Archives > Volume 22 (2025) > Issue 1 > Item 04
DOI: 10.55521/10-022-104
Allan Barsky, JD, MSW, PhD
Florida Atlantic University
This text may be freely shared among individuals, but it may not be republished in any medium without express written consent from the authors and advance notification of IFSW.
Abstract
When transgender youth come out to their parents, they often encounter conflicts regarding whether, when, and how the youth may socially transition. Family conflicts may be particularly challenging when parents feel confused, troubled, or scared about their child being transgender. This article explores ethical issues that may arise when social workers are helping families to manage these conflicts and determine the best course of action. Through a detailed case study, this article illustrates how social workers can apply the ethical principles of primary commitment, respect, integrity, informed consent, assent, confidentiality, beneficence, nonmaleficence, human relationships, and social justice to guide their interactions and effectively support each individual and the family as a whole.
Keywords:
transgender youth, ethics, social transition, gender identity, family therapy
Introduction
Adolescence represents a crucial period of transition from childhood to adulthood, marked by many physical and psychological changes including identity formation and other developmental tasks (Coleman et al., 2022). Given that transgender youth experience a gender identity differing from their sex assigned at birth, the process of identity development may be particularly challenging (Pullen Sansfaçonet al., 2020). Just when they are at a time of major transition, transgender youth may encounter negative attitudes and treatment from family members, peers, teachers, health professionals, and others in their social environments. Positive parental support facilitates healthy development of gender identity and expression, whereas transphobia, rejection, and disapproval from parents may lead to mental health concerns such as depression, internalized transphobia, suicide attempts, and high levels of emotional distress (Katiala et al., 2023; Magalhães et al., 2020; Tyler et al., 2022). Although not all families with transgender youth require social work assistance, social workers can play a key role in helping parents and families provide transgender youth with support to promote healthy psychosocial development. This article explores ethical issues that may arise when social workers are working with transgender youth and parents who are experiencing conflict over the youth’s gender identify and expression, including decisions about social transitions. In particular, this article explores how social workers may navigate the ethical principles of primary commitment, respect, integrity, informed consent, assent, confidentiality, beneficence, nonmaleficence, and human relationships when transgender youth want to pursue particular transitions with resistance from their parents.
This article will first define terms that are essential to the subsequent analysis. The second section examines healthy development for youth identifying as transgender. Subsequently, the author describes ethical principles relevant to social workers helping transgender youth and parents as they navigate conflicts over gender identity, expression, and social transitions. A case study in the fourth section illustrates how specific ethical principles and standards can guide a social worker’s decision-making processes. Finally, there is a summary of key strategies for applying the aforementioned ethical principles effectively in the context of supporting transgender youth and their parents through specific challenges.
Terminology
For the purposes of this article, youth refers to individuals between 10 and 17 years old. The reason for selecting this age range is to limit the discussion to minors (youth under 18 years old), while also focusing on individuals who are nearing puberty, going through puberty, or have recently gone through puberty. Youth within this age range can clearly express their wishes and concerns, although they have not reached the age of majority in terms of being able to provide informed consent for medical procedures. The age of consent to work with social workers and other mental health professionals varies from state-to-state and country-to-country; it also depends on the agency and type of social work assistance under consideration (Barsky, 2023; Noroozi et al., 2018). Consent refers to legally-recognized permission to provide services, which may be affected by a person’s age and their mental capacity to understand service options and the potential benefits and risks of each option. Assent refers to permission for services by a person who is not legally authorized to provide consent (Barsky, 2023). For surgery with a minor, for instance, medical providers may ask parents to provide consent and the child to provide assent. Although assent may not be legally required, it shows respect for the dignity and worth of the child (Cavanaugh & Hopwood, 2016).
In general, parents are legally authorized to provide consent on behalf of their minor children. Sometimes, children are in the care of other people, including grandparents, foster parents, or other caretakers. To simplify the discussion below, the term parents will be used below to refer to any caretaker legally authorized to provide consent on behalf of their child. When a child is in the care of a person who is not legally authorized to provide consent, it may be prudent practice to consult with this person for feedback and support, subject to permission of the person(s) who are legally authorized to provide consent. For instance, if a youth is in foster care, the foster parents may have legal decision-making power, but it may be helpful to consult them about the youth’s wishes, concerns, and interests.
