Developing Parenting Guidelines to Support Transgender and Gender Diverse Children’s Well-being

Experts from the United States, United Kingdom, Australia, and Canada were invited to participate in 1 of 3 expert panels (see Table 1 for sociodemographic characteristics). Potential participants were identified from (1) a systematic review of English-language scientific literature and recent scientific presentations to identify known clinical and/or academic leaders in the field, and (2) a systematic search of the gray literature to identify key opinion leaders with parent or caregiver and/or TGD lived expertise and advocacy organizations. Recruitment efforts aimed to capture the diversity of perspectives represented in the scientific and gray literature regarding the development and health of TGD youth. Potential participants were recruited via e-mail. Based on prior Delphi recommendations, we aimed to recruit 30 participants per panel to yield stable results while allowing for attrition across survey rounds; studies have found as few as 23 panelists can provide reliable decision-making.^33–35  The parent and caregiver panel (n = 61) included parents and caregivers of TGD children with ≥1 year of experience as a parent advocate. The TGD panel (n = 32) included TGD adults with ≥1 year of experience as a community advocate. The academic and clinical panel (n = 28) included experts with ≥5 years of experience as a mental health or medical professional and/or researcher specializing in TGD health. Participants who met the criteria for more than 1 panel (n = 20; eg, TGD and academic and clinical) chose which panel they would participate in. See Appendix 1 for additional information about recruitment and the Delphi method.

Between February and April 2018, we conducted a systematic search of online gray literature to replicate the resources parents and caregivers might encounter when searching online for guidance. Key search terms (eg, “parent(s) trans* child,” “gender confused child,” and “my kid trans”) were entered into Google search in the United States, United Kingdom, Australia, and Canada using incognito mode, clearing cookies, and adjusting for country location. The 4 English-speaking countries were selected because they have similar health and support systems for TGD youth.

The search aimed to collect statements to present to the panels for rating. Statements were extracted from the web source if they offered parenting advice or strategies. All statements were included from each source, regardless of the authors’ opinions on parenting strategies. The search generated ∼1600 statements that were used to develop the round 1 survey.

The next stage aimed to distinguish among novel ideas and draft clear statements to be rated in the survey. A working group of authors (N.P.J., S.K.W., A.G., and L.H.) with experience in TGD health research and Delphi methodology used a focus group format to distill the statements into 813 survey items with each containing 1 parenting strategy.^{28,29,36–39}  The research team reviewed items for wording, style, punctuation, structure, and content until consensus was reached. Each item was formatted into a statement of advice: “parents should be aware…” (knowledge items) or “parents should…” (directives). Original wording was retained when possible. The final survey contained a wide range of topics (from foundational concepts to family dynamics to navigating life outside the family), representing a comprehensive scope of advice for parents and caregivers of TGD children.

The Boston Children’s Hospital Institutional Review Board approved the study procedures. Guided by the Delphi method, statements were presented to panels in 3 online survey rounds (Fig 1). Panels rated each statement on a 5-point Likert scale indicating importance to include in guidelines for parents and caregivers of TGD children (essential, important, don’t know or depends, unimportant, should not be included – is harmful). After participants completed ratings, each statement was categorized as:

1. Endorsed: If ≥80% of all 3 panels rated a statement as essential or important it was included in the final guidelines.

2. Rerate: If 70% to 79% of all 3 panels rated a statement as essential or important, it was rerated in the next survey round.

3. Excluded: Any statements that received <70% of ratings as essential or important were not rerated or included in the final guidelines.

In round 1, participants were invited to provide feedback to improve wording or express new ideas, which led to 13 new statements added to round 2. After round 1 statements were rated and tabulated, a summary document was sent to participants reporting which statements were endorsed or would be rerated. In round 2, panels completed a second rating of the “rerate” statements and first rating of new statements. If a statement was rerated in round 2 and again failed to reach ≥80% endorsement as essential or important, the statement was excluded from the guidelines. Only new statements created for round 2 were eligible for rerating in round 3 if they achieved the rerate criteria above. After round 1, it was determined that although the academic and clinical and TGD panels were relatively aligned in their ratings, the parent and caregiver panel was more heterogeneous with fewer consensus items, indicating a range of perspectives that merited separate attention. Thus, for the remaining 2 survey rounds, the academic and clinical and TGD panels completed 1 set of reratings based on their round 1 survey results, whereas the parent and caregiver panel completed a different set of reratings based on their round 1 results. This process resulted in a set of items defined as “partially endorsed,” which achieved consensus among the academic and clinical and TGD panels but not the parent and caregiver panel (Fig 2).

