Grieving those Who Still Live: Loss Experienced by Parents of Transgender Children

Abstract Transgender identity can be defined as the self-awareness of a discrepancy between the assigned sex at birth and the personal gender identity of an individual. This study assumed the constructionist perspective, focused on the influence of culture on sex-typing and the representations of gender in child development. This research considers how parents of transgender children emotionally handled the transition. Being faced with a child’s transgender identity may cause an emotional experience similar to mourning, in particular, ambiguous loss (Coolhart, Ritenour & Grodzinski 2018, McGuire et al. 2016, Norwood 2013). In this qualitative research, 97 associations dealing with Gay, Lesbian, Bisexual and Transgender (GLBT) issues were contacted to recruit participants from three different countries: Italy, Spain and U.S.A. The sample includes 18 parents of trangender people who completed an ad hoc questionnaire. A brief standard story was constructed about an experience of sexual transition, followed by some questions on the experience of parental mourning during the transgender transition of their children. The corpora were analysed in the three original languages, and the analysis was performed with Atlas.ti. From the qualitative analysis of the texts that describe parents’ experience, three fundamental elements emerged. The first is inherent to the mourning orientation to loss and the fear of death; the second to the disenfranchisement of mourning and transgender identity between family and society; and the third illustrates the final restorative outcome of mourning.


Introduction
Transgender identity can be defined as the self-awareness of a discrepancy between the sex assigned at birth and the personal gender identity of an individual. From a psychological point of view, the term "gender identity" inheres in "a category of social identity and refers to Unauthentifiziert | Heruntergeladen 03.02.20 02:59 UTC the identification of an individual as a male, a female or, sometimes, as belonging to categories other than male and female" (DSM V, American Psychiatric Association 2013:527-528). From the sociological perspective, transgender identity has been studied with regard to rules and roles (i.e. Adachi 2018, Cordero-Coma & Esping-Andersen 2018, Horne et al. 2018, considering sexual identity as the progressive crystallisation of performative processes during the early developmental phases of life (Butler 1988, Thorne 2008. Rather than seeing gender as the manifestation of the already given sexed body, gender philosophers (i.e. Butler 2004) argue that the very notion of a body is often a product of a social apparatus and power structures, aiming to maintain a rigid binary between feminine and masculine gender roles. Their influence on the binary differentiation begins in the primary socialisation environment, when individuals construct a representation of reality, based on behavioural canons of their social environment (Berger & Luckmann 1969). Indeed, two fundamental views influence the performative processes facing each other: the traditional one, based on essentialism driving binary logic, which defines the irreducible natural difference between male and female, versus the constructivist one, which emphasises the compulsory action of culture and situates social factors in the development of identities (cf. Allen & Mendez 2018, Halim, Walsh, Tamis-LeMonda, Zosuls & Ruble 2018, Martin, Ruble & Szkrybalo 2002, Romm et al. 2018, Testoni 2012.
For a long time, academic psychology was based on the essentialist position (Testoni 2012) and only in the last two decades has it assumed that this differentiation is culturally driven and derived from the creation of shared expectations in social contexts (Bem 1981, Jacobs 1991  identified as males, females or other categories, and gender non-compliance is not considered as a mental or sexual disorder, the problem is not totally solved since transgender identity is still classified as "Gender Dysphoria", which implies a clinically significant problem. The entire discussion has intensely influenced GLBT people's practices in everyday life. Often these people have experienced difficulties and conflicts (Jachimiak 2012, Johnson & Repta 2012.
The queer revolution, like abortion and contraceptive techniques for avoiding pregnancy or treatments for sexually transmitted diseases (Katz & Tirone 2015, Rothman 1999, has been changing Western social customs, albeit to various degrees, depending on the level of traditionalism in different cultures. In fact, in traditionalist Italy (ISTAT 2012), 0.1% of the sample describe themselves as transgender persons, whereas in Spain, the proportion is even lower and oscillates between 0.01% and 0.1% (Chrysallis 2014). In the more liberal U.S.A., the rate is higher and goes up to 0.6% (Flores, Brown & Herman 2016), maybe because of the wide and open social debate about GLBT and queer issues and because of GLBT associations' activities for social communities (Bauer 2018, Stewart 2018, Wootton et al. 2018. However, it is difficult to determine whether the different percentages, which, furthermore, could not be compared because of the different methodologies of the surveys, are the effect of greater freedom of choice when coming out or not. The parental representation of gender-stereotypical appearance might be one of the first factors in children's emerging sense of sexual identity. As children become more aware of gender categories, they begin to adhere to gender stereotypes, such as by expressing interest in respecting feminine or masculine attitudes and behaviour (Halim et al. 2018). Usually, parents build a psychological image of their children, based on what they culturally believe to be their gender, depending on the sex assigned at birth (Eccles, Jacobs & Harold 1990, Weisgram & Bruun 2018. Then, parents with more traditional gender attitudes usually educate their children with more traditional gender views, compared to parents with more liberal gender perspectives (Tenenbaum & Leaper 2002). Based on their binary representations, parents try to provide gender-stereotypical models to their children, while being more responsive when their children engage in gender-stereotypical versus counter-stereotypical attitudes (Lytton & Romney 1991). That is why being faced with the child's transgender identity may destroy their traditional image and cause a grieving experience (Raj 2008, Wahlig 2015. This kind of suffering could be similar to what is already described by literature with regard to what happens with homosexual coming-outs (Connolly 2005, Perrin-Wallqvist & Lindblom 2015, Trussell 2017. In all of these situations, parental discomfort and inadequate reactions negatively influence the development of their children, whereas, on the contrary, their Unauthentifiziert | Heruntergeladen 03.02.20 02:59 UTC supportive behaviour facilitates a positive identification and transformation (Olson et al. 2016).
Young transgender people, especially if rejected by families, can suffer harmful psychological experiences, such as decreased life satisfaction and psychological health, lower levels of selfesteem (Rotondi et al. 2012), increased risk of depression (Stice, Ragan & Randall 2004), minority stress, internalised transphobia, risks of harassment and violence (Levine 2013), suicidal attempts and self-injurious behaviour (Liu & Mustanski 2012). Even though the parental unelaborated suffering deriving from a transgender child transition could be dangerous for the sequel of the transformation, this kind of mourning has not yet been investigated, and that is why we decided to survey this experience.