Gender identity is a social construct referring to an individual’s internal sense of their gender as male, female, a combination of both, or neither (Bhatt et al., 2022). For the purposes of this article, transgender is an umbrella term for any individual whose gender identity is different from the social expectations associated with their sex assigned at birth (Colman et al., 2022). According to this definition, transgender includes individuals who identify as gender diverse, gender nonbinary, genderfluid, gender nonconforming, two-spirit, or gender queer (Bhatt et al., 2022). Gender questioning refers to an individual in the process of discovering their gender identity. The individual may be uncertain about their gender identity or have a tentative sense of it (PFLAG, n.d.). Gender expression refers to the manners in which a person conveys their gender in relation to clothes, hairstyle, pronoun use, voice, body language, and other means (PFLAG, n.d.).
Gender-affirming care (GAC) may be defined as any form of medical, social, psychological, behavioral, voice and communication, or financial assistance or care that respects and supports a client’s gender identity and expression (Bhatt et al., 2022; Coleman et al., 2022). Gender-affirming medical care (GAMC) refers specifically to medical treatments such as puberty blockers, hormone treatments, and surgeries supporting the client’s gender identity and expression. Some states have laws prohibiting specific of forms gender-affirming medical care for minors (Human Rights Campaign, 2024). In June 2025, the U.S. Supreme Court upheld Tennessee’s ban on gender-affirming care for minors (U.S. v. Skrmetti). This precedent may support similar bans in other states. While the majority held states can restrict procedures they deem risky, the dissent argued such bans violate constitutional equal rights protections.
Transitioning is a process by which a person makes changes to affirm their gender identity (PFLAG, n.d.). Social transitioning includes changes in hairstyle, clothing, legal documentation, voice, and other forms of gender expression. Social transitioning provides transgender youth with opportunities to live full-time or part-time in their identified gender (Hughto et al, 2022). Medical transitioning includes hormone blockers, hormone treatments, and surgeries (e.g., mastectomies, gonadectomies, facial feminization surgery, chest reconstruction). Although some transgender individuals desire or choose particular types of social and, or medical transitions, these choice are very individualized (Coleman et al., 2022). These choices may be affected by a range of family, cultural, religious, financial, and personal considerations. In terms of social transitions, for instance, some transgender people may choose to be open about their gender identity in some situations but not in others (e.g., at home, school, or work).
This article focuses on the roles of social workers in assisting transgender youth and family members with decisions about social transitions. Social workers often work collaboratively with physicians, nurses, psychologists, educators, attorneys, and other helping professionals. While this article focuses on social work ethics, it is important for social workers to consider the ethical responsibilities of their co-professionals when jointly serving transgender youth and their families (Barsky, 2023; Tyler et al., 2022). As the principles of relational ethics suggest, clinical decision making should consider the interpersonal context of the clients’ situation, including relationships between family members, as well as relationships between various helping professionals and the family (Pollard, 2015).
Healthy Gender Identify Development
Children start developing a sense of their gender in early childhood, with most forming a relatively stable sense of their gender identity between ages 3 and 5 (American Psychological Association [APA], 2016). Gender is not necessarily a fixed trait, as it may be subject to fluctuation. Accordingly, gender exploration and fluctuation may be facets of healthy social development (Bhatt et al., 2022) Although the majority of children identify as male or female, gender is a nonbinary construct. As noted earlier, some people identify as gender fluid, gender expansive, or gender diverse. A range of gender identities is both healthy and normative. Being transgender, gender nonbinary, or gender questioning is not a mental illness (Abreu et al, 2022b).
Family cohesion and parental support are vital for healthy development of transgender children, including their gender identity formation and overall psychosocial wellbeing (Kaltiala et al., 2023; Tyler et al., 2022). According to the minority stress model, transgender youth face elevated stress levels due to institutionalized discrimination, individual prejudice, anti-trans violence, bullying, and rejection. These experiences may lead to mental health concerns such as anxiety, depression, suicidality, substance use disorder, and post-traumatic stress disorder (Bhatt et al., 2022; Magalhães et al., 2020). Positive support for a transgender child’s gender identity serves as a protective factor against these stressors. Supportive parents contribute to a positive home environment; they also foster affirming community environments by selecting and nurturing supportive extended family, school, peer groups, healthcare providers, and other community systems (Bhatt et al., 2022). Conversely, adverse parental reactions to their child’s gender nonconformity can increase the risk of psychological problems (Kaltilala et al, 2023). When parents reject their child’s gender identity, the child may feel compelled to conceal their true gender identity, leading to higher rates of depression, substance use disorders, and depression (Magalhães et al., 2020). Experiences of transphobia and discrimination may also lead to social concerns such as isolation, academic difficulties, and withdrawal from school.
