Psycho-Emotional and Well-Being Aspects in Caregivers of Transgender and Gender-Diverse Individuals: A Narrative Review

Abstract

Gender incongruence significantly impacts the family system, yet the subjective experiences of caregivers remain relatively underexplored. This narrative review synthesizes contemporary evidence regarding psychological distress, emotional burden, and quality of life among caregivers of transgender and gender-diverse individuals. A targeted literature search of PubMed, Scopus, PsycInfo, and Google Scholar (2015–2025) was conducted, identifying 16 studies for thematic synthesis. Results indicate that caregivers consistently report elevated emotional distress, characterized by chronic anxiety, hypervigilance, and ambiguous loss. This burden is primarily driven by prolonged exposure to uncertainty, the weight of complex medical decision-making—particularly regarding fertility and hormone therapy—and vicarious minority stress stemming from social stigma and systemic barriers. Notably, distress is often intensified by sociopolitical climates rather than the transition process itself. Conversely, access to peer support networks, healthcare relationships, and engagement in advocacy emerged as vital protective factors facilitating resilience and adaptive meaning-making. We can conclude that caregiver well-being is a multifaceted process deeply embedded in social and institutional contexts. These findings underscore the necessity of integrated, family-centered medical-psychological models that explicitly support caregivers to ensure more equitable and effective gender-affirming care pathways.

1. Introduction

Gender incongruence, as defined by the World Health Organization in the International Classification of Diseases, 11th Revision (ICD-11) [1], refers to a marked and persistent incongruence between an individual’s experienced gender and the sex assigned at birth. In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [2], the diagnosis of gender dysphoria is used to describe the clinically significant distress that may accompany this incongruence. Although these diagnostic frameworks primarily focus on the individual, clinical and relational literature suggests that gender-related distress and its therapeutic management often extend beyond the person, substantially involving the family system and, in particular, primary caregivers.

Caregiving in the context of gender incongruence is not a neutral or peripheral experience, but rather a complex process that may profoundly affect caregivers’ emotional, psychological, and relational well-being. Qualitative studies have documented that parents and family members of transgender (TGN) and gender-diverse individuals (GDI) frequently experience heightened levels of anxiety, uncertainty, fear for their child’s safety, and chronic emotional burden, particularly during early phases of gender disclosure and initiation of gender-related care [3,4,5]. Despite increasing attention to mental health outcomes among TGN populations, the subjective experiences of caregivers remain relatively underexplored, particularly in relation to their perceived well-being and coping strategies, which are often described qualitatively rather than assessed through standardized measures of quality of life (QoL).

From a clinical perspective, medical aspects of gender-affirming care represent a central source of stress for caregivers. Endocrinologists’ decisions related to puberty suppression, hormone therapy, and gender-affirming surgeries often involve complex, time-sensitive choices that carry significant emotional and moral weight [6]. These decisions are frequently made within contexts characterized by evolving scientific evidence, polarized public discourse, and, at times, inconsistent professional guidance [5]. Such conditions may intensify decisional anxiety, fear of irreversible outcomes, and perceived parental responsibility.

Within this framework, although not directly focused on caregivers, recent clinical contributions based on case studies provide additional insight into the psychological complexity of gender-affirming medical pathways [7,8,9]. Indeed, these care pathways are characterized by clinical complexity, prolonged uncertainty, and the need for multidisciplinary coordination [10]. The complexity and uncertainty inherent in medical decision-making may indirectly shape caregiver stress, particularly when caregivers are actively involved in supporting and navigating these processes.

Overall, empirical research specifically addressing the mental health and QoL of caregivers of individuals with gender dysphoria or gender incongruence remains limited and predominantly qualitative. Moreover, the existing literature tends to focus on Western, parent-based samples, which may limit the generalizability of findings to other cultural and familial contexts.

Considering these issues, the present narrative review aims to critically synthesize available evidence on psychological distress, emotional burden, and subjective well-being among caregivers of TGN and gender-diverse individuals. By identifying key sources of risk and protection, including social support, parental empowerment, and advocacy processes, this review seeks to provide clinical practice insights supporting the development of integrated medical-psychological models that explicitly recognize caregivers as relevant actors within the broader context of gender-affirming care systems.

2. Materials and Methods

We conducted a narrative exploratory review aimed at synthesizing available empirical and theoretical evidence on the mental health and subjective well-being of caregivers of individuals with gender dysphoria or gender incongruence. A narrative approach was selected in light of the limited availability of empirical studies, the predominance of qualitative research designs, and the substantial heterogeneity of methodologies and outcome measures characterizing this emerging field. This methodological choice was considered appropriate to allow conceptual integration and clinically informed interpretation of findings that would not be adequately captured through strictly systematic or meta-analytic approaches. This approach allows for in-depth conceptual integration of findings and is particularly suited to underexplored and complex research areas. However, we acknowledge that narrative reviews are inherently limited in terms of replicability and transparency when compared to systematic approaches.