The Research
Following the CORE-Q checklist (Tong, Sainsbury & Craig 2007), our study pertains to the field of qualitative research in psychology (Camic, Rhodes & Yardley 2003) and was had to contain words that refer to the universal meaning of grief, such as "loss", "grief", "grieving" and "mourning". To assemble the sample as an "intentional group" (Morse 1989), we chose to contact GLBT associations, so they could help us to recruit participants. countries, therefore, allows, on the one hand, the comparison of the social and legal situations of transgender people, and, on the other hand, the evaluation of different social contexts (based on the Hate Crime Index). In this way, it is possible to have a broader overview of the social and psychological situation that transgender people and their families may experience.

Aims
The main objective of the research is to consider how parents of transgender children handled the transition. Specifically, it was intended to analyse whether or not they had an emotional experience similar to mourning, such as that indicated by the dual process model (Stroebe & Schut 1999). In particular, we wanted to consider how parents experiencing loss go through mourning, aspiring to partially check whether this experience was more characteristic among Italian, Spanish or American parents because of the cultural influence on the emotional aspects linked to this type of transformation, and by paying attention to the disenfranchising social dynamics. The object of the qualitative analysis was the recognition of the interpretative repertory, that is, the system of terms used to characterise and value this possible form of mourning.
After analysing the texts retrieved from the Internet in the first phase of our research, we constructed a brief standard story where an experience of sexual transition was described, followed by some questions, among which were the following: "Please, could you possibly comment on the story?", "Would you like to narrate your experience?", "In your opinion, what does the parent of the story feel? Have you felt something similar?", "What are the differences between the story described and your experience?" and "Some parents experience a sense of grief or mourning when they discover that their children are transgender. They feel that they have lost their child. Have you experienced similar feelings?" The instrument was translated into Italian, English and Spanish and uploaded to the SurveyMonkeys online platform (cf. Finley & Finley 1999). A second time and independently from the researchers, the 18 associations sent the questionnaire with the informed consent to participants.