When parents discover that their child might be transgender, they may experience a range of emotions including surprise, denial, fear, hesitation, concern, anxiety, confusion, and anger (Abreu et al., 2022a). Some parents reject their transgender child due to misunderstandings, misinformation, or fear of social stigma. Other parents may envision the worst-case scenarios about what it means for their child to be transgender (Tyler et al., 2022). They may experience a child’s coming out about their gender as a threat to their cultural or religious belief systems (Reczek & Smith, 2021). Additionally, they might struggle with a sense of loss because they expected their child to grow up with a particular gender identity. McGuire et al. (2016) refer to this dynamic as “ambiguous loss” given the unclear nature of the loss: the transgender child is not physically leaving, but the parents experience a psychological loss. The parents may need time to adjust to the new reality and future for their child. Emotional support and education may help alleviate parental concerns (Abreu et al., 2022b; Tyler et al., 2022). Each parent may be at different stages of support or opposition regarding their child’s gender identity (Abreu et al., 2022a). Examples of positive parental support for a transgender youth include demonstration of love and acceptance, advocacy for their rights in education and health care, and accepting how the entire family system is affected by having a transgender child (Abreu et al., 2022a).[1]
Parental support for a transgender youth may or may not include support for particular forms of social or medical transitions while the youth is a minor. Some youths benefit from support for specific types of transitions which can help them express their authentic selves and reduce their levels of depression and anxiety (Magalhães et al., 2020). Decisions about transitions should consider the unique circumstances of each transgender youth and their family (Coleman et al., 2022). Most major national medical and mental health associations in the United States endorse accessibility to affirmative healthcare for transgender youth (APA, 2024; GLAAD, 2024; National Association of Social Workers [NASW], 2023). Research suggests that various gender-affirmation procedures are associated with improvements in psychological and social wellbeing (Hughto et al., 2020). While research on the long-term effects of affirmative medical care is limited (Cass, 2024), hormone blockers and hormone treatments may alleviate symptoms associated with gender dysmorphia or gender incongruence, including depression and suicidality (Bhatt et al., 2022; Tordoff et al., 2022). Hormone blockers may provide transgender youth with time to explore their gender identity without the pressure from experiencing pubertal changes such as breast development, facial hair growth, and development of other secondary sexual characteristics. Delaying puberty may improve mental health in the short-term (Turban et al., 2020). Hormone blockers and hormone therapies may support long-term wellbeing by allowing transgender youth to align their physical appearance more closely with their gender identity (Coleman et al., 2022). Risks of hormone blockers and hormone therapies include cardiovascular issues (including blood clots), liver disorders, weight changes, fertility, menstrual changes, mood swings, and decreases in bone density (Coleman et al., 2022). Specific risks depend on the particular form of hormone therapy, adequacy of monitoring, and individual differences. A detailed discussion of these risks goes beyond the scope of this article. Although some youth may benefit from gender-affirming surgery, such surgery is relatively rare in minors (Bhatt et al., 2022; Doe v. Ladapo, 2024; Coleman et al., 2022). Although some forms of gender-affirming surgery are irreversible (e.g., removal of gonads), others may be partially or fully reversible (e.g., facial feminization). Given the long-term implications of surgery, transgender youth will often transition socially while they are minors and wait until adulthood to consider surgery.