A targeted literature search was conducted using PubMed, Scopus, PsycInfo and Google Scholar. Reference lists of eligible articles were also hand-searched to identify additional relevant studies not captured through database searches. Records were screened for relevance based on titles and abstracts, with selection guided by consistency with the aims of the review.

Search terms were combined using the following keywords: “gender dysphoria”, “gender incongruence”, “transgender”, “gender-diverse”, “caregivers”, “parents”, “family”, “mental health”, “psychological distress”, “quality of life”, “QoL”, “stress”, and “burden”. The search focused on articles published between 2015 and 2025, reflecting contemporary diagnostic frameworks [1,2] and current models of gender-affirming care.

Studies were included if they explicitly focused on caregivers or family members (predominantly parents) of TGN or GDI and addressed caregivers’ psychological experiences relevant to mental health, emotional distress, stress, coping, or perceived QoL. Both qualitative and quantitative study designs were considered eligible. Only studies published in peer-reviewed journals and written in English were considered. To preserve conceptual and clinical specificity, studies addressing broader LGBTQ+ populations without an explicit focus on caregivers of TGN or GDI were intentionally excluded. To further enhance conceptual clarity, studies were excluded when caregiver experiences were mentioned only marginally or could not be analytically separated from general family or community narratives. These exclusion criteria were applied to avoid conflating caregiver-specific psychological processes with broader psychosocial dynamics. Editorials, opinion papers, and studies in which caregiver-related outcomes could not be clearly distinguished from those of the TGN or GDI were also excluded.

Although several included studies did not assess caregiver mental health or QoL using standardized quantitative instruments as primary outcomes, they were retained because they provided essential qualitative insight into caregivers’ emotional burden, stress processes, relational dynamics, and meaning-making trajectories that inform subjective well-being. We acknowledge that the construct of “QoL” is not used here in a psychometrically validated sense, but rather as an interpretive framework emerging from the data. In order to enhance epistemological transparency, the included literature was conceptually differentiated into two categories: (a) core empirical studies directly examining caregiver psychological experiences, and (b) contextual or conceptual contributions offering theoretical frameworks or clinically grounded reflections relevant to caregiver experience. Additionally, a limited number of conceptual studies were included when they offered contextually relevant frameworks or clinical reflections that enriched understandings of caregiver experience. These were explicitly marked and discussed as secondary evidence.

For each included study, key information was extracted regarding study design, caregiver sample characteristics, developmental stage of the TGN or GDI, caregiver-related psychological domains addressed, and reported risk and protective factors.

Given the heterogeneity of study designs, samples, and outcome domains, findings were synthesized narratively using a thematic approach. The synthesis focused on identifying recurring patterns related to caregivers’ emotional distress, minority stress experiences, medical decision-making, and perceived QoL, with particular attention to relational, contextual, and process-oriented dimensions of caregiving. In line with the exploratory and narrative nature of the review, no formal quality appraisal tools (e.g., PRISMA, CASP) were applied, and conceptual papers were included when explicitly relevant to contextualize empirical evidence. Given the sensitivity of the topic, particular care was taken to ensure transparency in how interpretive contributions were distinguished from empirical data to avoid conflating theoretical insight with measurable outcomes.

3. Results

The initial literature search identified approximately 140 records across the selected databases. After removal of duplicates and screening of titles and abstracts for relevance, 28 articles were reviewed in full text. Although a PRISMA flow diagram was not applied due to the narrative nature of the review, the selection process followed a structured screening of abstracts and full texts based on predefined inclusion and exclusion criteria. Nonetheless, we acknowledge that this procedure may not fully prevent selection bias and limits the replicability of the process.

Following full-text assessment, six studies met strict inclusion criteria as core empirical contributions directly addressing caregivers’ psychological distress, burden, or related mental health experiences and were retained as the primary evidence base for the narrative synthesis.

In addition to these core studies, a total of 16 studies were included in the review to provide a broader conceptual and contextual understanding of caregiver experiences.

Table 1. Studies included in the narrative review.