Method
Our analysis was partially theory-driven, framing interpretations within death studies theories and gender studies (Solomon, Testoni & Bianco 2017, Testoni 2016, because the combination of the emic view of the participants and the interpretative etic view of the researchers facilitates the understanding of cultural issues about health (Oliffe & Bottorff 2006).
Data were analysed using the framework method for thematic qualitative analysis, which allows sources to be examined in terms of their principal concepts or themes, because this approach is particularly appropriate, especially in research on sensitive topics (Marshall & Rossman 1999, Pope, Zeibland & Mays 2000. The process was developed based on both prior categories and others that only became clear as the analysis proceeded. The former were the basic "pre-fabricated themes", from which the latter emerged as unexpected topics.
Exploring connections between explicit statements and implicit meanings of discourses (cf. Attride-Stirling 2001, Testoni et al. 2016), the process was divided into six main phases: preparatory organisation, generation of categories or themes, coding data, testing emerging understanding, searching for alternative explanations and writing up the report (Marshall & Rossman 1999, Testoni et al. 2018. The corpora were analysed in the three original languages, and this was performed with Atlas.ti. The outcome resulted in network graphs, describing logical relationships between concepts and categories (Muhr 1993). (14) reported that the story was very similar to their personal experience: "Yes, this story is really similar to my husband's and my experience"; "Yes, I lived something that was really analogous to this example". Beyond this fundamental concordance, which confirmed the reliability of our initial work with the texts retrieved from the Internet, the analysis of the corpora recognised three macro-themes: the two binaries of the dual process model (cf. Stroebe & Schut 1999) characterised the first (orientation to loss) and the third (orientation to restoration) thematic areas, linked to each other by the second area inherent to the social disenfranchisement of parental loss (Doka & Aber 1989, Doka 2002) and transgender identity.

First thematic area: mourning orientation to loss and fear of death
From first analysis, some areas of meaning concerning the experience of loss emerged from the parents' narrations. The relationship that characterises these areas is not sequential (in fact they are not stages), but it is interdependent. These areas will be listed below.
In the beginning, the orientation to loss was characterised by shock and denial. It appeared in an early phase of the experience. Parents could not understand what their children were going through and so denied it. Next, parents experienced another emotion, like fear or powerlessness, because of a lack of understanding. They faced it without appropriate coping strategies and resources. The following phase was characterised by crying, anger and hopelessness: "I didn't know how to stop crying. I had to review everything again, and I was scared for her health. Operations and hormones: I didn't know how to manage it".
Running parallel with tears and anxiety, guilt and fear of death appeared as further emotions that characterised the experience of loss: "No parent can easily accept the discovery that their child is transgender. We immediately think about all the physical and psychological suffering that they will experience during the transition process due to the context of rejection.
The fear of operations. For me, it was a long period of suffering!" Finally, the specific experience of loss and mourning appeared: "I recognise that I have spent a lot of time in mourning as it took some time to accept that a daughter was leaving and that I now had a son".
Parents showed how they felt anger, fear and anxiety in the initial phases of the acceptance process. The second phase was characterised by the mourning experience. When children come out as transgender, a slow transition process (even if only a social transition) begins, during which they need support and acceptance (Olson et al. 2016). At the very same time, parents have to change their beliefs relating to sexual identity, and learn something about sexuality and about their children, which is totally new in their daily lives.

Second thematic area: the disenfranchisement of mourning and transgender identity between family and society
Parents manifested their social isolation ( Figure 3) and the difficulty of being understood regarding their own suffering and experience of loss in their network of family and social relationships. Difficulties relating to social acceptance, family and couple support could extend and complicate the mourning phase of depression and sadness.
Parents showed that they felt excluded from social contexts, and that often, communication with family members and network relationships were very difficult. Within the family relationships, the most painful was that with their intimate partner, in their role as the parental couple.

