Practice Briefs

Counseling Transgender, Nonbinary, and Gender Expansive Youth

Introduction

When counseling transgender, nonbinary, or gender expansive (TGE) youth, counselors must understand the diverse ways in which clients might experience their gender identity and expression. Trans identities are characterized by the experience of one’s gender identity (i.e., internal sense of gender) and/or gender expression (i.e., self-presentation) differing from norms associated with their assigned sex at birth (ASAB; Chang et al., 2018). TGE youth might identify within the gender binary (e.g., woman, transgender woman, man, transgender man) whereas others might identify outside of binary notions of masculinity and femininity (e.g., nonbinary, genderqueer). Additionally, some TGE youth might elect to transition in a variety of ways, including socially, legally, and physically/medically (Chang et al., 2018; Price et al., 2024).

Due to the exclusion of gender identity in many population-based surveys, research is limited regarding the percentage of youth who identify as TGE within the United States; however, researchers have estimated that 3.3% of youth between the ages of 13–17 identify as transgender and 2.2% as questioning (Suarez et al., 2024). Relatedly, researchers reported that over half of TGE individuals are under the age of 24 (Herman & Flores, 2025). The 2015 U.S. Transgender Survey found that 54% of TGE respondents knew they were trans before age 16, and 83% knew before age 20 (James et al., 2016), justifying the need for early, responsive, and affirming intervention.

Systemic Violence and Mental Health Considerations

Counselors must recognize that TGE youth’s presenting concerns and symptomology may be in response to systemic oppression and violence, as opposed to intrinsic pathology (Price et al., 2024). Anti-trans violence, marginalization, and legislation account for extremely disproportionate mental health concerns for TGE youth when compared to cisgender peers (Nath et al., 2024; Rastogi et al., 2025). Presenting concerns include elevated overall negative psychological states (Rastogi et al., 2025), depression (Guz et al., 2021; Suarez et al., 2024), self-harm (Surace et al., 2021), and suicidal ideation (Guz et al., 2021; Suarez et al., 2024). Specifically, TGE youth are 2–3 times more likely to report persistent sadness or hopelessness, twice as likely to experience bullying, and four times as likely to experience suicidal ideation and attempt suicide (Suarez et al., 2024).

These findings are mirrored within school settings, as well. In a GLSEN 2021 National School Climate Survey, TGE youth reported lower self-esteem, grade point averages, and sense of belonging compared to cisgender students (Kosciw et al., 2022). They also reported higher levels of depression, verbal and physical harassment, physical assaults, school policy discrimination based on gender identity and expression, and were less likely to attend college post-graduation. Furthermore, in the 2022 U.S. Transgender Survey, 80% of respondents over the age of 18 and 60% of respondents aged 16–17 years old reported experiencing one or more forms of maltreatment (e.g., verbal harassment, physical assault, online bullying, denied use of facilities) related to their gender identity while they were students in K–12 schools (James et al., 2024).

These experiences are amplified by the influx of anti-trans legislation flooding states across the nation, particularly creating barriers in access to care for TGE youth and their caregivers. In 2025, the American Civil Liberties Union (ACLU) tracked 616 anti-LGBTQ bills introduced across the United States with 74 being passed into law (ACLU, 2025). As of July 2026, the ACLU is already tracking 526 anti-LGBTQ bills across the United States, and many of these laws fully prohibit access to gender-affirming medical care for TGE youth under the age of 18 (ACLU, 2026), causing interruptions or delays in gender-affirming care. Relatedly, 90% of LGBTQ+ youth reported their wellbeing was negatively impacted by recent politics (The Trevor Project, 2024), and 45% of TGE youth reported that they or their families had seriously considered moving out of state due to the impacts of anti-LGBTQ laws (Nath et al., 2024, p.11), Thus, clients may face relocation-related stress and financial strain due to cross-state travel for care as counselors navigate uncertainty around referrals, documentation, and care coordination for clients.

Assessment Strategies

Assessment in counseling with TGE youth requires counselor awareness of the applicability of assessments and caution when integrating assessments not normed on TGE populations specifically (American Counseling Association [ACA], 2010; Goodrich et al., 2017). When selecting assessments, counselors recognize systemic barriers experienced by TGE clients and implications of inappropriate use regarding psychometrics of assessments and interpretation of results. 

