Contemporary Family Therapy

https://doi.org/10.1007/s10591-018-9480-z

ORIGINAL PAPER

An Ecological Framework for Transgender Inclusive Family Therapy

Lindsay Edwards1   · Annabelle Goodwin2 · Michelle Neumann3

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Despite current demands for transgender inclusive family therapy, family therapy training programs provide limited course-
work on gender identity and inclusive practice. As a result, written resources are critical for family therapists wanting to
provide inclusive services to transgender clients. In the interest of expanding available resources, this article uses an ecologi-
cal framework to summarize research findings on the unique resiliency and difficulties experienced by transgender people.
This was done in the interest of identifying implications for family therapy and distilling these implications into a collection
of concrete suggestions for transgender inclusive family therapy practice. A conceptual model and a table of concrete sug-
gestions are included at the end of the article.

Keywords  Transgender · Family therapy · Gender identity · Therapeutic techniques · Inclusive marriage and family therapy

Introduction for work with clients from marginalized and underserved

Despite the demand for knowledgeable and inclusive family
therapy services (Addison and Coolhart 2015; Blumer et al.
2013), there is little to no evidence that family therapists as
a whole are prepared to effectively serve transgender clients.
Unlike the American Psychological Association, which has
developed professional standards for work with transgender
clients (see APA 2009, 2015), the American Association
for Marriage and Family Therapy has no such standards and
has been slow to acknowledge the diversity of gender iden-
tity. It has only been with version 12 of the Commission on
Accreditation for Marriage and Family Therapy Education
(COAMFTE) accreditation standards that gender identity
was included in the definition of diversity and effectively
required family therapy training programs train students
Thank you to Atticus Ranck at SunServe for his review of our
work.
* Lindsay Edwards
ledwards002@regis.edu
Annabelle Goodwin
agoodwin@ncu.edu
1
Division of Counseling & Family Therapy, Regis University,
500 E. 84th Avenue, Suite 172, Thornton, CO 80229, USA
2
Northcentral University, Scottsdale, USA
3
Durham, NC, USA
communities.
Prior to version 12, family therapy programs were not
required to provide coursework or other training experi-
ences that encouraged competence for work with margin-
alized and underserved communities, and there is still not
clear language in the standards about skills for working with
transgender clients. With no professional standards and lim-
ited training on transgender inclusive family therapy, thera-
pists have generally been left with little direction or support.
While there is no research on the effectiveness of family
therapists working with transgender clients specifically, the
2015 U. S. Transgender Survey (USTS) provides cause for
concern, showing that 9% (n = 2,494) of the 27,715 partici-
pants reported that a mental health professional had tried to
stop them from being transgender (James et al. 2016). This
finding suggests that clinicians, in general, are ill-prepared
for serving transgender clients.
Without required coursework in training programs, both
continuing education and written resources become essential
for family therapists. While published outside of the family
therapy literature, there are a number of foundational and
essential resources—many written by family therapists—
that provide important clinically relevant information for
family therapists who are working with transgender clients
(see Bigner and Wetchler 2012; Coolhart et al. 2008; Cool-
hart and Shipman 2017; DeBord et al. 2017; Lev 2004).
These resources are especially critical because of the limited

