the dyad.Parents, regardless of when they knew their child to be trans, had to make sense of two roadmaps when making decisions about how and when to support their TNBA child: (1) a trans affirming map from their child and trans health provider/ social network which centered gender affirmation and (2) a cisgender dominant roadmap of their families and communities where the [trans] gender journey was invisible.For adolescents who came out in childhood, before puberty, the gender-affirmation process within the dyad typically happened in unison, with parents working alongside their child to support their gender affirmation.Previous research stemming from interviews with five mothers of young transgender girls between the ages of 8 and 11 found that the girls had time to intentionally affirm their gender across multiple social contexts before puberty (Kuvalanka et al., 2014).This included practicing gender in their home, going on trips to practice their gender expression in public, growing their hair to appear more stereotypically feminine, changing their name, and wearing feminine clothing (Kuvalanka et al., 2014).According to Kuvalanka et al.'s research, parents had time during their child's early childhood to gain knowledge and adjust to being a parent of a young trans child.
Although all TNBA in the present study confronted puberty associated with their assigned gender, adolescents who were understood to be transgender in childhood had entered puberty living life as their asserted gender for years.This early gender affirmation prior to puberty provided parents an opportunity to develop trans awareness and knowledge, amass resources, develop their identity as a parent of a trans kid, and connect to other parents and health and mental health care resources to intentionally prepare for gender-related medical interventions when their child was ready.Beyond puberty, these parents saw and understood their children as trans early in childhood and thus, did not question if their child's gender was real while they were making decisions to support the next steps of their child's journey.Many parents who understood and accepted that their child was trans in early childhood squarely placed this longer gender-affirmation process and early connection to care and support in contradiction to other families whose children came out during or after puberty.
Dyads with adolescents who disclosed that they were transgender during adolescence and puberty experienced a knowledge and readiness gap, which reflected two ends of a spectrum regarding readiness for adolescents' gender affirmation.Before disclosing to parents, adolescents spent time online gaining trans-related knowledge, connecting to trans role models, and developing a stronger sense of self.By the time TNBA in our study disclosed their identity to parents, being affirmed as their gender was non-negotiable and an emotional, social, and medical necessity.On the other hand, parents didn't start their gender journey as parents until after their child disclosed.Parents who navigated disclosure and gender affirmation for the first time during adolescence were simultaneously developing trans literacy and awareness, developing changing identities and roles as parents, connecting to care, navigating family and cultural ideas of gender and gender affirmation, confronting the power of trans-related stigma, managing insurance barriers, and emotionally preparing for medical and social gender affirmation while [silently] questioning if this was the right path.

Ambiguous Loss and What It Means for Support
Ambiguous loss is an unclear or perceived loss, originally studied in relation to (a) military families in which a parent or partner is psychologically present but physically absent; or (b) a family member with dementia who is physically present but psychologically absent (Adams et al., 2008;Boss, 2004;Huebner et al., 2007).Recently, research has used ambiguous loss to understand perceived losses tied to gender affirmation of a family member (McGuire et al., 2017;McGuire et al., 2016).One important finding from a recent study on ambiguous loss indicated that transgender families experienced both physical and emotional losses connected to the gender identity development and expression of a family member and also felt a sense of gain, support, and acceptance (McGuire et al., 2016).Parents in our study who knew their children were trans early in childhood had emotionally discussed challenges with stigma but were not actively grieving the perceived loss of their child at the time of their interviews.Parents in our study who experienced and coped with ambiguous loss earlier, before adolescence, were not simultaneously navigating ambiguous loss with stigma, knowledge-gaps, and decisions regarding social and medical gender affirmation.For these parents, the emotional weight of ambiguous loss was not a prominent factor regarding decisions related to their child's gender affirmation during adolescence.
Similar to previous work in the area of ambiguous loss in transgender families (McGuire et al., 2016), ambiguous loss for dyads in the present study was tied to parents' perceived emotional loss and a re-imagining of their child's gender and cultural identity, their own parental and cultural identity, and their imagined future relationship with their child.In our study, parents who experienced ambiguous loss typically had two distress processes attached to ambiguous loss: one that began immediately after disclosure and another after adolescents began their gender-affirming medical interventions.Parents of adolescents who disclosed in childhood didn't discuss ideas of loss or grief, likely because at the time of the interview, they predominantly saw their child as their affirmed gender since early childhood and saw themselves as a parent of a trans child very early in their parenthood.For these parents, medical gender affirmation was a relief.Experiences of ambiguous loss connected to gender affirmation were more common for parents who understood their child to be transgender starting in adolescence.Many of these parents described this process as mourning a deep loss, often connected to an attachment to a designated gender at birth and the idea of what that represented for parents.On the other hand, and similar to ambiguous loss research (McGuire et al., 2016(McGuire et al., 2017)), all parents we interviewed embraced a new vision and hope for their child's future, centered by their child's affirmed identity and building new memories of shared experiences.
Research has found that affirmation of gender diminishes the noise of gender dysphoria in adolescents' lives and allows them to focus on other social, educational, and future-oriented tasks (Kreukels & Cohen-Kettenis, 2011;Rafferty & Committee on Psychosocial Aspects of Child and Family Health, 2018).For some parents, however, our research suggests that gender affirmation initially makes the noise of ambiguous loss more prominent.Through this affirmation process, parents commonly experienced ambiguous loss tied to lingering ideas of their child and their own identity as a parent before their child disclosed that they were trans.In the present study, parents who were emotionally adjusting and were experiencing a grief and loss process initially took steps to support their child's gender affirmation not because they themselves were ready but because they wanted to keep their child alive.Nine adolescents experienced a previous suicide attempt and all dyads discussed experiencing stigma and/or dissonance between gender and cisgender dominant beliefs.Families were thus navigating a push-pull related to their child's gender affirmation: On one hand, overt and internalized stigma and dissonance enhanced parent hesitation, confusion, and delays; on the other hand, fear for their child's life and emotional safety motivated support.These parents questioned aspects of their child's gender and gender affirmation, were not emotionally prepared for this change, and didn't have a trans affirming path or role models in their community or family regarding how and when to provide support, yet, they supported the next steps.
For parents in our study, ambiguous loss started after disclosure and represented (a) perceived loss of or changed relationship with a child and/or members of their own family/community, (b) perceived loss related to their parental (including cultural) identity, and (c) perceived loss of plans for a child's future and ideas of their relationship with their child.Previous research also found that transgender people experience ambiguous loss, not necessarily related to their identity but connected to fear of or actual parental rejection and a changing relationship with their parents (McGuire et al., 2016).Adolescents in our study whose parents were silently questioning, emotionally adjusting, and/or experiencing ambiguous loss continued to perceive their parents' acceptance as unclear despite getting help from them for the steps of their social and medical gender affirmation.Parental support was also perceived as ambiguous when driven by the parents' distress and urgency to keep their child alive or when parental [super] support and advocacy was perceived by adolescents as self-serving or misaligned with parents continued adjustment.Thus, the relationship between parental support and acceptance was, for many dyads, tenuous, during the initial time of adolescents' gender affirmation processes.