Study	Study Design	Sample	Main Aim	Tools Used	Caregiver-Relevant Findings
Rahilly (2015) [11]	Transversal cohort study	24 parents of 16 youth (mean age: 8 years; 10 gender-variant AMAB, 1 trans feminine AMAB, 1 gender-variant AFAB and 4 trans masculine AFAB)	To analyze how parents develop a critical consciousness about gender binary ideology and work to accommodate their children’s nonconformity in diverse discursive interactions	Qualitative interviews	Parents of gender-variant children actively challenge the gender binary regime, developing child-driven, discursive, and practical strategies that make TGN and nonbinary identities socially viable from early childhood.
Sansfaçon et al. (2015) [12]	Transversal cohort study	14 parents of gender-variant children	To understand the issues and challenges experienced by parents of gender-variant children in the process of supporting their children’s gender identity	Participatory action research using SAM questions	Parents of gender-variant children experience pervasive invisibility and nonrecognition across personal, social, medical, and institutional contexts.
Gray et al. (2016) [13]	Transversal cohort study	11 cisgender parents (8 mothers and 3 fathers) of gender variant youth (ages 5–13)	To describe the experience of parenting a gender variant child	Qualitative semi-structured interviews	Parents sought to create a nonstigmatized childhood for their gender-variant children by either protecting them from anticipated stigma or openly affirming gender variance.
Pyne (2016) [14]	Transversal cohort study	15 parents (12 mothers and 3 fathers) of gender non-conforming youth (age 12 years or less)	To explore how parents come to know their children’s gender identities and to understand the knowledge underlying the decision to affirm children’s self-identities	Qualitative interviews	Parents of gender non-conforming children draw on relational, justice-oriented knowledge rather than pathologizing expertise, trusting their children’s self-defined experiences and relinquishing parental authority over gender
Barron and Capous-Desyllas (2017) [15]	Transversal cohort study	4 families with prepubescent TGN children (parents, siblings, children)	To explore lived experiences of TGN children and family members during early social transition	In-depth interviews, participant observation, journaling	Parents experience emotional strain, vigilance, and moral responsibility related to social transition, stigma exposure, and institutional scrutiny
Capous-Desyllas and Barron (2017) [16]	Transversal cohort study	Families of TGN and gender-variant children and adolescents	To explore challenges and therapeutic considerations in social work practice with TGN youth and their families	Clinical observation, case vignettes, theoretical reflection)	Caregivers experience confusion, grief, guilt, and relational disorientation when a child’s gender identity challenges binary expectations; parental distress is shaped by stigma, lack of social support, and medical pathologization
Chen et al. (2017) [17]	Transversal cohort study	40 parents of 24 prepubertal TGN and gender-nonconforming children (ages 4–11)	To explore parental perceptions of emotional and behavioral difficulties in TGN children and inform adaptation of evidence-based interventions	Targeted focus groups; free-listing activity; directed content analysis	Parents described continuous emotional vigilance, interpretive burden, and responsibility in understanding and managing their child’s emotional and behavioral difficulties in relation to gender nonconformity
Evans et al. (2017) [7]	Transversal cohort study	50 caregivers of TGN youth (≤22 years) and 15 TGN youth	To explore how TGN youth and their caregivers use online resources to seek information, support, and guidance related to TGN health and care	Semi-structured focus groups and interviews; online open-ended survey; inductive thematic analysis	Caregivers described significant informational burden, stress, and uncertainty when seeking reliable guidance on gender-affirming care, alongside reliance on online communities to compensate for limited local resources
Katz-Wise et al. (2017) [3]	Transversal cohort study	48 cisgender caregivers (32 women, 16 men) and 15 cisgender siblings (7 girls/women and 8 boys/men) of 33 TGN youth (age 13–17 years; 12 trans feminine AMAB, 17 trans masculine AFAB, 3 non binary AFAB and 1 non binary AMAB)	To describe the mental health status of TGN youth and to examine how TGN youths’ mental health may be associated with family functioning (communication and satisfaction), analyzed from Wave 1 of the TTFN	Family functioning: 8-item subscale from the FACES IV; Family satisfaction: 10-item subscale from the FACES IV	Better family communication and greater family satisfaction were associated with less adverse mental health outcomes and greater self-esteem and resiliency among TGN youth
Coolhart et al. (2018) [9]	Transversal cohort study	6 parents of TGN male youth (ages 14–19) recruited from U.S. clinical and community settings	To explore parents’ experiences of ambiguous loss following their child’s disclosure and gender transition	In-depth semi-structured interviews; Interpretative Phenomenological Analysis [18]	Parents described heterogeneous experiences of ambiguous loss, grief, and emotional ambiguity related to loss of imagined futures, gendered expectations, and rites of passage
Kuvalanka et al. (2018) [19]	Transversal cohort study	8 cisgender non-heterosexual mothers (4 bisexual, 3 lesbian, 1 pan/bisexual) of 8 TGN youth (age 6–11 years)	To understand sexual minority parents’ perspectives and experiences that influence their understanding and acceptance of their TGN children	Qualitative semi-structured interviews	Sexual minority mothers of TGN children were shaped by cisnormativity and heteronormativity, with their queer identities sometimes fostering greater empathy and advocacy for their children.
Schimmel-Bristow et al. (2018) [8]	Transversal cohort study	18 caregivers of TGN youth aged 14–22 years and 15 TGN youth recruited from a U.S. pediatric gender clinic	To explore youth and caregiver experiences across stages of gender identity recognition, coming out, and social transition	Semi-structured interviews and focus groups	Caregivers described emotional burden, uncertainty, and periods of perceived loss during their child’s transition, alongside progressive adaptation through education, advocacy, and social support
Kidd et al. (2021) [5]	Transversal cohort study	273 parents of TGN youth	To understand parent and caregiver perceptions of proposed legislation aimed at limiting access to gender-affirming interventions	Social media-based anonymous online survey	Healthcare barriers, costs, and geographical distance increase anxiety, frustration, and feelings of helplessness among caregivers.
Kahn et al. (2024) [20]	Transversal cohort study	18 caregivers of TGN and gender-diverse adolescents aged 14–17 receiving gender-affirming care	To explore caregivers’ perspectives on advantages, disadvantages, and preferences regarding telemedicine delivery of gender-affirming care	Semi-structured individual interviews; inductive thematic analysis	Caregivers reported reduced anxiety and increased comfort when accessing care via telemedicine, alongside persistent concerns related to privacy, technological barriers, and reduced relational depth
Katz-Wise et al. (2024) [21]	Transversal cohort study	TGN and/or nonbinary youth (n = 18), caregivers (n = 8), siblings (n = 8), and mental health providers (n = 9) involved across multiple phases of intervention development	To develop a family-level intervention to support families with TGN and/or nonbinary youth by improving communication, acceptance, and family functioning	Digital storytelling workshops, semi-structured interviews, focus groups, iterative content review	Caregivers described emotional burden, uncertainty, and minority-adjacent stress related to supporting their child, alongside a strong need for guidance, psychoeducation, and relational support
Stolk et al. (2025) [22]	Multicenter prospective cohort study	316 TGN and gender-diverse adolescents and their parents	To assess attitudes toward parenthood, fertility, fertility preservation, and decisional conflict prior to initiation of puberty suppression or gender-affirming hormone therapy	TYFAQ; DCS; clinical data from medical records	Parents showed active involvement in fertility-related decision-making and generally expressed a desire to preserve future reproductive options for their children while prioritizing the child’s autonomy

