This booklet has been written to provide information and support to families that have an adult member whose gender identity is not aligned with the sex that was registered on their birth certificate.

The booklet is also available to download and view offline in pdf format here.
 

CONTENTS    


The Gender Identity Research and Education Society (GIRES)   
Gender Incongruence and gender dysphoria   
Supporting the families of transgender people   
Gender non-conforming / gender variant children and adolescents   
Adult Family Members: Disclosure – the early days   
Transitioning as an older person (partners and spouses)   
Help for the trans person’s children   
Why families need support   
What is the best way for families to respond?   
Challenges to be faced   
Documents to be changed   
Understanding Gender Incongruence   
Intersex   
Sexual orientation   
Legislation   
Role of Gender Identity Clinics (GICs)   
Surgery   
Workshops for families – a possible model   
Information and Support  

 

The Gender Identity Research and Education Society (GIRES)

GIRES was set-up almost 20 years ago to improve the lives of trans and gender non-conforming people including those who are non-binary or non-gender.[1]  One aspect of our work is to provide information and support to families that have an adult member whose gender identity is not aligned with the sex that was registered on their birth certificate. This support takes the form of information; signposting to local Support Groups http://www.gires.org.uk/the-wiki and, for members of the Charity who attend the AGM, an informal family workshop is available.

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Gender Incongruence and gender dysphoria

Gender incongruence describes the situation where a person’s gender identity (as a man, a woman, or on a gender spectrum in between or outside these extremes, i.e. non-binary or non-gender) is not the identity typically associated with their sex assigned at birth. The discomfort or unease experienced by trans, non-binary and non-gender people (referred to in this document simply as ‘trans’) due to this mismatch is described as gender dysphoria.  Medical people use ‘gender dysphoria’ as a ‘diagnosis’.

The discomfort arises not only in relation to their physical sex characteristics, but also the social interactions and behaviours that are typically associated with their sex.

Trans people usually describe a very early awareness of something being different about them. As children they may not be able to express what that difference is. Their discomfort grows but is often repressed.  The pressure of hiding their gender identity becomes intolerable and they feel impelled to make a decision.  Either to make changes in their life to reflect their gender identity, or to continue to hide it with the inevitable negative impact this has on their mental health. 

It is currently estimated that about 1% of the UK population experiences some degree of gender incongruence but not all of them are uncomfortable so they do not necessarily seek medical help.

GIRES’ generic leaflet gives a brief overview which is useful for families to share information with each other, and with friends, to assist in their understanding.

See http://www.gires.org.uk/support/transgender-experiences-information-and-support-for-trans-non-binary-and-non-gender-people

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Supporting the families of transgender people

In the last few years public awareness of transgender has increased significantly.  There have been TV programmes (Girl meets Boy, Transparent), a film (The Danish Girl) and transgender story lines have been included in popular soaps (East Enders, Hollyoaks), and there has been a marked increase in balanced reporting in the media.

This is a welcome step in the right direction but like all social changes acceptance by society takes time to catch up.   Consequently families who have a transgender member (son/daughter, spouse/partner or sibling) often find it difficult to manage the changed relationship with their loved one and the changes to family life.  Frequently, family members blame themselves. Parents particularly, wonder if they have ‘caused’ this to happen, and question their own role in their child’s young life. They may feel, guilty and, perhaps, embarrassed and even ashamed. Families need to understand that this condition is not caused by parenting, and it is resistant to the usual societal pressure to conform to stereotypical gender behaviours and expressions.

It is also recognised that some cultures and religious beliefs require very strict conformity to typical man or woman gender expressions. Families who are part of these social structures may find it harder to be accepting of a family member who is unable to fit within these cultural and/or religious boundaries. 

Today, perhaps as a result of increased media coverage, many more children and young people are feeling able to disclose their gender identity and change their gender role, when they are very young.

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Gender non-conforming / gender variant children and adolescents

Note that children themselves may experience uncertainty about their gender identities or, depending on their speech development, may express an absolute conviction from a very young age that they are a ‘boy’ or ‘girl’ in contradiction to their sex appearance. Occasionally this can happen from as young as 18 months and frequently prior to primary school age.  Although helping these very young children is not the primary aim of this paper, the GIRES’ website does has age-appropriate stories in the lesson plan section of the GIRES’ website

With the benefit of hindsight, parents and families often acknowledge that there were indications of gender issues, which they may have pretended not to notice, or have even discouraged.  Discouraging the expression of a child’s or young person’s identity has the same effect as ‘reparative therapy’ designed to prevent a trans outcome. This is unethical and unsuccessful. Pubertal children and adolescents should have access to hormone-blockers to put their pubertal development on hold, and then later start cross-sex hormones.