Ethical Principles
Social work’s core ethical principles emphasize respect for the dignity and worth of all people, support for human relationships, and acting in a trustworthy manner (NASW, 2021). When working with transgender youth and their parents, social workers are guided by these principles to demonstrate respect for both the youth and their parents, acknowledging and valuing their wishes, beliefs, and relationships. While social workers may have particular views about whether certain types of social transitions are best for a particular youth, the principles of client self-determination and integrity suggest that social workers should refrain from imposing their views on either the transgender youth or their parents (NASW, ss.1.02, 1.06). According to the ethics of informed consent, social workers should ensure that clients are well informed about their service options, including the nature, benefits, and risks of each choice (NASW, s.1.03(a)). Social workers should not act as gatekeepers for what types of interventions are available to clients, but rather, help clients make good decisions for themselves (Cavanaugh & Hopwood, 2016). Social workers should also ensure that they do not drift outside the scope of their practice in terms of giving advice on medical procedures. For clients lacking capacity to provide consent, social workers should obtain consent from an appropriate third party (NASW, s.1.03(c)). In the case of a minor, the appropriate third party is typically a parent or legal guardian. Although the NASW Code of Ethics does not require seeking assent from minor clients, Standard 1.03(c) stresses that “social workers should seek to ensure that the third party acts in a manner consistent with clients’ wishes and interests.” Ethical challenges may arise when the wishes of a transgender youth conflict from those of their parents.
Challenges and options
To examine the ethical challenges that may arise when parents and transgender youth have differing views about gender identity and social transitions, consider the following scenario:
Alba, a 12-year-old middle school student assigned female at birth, recently gathers the courage to tell her parents, “I have something important to discuss with you and I’d really like you to listen. I am transgender… I want to start using male pronouns and a different name.” Both parents react with shock and silence. After a moment, Alba’s mother, Daisy, responds, “I know a lot of kids at school are changing their pronouns, but it’s just a trend or a phase. You’re our daughter, and you’ll always be our daughter.” Alba’s father, Raoul adds, “This is confusing. We raised you as a girl and now you’re asking us to believe that you’re not a girl? I don’t know what we’re supposed to think or do.” Distraught, Alba runs to her room, shaking and in tears. Convinced that something is wrong with Alba, Daisy and Raoul arrange to take her to meet Shari, a social worker. During their first meeting, Daisy and Raoul ask Shari to help them convince Alba that she is, and will always be, a girl. Alba firmly states, “I’m male, and I always will be male. I was so afraid to tell me parents up until now, but I can’t keep hiding. I need to be true to myself and the people I love.”
The following sections delve into ethical challenges arising from this situation, including options for how social workers can use ethics to guide their responses. These examples are intended to illustrate potential ethics-based approaches, not to prescribe the only ethical responses that social workers may consider.
Primary ethical commitment
Social workers owe their primary ethical commitment to the clients they serve (NASW, s.1.01). This duty is based on the principle of fidelity, the notion of being faithful and committed to one’s ethical responsibilities within a professional relationship (Barsky, 2023). Although social workers also have obligations to their employers, their communities, their profession, and others, they understand that building and maintaining trust with clients means that they put their clients’ interests first.
When working with Alba and her parents, one of the first questions that Shari should consider is, “Who is my client?” If her client is Alba, then her primary ethical commitment is toward Alba. With respect to the conflict over gender identity and expression, one of Shari’s roles may be to advocate on Alba’s behalf. If Daisy and Raoul want someone to provide counseling, support, and advocacy on their behalf, Shari might refer them to another social worker or mental health professional. If her client is the parenting couple, Daisy and Raoul, then her primary commitment is to them. In the situation described above, it is unlikely that Daisy and Raoul are the only clients given that they brought Alba to see the social worker for help. A more likely situation is that Shari’s client is the entire family and her primary ethical commitment is to the family as a whole. Let’s continue the analysis based on the premise that the family is the client.
Respect for all family members
When working with families, social workers should avoid taking sides or become triangulated in the family’s internal conflict (Sudland, 2019). When family members have different wishes and interests, social workers may experience split loyalties. From an ethical perspective, the duty to respect everyone and their right to self-determination means that social workers should strive toward mutually acceptable treatment goals, not taking sides or pressuring certain family members to act in a particular manner. From a clinical perspective, social workers should avoid taking sides to maintain trust with the whole family (van der Meiden et al., 2016). If Shari simply sided with Alba and told the parents that they should allow Alba to socially transition, then they may terminate services, sensing that Shari is disregarding their views and wishes. Conversely, if Shari sides with the parents, Alba may lose trust in Shari.