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amount of published work that addresses gender identity
within family therapy literature.
Blumer et al. (2012) surveyed 17 family therapy jour-
nals, including Journal of Marriage and the Family, Con-
temporary Family Therapy, and Journal of Feminist Family
Therapy, to see how frequently articles on transgender issues
were published during a 12 years period. Their findings
showed that only 0.0008% of the articles published within
the 17 journal they surveyed were focused on transgender
issues or used transgender status as a variable. In the interest
of expanding available resources within the family therapy
literature, we have used an ecological framework to sum-
marize research findings that pertain to the unique resilien-
cies and difficulties experienced by those identifying within
transgender communities. For each nested system of our
model, we synthesize current research and provide concrete
recommendations for inclusive family therapy practice. A
summary of these recommendations can be found in Table 1.
Model Framework
Our ecological framework has been adapted from the
Ecological Systems Theory described by Bronfenbrenner
(2005). Bronfenbrenner conceptualized human development
as a conversation between an individual and multiple nested
environmental systems at a particular time in history. These
systems include the microsystem, mesosystem, macrosys-
tem, and chronosystem. Our model (see Fig. 1), while not
developmental, uses a similar ecological structure to organ-
ize current research on the experiences of transgender indi-
viduals within multiple intersecting environmental systems.
While we provide examples of what might be included in
each intersecting systems, we acknowledge that our exam-
ples are not comprehensive. Furthermore, these systems are
presented as concentric, but we do not consider the various
systems to be distinct from each other. Instead we see these
as nested and interrelated systems through which influence
flows bidirectionally. Bidirectional influence is consistent
with Bronfenbrenner’s later work on proximal processes,
which explain how genetic potential invites responses from
the various systems (Bronfenbrenner 2005).
One adaptation we have made from the original model,
is to see the individual through an intersectional lens (see
Crenshaw 1989). From this perspective, individuals have
both genetic predispositions and a multitude of intersecting
sociocultural identities that influence how a person is treated
by others, can access power and resources, and is presented
with opportunities. Important dimensions of personhood
commonly cited include age, gender identity, cultural/eth-
nic identity, racial identity, sexual identity, ability status,
class background, nation of origin, and religious or spiritual
affiliation. From this perspective, a person who identifies as
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Contemporary Family Therapy
transgender, who has not completed high school, and who is
currently homeless, might have access to less social capital
and fewer resources than a person who identifies as transgen-
der, with an advanced degree, and financial security. Con-
ceptualizing the dimensions of an individual in this manner
accounts for the complexity of socially constructed identities
in addition to genetic potential.
Finally, we have included the context of time and his-
tory in this model because they are believed to underpin and
shape the entire experience of an individual and the nested
systems. As such, when we refer to history, we are doing so
within the context of United States history. We began this
project while President Barack Obama was in office and con-
versations about transgender people and related issues were
emerging on the national stage. For the first time, a President
of the United States addressed the civil rights of transgender
people. As we conclude this project, Donald Trump holds
the presidency and we have entered a period of time marked
by fear for many. To this point, President Trump has encour-
aged military bans for transgender people and has asked
attorneys in the Department of Justice to interpret law such
that transgender workers are not protected from discrimina-
tion based on gender identity (National Center to Transgen-
der Equality 2018b). In our current cultural context, we find
that we have a renewed call to mobilize toward resistance
against systems of dominance like racism, homophobia,
transphobia, ableism, xenophobia, and sexism. Although
these moments in time feel especially poignant for us from a
historical perspective, we recognize that our accounts of his-
tory are influenced by our own cultures, experiences, choices
of news outlets, and from the stories of people we know.
Suggested Use of the Model
We are compelled as authors to comment on the subjec-
tive nature of the information we include here and encour-
age the reader to consider, not just how we the authors are
influencing this discussion of relevant research findings, the
structure of this model, and our various implications and
suggestions, but also how you the reader are interpreting
what we present here and how you will then use this model
and its clinical implications. Note that what we present
in this model is largely quantitative research findings that
indicate common experiences for transgender individuals,
but readers would be remiss to assume that these research
outcomes apply to the experiences of all individuals who
identify as transgender. Although the experience of living
within a transphobic and cisnormative cultural environment
is a shared experience for all people, individual response
to stressors like discrimination and prejudice are unique to
each person and can manifest as poorer mental and physical
health outcomes for some and as paradigmatic examples of
 Table 1  Recommendations for inclusive clinical practice at each level
System level
Individual
Assess for resiliencies like hopefulness,
flexibility, spiritual beliefs, & emotional
expressiveness
Maintain consistent self-reflection on own
power/ privilege
Maintain awareness of how sociocultural
identities (of client and therapist) affect
therapeutic relationship
Use intersectional lens to consider clients’
experiences
Do person-of-the-therapist work around
microaggressions
Use strength based approach to conduct full
assessment of clients’ available resources
Explore constructionist theories of gender and Be aware of family creation options for tran-
sexuality (see The Gender Unicorn at Trans
Student Educational Resources)
Prioritize clients meaning and expressed goals
closely
Know developmental needs of transgender
youth, adults, & elders
Know resources like National Resource
Center on Lesbian Gay Bisexual and
Transgender Aging
13
Relational
Know parent support groups and resources
like http://www.hrc.org/resou​rces/ resources- resources
for-people-with-transgender-family-mem-
bers
Emphasize resiliency in family and couple
systems working to reconnect members
Support family members in each of their
transitions (both cisgender and transgender)
including the reorganization and redefinition