AFAB: assigned female at birth; AMAB: assigned male at birth; DCS: Decisional Conflict Scale [23]; FACES IV: Family Adaptability and Cohesion Evaluation Scales; SAM: social action model [24]; TGN: transgender; TTFN: Trans Teen and Family Narratives Project; TYFAQ: Transgender Youth Fertility Attitudes Questionnaire [25].

summarizes the characteristics of all included studies and presents them in chronological order to illustrate the evolution of research on caregivers of TGN and GDI.

Table 1 illustrates that caregivers of TGD and gender-diverse youth often face significant emotional burdens, including anxiety, uncertainty, and stigma, which are frequently exacerbated by a lack of institutional support. However, the studies also highlight that moving from distress to advocacy, accessing peer and online resources, and fostering open family communication are crucial strategies that build resilience and improve well-being for both caregivers and their children. The available literature is characterized by a predominance of qualitative methodologies, small to moderate sample sizes, and a focus on parental perspectives within Western sociocultural contexts, particularly North America. Most studies employed semi-structured interviews, thematic analysis, or qualitative content analysis. As none of the included studies employed validated psychometric instruments to directly assess caregivers’ QoL, subjective well-being was inferred from qualitative markers including emotional distress, stress symptoms, relational strain, and coping patterns. Consequently, references to ‘QoL’ in this review should be interpreted conceptually rather than as standardized psychometric data.

3.1. Emotional Distress and Mental Health Burden in Caregivers

Across qualitative and mixed-method studies, caregivers of TGN and GDI consistently report elevated levels of emotional distress, characterized by pervasive anxiety, chronic stress, emotional exhaustion, and heightened vigilance. This distress does not appear as a secondary reaction limited to later stages of medical decision-making, but rather emerges early in the caregiving trajectory, often coinciding with the initial disclosure of gender incongruence and the first encounters with social, educational, and healthcare systems [8,9,13].

A recurring phenomenological pattern involves persistent worry related to the child’s psychological well-being, physical safety, and social exposure. Caregivers frequently describe a state of continuous alertness, marked by fears of bullying, discrimination, and social rejection, particularly within school environments and peer contexts. This hypervigilant stance tends to become emotionally taxing over time, contributing to feelings of fatigue, helplessness, and progressive depletion of personal emotional resources [13,17].