Intake Paperwork

It is imperative that intake materials affirmatively address gender. Counselors build inclusive paperwork by asking about gender instead of essentializing sex assigned at birth and using blanks, as opposed to predetermined and binary checkboxes (Goodrich et al., 2017). Furthermore, as is safe for clients, counselors increase client access to self-determination by providing space for clients to self-identify names and pronouns (e.g., they/them/theirs, she/her/hers, he/him/his, ze/hir/hirs; Chang et al., 2018; Goodrich et al., 2017). By asking for client pronouns on intake materials or in-person, counselors avoid using incorrect pronouns or misgendering clients. Furthermore, asking for pronouns from all clients and sharing one’s own pronouns can demarcate a counselor as aware, affirming, and safe in their non-assumption of a client’s gender identity (Price et al., 2024).

Initial Psychosocial Assessment

Counselors recognize that there is no singular, linear narrative for all TGE youth—who are multidimensional individuals—and refrain from assuming that client presenting concerns are related to gender identity and expression merely because they identify as TGE (ACA, 2010; Goodrich et al., 2017, Price et al., 2024). Responsive counselors uphold confidentiality, taking measures to avoid outing TGE youth to family, verbally or in case notes (Griffith et al., 2017; Price et al., 2024). For example, if clients come out as TGE to counselors, counselors engage in intentional documentation practices to protect clients from being non-consensually outed if case notes are viewed by others. Counselors might document that a client “processed identity development in session” without stating client identities. If clients consent and communicate readiness to disclose their identity to others, counselors can offer support as determined by clients.

Transition-Related Assessment

State-level legislation banning access to transition-related care, such as puberty blockers or gender-affirming hormones, complicates mental health outcomes, as this type of affirming care has been shown to significantly decrease depression and suicidality among TGE youth (Tordoff et al., 2022). Counselors supporting TGE youth must remain aware of rapidly changing legal restrictions and be prepared to support clients and their families in understanding available options for care and responding to barriers and disruptions to care. If TGE youth aim for social or legal transition, counselors, with awareness of the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC; Coleman et al., 2022), can inform family and youth of resources and sources of support. Relatedly, counselors use the WPATH SOC as a guide for support rather than an absolute mandate for care (ACA, 2010; Goodrich et al., 2017; Price et al., 2024). If clients seek gender-affirming medical transition as they near puberty and are located in or can travel to a state that allows care, counselors have a responsibility to inform family of benefits and considerations related to transition, assess for diagnoses that could affect transition, and connect clients to integrated care resources (ACA, 2010; Chang et al., 2018; Price et al., 2024).

Furthermore, depending on type of medical intervention, some physicians and insurance agencies require counselors to write formal letters supporting a TGE youth’s medical transition (Chang et al., 2018; Price et al., 2024). Letters specifically address client capacity to make decisions related to gender-affirming care (Chang et al., 2018; Goodrich et al., 2017; Price et al., 2024). When providing support letters, counselors should collect and report clinically relevant information from youth and consult family, refraining from asking intrusive questions and reporting unnecessary information (Chang et al., 2018). Regarding transition-related assessments and letters, counselors can seek continuing education and use resources outlining best practices and more detailed guidelines to avoid becoming unnecessarily intrusive or gatekeeping. Additionally, affirming counselors without experience in these procedures will best support TGE clients by pursuing supervision and consultation from or referring clients to counselors who specialize in counseling TGE youth.

Cultural and Ethical Considerations

Counselors are ethically obligated to cultivate their own self-awareness, access consultation and supervision, and partake in continuing education opportunities related to TGE youth (ACA, 2010; Price et al., 2024). Counselors holistically assess client needs, barriers to care, strengths, and resiliencies by operating from an intersectional framework that validates the impacts of TGE youths’ multifaceted identities, including but not limited to gender identity and expression, sexuality, race, ethnicity, nationality, socioeconomic status, immigration status, language, spirituality, religion, ability, size, and age (Crenshaw, 1991). Relatedly, age considerations are critical in working with youth who do not possess the same access to agency and autonomy as non-minor clients. Therefore, discussion of informed assent and consideration of possible support or harm within family systems is critical to facilitating access to affirming clinical care (Goodrich et al., 2017; Price et al., 2024).

The Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.; DSM-5-TR; American Psychiatric Association [APA], 2022) specifies separate criteria for the diagnosis of gender dysphoria within children and within adolescents and adults. The revision of gender identity disorder in the fourth edition of the DSM, and the continued inclusion of diagnostic criteria related to gender identity and expression in the DSM-5 and DSM-5-TR, is a topic of much ethical debate, as iterations of the DSM have relied on and propagated heterosexist and cissexist assumptions (ACA, 2010; Chang et al., 2018; Goodrich et al., 2017; Sennott, 2010). Current diagnostic criteria include distress and/or impairment due to the incongruence between one’s gender identity and expression and the ASAB and associated primary and secondary sex characteristics (APA, 2022). Although this diagnosis is often used to justify or facilitate gender-affirming, transition-related medical interventions, controversy remains over its existence in the DSM-5-TR. Many argue that it facilitates continued pathologization of TGE clients within cisnormative frameworks, thereby doing harm and failing to maintain our ethical imperative of nonmaleficence (Chang et al, 2018; Goodrich et al., 2017; Sennott, 2010). Importantly, distress and dysphoria can result from systemic oppression and gender policing experienced when gender identity/expression do not align with gendered societal expectations (Price et al., 2024). Not all TGE youth will experience dysphoria, and expectations for the concept of gender expansiveness are socially and culturally variable (Goodrich et al., 2017; Price et al., 2024). Thus, counselors must recognize that this diagnosis “is only relevant when a client wishes to access medical treatments related to the transition process and is required by insurance” (Goodrich et al., 2017, p. 5).

Treatment Approaches

When counseling TGE youth, a gender-affirming psychotherapy (GAP) model requires counselors recognize their power as gatekeepers to transition-related care and encourages collaborative care (Goodrich et al., 2017; Price et al., 2024). Counselors holistically support TGE youth through integrating a theoretical foundation rooted in gender affirming psychotherapy (Price et al., 2024), multicultural and social justice counseling competencies (Ratts et al., 2016), and intersectionality theory (Chan, 2018; Crenshaw, 1991). Additionally, counselors apply a developmental (Coleman et al., 2022; Price et al., 2024) and trauma-informed (Chang et al., 2018) approach to incorporate considerations unique to client age, developmental stage, and associated psychosocial, familial, cultural, and sociopolitical impacts (ACA, 2010; Coleman et al., 2022; Price et al., 2024).

Individual Counseling

To support TGE youth who may be transitioning socially, legally, or medically, counselors must educate themselves, support client autonomy, and explore gender in an affirming manner (Goodrich et al., 2017; Price et al., 2024). Regarding the process of transition, counselors can support clients in navigating complex emotions, confusion, and questions related to social or physical changes and developing coping skills for any dysphoria-related distress (Coleman et al., 2022). Furthermore, affirming counseling extends beyond the session; integrating TGE-affirming materials in counseling offices and websites can increase visibility, and having gender neutral or family restrooms available on-site can increase safety for clients.

Within session, counselors may consider implementing a trans-affirming cognitive behavior therapy (TA-CBT; Austin & Craig, 2015) framework to challenge and avoid internalizing transphobic and cisnormative societal messages (Wittlin et al., 2023). This framework relies on counselor validation of client experiences of violence while supporting clients in combatting external transphobic behaviors and sources of maladaptive beliefs. Clients gain understanding of how maladaptive beliefs impact wellness, challenge negative self-talk, and explore ways in which rejecting these messages shapes client access to hope, personhood, community, and healing.

Additionally, counselors can integrate liberation psychology (Martín-Baró, 1994) to support client critical consciousness, illuminate connections between the personal and political, enhance pride through exploring TGE collective histories of resistance, and support engagement in community-based action. Counselors can facilitate client connection to community members, TGE elders, and TGE organizers working to uplift TGE communities and resist systemic violence. Additionally, through relational-cultural theory (RCT; Jordan, 2017), grounded in intersectionality theory and the assumption that people grow through connection, clients can challenge inequitable power distribution in society and relationships in exchange for accessing connections defined by mutual empathy. Within these frameworks, creative and expressive arts can also powerfully facilitate client healing and creating space for authentic expression, coping, joy, and resilience (Austin et al., 2023).