Following the Delphi procedure,^28,29,36,37  the outcome of the 3 survey rounds was an expert consensus-based guidelines document. The centerpiece of the guidelines were the items that all 3 panels achieved consensus on, complemented by additional sections with partially endorsed statements (ie, the academic and clinical and TGD panels achieved consensus, but the parent panel did not). The authors drafted the endorsed statements into prose and organized the guidelines into sections based on content. The guidelines were sent to panels for their feedback, which was incorporated into the final guidelines document.

The systematic search identified a wide range of web-based publications with strategies for addressing gender identity development and gender nonconformity in children. The major sources of information were websites, articles, blog posts, and personal essays by and/or for parents and caregivers of children who were TGD, gender nonconforming, or questioning their gender identity. A minority of sources were written by TGD adults. Some were sites specific to parents of TGD children, whereas others were sources for general parenting knowledge. Aside from a few official sources (eg, American Psychological Association), most websites were based on a mixture of opinion and lived and/or clinical experience. When websites mentioned research evidence, the citation was rarely included.

From 826 total statements, 115 (14%) were ≥80% endorsed by all 3 panels and included in the final guidelines (Appendix 2, Supplemental Table 5). A selection of fully endorsed statements is presented in Table 2. Major themes are discussed below. The relatively low level of endorsement is unusual; Delphi studies typically report a 40% endorsement rate.^28,29  Because of this, we conducted a subanalysis of statements endorsed only by academic and clinical, and TGD panels who were more aligned in their ratings than the parent and caregiver panel.

Items with a strong pattern of agreement among the academic and clinical and TGD panels (ie, rated as either essential or important by ≥80%) but less agreement among the parent and caregiver panel (ie, ratings of <80%) were defined as “partially endorsed” in the final guidelines (Table 3). Below, we discuss parent and caregiver ratings, as these offer insight into current areas of tension and debate regarding best practices for parents and caregivers of TGD children.

Overall, 711 (86%) of the 826 statements were not included in the final guidelines as they did not achieve consensus (≥80% endorsement as essential or important) over the 3 rounds. Among these, some statements were strongly rejected by the panel members (ie, rated as either unimportant or should not be included – is harmful). These items reflect agreement across the 3 panels about parenting strategies not considered appropriate for the guidelines document. Of these rejected statements, several suggested parents and caregivers should restrict a TGD child’s activities or behaviors (eg, not allow their child to socialize with TGD people or read autobiographies of adult TGD people). Other statements implied that supporting a child’s gender identity would harm the child (eg, “Parents should be aware that allowing children to believe that gender is fluid is psychologically dangerous”). Other statements explicitly referred to girls or women and boys or men and/or to heteronormative family structures (eg, “Parents should be aware that young girls and boys need both their mother and their father to show them what being a man or woman entails”). A selection of strongly rejected statements are presented in Table 4.

The final guidelines are publicly available for download and distribution here: www.genderandparenting.com. Based on the final endorsed items, the resulting guidelines included 2 main sections: (1) parenting strategies related to the development of gender identity and gender expression for all children; and (2) strategies for parents and caregivers of a child who identifies with a gender different from that assigned to them at birth. In this second section, endorsed items were grouped into 7 subsections: general guidance, supportive strategies (or “Dos”), parenting behaviors to avoid (“Don’ts”), common feelings for parents and caregivers, self-care for parents and caregivers, family dynamics, and navigating institutions as parents and caregivers (health care systems, schools, and advocacy). Partially endorsed items were included in 4 of these sections: dos, don’ts, family dynamics, and navigating institutions.