Families seeking help with the gender identity development of their children should contact Mermaids which is a support group for children and teenagers coping with gender identity issues and their families.  This charity provides a telephone helpline (020 8123 4819), e-mail contact () and website (http://www.mermaidsuk.org.uk).

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Adult Family Members: Disclosure – the early days

Dealing with the immediate impact of the disclosure raises many issues. You may feel you need time to process this information, but nonetheless, some matters have to be dealt with quite promptly, and some decisions have to be made about how and when to do this.

Everybody’s story is different, but there are also similarities

Sometimes, families are totally unaware of the hidden turmoil that their loved one has experienced, sometimes for many years. So when they disclose their situation, understandably, takes time for families to ‘catch up’.  It helps to remember that they are still the same person.  The same sense of humour, the same likes and dislikes, the same lovable characteristics and the same irritating habits.  The person they know is still there but one aspect of who they are has finally been revealed - their gender identity. 

Family members may have very different reactions to the news, not always positive, and these have to be managed so that they do not damage the trans person. Many parents and partners of trans people feel great fear that their loved-one will suffer discrimination, hostility and even violence. There may be concerns about the future in terms of education, employment etc.  Fortunately, the UK Equality and Human Rights legislation plays an important role in protecting them and makes bad outcomes much less likely. However, families do need to understand, that even though the future may be compromised to a certain extent, there is no future for a person who is obliged to continue to hide and play the charade of pretending to be someone they’re not. This has a very detrimental effect on their mental health. Their lives will be massively improved by coming out of the shadows, by being themselves – with your help.

As far as possible decisions should be made in partnership with the trans person; disclosure may be made by the person themselves, or by the family member who has been the first to know.

You will need to balance the timing of disclosure to other family members: siblings, for instance, may be about to sit important exams, parents may be struggling with a stressful work situation, grandparents may be unwell, then friends, neighbours and so on. Try to do this in a positive way, showing that your expectation of them is that they will respect and support the trans person. Family cohesion and support is one of the most important factors in achieving successful outcomes for trans people.

Until everyone knows, you may find that there are awkward situations where some people in the room do know, others don’t. There are many conversations where you almost feel that you are talking about two different people e.g. how are the boys? (one of them is now a girl); how is Michael getting on?  (she’s now Meg)

Telling work colleagues is not urgent, and may be deferred until you are more comfortable yourself, or it may never be necessary.

‘Coming out’ in any of these circumstances feels quite scary, so your own preparation in terms of gathering information and understanding is important, so that you are able to answer some of the questions that people ask you.  Dealing with a wide range of questions and misconceptions is not always possible in the early stages, but the important points to remember are: this is not the result of bad parenting; the predisposition to identify in a particular way is innate, and cannot be overcome by raising a child strictly in accordance with their birth sex; fighting it merely makes the person more uncomfortable and risks alienating them. This is not a mental illness; changes to the gender role are not ‘life-style’ choices.

Relatives and friends may make unkind or thoughtless remarks which usually stem from ignorance, but can be painful for you. To address this, you will probably need to educate people – discussing with what you have learned, and providing leaflets that explain the facts. But, sometimes you may need to be very direct:

“I’m sure you didn’t mean to be offensive, but actually, I found your comment very hurtful”

Family life will change, but the more you can embrace the new persona of your loved-one, the easier it becomes. Work hard on names and pronouns because they matter a lot to the trans person. There are barriers to medical treatment that can be frustrating; social, educational and employment difficulties may cause anxiety or distress. When your loved one has a bad experience, or is unhappy about something, ask them how you can help, demonstrate that you are on their side, give love and support.

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Transitioning as an older person (partners and spouses)

In cases where the transition occurs later in the trans person's life, it often involves partners/spouses and children. The changes or impending changes in all their lives puts great pressure on relationships. It is not just one person who ‘transitions’ but the whole family.

The partner/spouse may feel betrayed, especially if told late in the decision-making process.  If the trans person has children, the partner/spouse will be deeply concerned about the effect on them even though children usually respond positively as long as the adults around them do.  The partner/spouse in a straight relationship, may be deeply concerned about being labelled lesbian or gay. If they have been in a single-sex relationship up to that point, they will be equally uncomfortable being regarded as straight. For any of these couples, they may face compromises with regard to their sexual relationships. Sometimes, even though affection and love remain, the sexual aspect of their relationship may cease.

