Gender identity services must better integrate members of transgender People's social networks in care

Across countries, demand for gender-affirming care is rising at unprecedented rates.1Coleman E. Radix A.E. Bouman W.P. et al.Standards of care for the health of transgender and gender diverse people, version 8.Int J Transgender Health. 2022; 23: S1-S259https://doi.org/10.1080/26895269.2022.2100644Crossref PubMed Scopus (260) Google Scholar Services are struggling to adapt and some are failing to protect transgender health in fundamental ways. Given the complexity of this situation, both medically and politically, it is perhaps unsurprising that gender identity services have neglected to expand beyond addressing individual needs of transgender people themselves to integrate members of transgender people's social networks throughout care. Relational partners (e.g., parents, romantic partners, friends) play a key role in transgender health and, despite facing many difficulties and hurdles themselves, are not currently offered adequate support in most healthcare systems around the world (see Table 1).Table 1Factors relevant to integrating relational partners of transgender people in gender-affirming care.Why Do Relational Partners Matter for Healthcare?Why Might Relational Partners Struggle?What Systemic Hurdles Stand in the Way of Integrating Relational Partners?What Can Be Done to Better Support Relational Partners?Social supportInterpersonal factors in suicidalityFamilial rejection and homelessnessParental authority over transition“Spousal veto”TransphobiaLack of knowledge/own supportCourtesy stigma and blameLoss and mourningQuestioning own sexual orientation/identityFew services explicitly for relational partnersAd hoc and run with volunteers/donationsPoor signposting from clinicsDiscriminatory public policy (e.g., reporting for “safeguarding”)Strengthen international recommendations with best practiceDevelop clinical models integrating relational partnersUtilize established theoriesProvide resources and signposting for existing services Open table in a new tab There are a number of ways in which members of transgender people's social networks matter for outcomes of gender-affirming care, including by providing emotional and informational social support with medical, legal and personal issues.2Budge S.L. Adelson J.L. Howard K.A.S. Anxiety and depression in transgender individuals: the roles of transition status, loss, social support, and coping.J Consult Clin Psychol. 2013; 81: 545-557https://doi.org/10.1037/a0031774Crossref PubMed Scopus (445) Google Scholar In contrast, social strain and rejection can lead to negative outcomes, such as homelessness3Shelton J. Bond L. “It just never worked out”: how transgender and gender expansive youth understand their pathways into homelessness.Fam Soc. 2017; 98: 284-291https://doi.org/10.1606/1044-3894.2017.98.33Crossref Scopus (38) Google Scholar and risk for suicide, with transgender people being approximately twice as likely to attempt suicide compared to the general population.4Testa R.J. Michaels M.S. Bliss W. Rogers M.L. Balsam K.F. Joiner T. Suicidal ideation in transgender people: gender minority stress and interpersonal theory factors.J Abnorm Psychol. 2017; 126: 125-136https://doi.org/10.1037/abn0000234Crossref PubMed Scopus (252) Google Scholar Relational partners can also play direct roles in the care that transgender people are able to receive. In the United Kingdom, spouses of transgender people can enact what is colloquially referred to as a “spousal veto,” meaning that they can decide whether or not their partners are legally allowed to change gender. For transgender children and youth, parents exercise authority over social and medical transition, determining what steps they are permitted to take and when. While some members of transgender people's social networks might struggle because they are overtly transphobic, even the most well-intentioned relational partners are likely to face obstacles. Relational partners report that they sometimes do not know how to respond when their loved ones are experiencing severe gender dysphoria; relational partners are expected to provide support but often they feel that there is no one supporting them in turn.5Lewis T.O.G. Barreto M. Doyle D.M. Stigma, identity and support in social relationships of transgender people throughout transition: a qualitative analysis of multiple perspectives.J Soc Issues. 2022; https://doi.org/10.1111/josi.12521Crossref Scopus (6) Google Scholar For romantic partners, gender transition can lead to questioning of one's own sexual orientation and identity, which can be a transformative but difficult process,5Lewis T.O.G. Barreto M. Doyle D.M. Stigma, identity and support in social relationships of transgender people throughout transition: a qualitative analysis of multiple perspectives.J Soc Issues. 2022; https://doi.org/10.1111/josi.12521Crossref Scopus (6) Google Scholar sometimes even leading to divorce and family splits.6Dierckx M. Motmans J. Mortelmans D. T’sjoen G. Families in transition: a literature review.Int Rev Psychiatr. 2016; 28: 36-43https://doi.org/10.3109/09540261.2015.1102716Crossref PubMed Scopus (60) Google Scholar Furthermore, parents of transgender children sometimes question their own role in their child's development, facing courtesy stigma from those who “blame” them for their child's transition6Dierckx M. Motmans J. Mortelmans D. T’sjoen G. Families in transition: a literature review.Int Rev Psychiatr. 