Book Review: A Review of Transgender Children and Youth: Cultivating Pride and Joy in Families in Transition

Elijah C. Nealy, Ph.D., M.Div., LCSW. (2017). New York, NY: Norton. ISBN 978-0-393-7139-4. 423 pages.
/ CFLE Network, Winter 2020

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This is an astoundingly complete and comprehensive look at transgender children and youth and their families, with loads of information on the genetic, medical, legal, social, and educational impacts for kids wanting to or who are in the process of transitioning. Nealy is an assistant professor in the Department of Social Work and Latino Community Practice at the University of Saint Joseph in West Hartford, Connecticut, and a clergy member at Metropolitan Community Church. He is an out transgender man who has spent more than 25 years working extensively with lesbian, gay, bisexual, transgender, and queer communities. He is internationally renowned for his work in these areas and works extensively with families and youth who are transgender.

The audience for this amazing book includes children and youth who are transitioning, families and parents of transgender kids, teachers, clinicians of all kinds (social workers, psychologists, school counselors, family therapists, mental health professionals, physicians, nurses), youth workers, and anyone in the general public working with children and adolescents. The general public wishing to learn more about transgendered children and youth would do well to read this book as well. Part 1 addresses the complex questions of the foundation for understanding transgender youth (basic terms and vocabulary, gender diversity and gender dysphoria, trans kids in therapy, when a young person comes out—disclosure and social transition, medical transition, and transgender adolescents). Part 2 looks at trans youth and the complex world around them (helping families; gaining a much deeper understanding of what is happening; discussions about school and beyond, coming out, living a life, preparing for college and work). Part 3 focuses on supporting trans youth (the mental health professional and the top 10 life-affirming practices for adults in the lives of trans kids). These book chapters are followed by heavy-weight and comprehensive appendices of legal issues, resources, and sample mental health letters (to counselors and mental health professionals; to the Department of Motor Vehicles to change one’s gender marker; for hormone blockers; for feminizing/masculizing hormone therapy; for gender-confirming surgeries), as well as references.

This is the kind of research and reference book I really appreciate—a glorious mixture of qualitative and quantitative research, something that alters the way I view and understand the world and that challenges me on many levels. This book also includes a lot of remarkable self-disclosure of Nealy’s lived experiences to help us better understand what transgender youth live through. The book also includes statistics and information on diverse ethnic and racial communities and transgender issues.

These kids (and adults) are at very high-risk for hostility; discrimination; denial of equal treatment; verbal, physical, and sexual harassment; assault and abuse; depression; anxiety; self-harm; sexually transmitted disease and HIV infection; suicide; job loss due to gender identity or expression; lack of family acceptance; expulsion from family; homelessness; drug and alcohol abuse; eating disorders of all kinds; poor school performance; school dropout; and many other negative outcomes. It can be almost impossible for these kids to find stable housing and stable school and work lives. Approximately 40% of transgender adults have attempted suicide (the national rate is 4.6%), and these rates are even higher for those who have lost jobs due to bias, been bullied at school, been homeless, or physically/sexually assaulted (see p. xvii). Mental health professionals, physicians, and nurses who want to help and talk productively to transgender patients would find this book beneficial for themselves and their trans patients.

The text is packed with verbatim quotes from trans kids and youth, as well as vignettes, case studies, qualitative and quantitative research, statistics and studies, resources, lists of questions for reflection (highlighted in gray boxes throughout the book), terms to use (or not use), and much more. Many in the general public who may never have considered these issues tend to think of sex, gender expression, gender identity, and sexual orientation as a rigid binary system of male and female. In fact, over my years as a health care researcher, I have come to recognize that there is a wide spectrum of possibilities, with many complex points along the spectrum from male to female. Further, a person’s orientation may not be fixed but may shift over time, depending on their experiences and deeper understanding of who they really are. In other words, biological sex is neither binary nor unambiguous (see p. 5). There are charts and graphs throughout the book, such as “Gender-Diverse Behavior and Expression Among Children” (p. 17). It is also helpful that Nealy has laid out the circuitous changes to the Diagnostic and Statistical Manual of Mental Disorders over time (p. 23ff.) Especially helpful for mental health workers and counselors are suggestions for language to use when interviewing parents of young children or adolescents (pp. 36–41).

In another section of the book, Nealy addresses the experiences of trans youth of color and homophobia and transphobia within racial–ethnic communities (see p. 128ff). My guess is that we know even less about trans kids of color than we know about trans kids in general; we clearly need more research and reliable statistics in this area if we are to help and support all trans kids effectively.

Nealy discusses the important role of mental health professionals in supporting trans youth. Training, education, experience, and consultation are all key underpinnings for mental health counselors. They have a role in the assessment and diagnosis of the youngster’s gender dysphoria, support and counseling for families, assessment and treatment for other mental health concerns as relevant, assessment of eligibility and readiness for hormone therapy and surgical procedures, referrals for medical treatments, education and advocacy within the wider community, and information on and referral to peer support for youth, family, and friends (p. 292).

Unfortunately, mental health professionals are thrust into the role of gatekeeper, which can impinge on their therapeutic role; that is, therapists are gatekeepers who authorize or deny access to other providers and to medical interventions and treatments. Mental health professionals need to examine and be aware of their own assumptions and possible biases regarding transgendered children and youth (e.g., it is not possible for a young child to sense that she or he is gender dysphoric; the parents are to blame; all transgender youth have mental health problems; the binary concept is correct and cannot be altered; what do families with conservative faiths do with their transgendered child; this is a mental health illness that needs to be fixed). A major qualitative study examined the experiences of trans clients with mental health professionals and found a large number of missteps and problems. A list, based on the research of Mizock and Lundquist from 2016, offers ways for mental health professionals to assess their potential for making missteps with trans clients (p. 306).

The last chapter includes a list of the top 10 life-affirming practices for adults in the lives of trans kids. This is a great distillation of the whole book and a good road map for anyone wishing to provide support and advocacy for trans individuals in their lives. Use their affirmed name and pronouns. Don’t lose sight of their resilience. Appreciate the courage it takes to be who they are in this world. Do not reduce what they are feeling to body parts. Pay attention to the intersections and impact of trauma. Introduce them to trans adults who are thriving. Connect them to their peers. Be willing to step outside the box. Never give up on a family, no matter how rejecting they appear to be today. And, finally, say I love you often in any way you can think of (see pp. 319–326).

We are fortunate that Dr. Nealy has written this book, which is a personal life story and reflection, but also a fantastically powerful qualitative and quantitative research tome, loaded with case studies, vignettes, resources, and questions for self-knowledge, personal growth, and professional development. There is a lot here, and I urge anyone with an interest in the topic of transgender children and youth, or adults for that matter, to obtain this astonishing book and read it cover to cover. It should absolutely be required reading for mental health professionals and indeed all health care providers and researchers. We are lucky to have Dr. Nealy to lead us through this world and offer suggestions of ways to support transgendered persons, no matter where they might be on their journey.



Reviewed by Marcie Parker, Ph.D., CFLE who has a private research and consulting firm in healthcare, aging, and long-term care in Excelsior, Minnesota.