So, if Shari is not supposed to take sides and the family has a significant conflict over whether to support Alba’s gender identity and expression, then what is Shari to do? A good place to start is engagement—the process of getting to know each family member and building trust. Shari can demonstrate empathy, respect, and genuineness with each family member without taking sides (Hepworth et al., 2023). The notion of multidirected partiality in family therapy suggests that the therapist can demonstrate empathy to one family member after another, demonstrating caring and concern for each person in turn, while maintaining a sense of reliability and confidence with the whole family (van der Meiden et al., 2017).
As Shari engages the whole family, she encourages everyone to elaborate on their concerns by showing that she is open, understanding, and respectful of each of their perspectives. “Thank you all for sharing your concerns. Let me ensure that I’m understanding everyone correctly. Daisy and Raoul, I understand that Alba recently came out to you about her gender identity. She is asking for your compassion and support. I also understand that this news was surprising to you. You see Alba as your daughter. You love Alba as you’ve always known her. You don’t want Alba to change. And Alba, you are expressing your need to be recognized as male and to live authentically, as your true self. Is that a fair summary or have I missed anything?”
Assume that Daisy and Raoul agree with your summary and then go back to their original question. “So, what can you do to convince Alba that she is a girl and always will be a girl?” Shari continues to show empathy and respect, while also being honest with them about her role. “I understand that you hope that I can convince Alba that she is a girl. However, my role as a social worker is to work with all of you, to find out what’s going on, to assess your concerns, and to help the whole family determine the best next steps. It may take several individual and family sessions to gain a better understanding of each of you and the family as a whole. I have experience with similar family situations, so I know how troubling and confusing it can be for parents when their child discloses that they are transgender. While I can offer various treatment options, we are early in the helping process. We need to gather more information before determining the best options for everyone.” Shari describes what it means to conduct a comprehensive psychosocial assessment, including an assessment of Alba’s gender identity, development, and desires, as well as the family’s relationships, strengths, and concerns (Taylor et al., 2024). Shari also discusses setting ground rules for respectful dialogue, helping the family establish guidelines such as listening to one another for the purpose of understanding, not interrupting, acknowledging valid differences of opinion, and using polite language.
Daisy, Raoul, and Alba may each benefit from the social worker’s support, so even though they are in the early stages of engagement and assessment, it may be helpful for Shari to meet individually with each of them. Meeting Daisy and Raoul without Alba allows them to discuss personal feelings that they may find too hard to express in front of Alba (Tyler et al., 2022). Likewise, Alba may be able to discuss issues with Shari that she may not be ready to discuss with her parents. Separate meetings allow Shari to give individualized support while minimizing the risk of escalating the family conflict or being perceived as biased when providing empathy and help to each family member. Shari might provide Alba with resources such as self-help groups or other sources of support. If Daisy and Raoul discontinue services, at least Alba will know where she can access other assistance. Shari might provide Daisy and Raoul with information about how parents can support transgender or gender-questioning youths; however, it may be too early to offer such information. In addition, Daisy and Raoul may be in different places regarding reactions to Alba’s disclosure (Olson et al., 2020). Daisy seems to reject the notion of transgender altogether, whereas Raoul said he is confused. He might be more open to learning about gender identity and expression. In addition to offering individual forms of support, separate meetings also allow Shari to assess for urgent concerns such as suicidal ideation, high levels of distress, bullying, and child abuse or neglect.
Honesty and integrity
Daisy and Raoul persist in questioning Shari about her views on gender identity and expression, particularly asking if she can convince Alba that she is a girl. They inquire about Shari’s opinion on conversion therapy, an intervention for transgender children that they discovered online. Although Shari is not supposed to impose her beliefs on clients, her ethical commitment to integrity instructs her to be honest (Barsky, 2023; NASW, 2021). Shari informs Raoul and Daisy, “The stated purpose of conversion therapy for transgender youths is to change their gender identity from transgender to cisgender—essentially, to convert Alba to identify as a cisgender girl. My professional association and the associations of other mental health professions have found that conversion therapy is not only ineffective, but also harmful to the youth’s mental health. Research indicates conversion therapy increases risks such as depression, anxiety and suicidal thoughts. Research also suggests that transgender youth will benefit more from parental support and acceptance, rather than attempts to change their gender identity. In some states, licensed clinical social workers can be disciplined for recommending or providing conversion therapy.” Shari is open and honest about her knowledge and views of conversion therapy, including her sources of information.