Importantly, several studies indicate that such distress is present even in the absence of formal diagnostic assessments or irreversible medical interventions. Gray et al. highlighted that caregivers often experience intense emotional burden during early stages of identity exploration, when uncertainty is high and access to reliable information and specialized support is limited [13]. Similarly, Chen et al. observed that parental stress is strongly associated with navigating school systems, negotiating disclosure decisions, and managing anticipated stigma, rather than with the medical aspects of gender-affirming pathways per se [17]. Taken together, these findings suggest that caregiver distress is less driven by specific clinical procedures and more by prolonged exposure to ambiguity, responsibility, and perceived social threat.

Another salient dimension of caregiver distress concerns the internalization of responsibility for the child’s future outcomes. Many caregivers report a strong sense of moral weight and anticipatory guilt, particularly in relation to decisions perceived as potentially determining long-term well-being, social integration, and mental health. This perceived responsibility often coexists with doubts about personal competence, fears of making irreversible mistakes, and the absence of clear societal or institutional guidance, further amplifying emotional strain [8,9]. Nonetheless, several studies also highlighted moments of resilience and adaptive growth among caregivers, including increased emotional closeness with their children, a stronger sense of purpose, and the development of advocacy skills and community engagement. These aspects, although less frequently emphasized, suggest that caregiver trajectories are not solely defined by burden, but may also encompass positive transformation and relational empowerment.

Overall, literature portrays caregiver distress as a multifaceted and temporally extended process, shaped by uncertainty, hypervigilance, and sustained emotional labor. Rather than a transient reaction to discrete events, distress appears embedded within the caregiving role itself, evolving across developmental stages and social contexts. These proximal emotional burdens interact with broader sociocultural and structural factors, which will be examined in subsequent sections, particularly in relation to minority stress and sociopolitical climates. While the studies reviewed provide rich qualitative insight, they often rely on small, self-selected samples and may disproportionately represent caregivers who are more psychologically impacted or engaged in healthcare systems. This may limit the representativeness of the reported distress levels and calls for caution when generalizing across diverse caregiver populations.

3.2. Anticipatory Anxiety and Future-Oriented Distress

The Trans Youth Family Study examined how TGN and gender-nonconforming youth and their caregivers mentally represent the youth’s future [3]. Through qualitative interviews with 16 families, caregivers frequently reported uncertainty and concern regarding long-term outcomes, including discrimination, social acceptance, and physical and emotional safety. These concerns were characterized not as transient stress reactions but as a persistent form of future-oriented psychological distress, marked by anticipatory worry and heightened vigilance [3,8,9]. This future-oriented distress was often shaped by caregivers’ attempts to imagine developmental trajectories in sociocultural environments that may not be affirming, reinforcing feelings of isolation and helplessness. At the same time, some caregivers described the development of future-oriented coping strategies, including proactive planning, community engagement, and efforts to secure affirming educational or medical settings. These anticipatory efforts, while emotionally taxing, also reflected agency and resilience in navigating structural uncertainty.

3.3. Ambiguous Loss, Uncertainty, and Non-Linear Adaptation

Across qualitative studies, caregivers of TGN and GDI frequently report experiences consistent with ambiguous loss, particularly during early developmental stages. This form of loss does not concern the child as a person, but rather the disruption of anticipated narratives, imagined futures, and previously held assumptions regarding identity and life trajectories [3,8,9].

Qualitative evidence highlights how ambiguous loss is embedded in relational and non-linear processes of adaptation rather than resolved through diagnostic certainty or expert-driven models. A Canadian qualitative study described how caregivers move through phases of fear, confusion, and uncertainty, gradually developing meaning through sustained relational attunement to their children’s verbal, affective, and embodied communication [14]. Within this process, parents often relocate the source of distress from the child to broader social and institutional contexts, actively rejecting pathologizing interpretations of gender non-conformity. While such meaning-making processes are complex and emotionally taxing, they often enhance parental sensitivity, strengthen emotional bonds, and improve the capacity to tolerate ambiguity.

Findings from the Trans Youth Family Study further illustrate how ambiguous loss coexists with future-oriented uncertainty, concerns about physical and emotional safety, and reflections on social and relational outcomes, without implying disengagement or rejection [3]. Rather, caregivers remain emotionally and relationally invested while navigating unresolved uncertainty and shifting meanings over time. This active engagement, in the face of unresolved grief and unpredictability, suggests that ambiguity can become a space for resilience, rather than dysfunction.