Parent Support Groups as a Path for Support but Not Necessarily Parental Adjustment
In the present study, adolescents connected with transgender role models online and peer allies in their communities both before and after disclosure to parents.Parents, on the other hand, didn't connect to transgender parent support groups until after their child disclosed that they were transgender, during a time when adolescents were not only ready but yearning to move forward with their transition.Unlike adolescents and similar to previous research, support groups were the primary or sole space for parents to connect to similar others (Hidalgo & Chen, 2019;Riley et al., 2011) and to learn how to support their trans child.
Support groups were a personal process, and they did not feel right for everyone.Parent support groups helped families build knowledge, acquire resources, feel validated, and connect to shared experiences.Many parents leaned on their trans-parent and trans-health community when making complex decisions to support their children amidst stigmas.Some parents became empowered to 'draw a line in the sand' with unsupportive social networks including family, making ultimatums to ensure emotional safety and affirmation.Others learned how to advocate in schools and with health providers to ensure their child was affirmed.These efforts were emotionally taxing and commonly hidden.At the same time, some did not feel safe questioning gender affirming care in the support group and felt isolated from majority-narratives that did not represent meaningful intersections of cultural values, identity, and stigma.Thus, some parents kept their adjustment process and grief silent, and [in]visibly struggled with fear, shame, and loss while simultaneously becoming vocal advocates and supporting their child's next steps.For some adolescents, parents' [in] visible struggles were noticeable and contradicted their advocacy, thus for them, parent support felt unclear and tenuous.Other parents lacked access to parent support groups in their community.For Adolescents G and I, the nearest support group or medical provider was hours away from their neighborhood.Poor access to health and mental health providers and supportive resources that are nearby (Oswald & Culton, 2003), are knowledgeable about and can competently address complex barriers to support and acceptance, and have been trained and equipped to support and treat trans adolescents represents structural stigma for the trans community (Cruz, 2014), including parents.These structural barriers contribute to parents' own adjustment and subsequent process of supporting and accepting their child, thus affecting the timing and types of support parents provide their TNBA, even in times of crisis.
Broadly, through listening to the stories of other group members, parents began to connect with their child, develop trans literacy, gain access to resources, and learn how to support their child's gender journey across social domains.For many parents, attending these support groups began to close the adolescent-parent gender affirmation knowledge and readiness gap.Riley and colleagues' (2013) study with transgender adults indicated that parents' lack of knowledge and awareness about gender diversity not only contributed to minority stressors among adolescents but also hindered parents' acceptance and support.As Meadow's (2011) research with parents of gender-variant and transgender children suggested, institutionalized knowledge has informed the ways gender identity and development is regulated and at the same time, these fields, including sociology, also informed parents' knowledge regarding the complexity of gender.Although dyads didn't explicitly discuss the historical impact of institutionalized genderbased knowledge production, they did discuss how support groups and trans medical providers helped to disrupt cisgender-dominated knowledge about gender.Dyadic narratives are in line with what Meadow (2011) suggested: Various forms of knowledge and discourse helped parents construct alternative ideas of their child's gender expression and co-create with their child a new shared reality of their child's gender.In the same vein, previous research suggests that ambiguous loss provides an opportunity to redefine and co-create shared alternative narratives and a new path of connection (McGuire et al., 2017).Through support groups, parents reported that their experiences were normalized and for the first time, they had access to a roadmap regarding how to provide support and adjust to their emerging identity as a parent of a transgender child.