Self-determination
Daisy, visibly upset, accuses Shari of siding with Alba. Shari responds, “My role is to help the entire family. I am sharing what I know from the research and from working with families facing similar concerns. Ultimately, you as a family will decide what is best for you. I respect your role as the experts in your own lives” (Cavanaugh & Hopwood, 2016). Shari reminds herself to start where each of her clients are. Applying the Transtheoretical Model of Change (Rollnick et al., 2022), Shari believes that Daisy is in the precontemplation stage while Raoul is in the contemplation stage in terms of the possibility of making changes to support Alba’s gender identity and expression. To help Daisy gain insight into Alba’s situation, she asks Daisy a scaling question: “On a scale of 1 to 10, how distressed would you say that Alba has been since she first discussed her gender with you?” Daisy responds, “Probably an 8 or a 9.” This response opens a dialogue about the urgency of addressing Alba’s high levels of distress. Shari does not expect her clients to commit to specific action at this stage. She respects their right to self-determination and honors the family’s need for more time to make specific decisions.
Informed consent
Raoul expresses that he might be able to accept that Alba is transgender if he were certain that it is truly her identity. He worries that it might just be a phase. “What if we help Alba make these transitions and she gets bullied at school—or worse! What if, after everything, she decides she’s not transgender after all? I don’t want her to go through that.” Shari reassures Raoul that providing Alba with acceptance and support does not mean that they have committed to any specific social transitions. She explains that they can provide Alba with support even if they are not entirely sure whether she is transgender or her gender identity might evolve over time. “Let’s imagine that Alba said she was nervous about an upcoming test at school and fears she might fail. Would you question whether she was nervous, or would you provide her with support? I’m not asking what kind of support that might be, just whether your uncertainty about her situation might stop you from providing some type of support.” Raoul concedes that he would, of course, support Alba. He loves her unconditionally. Still, he is unsure about what “providing support” would actually involve. Shari reassures Raoul about his right to informed consent. “I’m not asking you to agree to any specific course of action to support Alba—It’s too early for that. Before making any decisions, you need to know about all the available options, including the potential benefits and risks of each. Only then will you and the family be in a position to provide truly informed consent.” Shari provides Raoul and Daisy with a pamphlet with guidance on how to support a transgender or gender-questioning child. Daisy is intrigued by a particular sentence in the pamphlet explaining that parents should neither push their child to social transition nor coerce them not to transition (Olson et al., 2020).
Confidentiality
In a private meeting with Shari, Alba confides that she thinks she’s transgender, but isn’t 100% certain. Shari assures Alba that it is certainly okay to be unsure and that understanding one’s gender identity can take time. Alba admits that she is afraid to discuss her uncertainty with her parents, as they are already questioning the authenticity of her gender identity. Alba asks Shari not to tell her parents about her uncertainty. Shari agrees to keep her uncertainty confidential for now, but mentions that she will consult a trusted professional colleague to ensure that they are taking the best approach with the family. During consultation, Shari’s consultant reviews the family’s informed consent form, which outlines that information shared during individual meetings will be kept confidential unless the individual consents to share the information or if disclosure is necessary to prevent a serious risk of harm (e.g., child abuse or suicide). They discuss how disclosure may help the family gain a better understanding of Alba’s situation and how Raoul and Daisy may become upset if they later discover that Shari knew Alba was uncertain about her gender. After weighing these factors, they decide Shari should prioritize Alba’s confidentiality as everyone had agreed to confidentiality for individual meetings. Shari lets Alba know that it may be helpful to be open about her uncertainty with her parents, but that she understands and respects Alba’s decision to keep this information private for now. With Alba’s permission, Shari conducts a joint educational session with the whole family, explaining that gender identity development is an ongoing process in which a youth may have questions about their gender identity and that their identity may fluctuate over time. While Alba neither confirms nor denies that this description applies to her, she appreciates Shari for providing this information to her parents in a nonthreatening manner.
Beneficence and nonmaleficence
As summer approaches, Alba expresses her desire to begin transitioning during the summer so she can start the next academic year at a new school that would be more supportive of her gender identity. Shari helps Alba present this plan to her parents, encouraging them to listen with an open heart. She suggests discussing the pros and cons of various options before making any decisions. The process of weighing the benefits and risks of different choices fits with the principles of beneficence (do good) and nonmaleficence (do not harm).