Figure 3 Isolation feelings in parents
Parents were often faced with exclusion from social contexts, and, above all, with rejection from partners or family members. Such rejection could make the path of acceptance even more complicated because of the absence of social resources, which are useful to cope with the mourning experience (Stroebe, Stroebe & Abakoumkin 1999).
Running parallel with the perception of disenfranchisement from the affective relational context, anxiety was especially related to the social consequences: "I was terrorised by some images. I imagined that my child risked being raped or battered after the transition"; "I was scared by the idea of the labelling effects"; "I worried about how society would treat him.
Would he have a peaceful life?"

Third thematic area: the mourning orientation to restoration
During the elaboration process, some parents were oriented towards the resolution of their mourning and the reconstruction of their lives, as shown in their answers: "It took me a while to accept I would lose my daughter, but it is possible to overcome it" or "I never thought it was our fault, that we, the parents, were wrong. Nevertheless, it was a very hard blow. At first, we suffered deeply, but then, as we saw the suffering of our daughter, the pain decreased".
In the survey, researchers asked parents if there was a particular factor or resource that helped them to face the process of acceptance and cope with it positively (Question n. 7 "What helped you to accept the situation?"). Among the parents involved in the study, those who best overcame the grief were those who had a type of social support (social context, family and partners): "I was lucky to have a wife who understood my and her suffering"; "I was lucky to meet A.GE.DO along the way. This association gave me the opportunity to talk to other parents who had gone through more or less the same things before me. All this has been a lot of help".
Most participants were involved in advocacy activities. These experiences helped them in reorganisation of their own biographical narrations with different roles: "I think I am a better person than before"; "My homophobia has gone away". These parents were able to use a new social identity as parents of transgendered people and activists in defence of their rights.
Moreover, the support of the associations reinforced the most important resource, which facilitated the positive evolution of the process: the awareness that their children's identities were the same: "My son is always the same person"; "I didn't lose him. My son is still my son"; "He, his person is still here, he is with me".
Another fundamental pivot for resilience was the awareness that their children could be happy. The love for their children was the engine that allowed the parents to face the whole path: "The transition process has been long, difficult and painful, but it ended with the surgery, and now we are more serene because she is happy"; "It was important to know that he would regain his serenity, that he could have his own life, the one he wanted, that he could like himself when he looked in the mirror, that he could accept himself, that he could marry the girl he was in love with". In particular, the examination of reality helped parents to overcome their grief, through positive thoughts linked to the discovery and the meeting of a "new child" who was the transformation of the lost one. This feeling was defined as a particular form of grief: "I lived it as mourning but with rewards". In fact, the final recompense was living with children who were happier and maintaining a more trustworthy relationship with them: "Now I really know my daughter, and I have a more authentic relationship with her"; "More than losing something, I feel I have gained a true relationship"; "I accept 100% that they were born this way"; "I am Unauthentifiziert | Heruntergeladen 03.02.20 02:59 UTC preparing everything to try to change his name on his identity card"; "I helped my son to become what he wanted, both economically and by supporting him with my love"; "The important thing is that they are happy"; "My son is happy now"; "Now I see him happy".
Two parents reported having immediately accepted their children's transformation, without experiencing any difficulty or mourning experience. They were American and considered gender as a "social construct", claiming that gender has nothing to do with personality: "I understand that gender is a spectrum just like sexuality". However, they also reported their familiarity with GLBT realities, assuming that such a competence might have helped them to better understand their children's feelings: "I'm a non-binary person. I was familiar with language and emotions"; "I am bisexual and I have been part of the queer community for most of my adult life".