Limitations
The findings from the present study must be interpreted alongside limitations related to the study design and sampling.The retrospective qualitative approach demanded that adolescents and parents reflect on and recall memories of early childhood.Past experiences are framed from the perspective of the present, which likely skews how events are remembered or understood.Additionally, interviewers asked dyads to reflect on sensitive experiences related to adolescent identity and affirmation and parental support and acceptance.The interview method may have increased the risk of social desirability bias if participants believed their responses would be perceived in a negative light.Consequently, dyads may have withheld or masked those experiences to protect against perceived interviewer judgment.
Additionally, we recruited families from transgender family support groups, a Southern California LGBTQ center, and an adolescent transgender-specific health care clinic.The sample was limited to adolescents between the ages of 12 and 17 who were within their first 12 months of starting puberty blockers or gender-affirming hormones; thus, parents had already taken important steps to support their child's gender affirmation.These results represent the experiences of families who had awareness of and were ready and logistically and financially able to support their child's social affirmation and medical gender affirmation or transition.We interviewed families in California, a region considered to have more trans-affirming resources and creates an accepting social and political climate for trans families than many regions of the United States.Thus, research that further explores parent support amid legal and punitive barriers to trans-affirming care is necessary to underscore how structural stigma and facilitators affect TNBA families.While these findings must be considered in the context of this narrow sample of families who had access to transgender-affirming health care and whose barriers did not prevent access to that care, many families struggled amidst interpersonal and structural barriers to care, acceptance, and support.

Implications
Most families whose TNBA disclosed to parents during adolescence, experienced a knowledge and readiness gap and these parents often lacked a roadmap to support their trans child.Helping professionals who work in schools, mental health, and health care settings commonly lack educational opportunities focused on supporting gender diverse and transgender children and adolescents (Collazo et al., 2013).Trans youth and families who have multiple minoritized identities undoubtedly experience complex stigma, oppression, and resilience.Helping professionals, including support groups can benefit from trans-related psychoeducation and trauma informed support that meaningfully incorporates adolescents and parents' perceptions of cultural norms, traditions, and values within the context of adolescents' gender affirmation processes.Furthermore, using an ambiguous loss framework as a source of empowerment (McGuire et al., 2017), helping professionals can work with families to acknowledge uncertainty and ambiguity within relationships and attachments during times of change.Building on the present study plus the extant literature on ambiguous loss (McGuire et al., 2016), trans family growth and adjustment (Meadows, 2011) and minority stress (Hidalgo & Chen, 2019, Meyer, 2003) helping professionals can support families to redefine selves and create new meaning related to relationships and identity, further demonstrating adolescents and parents' capacity to address and grow amidst transitions moving forward.

Conclusion
Structural barriers related to access to physical space and diverse representation contribute to non-affirmation and trans invisibility thus perpetuating isolation from support.Social isolation and a lack of cultural humility contributes to the knowledge and readiness gaps between parents and adolescents and between trans families and service providers.Helping professionals and parent-support group facilitators have an opportunity to apply trauma informed care approaches that validate and meaningfully address the intersecting needs and experiences of trans families experiencing multiple and simultaneous intersecting axes of stigma and oppression.Our findings indicated that disparities in both access to and cultural representation within support groups had a meaningful impact on parent support processes and adjustment.Parents in our study provided support driven by their urgency to protect their child from stigma, prevent suicide and ensure acceptance for their child.Thus, parental support driven by distress versus acceptance potentially underscores the importance of continually studying complex drivers of support and the potential impact of these complex support processes on adolescent and parental well-being.
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Table 1
Participant Demographics

Table 2
Themes and sub-themes from dyadic interviews with adolescents (n = 20) and parents (n = 20) Parent-adolescent knowledge and readiness gap 1a."Nobody gives you the book for this": Parents trying to understand and catch up.1b."People were noticing, and they were doing something about it": The benefit of having time 1ai."I was just tired of listening to everyone": Parents turn to familiar sources of support.•Trans Adolescents guided parents to support.
2. Parents (silently) adjust to their child's gender identity affirmation process while becoming (super) supporters 2a "Flip it once and I will flip it again": Parental support was fierce and in the background.2b."It's a mourning process for myself": parent support through grief 2c."I still wanted someone to relate to me": Support groups were life-saving but not always accessible 2d."The bottom line" of parent support