of self and family roles
Think expansively about family based support Know of inclusive homeless and domestic
systems (supportive family members like
siblings, family of choice, and extended
family)
Connect clients to broader LGBTQ commu-
nity
Emphasize flexibility with family members
related to family structure and form
sitioning individuals to invite possibility of
family creation post-transition
Community
Maintain current referral lists of legal
Know local & national transgender advocacy
organizations
Know trans-operated LifeLine at (877)
565–8860 /Text Help Line at 741741
violence shelters
Maintain current referral lists of inclusive
hospitals, primary care clinics, emergency
rooms, mental health centers, and other
private practice therapists
Advocate for improved training on trans-
related clinical services within organization
Regularly visit websites like Human Rights
Campaign & Transequality.org
Maintain current lists of gender confirmation
surgeons
Promote transgender inclusive language in
organization policies
Know transition options & WPATH Standards
of Care
Know Endocrine Society Clinical Practice
Guidelines
Stay current on state name change procedures
Follow local events/news that impact
transgender people
Societal
Promote antidiscrimination laws specific to
transgender people by voting
Contemporary Family Therapy
Write white papers that promote antidiscrimi-
nation, anti-violence and anti-assault laws
specific to transgender people
Stay current on policies and laws affecting inter-
actions between justice system & transgender
individuals
Stay current on policies and laws affecting
people with multiple marginalized identities
(transgender undocumented immigrants)
Be a visible advocate by attending community
events
Stay current on private insurance, Medicaid,
Medicare coverage for transgender-related
health care (See Human Rights Campaign
website)
Follow popular media (TV shows, YouTube
videos, movies, blogs, books, documentaries)
with authentic representations of transgender
people
Support clients in developing social capital and
use own social capital to create opportunity
and resources for transgender communities


Table 1  (continued)
System level

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Individual Relational Community Societal

Review Mizock and Lundquist’s (2016) find-

ings ontherapists’ missteps
Create inclusive clinical environment
• Paperwork with open response format for
gender identity
• Clear and overt statement of transgender
inclusiveness on website and posted in
physical location of business
• Include gender identity in anti-discrimina-
tion statements
• Ensure “All Genders” bathroom options for
clients
• Advocate for relaxed dress code to honor
each person’s individuality and unique
gender expression
• Practice asking about & using correct pro-
nouns/names
• Mandated inclusivity training for staff
Contemporary Family Therapy
Contemporary Family Therapy
Fig. 1  Ecological framework
for transgender inclusive family
therapy
strength and resiliency for others. To assume, therefore, that
all transgender clients experience distress related to gen-
der identity would be a significant overgeneralization of the
ideas presented in this model.
It is also important to note that research studies with
transgender participants often include variation in gender
identity within a study sample, which limits the generaliz-
ability of this research. The studies we describe here likely
include nonbinary participants who identify as transgender,
although the focus of these studies were not explicitly on
nonbinary experiences. Currently, little to no scholarship
explicitly addresses the experiences of transgender individu-
als who do not identify with the gender binary. Our focus
for this article is on individuals who identify as transgender
and have the experience of being assigned a gender that is
not congruent with their gender identity. This includes non-
binary transgender people and people who are transgender
and not nonbinary. So while much of what we write here is
relevant for nonbinary clients, we want to be frank that we
do not specifically address the unique experience of nonbi-
nary people in this article. Furthermore, we have decided to
use the terms transgender and transgender people because
these are generally accepted terms at the time of our writing,
but we acknowledge that these terms are themselves limited
in that they, like most gender and identity terms, are reduc-
tionist in nature. We use specific terms for our writing here,
but we recommend therapists always ask clients how they
identify in order to honor their language and unique identity.
Finally, we want to mention that two out of three authors
do not identify within the transgender communities about
which we write. More specifically, one of us identifies as
transgender nonbinary and two of us identify as cisgender.
While our individual identities and experiences vary in
Healthcare Policy & Media
School, Employment, Physical
and Mental Health Care,
& Procurement of Identity Documents
Relational
Family of Origin, Created
Family, & Friendships
Individual
Genetic Predispositions
for Mental/Physical Health,
Sociocultural Identities,
& Chronological Age
terms of our sexualities (two of us are heterosexual and one
of us is queer), ability (one of us is disabled and two of us
are presently able-bodied), class background (one of us has
lower middle class socialization and ones of us upper mid-
dle class socialization), and religious/spiritual backgrounds
(one of us has secular socialization and two of us Christian
socialization), we collectively share white racial identity. We
acknowledge the influence of our contributing identities in
shaping our interpretation of the research and ask that the
reader consider any resulting bias while reading the presen-
tation of this model and clinical implications.
We have, however, worked to address these biases by inte-
grating feedback from a stakeholder outside of our writing
team and using a self-reflective process to examine our own
biases. The stakeholder who reviewed our work identifies
as transgender, is a practicing clinician, and is the director
of transgender services at a non-profit agency that serves
LGBTQ communities. We made numerous changes based
on the comments of our stakeholder and then returned our
article to him to be sure we accurately addressed his sugges-
tions. Our process of self-reflection included regular group
meetings where we discussed theory, clinical practice, and
current world events as a vehicle for examining biases. For
us, these meetings were an opportunity to share and reflect
on writings from multiple disciplines, as well as for self-
reflection and personal growth as we challenged one another
and raised new perspectives. We were not always in agree-
ment and we used these disagreements as opportunities for
examining biases. Similar to how we have reflected on the
influence of our identities while developing this model, we
suggest readers consider how their own cultural identities
and personal experiences color the lens through which they
read and use this model and our suggestions. We recommend
13