This study used the Delphi method to develop guidelines for parents and caregivers to support the mental health and well-being of TGD prepubertal children. The panels reached consensus on a wide range of topics related to supporting TGD children. Statements endorsed by all 3 panels offered strategies for parents and caregivers to talk openly with their child about gender identity and expression, as well as strategies for supporting a TGD child and their siblings, parent and caregiver self-care, and navigating health care systems, schools, and parent and caregiver advocacy. Rejected statements included suggestions that parents and caregivers restrict the activities or behaviors of their TGD child, statements claiming harm would be caused by a parent and caregiver supporting their child’s gender, and statements that described gender as binary (girl versus boy) and/or included heteronormative assumptions about family structures (mother and father).

Although the 3 panels agreed on numerous topics related to supporting TGD children, there was some disagreement. The academic and clinical, and TGD panels were generally more aligned in their assessment of the statements, whereas the parent and caregiver panel was more heterogeneous. Key areas of disagreement related to misgendering (eg, using a child’s birth name [“dead name”] or pronouns that do not affirm a child’s gender identity⁴⁰ ) and “conversion therapy,” which purports to change a child’s gender identity and has been widely discredited.^41,42  The academic and clinical and TGD panels tended to support recommendations that parents and caregivers never misgender their child or access conversion therapy, whereas the parent and caregiver panel did not feel that such statements should be included in the guidelines. Many topics reflect tension in societal discourse about how best to parent TGD children, with some parents and caregivers and experts believing TGD children should be affirmed in their gender identity and others believing the best way to support children is to help them become comfortable living as their assigned gender.⁴³  Notably, the academic and clinical and TGD panels who represent those with clinical and/or research experience and/or TGD lived experience, tended to endorse statements representing a gender affirmative approach. This aligns with prior research of TGD adults reflecting on their childhood needs,⁴⁴  as well as research demonstrating a strong link between using a gender affirmative approach and TGD children’s mental health and well-being.^26,30 

A strength of the Delphi method is that it facilitates consensus-building based on independent ratings across multiple areas of expertise, including both professional and lived experience expertise; this is valuable when trying to identify common goals across diverse stakeholders invested in a nuanced topic such as the subject of the current study. However, this study had a number of limitations. First, across panelists, participants were 55% cisgender women, 12% cisgender men, and 33% TGD; 83% White race and ethnicity; and 91% United States-based. This panel composition may make the guidelines less reflective of the perspectives of participants of color and those from the other 3 countries in the study. In addition, we did not collect information from panelists about their political views or views on gender affirmative approaches to TGD children’s health or parenting. Future research should explore how best practices for parenting TGD children may vary depending on sociocultural contexts. Second, community, medical, and legal perspectives on how to best support TGD children are rapidly evolving. Thus, terminology commonly used when this study began in 2018 (eg, “gender nonconforming”) is less common today. To address this, the guidelines are transparent about the distinction between the language used on the original Delphi survey (based on original source material) and more contemporary terms.

Although these guidelines are publicly available online for parents and caregivers of TGD children, they may also be useful in pediatric clinical settings. In the past decade, the number of TGD children presenting in these settings has increased,^45,46  yet most pediatricians are not prepared to treat prepubertal TGD children, in part because existing best practice guidelines focus on medical gender affirmation for TGD youth who have already begun puberty.⁴⁷  In addition, few scientific resources exist to support parents and caregivers of TGD children.¹⁵  Pediatricians can use these guidelines to support parents and caregivers who are seeking care for their prepubertal children who may be too young to undergo gender affirming medical treatment.

Guidelines for parents and caregivers to support the mental health and well-being of TGD prepubertal children were developed based on consensus of 3 expert panels. These guidelines provide information on a range of topics to support TGD children and create an invaluable and timely resource for both parents and caregivers and pediatricians working with TGD children and their families. These guidelines also provide a basis for potential interventions to support parents and caregivers in affirming their TGD children.

We thank the experts who participated in developing these guidelines.

TGD

transgender and gender diverse