This non-linear adaptation is also reflected in studies adopting ecological and family-based frameworks. Gray et al. described caregiving as a dynamic process characterized by persistent worry, heightened vigilance, and movement between protective and affirming strategies in response to anticipated stigma and social pressures [13]. Similarly, ethnographic and interview-based studies documented sustained emotional strain related to discrimination, social exposure, and everyday relational contexts, alongside continued commitment to the child’s well-being [9,15]. These findings underline that adaptation is neither linear nor unidirectional but oscillates over time and across contexts, incorporating both vulnerability and strength.

Overall, ambiguous loss emerges as a central emotional process in TGN caregiving, marked by the coexistence of grief, uncertainty, and relational closeness. This framework underscores the relational and evolving nature of caregiver adaptation and highlights the importance of clinical approaches that acknowledge parental grief without framing it as detachment or lack of acceptance [4]. However, most studies exploring ambiguous loss in this context rely on small, qualitative samples and narrative designs, which, while rich in depth, may not fully capture the variability of caregiver experiences across different cultural, familial, and institutional settings. This calls for caution in generalizing findings and suggests the need for further research examining diverse trajectories of adaptation.

3.4. Medical Decision-Making as a Central Stressor

Across qualitative studies, medical decision-making consistently emerges as a central source of psychological burden for caregivers of TGN and youth GDIs. Parents frequently describe feeling overwhelmed by the strong responsibility of supporting or authorizing decisions related to puberty suppression, gender-affirming hormone therapy, fertility preservation, and potential future surgical interventions, particularly within contexts characterized by uncertainty, limited access to specialized services, and inconsistent clinical guidance [5,7,8,9]. This decisional burden is not only clinical but deeply ethical and emotional, often situated within rapidly evolving medical norms and sociocultural controversies that amplify caregiver confusion and fear.

Caregivers often report engaging in extensive information-seeking behaviors to compensate for perceived gaps within healthcare systems. While accessing online and informal resources may foster a sense of agency, this process is frequently accompanied by emotional burden, decisional uncertainty, and anxiety related to conflicting information, misinformation, and the perceived weight of responsibility for making “right” choices on behalf of their children [7]. Despite these challenges, some caregivers develop adaptive decision-making strategies over time, including the formation of peer-support networks, reliance on trusted medical professionals, and collaborative approaches that center the adolescent’s voice in shared decision-making.

Medical decision-making is further shaped by broader sociopolitical contexts. In settings marked by legislative threats to gender-affirming care, caregivers describe heightened anticipatory anxiety, moral distress, and feelings of powerlessness, framing medical decisions as existential dilemmas directly tied to parental responsibility, attachment, and fears of irreversible psychological harm [5]. These broader dynamics reveal how caregiver stress is not solely a function of personal uncertainty but also reflects structural vulnerabilities and contested political landscapes.

Complex decisions surrounding fertility preservation represent a particularly salient stressor. Caregivers report elevated decisional conflict when weighing the urgency of gender-affirming treatment against concerns about potential future regret related to fertility loss [6]. These decisions are often complicated by adolescents’ developmental stage, evolving identity trajectories, and the inherent difficulty of translating probabilistic medical information into meaningful long-term implications, intensifying emotional burden and moral tension [22]. Yet, some studies indicate that when provided with anticipatory guidance, emotional support, and developmentally appropriate counseling, caregivers are better able to tolerate uncertainty and engage in values-based decision-making.

Overall, medical decision-making functions as a psychologically dense and emotionally charged process rather than a purely clinical task. These findings highlight the need for integrated, multidisciplinary approaches that attend not only to medical information but also to caregivers’ emotional experiences, decisional conflict, and relational concerns throughout gender-related care pathways. Future research should examine how different models of shared decision-making, cultural values, and access to psychosocial support shape caregiver responses across diverse populations.

3.5. Minority Stress and Social Stigma as Secondary Stressors

Beyond medical decision-making, caregivers consistently report significant psychological burden arising from sociocultural stressors, including stigma, discrimination, and social rejection. Qualitative evidence indicates that caregivers frequently experience forms of secondary or vicarious minority stress, whereby stigma directed at TGN and GDI extends to the family system, shaping caregivers’ emotional well-being and daily functioning [5,7,8]. This indirect exposure to minority stress may manifest as emotional fatigue, relational strain, and internalized vigilance, even in caregivers who do not identify with the minoritized group themselves.

Across the studies hereby examined, caregivers describe chronic vigilance, fear for their child’s safety, and sustained exposure to stigmatizing social environments, particularly within educational, healthcare, religious, and community contexts. Ethnographic and interview-based research highlights how repeated encounters with institutional barriers, lack of recognition, and social exclusion contribute to feelings of isolation, emotional exhaustion, and persistent anticipatory stress [12,16]. However, some caregivers respond to these challenges by becoming more engaged in advocacy and systemic change efforts, transforming personal stress into collective action.