readers give vigorous attention to their own biases and hold
this awareness at the forefront while reading this article. We
also suggest readers see this reflection process as continuous
and without an end-point, as this field of study is constantly
evolving.
Model Components
In the following sections, we discuss research related to each
intersecting system of our model (Fig. 1) and then provide
specific suggestions for transgender inclusive family therapy
practice at each system level.
Dimensions of the Individual
Dimensions of an individual should be understood from
an intersectional lens that includes biological features like
chronological age and genetic predispositions for physi-
cal and mental health vulnerabilities, but also the multiple
socially constructed identities that an individual claims or
that are ascribed to them by others. These identities are
intersecting and include age, gender identity, cultural/eth-
nic identity, racial identity, sexual identity, ability status,
class background, nation of origin, and religious or spir-
itual affiliation to name a few. Together this constellation of
identities influences how individuals present themselves and
are regarded by others, which in turn influences a person’s
interactions with the broader network of systems.
Research on identity dimensions and stressor experiences
suggest that a minority racial identity can be protective
(Xavier et al. 2005) and/or one of compounding vulnerabili-
ties (Grant et al. 2011). In their needs assessment, Xavier
et al. (2005) found that African-American transgender par-
ticipants were the least likely to report suicidal ideation and
these authors proposed that it was strengths within African-
American communities that explained this result. Examples
of these strengths might include “strong religious beliefs, a
collective social orientation, strong family/kinship bonds,
communalism, cognitive flexibility, affective expressiveness,
and present time orientations” (Utsey et al. 2007, p. 406).
Conversely, the 2011 National Transgender Discrimination
Survey (NTDS) and the 2015 USTS data both showed white
transgender respondents had the lowest prevalence of life-
time suicide attempts compared to transgender people of
color, who were at greater risk (Grant et al. 2011; James
et al. 2016). These study findings are inconsistent, but they
collectively suggest therapists should consider all of a cli-
ent’s sociocultural identities when assessing for strengths
or stressors.
Research exploring the intersection of individual dimen-
sions like chronological age and transgender identity shows
that younger age may function as a strength in situations
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Contemporary Family Therapy
where pausing puberty and delaying the development of sec-
ondary sex characteristics are ideal and attainable (Cool-
hart et al. 2013). In other situations, youth may operate as a
stressor in that minors are unable to give consent for mental
and physical healthcare services and minors living in pov-
erty may have limited access to healthcare services in gen-
eral (Coolhart et al. 2013; Grossman et al. 2005). This situ-
ates youth in a place of little power for influencing their own
well-being and identity expression by preventing them from
independently accessing supportive mental health services
and resources for transition. Advanced age, however, can
also be a stressor for individuals in that receiving hormonal
and/or surgical procedures at an older age can be associated
with unique health issues like increased risk for cardiovas-
cular disease, liver damage, and diabetes (Persson 2009).
Furthermore, social isolation resulting from discrimination
can have especially devastating outcomes for aging transgen-
der individuals in regards to receiving safe and respectful
caregiving during later phases of life (Witten 2009).
Another important dimension of the individual to con-
sider is a person’s predisposition for mental health concerns.
Dhejne et al. (2016) found that mental health diagnosis like
bipolar and schizophrenia occur for transgender individu-
als at rates similar to the general public. While the preva-
lence of these diagnosis are similar, the experience of these
disorders is uniquely stressful for transgender individuals.
Findings from research on mental health diagnosis and gen-
der identity shows that transgender participants describe
their gender identity and their mental health diagnosis as
multiple sources of stigma that affect their ability to build
relationships and find support (Kidd et al. 2011). Specifi-
cally, participants in the Kidd et al. (2011) study described
feeling as though they did not fit anywhere, being marginal-
ized in general because of their gender identity and within
transgender communities because of mental health difficul-
ties. It is important to mention here that the experience of
having a mental health diagnosis for transgender individuals
is shaped by a history of psychiatrists confounding gender
dysphoria as a symptom of schizophrenia (see Latorre et al.
1976), effectively invalidating and pathologizing transgender
people. Given this context, inclusive therapists will want to
consider a transgender client’s mental health diagnoses, but
be extremely careful not to conflate mental health issues
with gender identity.
Implications for Inclusive Clinical Practice
This research collectively suggests that therapists should
consider how a client’s various sociocultural identities oper-
ate as unique sources of resiliency and/or as compounding
stressors, depending on the client’s context. To do this,
therapists will want to have a firm grasp on the theory of
intersectionality (see Crenshaw 1989; Moradi 2017) as well
Contemporary Family Therapy
as knowledge of human growth and development in order
to understand developmental needs at various life stages.
Chang and Singh (2016) provide a valuable resource for
inviting discussions of race alongside conversations of gen-
der identity with clients. This article describes affirmative
practice suggestions for work with transgender people of
color and details a useful case vignette. Family therapists
may also appreciate reading Addison and Coolhart’s (2015)
application of a Relational Intersectional Lens in order to
see how one might apply intersectional theory to work with
couples. In this article, Addison and Coolhart integrate an
intersectional framework with a systemic framework and
invite therapists to explore how the sociocultural identities
of each partner intersect with one another, how the partners’
identities together intersect with the therapist’s multidimen-
sional identities, and how these intersections then organize
the couple’s dynamics and the therapeutic relationship.
Finally, we suggest therapists access the many resources
available for transgender older adults on the National
Resource Center on Lesbian Gay Bisexual and Transgender
Aging website (i.e. Auldridge et al. 2012). The resources
listed here and in Table 1 are only a few of the resources
currently available on the diversity of experience within
the transgender communities. With this in mind we want to
mention that, while it is generally considered good clinical
practice to develop therapeutic goals in conjunction with
clients, this is a critical process for work with transgender
clients. Affirming therapists should follow clients’ mean-
ing and expressed goals closely while maintaining rigor-
ous self-reflection on what bias might be influencing the
therapeutic agenda. For instance, it would be misguided to
have hormonal and/or surgical transition as a goal if this was
based solely on the therapist’s assumption that all transgen-
der clients desire hormonal and/or surgical transition or that
this is necessary for the consolidation of gender identity.
Critical self-reflection and engaging in continuing education
are some of the most important steps a clinician can take
toward becoming a transgender inclusive family therapist.
Relational System
Relational systems are the meaningful and fundamental
interpersonal relationships a person has within their family
of origin, created family, and friendships networks. Each
relational system has unique risks for transgender people
in large part because of cultural norms, faith systems, and
social expectations that impose transphobic messages on
families. This, coupled with a lack of helpful information
pertaining to the experiences of transgender individuals, can
lead to insensitivity, bias, and strained interpersonal relation-
ships. At the same time, research shows there is systemic
resiliency in families with transgender members-finding
that parents with transgender children experience positive
transformations that ultimately result in them affecting sur-
rounding communities to be more inclusive (Kuvalanka
et al. 2014). The bidirectional nature of relational systems
means that families of origin, created families, and friend-
ships networks can impact transgender people in both posi-
tive and distressing ways, while being similarly impacted by
transgender members.
Family of Origin
Family of origin is thought to be the first social system a per-
son belongs to and may include a person’s biological and/or
adopted family members. Families of origin constitute mul-
tiple subsystems within the broader family system, including
parent/caregiver child relationships, sibling subsystems, and
extended family networks.
Parents/Caregivers and Child Relationships  Whether reject-
ing or supportive, parents/caregivers have been shown to
play a critical role in health and resilience for transgender
individuals throughout the life course (Erich et  al. 2008;
James et al. 2016; Simons et al. 2013). Erich et al. (2008)
found that higher levels of support from mothers and higher
levels of support from fathers were both associated with a
higher life satisfaction scores in a sample of transgender
adults-suggesting that parental support remains important
into adulthood.
Parental/caregiver support is also critical for transgender
youth, with research showing that support from parents is
directly associated with ratings of health and general well-
being for transgender youth (Travers et al. 2012). Coolhart
et al. (2013) note that family support is important because
youth are dependent on parents/caregivers for navigating
aspects of life. Specifically, guardians have legal responsi-
bility and authority for youth and are often solely responsi-
ble for signing waivers and approving mental and physical
healthcare services. Youth simply cannot give consent in
order to access the support they need without the assistance
of guardians (Coolhart et al. 2013; Grossman et al. 2005).
This makes it virtually impossible for youth without guard-
ian support and those without guardians (e.g. those in foster
care or who are homeless) to access mental and physical
healthcare services.
Institutional structures place parents/caregivers in a
uniquely powerful position with regard to the well-being
of transgender youth, yet parents/caregivers enter therapy
at many different levels of support and acceptance (Koken,
Bimbi, & Parsons, 2009). A common dilemma in families is
disagreement between parents/caregivers regarding accept-
ance and support of a transgender youth, with fathers being
less likely to respond with acceptance (Koken et al. 2009;
Hill and Menvielle 2009). Studies exploring variations in
parental support have shown that parental rejection ranges
13

