Case vignette

Creating an affirmative space

Inclusive Language Illustration

Creating an affirmative space

A 13 year old patient is brought in by her mother. Her mother explains the patient has recently come out to her as transgender and has asked them all to use she/her pronouns. The mom immediately begins to misgender the patient and tells the therapist she is worried her “son” is getting ideas in “his” head from social media or school and has also been becoming more isolated and angry. The mom also mentions she has noticed multiple red spots on her son, but this is probably a medical question. 

The therapist thanks the mother for sharing and asks to speak to the teen alone. The therapist asks the patient if she/her pronouns are correct and if the patient has a name she would like the therapist to use. The patient confirms she does use she/her pronouns and she has been thinking about using the name Delilah. She explains, so far, she has asked some of her friends and her drama teacher to start using this. The therapist then shares that they can’t help but notice it sounds like coming out at home hasn’t gone to plan and asks if the patient would like to talk more about this. The patient starts to share the sadness she feels surrounding her mom thinking she is doing this for attention, when it took her a long time to even figure out what to say. The teen says she feels angry and hides in her room because being misgendered makes her feel unseen, unheard, and not important. She also shared she would rather avoid her mom than fight. She explains her mom has always listened and been supportive so to hear her say she thinks the teen is just being influenced by media hurts. The teen also opens up about how she feels starting puberty has led her to feel really uncomfortable about some of the recent physical changes she has noticed. She explains she has started to avoid looking in the mirror and has started pulling out hair she notices on her body. She also says she regrets showing her mom the trans woman on TikTok who helped her better understand what she is feeling, because she feels like this made her mom think she’s just influenced vs. thinking for herself. 

The therapist also takes time to ask the teen what she feels she would like to focus on in therapy. The teen explains she has a friend who went to therapy where they learned how to cope with negative thoughts better and she would like to try this. The therapist notes they can work on that and also asks if it might be helpful to work on how the patient can feel more confident and stop pulling out hair. The patient laughs a little and agrees the hair pulling does hurt. At the end of the session the therapist also shares that she can tell the mom cares about the teen and wonders if maybe the mom is reacting to her own emotions, but that’s not how it’s coming across. The therapist then asks the teen if she can talk to the mom one on one and discusses what this would look like.

Things to consider.


The therapist is careful to not disbelieve, discourage, or deny the teens experience and feelings. Instead, the therapist gathers information that affirms the patient's gender and uses this to help build rapport, trust, and better understand the teens side of the story, but also makes treatment about the teen vs. only the mothers requests. The therapist also explains the next steps to the teen and makes the teen feel included and know her opinion matters. 


Creating an affirmative treatment space is about making the patient feel supported, seen, and heard. If the therapist had immediately started asking really detailed questions about why the teen “thinks” they are transgender etc. this would likely have led the teen to shut down and become defensive. It also could have potentially led the teen to feel the therapist was “taking sides”.

Question to think about:

How can you make sure therapy does not become rooted in believing if what the teen is saying or experiencing is “real”, “correct”, “right”, “popular”, but instead about providing safety, validation, support, and empathy?