Importantly, caregivers’ emotional burden appears amplified not only by present experiences of stigma, but also by future-oriented concerns shaped by awareness of discriminatory social norms and anticipated rejection. Findings from the Trans Youth Family Study suggest that caregivers’ worries are embedded within broader sociopolitical climates, in which legislative debates, public discourse, and social attitudes toward gender diversity intensify perceptions of threat and marginalization [5,26]. This dynamic highlights how caregiver stress is not reducible to personal emotional responses but reflects deeper entanglements with structural inequality and cultural narratives.

Overall, minority stress processes function as secondary yet pervasive stressors in TGN caregiving, interacting with emotional distress, anticipatory anxiety, and medical decision-making demands. These findings underscore how caregivers’ psychological experiences are deeply embedded within social and institutional contexts, highlighting the need for interventions that address stigma-related stressors alongside individual and relational processes. At the same time, future research should further explore how protective factors—such as community affiliation, access to affirming networks, and caregiver activism—mediate the impact of minority stress, supporting more balanced and resilient caregiving experiences across diverse contexts.

3.6. Protective Factors and Processes Supporting Caregiver Adaptation

Despite the substantial emotional burden documented across studies, literature also identifies several protective factors and processes that may mitigate psychological distress and support caregiver adaptation over time. These include access to social support networks, affirming healthcare relationships, engagement in advocacy, and participation in community-based or peer-led resources [7,11,12]. However, the evidence base remains limited and predominantly qualitative, requiring cautious interpretation regarding the consistency and generalizability of these protective dynamics.

Social support from peers, community groups, and extended family consistently emerges as a key protective factor. Caregivers with access to supportive networks, either in-person and online, report reduced isolation, greater emotional resilience, and enhanced capacity to tolerate uncertainty. Participation in peer and online communities has been associated with increased access to practical information and emotional validation, contributing to more adaptive coping [7,21]. Nonetheless, access to such networks may vary significantly depending on geographic location, language, digital literacy, and cultural acceptance, suggesting that these benefits are not universally available.

Access to knowledgeable and affirming healthcare providers is similarly described as protective. Caregivers who perceive clinical interactions as supportive and informative report greater confidence in medical decision-making and lower levels of anticipatory anxiety.

Conversely, experiences of dismissiveness, lack of provider expertise, or perceived judgment are associated with heightened distress and erosion of trust [7,8]. These contrasting experiences highlight the pivotal role of healthcare contexts in either buffering or amplifying caregiver stress.

Engagement in advocacy represents a complex and potentially transformative dimension of caregiving. Several studies indicate that advocacy at family, school, or community levels is associated with increased empowerment, identity reformulation, and adaptive meaning-making, allowing caregivers to reframe caregiving not only as a burden but also as a source of relational growth and social engagement [11,12,14]. However, advocacy work may also place significant emotional demands on caregivers, particularly when systemic resistance, public hostility, or burnout occur. These dual aspects should be carefully considered in both clinical practice and future research.

Overall, these findings underscore the importance of integrating psychosocial support for caregivers within gender-affirming care models. Clinicians and healthcare systems play a critical role in facilitating access to peer networks, providing psychoeducation, and validating caregivers’ emotional experiences as part of comprehensive, family-centered approaches. Yet, to effectively inform such models, further research is needed to clarify how protective factors function across diverse caregiver populations, cultural contexts, and stages of the caregiving journey.

4. Discussion

This narrative review examined the existing literature on mental health and QoL among caregivers of TGN and GDI, with particular attention to emotional distress, minority stress processes, and protective factors. Across studies, caregiving in the context of gender incongruence emerged as a distinct psychosocial experience characterized by sustained emotional burden rather than transient stress reactions. Caregivers consistently reported anxiety, fear for their child’s physical and psychological safety, uncertainty related to complex medical decision-making, and experiences of ambiguous loss involving disrupted or previously imagined life trajectories [3,5,8,9]. However, the reviewed literature also reveals pathways of resilience, relational growth, and adaptive coping, particularly when caregivers have access to affirming social support, informed healthcare providers, and opportunities for advocacy.

Importantly, caregiver distress did not appear to stem from the child’s gender identity or transition-related processes per se. Instead, the reviewed evidence highlights an interaction between caregivers’ emotional responses, structural barriers within healthcare systems, and broader sociocultural stigma as central contributors to caregiver burden. This interactional pattern supports the conceptualization of caregiver mental health within an ecological and minority stress framework, in which relational dynamics, institutional contexts, and sociopolitical environments jointly shape psychological outcomes [4,5,7]. At the same time, these frameworks must be applied with contextual nuance, as caregiver experiences are not uniform and may differ significantly across cultural, familial, and developmental configurations.