from covert or unexamined neglect to overt discrimination
and violence (Grossman et al. 2005; Koken et al. 2009). In
their qualitative interviews, Koken et al. (2009) documented
frequent abuse and violence from parents. A comparable
study by Grossman et al. (2005) found that a majority of
their participants were called things like “sissy” or “tomboy”
by parents. Together the Grossman et al. (2005) and Koken
et al. (2009) studies show that the reaction of some parents
might be extreme enough to include abuse and violence.
On the other end of this range of reactions, however, are
parents who respond with warmth and support. Participants
of Koken et al. (2009) also described having mothers who
accepted them fully and who were active supporters of their
transition. Similarly, the mothers of five transgender chil-
dren in Kuvalanka et al.’s (2014) study reported that despite
starting in a place of uncertainty, they eventually became
“experts” on transgender issues, advocates, and leaders of
advocacy initiatives. For these mothers, their child’s suicide
risk motivated them to learn how to support transgender
youth. Kuvalanka et al.’s findings, in particular, highlight
the potential for family transformation and growth when one
family member identifies as transgender.
Sibling System  Despite being an important relational sys-
tem, little research exists on sibling dynamics in families
with transgender members. What has been done, showed
that 34.6% of the time, siblings were a good or excellent
source of support (Erich et al. 2008). Toomey and Richard-
son (2009) surveyed 56 lesbian, gay, bisexual, and transgen-
der individuals between the ages of 18–24 and found that
sisters were second to mothers as the most likely family
member for participants to disclose a transgender identity.
In the same study, 72% of respondents were out to a sib-
ling, suggesting siblings could be a critical resource. This
could especially be the case for individuals who do not have
supportive parents/caregivers but who wish to remain con-
nected to their family of origin. In this way, sibling rela-
tionships might be an essential, but overlooked, source for
support.
Extended Family Networks  Much like research on sibling
relationships, little is known about extended family net-
works with transgender members. Only two studies we
found included extended family members in their investiga-
tions. In Koken et  al. (2009), family members like aunts,
cousins, and grandmothers were a critical source of sup-
port for some participants. Results from Kuvalanka et al.’s
(2014) study showed that extended family members experi-
enced transformation as the entire family flexed to embrace
the transgender family member.
Created Family  While studies on chosen families do exist
and their findings suggest families of choice are an essen-
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Contemporary Family Therapy
tial support system (Frost et al. 2016), these studies focus
primarily on the experiences of lesbian, gay, and bisexual
(LGB) individuals. When transgender individuals are
included in discussion of families of choice, it is often
from the perspective that LGBT (lesbian, gay, bisexual,
and transgender) communities are a homogenous group,
of which these diverse communities are not. Currently,
there is no research that addresses families of choice with
transgender members only. Given the importance of fami-
lies of choice for LGB individuals (Blumer and Murphy
2011; Frost et al. 2016), it is likely that families of choice
would be important for transgender individuals.
Child‑rearing  Although research on child-rearing expe-
riences of transgender individuals is minimal, the USTS
showed that 18% of participants reported being parents
(James et  al. 2016). James et  al. (2016) compared this
number to all US adults (34%) in the Current Population
Survey (see U.S. Census Bureau 2015) and suggested
that these rates were different in a meaningful way. One
explanation for this lower rate of parenthood is the set of
barriers that exist for transgender individuals. These bar-
riers often include discriminatory policies and laws, the
financial cost of medical services, and bias during adop-
tion processes. In fact, von Doussa et al. (2015) reported
that the obstacles to becoming a parent seemed so insur-
mountable, many of their participants had foreclosed on
the idea of parenting despite their desire to be a parent.
Not surprisingly, 68% of USTS participants listed parent-
ing and adoption rights as “Very Important” in regard to
policy priorities for the community. This suggests that,
despite lower rates of parenthood for USTS participants,
parenting is an important role for transgender individu-
als. As with anyone, however, the path toward parenthood
includes multiple intersecting considerations.
Romantic Partnerships  Another important relational sys-
tem to consider are romantic partnerships. A common but
inaccurate assumption is that relationships formed before
the disclosure or discovery of a partner’s transgender
identity will most certainly end (Lev 2004). Research on
romantic relationships indicates that many transgender
individuals remain with the partner they had prior to a
disclosure. Meier et al. (2013) found that 51% of their 593
transgender men participants were in romantic relation-
ships and that over half of these participants were with
the same partner before and after their transition. Further-
more, social support from a partner moderated the rela-
tionship between relationship status and depression for
transgender participants, suggesting there is a protective
effect of partner support. Meier et al.’s finding is consist-
ent with older research on relationships that found a sig-
nificant correlation between life satisfaction for transgen-
Contemporary Family Therapy
der individuals and support from a significant other (Erich
et al. 2008).
While Meier et al. (2013) and Erich et al. (2008) indicate
romantic partnerships are an important source of support for
transgender individuals, other research suggests this is not
always the case (Liu and Wilkinsen (2017). Liu and Wilkin-
sen’s study on marital status and perceived discrimination,
indicated that there were no differences between never mar-
ried and married transgender participants when covariates
like transition stage, age, race/ethnicity, and sexual orienta-
tion were controlled for (Liu and Wilkinsen 2017). There
were, however, differences in perceived discrimination
between individuals who had experienced relationship dis-
solution and people who were still married. When discussing
their findings, Liu and Wilkinsen suggest that higher levels
of perceived discrimination was the result of experiencing
marital dissolution. Thus, the benefits of marriage may not
be clear cut. Liu and Wilkinsen also made the point that
married transgender people who experienced marriage as a
protective factor likely experienced it as protective because
they were afforded the economic, social, and psychological
resources that come along with being able to and deciding to
participate in culturally sanctioned institutions like marriage.
An important point to remember when interpreting this
literature is that this research looks primarily at relation-
ships with two partners. Though we have not found research
focused on other forms of romantic relationships (polyamory
for example) within the transgender community, we want to
point out that it would be useful for a therapist to explore
what type of relationship is meaningful for a client.
Friendships
According to Galupo, Bauerband et al. (2014), the benefits
of friendships for transgender individuals includes a sense
of belonging with other transgender friends, being able to
process experiences of discrimination and marginalization,
and feeling connected to mainstream society with cisgender
friends. In fact, Trujillo et al. (2017) found that experiences
of discrimination only led to suicidal ideation for partici-
pants who had low levels of social support from friends.
This finding indicates that support from friends can buffer
the effects of discrimination at moderate and high levels.
While the importance of friendship networks for
transgender individuals is well-established, barriers do exist
in friendships for transgender people. These barriers include
cisgender friends not knowing about issues of gender, sex,
and privilege in general, friends using insensitive language,
the potential of being “outed” by friends, and friends invali-
dating gender identity and personal experiences (Galupo,
Bauerband et  al. 2014). Furthermore, microaggressions
persist within friendships, including friends who ‘should
have known better’ (those within LGBT communities)
(Galupo et al. 2014, p. 466). For participants in Galupo,
Henise et al. (2014), experiencing microaggressions with
LGBT identified friends was the most disappointing. Hav-
ing friends behave in ways that communicates discomfort or
disapproval, denies having internalized transphobia, ques-
tions the legitimacy of gender, and assumes sexual pathol-
ogy or abnormality was shown to be the most harmful for
participants.
What is increasingly documented in research on friend-
ship networks, is how important connection with other
transgender people and the broader lesbian, gay, bisexual,
transgender, and queer (LGBTQ) community can be for
transgender individuals. Researchers like Pflum et al. (2015)
and Stanton et al. (2017) have shown that increased connec-
tion with the broader LGBTQ community is associated with
greater well-being for transgender individuals. What is more,
the results of Sánchez and Vilain (2009) have shown that
positive identification with broader transgender communities
is related to lower levels of psychological distress.
Implications for Inclusive Clinical Practice
Research on relational systems points to many important
clinical implications for inclusive work with individual
transgender clients as well as couples and families with
transgender members. To start, therapists will want to hold
two perspectives at once related to families of origins. The
first being that families of origin, including parental, sib-
ling, and extended family subsystems, can serve as important
sources of support for transgender individuals. Therapists
will want to be sure they inquire about supportive family
members in order to include these family members in ther-
apy when a client indicates wanting to foster these relation-
ships. When working with couples, therapists should also
consider how they can expand the client unit to include sup-
portive family members as a way of building a supportive
network for the couple.
A second critical perspective to hold, however, is that not
all families of origin provide healthy contexts for transgen-
der individuals, and for some, there is more harm than good
staying connected with families of origin. In line with this, it
is important for therapists to have expanded views on family
structure and family formation options. To do this, thera-
pists must explore assumptions and biases they hold related
to family structure and family formation in order to avoid
inadvertently reinforcing heteronormative and essentialist
assumptions. One specific suggestion we have for this self-
exploration process is to consider what image comes to mind
when thinking of a “family” and what assumptions underpin
this image.
Family therapists would also do well to think broadly
about relational support structures for transgender clients.
When working with transgender individuals, couples with
13