As the family starts listing the pros and cons of different options, they disagree on many points. Shari shows respect for all their views, listing their hopes and concerns as they review each option. She offers them educational readings and engages them in discussions about what learned from the support groups they attended. When they discuss the option of “no changes, everything remains the same,” it becomes apparent that Alba’s distress levels might intensify, potentially affecting her ability to attend school and socialize with peers. When discussing the option of beginning Alba’s transition over the summer, Raoul expresses deep concerns about the potential for teasing and harassment. This leads to a discussion of a staged approach, identifying safer spaces where Alba can express her authentic gender identity. They agree to start by coming out to particular friends and family, and postpone decisions about school. Shari describes research findings that indicate how disclosing one’s transgender identity and experience in a supportive environment is linked to improved psychological wellbeing (Hughto et al, 2022). Daisy still questions the validity of Alba’s transgender identity, so she views the next few weeks as a trial period. Daisy and Raoul say they will try to use he/him/his pronouns for Alba, noting that won’t be easy for them. In accordance with this shift, the following discussion also uses he/him/his pronouns for Alba.
Alba voices concerns that his breasts are starting to develop, causing additional distress. Daisy and Raoul react with shock, thinking that Alba may be thinking of surgery. Shari introduces the family to the WPATH Standards of Care for the Health of Transgender and Gender Diverse People, SOC 8 (Coleman et al., 2022), which provides evidence-based guidance on providing health care and support (Taylor et al, 2024). Shari discusses options such as hormone blockers, hormone treatments, and surgery, noting that hormone treatments and surgery are not generally appropriate before a youth has begun the process of social transitioning. Shari notes that Alba may be at an age when hormone blockers could help him by delaying pubertal development. Shari clarifies that as a social worker she is not authorized to prescribe hormone blockers or offer medical advice. She offers a referral to a pediatric endocrinologist if they want further information or an initial assessment. Daisy and Raoul say that they are not ready to even think about hormone blockers at this stage. Shari explains that if they have questions about medical options in the future, she can refer them to a physician with specialized expertise in helping transgender individuals.
Consent and assent
If Alba wants to see an endocrinologist to obtain hormone blockers, his assent alone is insufficient; as a minor, he will need parental consent. Shari introduces the option of meeting with an endocrinologist, understanding that Daisy and Raoul are not yet prepared to entertain the idea. Alba then asks about other options, such as a chest binder to flatten his breasts (Taylor et al, 2024). Initially, Daisy vetoes this idea, citing safety concerns. Shari acknowledges the risks, including health issues such as breathing problems and broken ribs. She also informs them about safety measures that can reduce risks of harm.
Initially Daisy does not want to talk about safety measures because she forbids Alba from binding his breasts. Alba says he can do what he wants with his body because it’s his body. Technically, he may not need parental consent to start using a chest binder. He could obtain a binder and use it without his parents’ knowledge. Shari explains how it could be more constructive to discuss safe options rather than avoid any family discussion about binders. As part of this discussion, they explore alternatives such as sports bras and layered clothing. Shari encourages them to ask other parents and youth in their respective support groups about ways that they have navigated these issues, noting that different options may be suitable for different people.
Human relationships
Over time, the conflicts between Alba and his parents fluctuate, sometimes calming down and sometimes escalating. While Alba is pleased that his parents have acknowledged his gender identity, they still refuse to use his preferred name, August. They are also not allowing Alba to socially transition at a new school. Raoul expresses fear that if Alba is allowed to socially transition now, he’ll soon be requesting hormones and surgery. Shari notes that while some youth who socially transition will decide to undertake medical transitions later, this is not always the case (Hughto et al, 2022; Taylor et al, 2024). Each decision is separate and should be made at the right time and with complete information (Coleman et al., 2022).