Several limitations should be considered when interpreting these findings. The available literature remains limited in scope, predominantly qualitative, and largely focused on parents within Western sociocultural contexts. These characteristics reflect both the emerging nature of the field and the complexity of caregiving experiences rather than methodological shortcomings per se. While qualitative approaches are particularly well suited to capturing emotional, relational, and process-oriented dimensions of caregiving, this methodological profile constrains generalizability and limits systematic comparisons across studies. Moreover, the lack of standardized tools to assess caregiver QoL, minority stress, and decision-related distress restricts the comparability and operational clarity of the constructs under investigation. Future research should prioritize the development and validation of psychometric instruments tailored to caregiver experiences in gender-affirming contexts.

Additionally, most included studies focused on caregivers of TGN children and adolescents, with comparatively limited attention to caregivers of TGN adults or to caregiving configurations beyond parenthood. This represents a significant gap in the literature, given that caregiving demands, relational dynamics, and stressors may differ substantially across developmental stages and family structures. Although several influential contributions derive from the Trans Youth Family Study and related research programs [3], similar patterns of distress, uncertainty, and non-linear adaptation were observed across independent qualitative studies conducted in diverse clinical and sociocultural settings, supporting the broader relevance of the identified themes. Nevertheless, the predominance of Western-centric samples and English-language sources limits the cultural transferability of current findings. These geographic and cultural constraints call for caution in interpreting the results as universally applicable, particularly in non-Western contexts where family, legal, and religious frameworks may differ substantially. This reinforces the need for more inclusive and cross-cultural research designs.

Future research would benefit from longitudinal and mixed-methods designs capable of examining how caregiver mental health and perceived QoL evolve across different phases of the gender-related care process, including pre-disclosure, medical decision-making, and longer-term adaptation. The systematic inclusion of diverse caregiver perspectives—including those from underrepresented cultural settings, non-parental figures, and families of TGN adults—would enhance ecological validity and foster a more comprehensive understanding of caregiver experiences. Furthermore, exploring protective processes—such as advocacy engagement, peer support, and meaning-making—through a culturally sensitive and intersectional lens may contribute to more balanced and clinically useful understandings of caregiver adaptation.

To strengthen the theoretical integration of findings,

Table 2. Application of theoretical frameworks to caregiver experiences.

Theoretical Framework	Core Concepts	Application to Review Findings
Minority Stress Theory	Distal (e.g., discrimination) and proximal (e.g., vigilance, internalized stigma) stressors faced by minority populations	Caregivers report vicarious stigma, anticipatory anxiety, and institutional discrimination (e.g., school, healthcare settings) as indirect sources of stress, mirroring TGN individuals’ minority stress processes.
Family Systems Theory	Families function as interdependent emotional systems; stress in one member affects the whole system	Emotional distress, ambiguous loss, and reorganization of family roles reflect systemic adaptation processes; caregivers often describe relational disruption and gradual re-attunement across transitions.
Stress–Coping Models	Stress is mediated by coping strategies and available resources; protective factors modulate psychological impact	Peer support, affirming providers, and advocacy serve as protective factors, helping caregivers move from chronic stress to adaptive coping and meaning-making over time.

has been designed to summarize how three key frameworks—Minority Stress Theory, Family Systems Theory, and Stress-Coping Models—map onto the themes identified in this review.

5. Conclusions

Caregivers of individuals with gender incongruence—particularly parents of TGN and gender-diverse children and adolescents—experience substantial emotional and psychological burden with potential implications for mental health and perceived QoL. At the same time, the literature highlights caregivers’ capacity for adaptation, resilience, and supportive behaviors in the context of complex and sustained stress. Protective factors, including social support, affirming healthcare relationships, and engagement in advocacy, may buffer distress and facilitate psychological adjustment over time. Caregiving trajectories appear non-linear and, in some cases, transformative, evolving from initial fear and uncertainty toward acceptance, empowerment, and strengthened relational bonds. However, these adaptive processes are not universal and may depend on access to resources, cultural norms, and the specific challenges encountered by caregivers across diverse sociopolitical and familial contexts.

Nevertheless, it is crucial to emphasize the distinction between clinical implications and theoretical contributions in this field to ensure that these insights are not understood as prescriptive normative recommendations but merely as interpretative frameworks. These findings underscore the importance of integrated medical and psychological support systems that explicitly include caregivers as a core component of gender-affirming care. Clinicians, healthcare systems, and policymakers should ensure caregiver well-being alongside the health outcomes of TGN and GDI, recognizing family-level support as essential to equitable, effective, and compassionate care. Ideally, interventions should be culturally responsive and developmentally tailored to the complex identities of caregivers. Research and practice must also account for distinct caregiver trajectories, acknowledging dynamic fluctuations in adaptation, vulnerability, and support needs over time.