transgender partners, and families with transgender mem-
bers, therapists will want to encourage and facilitate con-
nection with other transgender identified people as well as
fostering connection with broader transgender communities.
This might look like urging families to participate in PRIDE
events, directing both transgender and cisgender partners to
online support communities, and hosting individual, cou-
ples, and family support groups.
With regard to family creation, therapists working with
transgender clients should hold an unassuming perspective
that balances the possibilities of child-rearing with the rec-
ognition that this is not something all clients desire. When
supporting clients through child-rearing experiences, thera-
pists will want to deconstruct and expand cultural assump-
tions about how families form and what they look like, while
also emphasizing client autonomy. For discussion of the
various family creation options for transgender individuals
as well as couples with transgender partners, we recommend
reading Dicky et al. (2016). Dicky et al. highlight a critical
consideration for family therapist working with transgender
youth and their parents/caregivers. Namely, they explain
that during discussions of hormonal and/or surgical transi-
tion, transgender youth and their parent/caregivers are often
having to make future life choices about reproduction and
child-rearing far in advance of a typical developmental time-
line. Family therapists working with transgender youth and
their families with will want to be knowledgeable about the
impact of hormonal and/or surgical transition on fertility
in order to help clients explore strategies for maintaining
reproductive options if they so desire.
Community Systems
Community systems are those found in an individual’s local
community and include organizations like places of employ-
ment, school systems, law enforcement, mental and physical
healthcare systems, and other general community associa-
tions. For transgender individuals, interacting with commu-
nity systems presents unique risks in terms of well-being
because of the enormous amount of transphobia that perme-
ates these systems. Researchers have documented alarmingly
high rates of gender based violence, harassment, and dis-
crimination experienced by transgender individuals in com-
munity systems. A study on lifetime experiences of violence
and harassment, found that nearly half of their sample (47%)
of 402 transgender participants had experienced physical
assault of some type as a direct result of their gender iden-
tity (Lombardi et al. 2001). Similar numbers (43%, n = 248)
were found by Xavier et al. (2005) in their needs assessment
of transgender participants of color. The 2015 USTS also
documented community based discrimination, finding that
14% (n = 3,880) of their sample had been denied equal treat-
ment in public places, 24% (n = 6,652) had been verbally
13
Contemporary Family Therapy
harassed, and 2% (n = 554) had been physically assaulted
in places of public accommodation like retail stores (James
et al. 2016). In general, community systems appear to be
callous at best, and utterly unsafe at worst, for transgender
people.
The negative effects of discrimination from community
systems has also been shown to extend in impact to the
well-being of cisgender people in romantic relationships
with transgender partners. Gamarel et al. (2014) looked at
how minority stress manifests dyadically for couples with
transgender women who were partnered with cisgender men.
Their results show that not only did experiences of daily
discrimination and relationship stigma inversely associate
with transgender women’s relationship quality scores, higher
levels of discrimination were also associated with lower
relationship quality scores for their cisgender men partners.
Additionally, both the transgender women and the cisgender
men in Gamarel et al.’s study had increased odds of depres-
sive distress when they experienced gender identity related
discrimination. Results from Gamarel et al. (2014) dyadic
analysis collectively show that minority stress experiences
operate dyadically in such a way that discrimination and
stigma can impact a couple at both the individual health
level and the relationship level.
School Systems
Research on the experiences of transgender youth in school
settings suggests that educational contexts are one of the
more hostile community systems for transgender identify-
ing individuals (Toomey et al. 2013; Russell et al. 2011).
The most recent school climate survey completed by the
Gay, Lesbian, and Straight Education Network (GLSEN;
Kosciw et al. 2016) reported that, of the 15.2% (n = 1600)
of transgender participants in their survey, 75.1% felt unsafe
at school because of their gender expression. These find-
ings corresponded with reports of physical assault based on
gender expression (12.0%) and discriminatory policies and
practices within schools such as being prevented from using
a true name or pronoun (50.9%) or being required to use a
particular bathroom or locker room (60.0%; Kosciw et al.
2016).
Qualitative oral histories collected by Graham (2014)
from transgender women of color corroborated that school
was the context where these women faced the most direct
pressure to conform to the gender binary. More specifically,
administrators in their schools required students to maintain
cisnormative expressions of gender and would actively pun-
ish children who did not conform. For these participants,
the behavior of administrators fostered an unsafe climate
that was harmful for them mentally and emotionally. Find-
ings from Seelman’s (2014) secondary data analysis of the
2011 NTDS data suggests that university contexts may be
Contemporary Family Therapy
equally as inhospitable, showing that 19% (n = 527) of their
sample of transgender women and transgender men were not
allowed to use gender appropriate housing during their stays
on campus and 23.9% (n = 663) were prevented from using
a bathroom while being a student.
Employment Systems
Research on employment contexts, which is another critical
community system, shows transgender individuals experi-
ence significant direct and indirect discrimination in work
environments. In their qualitative study on career decision-
making processes for transgender workers, Budge et al.
(2010) identify numerous barriers to stable employment that
are rooted in prejudice. These barriers include overt discrim-
ination like name-calling, destruction of property, deliberate
use of incorrect pronouns and former names, job loss, diffi-
culty gaining employment following job loss, and bathroom
discrimination. Participants in Budge et al.’s (2010) study
described a set of experiences that developed into a negative
cycle of unemployment for them. These narrative accounts
of unemployment are consistent with unemployment rates
reported by Mizock and Mueser (2014) in their sample of
transgender workers (29%, n = 55), which was over three
times the national average (7.9%).
On its own, job loss based on discrimination is extremely
concerning, but collectively these barriers to employment
are a perfect storm of compounding stressors. Increased
risk for job loss and difficulties regaining employment puts
transgender people at unique risk for prolonged unemploy-
ment and homelessness. Not surprisingly, the 2015 USTS
survey shows 8,314 of 27,715 participants (30%) report
experiencing homelessness at some point in their life (James
et al. 2016). For those able to maintain employment, it is
often at the cost of tolerating on-the-job discrimination and
microaggressions. Many of Budge et al.’s (2010) partici-
pants described limiting their career aspirations and feeling
as though certain employment situations were unobtainable
because of their gender identity. Essentially these partici-
pants described feeling that they had to continue working
in the job available to them because of the bias they would
face during promotion processes and interviews for other
positions. It appears that even in inclusive work contexts,
there is often a lack of understanding and limited knowledge
regarding how to support transgender employees and create
a safe and discrimination-free environment.
Physical Health Care Providers
Research on physical healthcare providers shows transgen-
der individuals frequently experience discrimination perpet-
uated by medical providers and staff within this community
system. 33% of the 27,715 participants in the 2016 NTSD
study report they had negative experiences with healthcare
providers in the previous year (James et al. 2016). These
included the refusal of transition-related and non-transition
related healthcare services, unnecessarily invasive question-
ing, having to educate healthcare providers, verbal harass-
ment, and physical and sexual assault. These study findings
suggest that one of the most critical systems for maintaining
physical health, as well as for completing a hormonal and/or
surgical transition, is another inhospitable and unsafe envi-
ronment for transgender people. This is especially true for
transgender people of color, who experience significantly
higher rates of anti-transgender discrimination in healthcare
contexts like emergency rooms, with doctors/hospitals, and
with ambulances/EMTs (Kattari et al. 2015).
Experiences of discrimination in healthcare contexts
operate as one of many barriers for transgender individuals
hoping to access healthcare services (Nemoto et al. 2005;
Safer et al. 2016). Other barriers to healthcare for transgen-
der individuals include ill-prepared healthcare providers,
institutional cisnormativity in health record systems/clini-
cal facilities, and financial hurdles like limited insurance
coverage and a lack of income (James et al. 2016; Safer
et al. 2016). It bears noting that the last two barriers listed
here are relevant to experiencing on-the-job discrimination
and unstable employment since access to health insurance
and sufficient income require stable employment for most
individuals. This is just one example of how compounding
experiences of discrimination in the community system can
lead to healthcare disparities for transgender people.
Collectively, these barriers to health care explain why
those in the transgender community report low levels of
healthcare utilization, including prevention services (Radix
et al. 2014), general medical services (Sperber et al. 2005)
and transition services (deHaan et al. 2015). In some situ-
ations, these barriers to transition services have resulted in
some transgender individuals addressing healthcare needs
through indirect routes. These indirect routes include uti-
lizing loopholes in insurance policies for transition related
procedures (Roller et al. 2015), accessing hormones for tran-
sition through unlicensed sources (deHaan et al. 2015), and
even self-performed surgeries or surgeries in non-medical
settings (Nemoto et al. 2005; Khobzi Rotondi et al. 2013).
Although it is evident how risky self-performed surgeries
and surgeries in non-medical settings are for a person’s
health, it can be said that accessing hormones through unli-
censed sources is nearly an equally dangerous prospect.
Hormones obtained through unlicensed sources are often
unmonitored and can put individuals at risk for contami-
nated hormones or incorrect dosing (Nemoto et al. 2005).
Not only do transgender people experience health disparities
from avoiding medical services for general health concerns,
but many may be at risk for physical side effects from non-
prescribed hormones or risky surgeries.
13