Some families may, for many years, have wondered and worried about some inexplicable ways in which their loved one has behaved. There may be relief that a mystery has been solved.

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Help for the trans person’s children

Major issues often arise concerning the children of a trans person.  Parents may wish for help in informing their children about gender identity and transgender issues.  For this purpose, GIRES can provide explanations, according to the family’s needs set at two levels: one for pre-teens, the other for teenagers. GIRES can adapt these for your particular family circumstances. (http://www.gires.org.uk/support/explaining-to-children ).  Schools that have to deal with such issues, because either pupils have trans parents or pupils are themselves gender dysphoric,  may find it helpful to refer to the GIRES lessons at: http://www.gires.org.uk/education/classroom-lesson-plans (see Peter’s Story, and the e-learning at http://www.nlmscontent.nesc.nhs.uk/sabp/gv/

In some cases, parents may separate, with one of them having custody of the children.  The parent having custody may deny the other parent reasonable access to the children.  In such a case, a court hearing may ensue.  GIRES provides information to help the trans parent in such circumstances. http://www.gires.org.uk/law/court-information-for-trans-parents

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Why families need support

In order for families to give support, they may also need help to understand, respond to and support their loved one in their transition. 

Despite the wider awareness of trans people, it is likely that many will have little or no understanding of trans issues, and therefore having access to clear, objective information is helpful in two ways.  It helps the family to understand what the trans person is going through, as well as helping the trans person to understand the family’s sense of loss and bewilderment.  This shared understanding enables families to keep talking to each other and encourages optimism, realism and a feeling of working together. If they also know other families who are going through the same thing it can provide opportunities to talk and help them feel less alone.

It takes time, understanding and patience for a family to learn to be comfortable with a son or daughter, spouse or partner, brother or sister who transitions (changes their gender role and expression).  Developing an understanding of transgender, how best to respond, the challenges to be faced, and changes to documents  helps them to become more comfortable with the change, to be supportive and to start moving forward.

In their anxiety, families often fail to recognise that the trans person’s love for other family members remains unchanged.  The trans person is often acutely aware of the pain that the situation is causing the family and feels deeply sad about it.  However, the family should be aware that the trans person is driven by an overwhelming need to live in accordance with the gender identity.  They may become entirely self-focussed throughout the transition process.  They may feel that they have spent their entire lives pleasing everyone else.  Now it’s their turn and they will want their families to be happy for them, to accept them, to listen to them, perhaps advise them but above all to continue to love them.  Sometimes, they will have difficulty in understanding why their families are not enthusiastic about this transformation.

Despite these difficulties families can and do remain together. Sometimes a spell apart helps family members to come to terms with the changes.  Others remain together and work their way through the events, a bit at a time, focussing on the love and friendship that they share. In this way, they are often able to come to terms with their altered circumstances.

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What is the best way for families to respond?

Although all families are different we have found that the most valuable approach is to:

  • Realise that you can’t ignore the issue and hope that it will go away;
  • Encourage and be open to discussion with your family member whenever they wish to talk about gender identity issues;
  • Accept, as quickly as possible, your loved one's decision about their gender identity and give them your unconditional love and support.  This means:
  • Respecting their fundamental human right to be true to themselves;
  • Accepting that living in accordance with their core gender identity is now absolutely essential for their future happiness;
  • Being realistic rather than pessimistic about the challenges you will all have to face;
  • Accepting that you are not to blame or in any way responsible for your loved one's decision;
  • Sharing the news with at least one other person you trust to keep it confidential until you and your family member are ready to share it more widely. You should have the consent of the trans person before sharing with anyone else;
  • Contacting a support group, see http://www.gires.org.uk/the-wiki
  • Obtaining professional help, perhaps via your GP, if you are feeling continually stressed;
  • Ensuring that home is a place where your loved one can totally relax and re-energise themselves away from the outside world.
  • Using the name and the pronouns that your loved one prefers: ‘he or she’, ‘him or her’, ‘his or hers’; ‘they’, ‘them’ or other pronoun of choice. This will take time and initially you will often get this wrong; apologise and try to use the correct one even when the person concerned isn’t present;
  • Exploring opportunities to offer tactful advice on clothes, make-up, etc.
  • Learning about gender identity development, see GIRES website
  • Understanding the difference between the ‘sex’ of a person and the ‘gender identity’ of a person
  • Understanding the language used in the transgender space including gender identity, gender role, gender dysphoria, transgender, transition, trans man, trans woman, non-binary/gender queer (see http://www.gires.org.uk/terminology )
  • Appreciating that your loved one is having to explore a new world of trans people who serve their special needs – and that you will not always feel part of it;
  • Gradually informing others who need to know, especially family members and close friends (with the consent of the trans person);
  • Becoming confident and knowledgeable enough to challenge ignorance and intolerance in others;
  • Looking for ways to help others in a similar position.