Family Counseling

Much like individual counseling, GAP is a foundational approach to build family capacity for support and affirmation of TGE youth (Price et al., 2024) which is critical to enhancing overall mental health and psychosocial outcomes (Lampis et al., 2023; McGregor et al., 2024). Although familial rejection of TGE identity is correlated with increased suicidal ideation and internalized transnegativity (McGregor et al., 2024), parental closeness and support are powerful protective factors against posttraumatic stress disorder, psychological distress, depression, and suicidal ideation (Wilson et al., 2016). Additionally, family acceptance has been associated with higher levels of psychological well-being (Lampis et al., 2023) and enhanced feelings of hopefulness and connection (Johnson et al., 2020) in TGE youth.

Adolescents experience varying levels of caregiver support. If caregivers reject a youth’s gender identity/expression or feel inclined to postpone/delay support of a youth’s desired transition, GAP supports intervention at the time of a client’s readiness (Price et al., 2024). Counselors engage with caregivers by validating complex emotions and thoughts regarding their child’s gender, gently challenging unfounded misconceptions and fears around a child’s TGE identity, offering psychoeducation around the positive and protective impact of family acceptance, connecting families to community resources, offering opportunities to build allyship, and grounding approaches within intersectional frameworks (Chang et al., 2018; Coleman et al., 2022; Malpas et al., 2022; Nieder et al., 2021; Price et al., 2024; Turban et al., 2022; Wittlin et al., 2023).

Referrals and Adjunct Services

Counselors must vet referral sources, ensuring TGE-affirming practices prior to referral. Referrals can include providers such as pediatricians, endocrinologists, surgeons, vocal therapists, psychiatrists, social workers, addiction counselors, attorneys, financial planners, hair-removal specialists, and school system officials (Chang et al., 2018; Coleman et al., 2022; Goodrich et al., 2017). Additionally, clients may benefit from participation in in-person or online TGE youth support groups, arts and cultural programming, and social justice and advocacy groups, and they might desire additional forms of support such as books, internet resources, and social media platforms (Goodrich et al., 2017).

Conclusion

Care for TGE youth requires counselors embody their advocate identity outside of the counseling space, recognizing calls to action within numerous sets of competencies and standards of care (ACA, 2010; Council for Accreditation of Counseling and Related Educational Programs, 2024; Goodrich et al., 2017; Griffith et al., 2017; Ratts et al., 2015). Counselors advocate with TGE youth in their communities and school systems to remove institutional barriers and educate officials on needs that will increase access to safety and success (ACA, 2010; Chang et al., 2018; Price et al., 2024).

Engaging in community and political advocacy surrounding TGE communities’ needs can also effect systemic change (Chang et al., 2018; Price et al., 2024). Furthermore, TGE-affirming counselors can support youth in developing their own advocacy identities, resulting in increased self-efficacy, autonomy, and resiliency.

Resources

• Understanding gender identities & pronouns, The Trevor Project
• Identity documents & privacy, Advocates for Trans Equality
• Transgender rights, American Civil Liberties Union
• The school counselor and LGBTQ+ youth, American School Counselor Association
• Supporting transgender youth in schools, by April Megginson
• The transgender child: A handbook for parents and professionals supporting transgender and nonbinary children, by Stephanie Brill & Rachel Pepper
• Championing LGBTQ+ issues in K–12 education, Glisten
• Educator, staff, and administrator advocacy guide, Glisten
• Supportive schools & LGBTQ dignity—Know your rights, and how to fight for them, Campaign for Southern Equality
• Passport and identity document information for the transgender community, Lambda Legal
• Gender-Affirming Psychotherapy (GAP): Core principles and skills to reduce the mental health care “GAP” for transgender youths, Psychiatric Services
• Competencies for counseling with transgender clients, Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling
• The queer and transgender resilience workbook: Skills for navigating sexual orientation and gender expression, by Anneliese A. Singh
• Gender identity workbook for teens: Practical exercises to navigate your exploration, support your journey, and celebrate who you are, by Andrew Maxwell Triska
• Parenting your transgender teen: Positive parenting strategies for transgender, nonbinary, and gender nonconforming teens, by Andrew Maxwell Triska
• Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people, UCFS Gender Affirming Health Program.

To Cite This Practice Brief:

Akers, W. P., & White, M. E. (2026, September). Counseling transgender, nonbinary, and gender expansive youth [Practice Brief]. Counseling Nexus. https://doi.org/10.63134/CWFN5764