2016; 28: 36-43https://doi.org/10.3109/09540261.2015.1102716Crossref PubMed Scopus (60) Google Scholar and in many cases, even after accepting a new gender identity, friends and family experience a sense of loss and mourning.6Dierckx M. Motmans J. Mortelmans D. T’sjoen G. Families in transition: a literature review.Int Rev Psychiatr. 2016; 28: 36-43https://doi.org/10.3109/09540261.2015.1102716Crossref PubMed Scopus (60) Google Scholar,7Lewis T. Doyle D.M. Barreto M. Jackson D. Social relationship experiences of transgender people and their relational partners: a meta-synthesis.Soc Sci Med. 2021; 282114143https://doi.org/10.1016/j.socscimed.2021.114143Crossref PubMed Scopus (9) Google Scholar In countries such as the United Kingdom and the Netherlands where services for relational partners do exist, these tend to be support groups or charities run on an ad hoc basis by volunteers that rely upon donations. Signposting to such services through formal clinics tends to be poor—in the United Kingdom, none of the gender identity clinics actively refer relational partners to such groups and only one displays publicity material in the clinic. Worryingly, public policy recently debated and enacted in places such as the United States (e.g., in Texas) threatens to investigate families of transgender children for “abuse” when they seek gender-affirming care.8Kraschel K.L. Chen A. Turban J.L. Cohen I.G. Legislation restricting gender-affirming care for transgender youth: politics eclipse healthcare.Cell Rep Med. 2022; 8100719https://doi.org/10.1016/j.xcrm.2022.100719Summary Full Text Full Text PDF Scopus (13) Google Scholar Such discriminatory policy not only adds to courtesy stigma faced by well-intentioned members of transgender people's social networks, it also risks enforced social disruption by dividing families and communities. In order to better support members of transgender people's social networks, services must fully integrate relational partners throughout the care process. The World Professional Association of Transgender Health explicitly calls for involvement of relational partners in healthcare, including for child and youth assessment as well as adult sexual and mental health, in its Standards of Care.1Coleman E. Radix A.E. Bouman W.P. et al.Standards of care for the health of transgender and gender diverse people, version 8.Int J Transgender Health. 2022; 23: S1-S259https://doi.org/10.1080/26895269.2022.2100644Crossref PubMed Scopus (260) Google Scholar Such international recommendations should be strengthened and complemented by new guidelines for best practice. Healthcare providers should develop models of clinical pathways integrating relational partners (not only parents and romantic partners, but also wider family and friendship networks). Researchers should draw upon established theories, such as family systems theories,9Garris B.R. Weber A.J. Relationships influence health: family theory in health-care research: relationships influence health.J Fam Theory Rev. 2018; 10: 712-734https://doi.org/10.1111/jftr.12294Crossref Scopus (12) Google Scholar to test programs and clinical approaches that may aid relational partners of transgender people. Existing services, such as Depend in the United Kingdom, (H)Erkenning in the Netherlands and LISTAG in Turkey, should be provided ongoing resources and funding and be clearly signposted in their respective healthcare systems, ideally from the point of referral to gender-affirming care, rather than at entry, as waitlists currently extend for months or even years. Proper healthcare for transgender people involves attending to not only their physical and mental health, but their social health as well,10Doyle D.M. Link B.G. On social health: conceptualization, correlates and patterning.PsyArXiv. 2022; https://doi.org/10.31234/osf.io/m2ypwCrossref Google Scholar necessitating integration of relational partners throughout care. Ensuring strong and supportive social relationships is a matter of health equity for transgender patients. DMD is the sole author and conceptualized, wrote, reviewed and edited the commentary. The author declares no conflict of interests relating to the commentary. The author wishes to thank members of Depend as well as Manuela Barreto, Koray Başar, Debby Jackson and Baudewijntje Kreukels for their generous discussions of this topic. Problems with the call to “fully integrate” relational partners into the care of people identifying as transgenderDavid Doyle calls for gender identity services to “fully integrate relational partners [of people identifying as transgender] throughout the care process,” and claims this should include “not only parents and romantic partners, but also wider family and friendship networks.”1 In doing so the author fails to answer two important questions. Full-Text PDF Open AccessSummarizing evidence for the need, efficacy and value of integrating members of transgender people's social networks in careIn response to a call for gender identity services worldwide to better integrate members of transgender people's social networks in care,1 it was asserted that two relevant questions have not yet been addressed: 1) What is the evidence base for integrating relational partners in care? and 2) How should cost considerations be evaluated? In the following sections, these two questions are addressed in turn. Full-Text PDF Open Access