Mental Health Care Providers
Research on experiences of transgender persons in mental
health systems must be considered within the context of a
long and complicated history. This history includes stig-
matizing diagnoses like Gender Identity Disorder (GID) in
the Diagnostic and Statistical Manual of Mental Disorders
(DSM versions III-V; Koh 2012) and mental health provid-
ers functioning as gatekeepers for transition related services.
Even the DSM-V, which is the most current version at the
time of this writing, includes a diagnosis that situates dis-
tress related to gender identity within an individual, rather
than with society-as a feature of living in a cisnormative,
transphobic, and binary-based culture. With this said, the
removal of GID from the DSM-V is generally thought of as
a shift away from pathologizing gender identity.
The World Professional Association for Transgender
Health (WPATH 2012), which is thought to set the stand-
ard for quality care, dictates the number of mental health
referrals needed to meet their recommended criteria for
hormone replacement therapy (HRT), breast/chest surgery,
and genital surgery. While WPATH does mention that their
Standards of Care (SOC) are only clinical guidelines and
can be modified for patients with unique needs (see Appen-
dix C; WPATH 2012), these guidelines are often used and
talked about in terms of a requirement for receiving transi-
tion services. Mental health providers are frequently asked
to write endorsement letters by clients seeking transition ser-
vices from healthcare providers who rigidly follow the SOC
guidelines. As a result, therapists sit with an unusually large
amount of power when working with clients who are seeking
transition services. Unfortunately, research on transgender
individuals in therapy indicates that, all too often, therapists
commit egregious misuse of this power and in general do not
work effectively with clients from transgender communities
(Mizock and Lundquist 2016).
Mizock and Lundquist’s (2016) qualitative findings
recount common missteps made by psychologists working
with transgender clients. The 46 transgender participants in
this study explain that they frequently had to educate their
clinician on transgender related issues in order for therapy
to continue. These participants also explain that their clini-
cian had overlooked salient aspects of their life that were
not related to gender identity, or antithetically, had avoided
discussing gender identify all together. Additional missteps
mentioned were applying preconceived notions of gen-
der with transgender clients, making assumptions that all
transgender individuals were the same, pathologizing gen-
der identity by treating it as the cause of various problems
and the thing to fix, and focusing on the clinician’s role as
a gatekeeper to medical transition services. This last mis-
step can be an especially egregious misuse of clinical power
in situations where a client is not autonomously choosing
13
Contemporary Family Therapy
to attend therapy and/or if the cost of sessions is a financial
impossibility. Mizock and Lundquist’s (2016) study results
coupled with the research on clinical competency, suggests
that therapists are not well trained for work with transgender
clients (see Dispenza and O’Hara 2016; O’Hara et al. 2013).
This is especially concerning given that the 2015 USTS data
shows participants who had a mental health professional try
to ‘stop them from being transgender’ were more likely to
have attempted suicide than those who had not (James et al.
2016).
Identity Documents
Having accurate and consistent identity documents is essen-
tial for navigating the various community based systems of
the United States, but only 11% of the 27,715 2015 USTS
participants report that they had an accurate name and/or
gender marker on all of their identity documents (James
et al. 2016). For many this was directly related to institu-
tional barriers like the cost of a legal name change or worry
that they might lose benefits or services with the change.
Examples of situations where a person would encounter
difficulty without accurate and consistent identity docu-
ments might include boarding a plane, voting in elections,
receiving reimbursements for medical claims, filing annual
taxes, receiving a speeding ticket, and accessing VA ben-
efits. For individuals in the process of changing their name
and/or gender marker on identity documents, situations such
as these can be moments of extreme tension and anxiety.
Not surprisingly, the 2015 USTS findings show that 16%
of their participants who used an identity document were
denied services or benefits based on the identity document
(James et al. 2016).
Implications for Inclusive Clinical Practice
Despite the dire picture research paints of community sys-
tems, resources do exist that therapists will want to be aware
of. There exists an ever expanding list of inclusive com-
munity organizations, some local and some national, that
provide legal services, physical health care services, and
transition related services. Inclusive family therapists will
want to maintain a current referral list for each of these ser-
vices, be well versed in the WPATH Standards of Care, and
have at least a cursory knowledge of the Endocrine Society
Clinical Practice Guidelines. In addition to a robust referral
list, family therapists will want to consider how their clini-
cal environments and protocols may reinforce cisnormativ-
ity and pathology related to gender identity. For discussion
of inclusive clinical environments written by family thera-
pists we suggest reading Blumer et al. (2013) and Benson
(2013). Family therapists can also look cross-discipline to
the American Counseling Association clinical competencies
Contemporary Family Therapy
(ALGBTIC Transgender Committee 2010) and at the Amer-
ican Psychological Association guidelines (American Psy-
chological Association 2015) for additional suggestions.
Our last implication for community systems is to address
the limited way that gender identity is taught in family
therapy training programs. It is common for family therapy
students to receive little to no exposure to the experiences of
transgender people. If gender identity is addressed in a train-
ing program, it is often in a way that pathologizes transgen-
der clients. Rather than promote gender identity as an impor-
tant consideration for all clients, training programs often
discuss work with transgender clients in courses that focus
on psychopathology and/or diagnosis, effectively patholo-
gizing and medicalizing individuals with a transgender
identities (Singh and Dickey 2016). The result is an implicit
message that clinical work with transgender clients is a sub-
specialty. As a clinical subspecialty, it is not necessary for
all therapists to work effectively with transgender clients,
and subsequently, therapists believe they can refer transgen-
der clients. We will not delve into the many reasons this is a
problematic perspective here, but we suggest that interested
readers see McGeorge (2016) discussion on the ethics of
referring based on a client’s demographic characteristics.
As a whole, our profession must come to see transgender
inclusive training as an essential clinical competency for
work with all clients, rather than as a subspecialty.
Societal System
The societal system consists of wide-ranging institu-
tions that affect everyone in a cultural context, including
media and state/federal laws. Societal institutions such
as these operate as macro level stressors by shaping what
occurs within the other encompassed systems. Consider
laws like HB2 in North Carolina, which bans transgender
individuals from using restrooms that match their gender
identity. This transphobic law validates and emboldens any
business owner, who is already inclined to deny access to
restrooms, to do so with greater force and determination.
Ultimately, this increases the risk that transgender people,
who are already disproportionately targeted by law enforce-
ment (James et al. 2016), will encounter the legal system.
In essence, as transphobia is increasingly formalized at the
macro level by being written into laws like HB2, commu-
nity systems become ever more dangerous for transgender
people.
Health Care Access and Coverage
Prior to 2014, there were no protections in place to prevent
insurance companies from denying coverage to transgen-
der people based on the ‘pre-existing condition’ of being
transgender. This changed with the passage of the Affordable
Care Act (ACA; Stroumsa 2014). While the stability of the
ACA is uncertain given our shifting political climate, the
ACA currently affords this protection for transgender people.
Additionally, the ACA creates expanded options for insur-
ance coverage through the health insurance marketplace.
Findings from the 2015 USTS suggest that a number of
transgender people have utilized these expanded options,
showing that 26% of participants had sought insurance from
a state or federal health insurance marketplace (James et al.
2016). Although the ACA protects against the use of pre-
existing conditions for denying services, it does not spe-
cifically require health insurance providers cover transition
related services. As a result, the ACA includes loopholes
for insurance companies to deny transition related services.
One loophole used to deny transition related services
is the requirement that gender markers match on both the
insurance policy and the individual’s social security card
(Human Rights Campaign 2018). It is not uncommon for
individuals in the midst of transition to have different gender
markers on identity documents, since a legal name change
is costly and time consuming. This policy can operate to
uniquely target transgender people and is one example of
how policies can be systematically used to deny services to
transgender individuals. Not surprisingly, 55% of the 2015
USTS participants who sought transition-related surgery
were denied coverage for the procedure.
While the previously mentioned policy can be prohibitive
for some people, it is not always the case that having differ-
ent gender markers on identity documents impedes access to
healthcare services. For some, having different gender mark-
ers on identity documents may actually facilitate access to
healthcare services that are covered for specific body types
(i.e. pelvic exams, pap tests, testicular ultrasounds, prostate
exams). Furthermore, 45% of the 2015 USTS sample did
receive coverage for their transition-related surgeries. The
ACA also currently prohibits insurance companies, who
receive federal funding or participate in a federal or state
marketplaces, from excluding transition-related care from
coverage if the insurers offer coverage for similar proce-
dures in situations not related to transition (National Center
for Transgender Equality 2018a). While the ACA can be
considered an improvement in the policy realm, it under-
scores a broader inconsistency and inequity in the provision
of healthcare services.
Media
As a macro level system, media can operate as both a stressor
and a source of support for transgender people. Online media
is an anonymous and quickly accessed resource for learn-
ing about the experiences of transgender people (Craig and
McInroy 2014). It also provides opportunities for developing
community connections and fortifying one’s gender identity
13