Feeling frustrated, Alba says that maybe it would be best for him to run away and live on the streets, or call child protection services to report Daisy and Raoul for emotional abuse. Daisy says, “Maybe it is time for you to find a new place to stay.” Shari intervenes, engaging the family in a discussion of what might happen if this conflict escalates and Alba leaves home. She notes that many transgender youth end up in foster care or living on the streets. She cites research on how conflicts over gender identity and expression may lead to parent-child estrangement, homelessness, and poverty (Reczek & Smith, 2021). She also describes research emphasizing the value of positive family relationships: transgender youth with parental support are less likely to develop depression, substance abuse problems, and school challenges (Kaltiala et al., 2023; Magalhães et al., 2020). Alba presses Shari about whether the family should support his full social transition at school. Shari responds that this is a family decision; however, as a social worker, she does recognize the importance of family relationships and encourages everyone to do what they can to preserve these bonds. Raoul and Daisy say that they do not want Alba to run away and agree to at least discuss the next steps in his social transition. There may be no quick and easy fixes for families like Alba and his parents; however, social workers can help them maintain good relationships even when they are experiencing significant conflict.
Social justice
While this article focuses on conflicts within particular families, it is essential to situate these conflicts within a broader societal context. Laws, social policies, and community attitudes significantly shape the experiences of transgender youth and their families. When transgender youth are raised in environments that are supportive of their gender identities and expressions, it is much easier for them and their families to manage the challenges of social transitions. Conversely, exposure to transphobic and discriminatory laws, social policies, and attitudes correlates with increased rates of depression, anxiety, and risks of suicide among transgender youth (Abreu et al., 2022b; Barsky, 2024).
Since 2023, 25 U.S. states have proposed or enacted laws that ban access to gender-affirming medical care for minors (Human Rights Campaign, 2024). These bans include prohibitions against medically approved hormone blockers, hormone replacement therapies, and gender-affirming surgery. These laws have been enacted despite extensive research supporting the efficacy of GAMC in reducing gender incongruence and promoting positive psychosocial wellbeing (Coleman et al., 2022). False and demeaning political rhetoric and social media discourse have accompanied these bans, further stigmatizing transgender youth and their families (Abreu et al., 2022b). As proponents of social justice (International Federation of Social Workers, 2018), social workers have a critical role in challenging these injustices. This includes countering misinformation, raising public awareness, and advocating for policies that uphold the rights of transgender youth. These fundamental rights include being treated with dignity and respect, living free from harassment and discrimination, and the open access to gender-affirming psychological, social, and medical care. Social workers must champion these rights to ensure that transgender youth and their families receive the dignity, support, and protection they deserve.
Conclusion
When parents and transgender youth face conflicts related to gender identity, expression, and social transitions, there is no “one-size-fits-all” solution for how social workers should help them ethically navigate these issues. By applying the principles of respect and integrity, social workers can initially demonstrate empathy, unconditional positive regard, and genuineness to develop rapport with the whole family, without taking sides or imposing their views on what the family should do. Employing the principles of informed consent and human relationships, social workers may educate family members about the research on gender identity, expression, and transitions, including the importance of family support and the critical roles that parents can play in helping their children manage these challenging decisions and situations.
When facilitating informed consent for gender-affirming care, social workers should be able to help transgender youth and their parents understand the potential benefits and risks associated with various options, grounded in current, reliable research (Coleman et al., 2022). Social workers also need to understand that family decision making may be affected by religious and cultural beliefs, as well as the parents’ stage of acceptance regarding their child’s gender identity, gender expression, and thoughts about social transitioning. Social workers may need to provide families with time and supportive environments to process their concerns before they can make appropriate decisions. Numerous sources of information and support are available for both social workers and clients. Decisions about social transitions depend very much on individual and family circumstances. Accordingly, it may be beneficial to reach out to transgender support groups, peer mentors, gender-affirming health and mental health professionals, and clinical supervisors or consultants to gather information, explore options, and obtain support. For transgender youth and their parents dealing with concerns about gender identity and social transitions, social support may be key to their psychosocial wellbeing (Magalhães et al., 2020; Tyler et al., 2022). For social workers, accessing professional consultation and peer support may be essential to delivering effective, evidence-based services.
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Acknowledgment
Dr. Barsky would like to acknowledge the helpful review and suggestions from Dr. David Landsman-Wohsifer, a professor and social worker who provides therapy and support for transgender youth and their family members.
Correspondence
Please direct any correspondence about this article to abarsky@fau.edu.
[1] Parents may also experience relief, understanding, connection, and joy.