What is unhelpful is to:

  • Refuse to believe or accept what your loved one is telling you.
  • Try to make things like they previously were.
  • Keep the news a complete secret from everyone (unless the trans person insists on secrecy);
  • Become antagonistic towards the professionals who are trying to help your loved one;
  • Believe that there is nothing positive you can do;
  • Expect only bad consequences from your loved one's decision to have treatment for gender dysphoria.

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Challenges to be faced

Although the list is long, we have found that it is helps trans people and their families to plan if they have an overview of treatments and interventions undertaken to support transition:

  • Mental health assessment to confirm the diagnosis of gender dysphoria;[2]
  • Accessing hormone treatment;
  • Hair removal (trans women);
  • Speech and language therapy (usually trans women, but sometimes trans men);
  • Counselling support, with or without partner/spouse;
  • Accessing appropriate accessories: trans women may need wigs, padded bras and restrictive underwear; trans men may need ‘packers’ to give a male genital appearance, and ‘binders’ to flatten the chest;
  • Accessing appropriate clothing, footwear;
  • Changing the gender role to align it with the gender identity (the so-called real life experience, RLE) and living in that role full-time; this is mandatory for 12 months before referral for genital surgery, but should NOT be required in order to access hormones. It should be noted that those who are non-binary may have difficulty in demonstrating that they have undertaken RLE. The RLE concept is increasingly regarded as dated;
  • Carefully informing all who need to know see: employers, work colleagues, banks, pension and insurance providers, state benefits, clubs etc.
  • Statutory Declaration or Deed Poll for change of name and title. This is not obligatory under UK law, but it facilitates the process of obtaining new documents, such as Driving Licence and Passport (see list below)
  • Housing, where breakdown in relationships has occurred;
  • Accessing legal help for extreme problems such as maintaining contact with children;
  • Perhaps creating a new social life;
  • Dealing with media intrusion;
  • Dealing with transphobic hate crime, and reporting to the Police (GALOP at www.lgbthatecrime.org.uk; )

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Documents to be changed

The trans person will also need to change their personal details on documents.  Although the list is long some documents will be more important than others and can be prioritised over the others

  • Driving licence
  • Passport
  • Degrees and other qualifications
  • NHS name and number (usually via GP)
  • Other medical services e.g. Dentist, Optician
  • Tax and National Insurance
  • Personal records at work
  • Pension records
  • Jobcentre Plus
  • Bank and Building Society
  • Personal and household insurance policies
  • Mortgage
  • Credit Agreements
  • Credit cards
  • Utilities: Gas, Electricity, Water, Phone
  • Council Tax
  • Electoral Roll
  • Club memberships

 

A new Birth Certificate can only be obtained following the granting of a Gender Recognition Certificate (GRC). At the time of writing (2016) the GRC cannot be obtained until the person has lived in role for two years, so it is not of any use to those undergoing transition and treatment in the first couple of years. Once achieved, it established that the person is of their affirmed gender, for all purposes, and it provides a high degree or personal privacy.

Although there is a growing number of local groups that support families; see www.TranzWiki.net there is still not complete coverage of the UK.  Many more groups are needed. GIRES strongly encourages the establishment of other trans groups and organisations to provide help in their area. If you are a family member, you might consider starting a support group in your area for other family members. You should apply to be entered on the Tranzwiki list http://www.gires.org.uk/the-wiki

Creating small leaflets that can be put in GPs’ surgeries, libraries, Samaritans and Citizens Advice Bureaux  etc, can help to alert people in your area.