and expression (Kosenko et al. 2016). In their study of media
usage, Kosenko et al. (2016) identify a number of impor-
tant ways transgender people use online media sources to
consolidate gender identities and expressions. These include
researching possible ways of presenting gender identity,
finding information related to different options for transi-
tion, and understanding the mechanics of sexual activity for
their particular body type.
For some people, virtual environments like the Second
Life provide a virtual world that can be a safe context for
exploring and experimenting with gender expression and
identity. Multiple studies (Green-Hamann et al. 2011; Green-
Hamann and Sherblom 2014) document the informational
and emotional benefits of participating in the Second Life
Transgender Resource Center for transgender people. Green-
Hamann and Sherblom (2016) report finding that experi-
ences with a virtual identity in a Second Life Transgender
Resource Center support group affected participants’ well-
being and assisted them in transition.
Kosenko et al.’s (2016) participants describe using online
media as a way to identify potential partners in a manner that
was safe. For many transgender people, the question of if,
when, and how to disclose one’s gender identity to romantic
partners is a critically important question that is often dif-
ficult to answer. One primary fear is the possibility of facing
rejection and violence from a potential partner following a
disclosure. Connecting with potential partners and disclos-
ing through online media in advance of meeting in person is
one strategy for sharing one’s gender identity in a way that
is potentially physically safer. Participating in online media
might also involve some risk, however, since the anonymity
of the internet can often foster cruelty. People, who might
otherwise withhold discriminatory and hate based language
in person, often state biases without reserve on the internet.
Implications for Inclusive Clinical Practice
Suggestions for inclusive clinical practice at the societal
level require one to think expansively about the role of a
family therapist and previously established notions of sys-
temic intervention. Many concerns that transgender clients
bring to therapy result from society-based inequity that is
institutionalized as policy (e.g. difficulty obtaining cor-
rect identity documentation). For this reason, it is essential
for family therapists who are invested in the well-being of
transgender clients to address the source of the distress and
not just the symptom. To do this, therapists should operate as
advocates within larger society based systems to effectuate
change at the societal level. We suggest reading Coolhart
and MacKnight (2015) for a discussion of advocacy work
on behalf of clients outside of the therapy room. Additional
ideas for how family therapists might serve as advocates are
offered within Table 1 of the current article, but examples
13
Contemporary Family Therapy
include supporting anti-discrimination laws through voting
and promoting the creation of transgender affirming policy
by writing white papers in support of affirmative legislation.
Inclusive family therapists will also want to stay current on
mainstream media representations of transgender people
and online transgender communities to know what cultural
trends are impacting clients.
Conclusions
In presenting this ecological framework, we have provided
discussion of some of the research findings for inclusive
work as a family therapist. This was in the interest of identi-
fying implications for inclusive clinical work with transgen-
der clients and distilling these findings into a collection of
concrete suggestions for those wanting to work more inclu-
sively. While we include as much as possible in this article,
we are working with a limited scope and our discussions
of each system is not comprehensive. Instead we consider
these implications to be starting points for further investiga-
tion and study. Readers will want to find the many resources
we have collected here, but also continue accessing current
scholarship and advocacy resources for a robust understand-
ing of the many things described here.
Compliance with Ethical Standards 
Conflict of interest  The authors declare that they have no conflict of
interest and there are no funding sources to note for this project. We
did not seek approval from the Institutional Review Board of our uni-
versity because we did not collect human subject data for this project.
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