Discussion
Our study assumed the constructionist perspective, focused on the influence of culture on sex-typing and on the representations of child gender development (Bem 1981, Bornstein 2013, Halim et al. 2018, Martin, Ruble & Szkrybalo 2002, Shirani, Henwood & Coltart 2012 to survey its influence on parents' loss deriving from their children's transgender identity. After checking the informal literature on the Internet and writing a story inspired by narrations found on websites, thanks to queer associations, we contacted parents from the U.S.A., Italy and Spain. On the one hand, we were looking into their possible experiences of loss and grief and, on the other, into the identifiable differences among the three groups of participants because of the different levels of social diffusion of sexual identity issues in their countries. Most participants considered the story to be very similar to their own experiences, and, with respect to the first purpose, we could confirm that almost all participants grieved for the loss of the appearance of their children as they were before the transition. Their mourning was very similar to those experiences we found described on the Internet and was hugely influenced by negative reactions of family and society. The qualitative analysis permitted us to recognise the two dimensions of the dual process model (Stroebe & Schut 1999), but, furthermore, the Kübler-Ross (1969) phases could have been considered in this kind of parental suffering. In particular, before the final acceptance, in the stage of the grief oriented to loss, we recognised denial, anger, bargaining and depression. But, before the conclusive reorganisation and recovery, there was also shock, bewilderment and confusion, as described by the four-stage models of Bowlby (1961Bowlby ( , 1980 and Parkes (2010). However, in this initial scenario, especially in the pre-transition period, the grief oriented to loss was especially characterised by fear and Unauthentifiziert | Heruntergeladen 03.02.20 02:59 UTC anguish for the future of the children, and by loneliness because of the social disenfranchisement not only of the parental mourning but also of the transgender identity. The absence of social support and the incapability of the family members, in particular of the partner (Kuvalanka, Weiner & Mahan 2014), had a deleterious effect on the entire process. The orientation to restoration was characterised by processes very similar to those indicated by Rando's (1993) six Rs model (recognise, react, recollect and re-experience, relinquish, readjust and reinvest). After the recognition of the loss with the understanding that it had happened and the emotional reaction to their loss, parents recollected and tried to re-experience through reviewing memories of the lost representations of the child's gender.
After the complete acceptation of the change with its accompanying burdens and being able to move on from them, the final stage of reinvestment aimed at them re-entering the world, permitting them to form new relationships and commitments (Field & Mattson 2016).
Furthermore, an important concept passed from complexity epistemologies (i.e. Varela, Thompson & Rosch 1991) to gender theories (Blackburn & Smith 2010, Dwyer 2008, Migdalek 2016, Roen 2001 can also help parents less familiar with constructionist theories and more oriented towards traditionalist essentialism. Indeed, in Italian and Spanish texts, the concept of "embodiment" appears in a latent form, inspired by the representation of the authentic identity of their children. What helped them most was the awareness that their children were finally comfortable with their bodies. The wellbeing of the children was what most helped them to sustain the effort of the entire journey, overcoming any form of grief, to the point of becoming activists in the field of GLBT.

Conclusions
All participants in the research could manage the loss experience and put it behind them, realising and accepting that their children had truly changed. But the most significant change lies in parents' conception of who their children were. With acceptance parents realized that there was no turning back. Indeed, the reward of creating a more authentic relationship with their children characterised all chapters of their mourning. Then the readjustment began with having to face daily life, which required a lot of complex actions, useful in supporting the children's transitions.
In particular, the desire to understand the contents and values of gender theories and the choice to collaborate with the associations that have helped them, allowed them to discover a new existential design for the future. Undeniably, the cultural factors played two opposite roles: on the one hand, the social disenfranchisement of transgender identity and the parental grief Unauthentifiziert | Heruntergeladen 03.02.20 02:59 UTC were extrinsic loss-oriented stressors, which caused hopelessness and powerlessness, and, on the other, queer activism has given meaning to the whole situation, offering parents useful indications both from a theoretical and practical point of view.
Despite the positive result, we reinforced our conviction that psychologists are absent in the initial phase of the parental experience of loss. We think that psychologists and counsellors are therefore called upon to acquire competence in this regard, so as not to pathologize the experience, and, thus, address it at least at an early stage from a culturally open and competent perspective.

Limits of Research
The qualitative paradigm used makes it possible to investigate the meanings of reported experiences. However, it was characterised by an important interpretative component because of the small number of participants. All of this could potentially be a limitation. Furthermore, the use of a written questionnaire limited the possibility of dialogue with participants. Further research will be aimed at more in-depth analysis of the socio-cultural background and its influence on grief and could be realised with face-to-face interviews, adopting the interpretative phenomenological analysis technique, to more widely investigate the interaction between these factors.