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Understanding Gender Incongruence

Being trans is not a mental illness, and it is not a choice. The International World Professional Association for Transgender Health says:

“the expression of gender characteristics that are not stereotypically associated with one’s assigned sex at birth is a common and culturally diverse human phenomenon that should not be judged as inherently pathological or negative".[3]

It is helpful to understand the difference between ‘sex’ and ‘gender identity’.  ‘Sex’ describes our physical body, our external appearance, internal reproductive organs and brain with clear differences between males and females.  ‘Gender identity’ describes the inner sense of knowing that we are boys or girls, and later men or women. The term ‘gender’ also applies to ‘gender role’ which describes how we behave in society, and ‘gender expression’ which is about how we dress and present ourselves.  For instance, even though we now live in a more equal society, boys and girls are still expected to dress differently from each other, have different interests and different groups of friends. This notion of being ‘one thing or the other’ is called the ‘binary’ model.

People who fall under the umbrella term ‘transgender’ or simply ‘trans’ may identify at the opposite end of the gender spectrum from their assigned sex. They have been assigned male at birth, but identify as a woman or towards the feminine end of the spectrum (a trans woman) or assigned female at birth and identify as a man or towards the masculine end of the gender spectrum (a trans man). There are many different identities that are not ‘man’ or ‘woman’ but fall outside or between the binary identities, and are known as ‘non-binary’  or ‘gender queer’ identities which include fluid and non-gender identities.

Gender incongruence is the term used to describe the situation where a person’s gender identity is not congruent with the male or female sex assigned at birth. Gender dysphoria describes the emotional, social and physical discomfort that is associated with this incongruence.

More is now known of the biology that underpins this condition. Although the biological pathways to the development of gender dysphoria are many and varied, and cannot be relied upon to provide a diagnosis, there is now convincing evidence, that the brains of trans people are not typically differentiated. There is evidence that atypical development is associated with unusual hormone levels at critical stages of development in the womb. A variety of triggers may be involved, such as: chromosomal/genetic and environmental. It is not caused by parental influences, and is resistant to social pressure to conform.

For a clear explanation of what gender incongruence is and why people are different in this way, see http://www.gires.org.uk/research/etiology-in-adults

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Intersex

Some people have conditions known as ‘intersex’, where their sex characteristics are mixed. Although as many as 1 in 100 babies have an intersex condition, only 1 in 2000 are born with genitalia that are neither clearly male nor female. In the past, this ambiguity was often overcome by surgical assignment as female and the child would be raised as a girl. This did not guarantee a congruent gender identity as a girl, and is now regarded as unethical, and in some jurisdictions, unlawful. Whether they have had surgery or not, the gender identity of an intersex person will emerge as the child grows. It’s not always possible at birth, to predict their gender identity. It is more appropriate to adopt a ‘wait and see’ approach.

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Sexual orientation

Gender dysphoria has nothing to do with sexual orientation, that is, whether a person is gay, lesbian, bisexual, straight or asexual.  The sexual orientation of trans people, as in the population generally, may be towards men (androphylic), women (gynaephylic) or both, or they may have no sexual interest at all. In most cases, trans people’s sexual orientation remains the same as it was pre-transition. However, in a few cases, their orientation appears to change or, in some cases, they are bisexual and comfortable with partners of either sex. Trans people may make relationships with other trans people and we do not have ‘labels’ to describe these potential situations.

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Legislation

Trans people have rights under the Equality Act 2010 (EA), by virtue of their ‘protected characteristic’ of ‘gender reassignment’ Those employed in the public sector, fall under the EA Public Sector Equality Duty. Trans people are also protected, like everyone else, by the Human Rights Act 1998. These laws combine to ensure that their dignity and privacy is preserved, and that they do not experience discrimination in employment and access to services.

The Gender Recognition Act allows trans people who have been ‘diagnosed’ with gender dysphoria, and who have lived continuously in the new gender role for two years, to obtain a gender recognition certificate (GRC). Those in heterosexual marriages must change their official status to same-sex marriage (or Civil Partnership), with the written consent of the non-trans partner in order for the trans person to be granted a GRC. Those in civil partnerships must convert to a marriage where the trans person wishes to obtain a GRC, again with the written consent of the spouse. A GRC automatically qualifies the trans person for a new birth certificate as long as the birth was registered in the UK.

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Role of Gender Identity Clinics (GICs)

Gender Identity Clinics provide assessment and treatment to people with gender dysphoria who have been referred to the Clinic by their GPs.  Clinics do not treat people less than 17 years of age. [4] Following a period of assessment, hormone treatment may be recommended. The GP is informed and should provide this treatment. For information about the role of the GP see http://elearning.rcgp.org.uk/gendervariance

Trans people sometimes fear that their family will try to influence treatment decisions in a negative way, or that clinicians will use it as an opportunity to check on what the trans person has told their clinician. It is therefore very important that the trans person is comfortable with a family member being present, and has consented to this.

Often Clinics are very stretched and do not have the capacity to reach out to families. Of course, if your trans family member wishes you to attend an appointment with them, this is usually accommodated by the Clinic. Clinics should recognise that family support is an important ingredient in successful transition, yet families do feel shut out of the process at a time when they, themselves, are subjected to extreme stress. Based on the comments of previous Family Workshop participants, the following input from Clinics would be welcome:

  • helping the trans person to consider how best to preserve family relationships
  • permitting other family members, with the consent of the trans person, to attend at least one meeting with the supervising clinician
  • providing advice and information for family members
  • organising opportunities to meet other families in the same situation
  • providing information on other sources of information and support

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Surgery

Very often trans people and their families over emphasize the importance of surgery in comparison with the many other factors that have to be dealt with effectively to ensure a happy life for the trans person.  However, for many trans people surgery is essential.   NHS England funds the treatment of gender dysphoria, but certain surgeries, such a facial feminising surgery are excluded. Waiting lists for access to the Gender Identity Clinics and for surgery are very long and getting longer.  Referral for genital surgery will not be obtained until the person has lived in the new role continuously for 12 months. Private treatment is also available but this is very expensive. 

We have provided an overview of the main surgical options on our website

http://www.gires.org.uk/health/medical-treatment-options-for-gender-variant-adults, and booklets on “Lower surgery for those assigned female, identifying as trans men, trans-masculine, non-binary and non-gender”; and “Lower surgery for those assigned male, identifying as trans women, trans-feminine, non-binary, and non-gender”

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Workshops for families – a possible model

GIRES no longer runs Family Workshops but has run many in the past on a very successful model.  The Workshops allow participants to share their experiences and put questions to the trans people and family members that make up the team of presenters.  Workshops last for three hours.   The focus is on the needs of family members, so although trans people may attend at the invitation of their families, they are not allowed to attend without family members. Participants include partners, children, parents, siblings, friends and also trans people (with their families)

A shorter family workshop is always offered to members at the GIRES AGM.

GIRES set ground rules that created a safe and supportive atmosphere:

  • Everyone should be treated with respect
  • Confidentiality should be assured
  • No information will be passed on to those providing treatment.  Family members were cautioned not to interfere in treatment

For part of the time, participants are divided into three smaller groups:

  • trans people
  • partners
  • parents and siblings

Each group was facilitated by an appropriate team member.  This enabled participants to concentrate on issues specific to their personal situation, and it greatly facilitated discussion in a safe environment.

Feedback by participants showed that they had been helped to understand and accept their loved one’s condition.  Their comments also showed that they had obtained reassurance through:

  • knowing "I'm not the only one"
  • companionship and sharing
  • ability to talk openly
  • hugs with other participants

Another important benefit of bringing families together is that it enables them to network if they wish after the workshop is over.

In presenting the workshops, GIRES collaborated with two other organisations that provide support for families nationally.  One of these is Mermaids who support young people and their families.  GIRES provides information about the other national and local groups that support families throughout the UK via http://www.TranzWiki.net

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Information and Support

GIRES can provide further information

Web site: www.gires.org.uk

Telephone: 01372 801554

Address:

Melverley, The Warren,

Ashtead, Surrey, KT 21 2SP

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[1]GIRES is a membership organisation. The annual fee is £5 minimum. See ‘joining GIRES

[2] The concept of ‘diagnosis of gender dysphoria’, is becoming dated and, hopefully will be changed, as the condition is out of the section entitled ‘Mental and Behavioural Disorders’ in the International Classification of Diseases, into a somatic classification, rather than a psychopathological one. It may be referred to as gender incongruence.

[3] World Professional Association of Transgender Health (2011) Good Practice Guidelines for the assessment and treatment of gender dysphoria in adults  http://www.wpath.org/

[4] Young people up to the age of 18 may access treatment at the Tavistock and Portman Clinic, but may also be referred to an adult clinic at the age of 17 ( http://tavistockandportman.uk/care-and-treatment/information-parents-and-carers/our-clinical-services/gender-identity-development)

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