I recently read Nadine Burke Harris’ (MD) book "The Deepest Well Healing the Long-Term Effects of Childhood Adversity."  I found this an extraordinary and important book for anyone who has been affected by trauma, whether themselves, their children, or for caretakers of children who have experienced trauma.

Ms. Burke Harris is a pediatrician who opened a clinic in a low socioeconomic area of San Francisco.  In her patients she began to observe a pattern between adversity and a biological connection.   She was seeing a significant amount of her patients presenting with abnormal development or disease.  She began to suspect that trauma was the underlying cause of these issues. In her book Ms. Burke Harris finds proof for her suspicions and lays out a treatment plan for these children and adults.

In twenty years of practice I have also noticed many commonalities in people who have untreated trauma.  Johnny was a seven year old boy who was being raised by his grandfather.  His mother was addicted to drugs and in the time that he had lived with her he had been witness to many things a child shouldn’t see.  He was then separated from his mother at age four and has not seen her since.  He was brought to see me because of behavioral issues in the home and at school. His Grandfather was at his wits end trying to manage Johnny. He was hitting, kicking, and refusing to follow instructions at both home and school. He had been kicked out of several extra-curricular activities. Bedtime was the biggest problem.  He never seemed to sleep. His teacher was sure he had Attention Deficit behavior with Hyperactivity (ADHD) and wanted to refer him for medication.

Sally was a young adult who came to me when the Doctors told her they could find no medical cause for her ongoing stomach issues and panic attacks she had been having for several years. She had tried many ways to treat her issues but had not had any success.

The tool Ms. Burke Harris uses to assess for childhood adversity is called the Adverse Childhood Experiences Questionnaire or the ACE.  This simple, ten item questionnaire, asks about stressful events of abuse and neglect that may have affected the individual’s health and well-being as a child and into adulthood. A numerical score is given.  (Feel free to take the assessment yourself below.)  A score of one or more indicates the probability the individual may struggle with health, behavior, stress, or difficulties with social and emotional growth into adulthood. Examples of symptoms include but are not limited to; syndromes, diseases, depression, anxiety, hair loss, growth issues, asthma, eczema, ADHD, restlessness, and  difficulty sleeping.

I use this assessment with my clients, children and adults, as an indicator of the roots of their ongoing struggles for which no root cause has been identified.  This serves as an illustration for the client and a road map for both of us.

I had  Johnny’s grandfather complete the ACE for Johnny.  Johnny had a high score, meaning, he had experienced many traumatic experiences in his young life.  His behavior was a result of his traumatic and untreated experiences.  I explained this to his grandfather, who was a Military Veteran with Post Traumatic Stress Disorder (PTSD).  The grandfather stated, “Now I understand, he is like me!”

Sally also scored high on The ACE.  I explained to her how her body and brain were holding onto the traumatic memories and converting them to issues in the body.  Her trauma was being held onto and was being expressed through panic attacks and stomach issues.  Sally had PTSD.
 
In the book six critical areas for treatment and self-care are outlined:

1. Proper nutrition
2. Adequate exercise
3. Proper sleep
4. Mental health treatment
5. Healthy relationships
6. Mindfulness and meditation.

By paying attention to and integrating these six areas into our lives we can treat the underlying issues and reach our maximum level of health. Even without symptoms and issues this is a model for self-care and health.

I explained the six areas to Johnny, his grandfather, and Sally.  We assessed for what areas they needed to better incorporate into their lives.  This became the treatment plan in therapy.  Johnny has done very well and has graduated from therapy with me.  His grandfather keeps in touch and sticks to the six areas of self-care for both Johnny and himself.  Sally is also doing well and has become significantly more aware of herself, her body, and her past.

If you have chronic, unexplained illness or if someone close to you does, I recommend reading "The Deepest Well."  It is an extremely insightful read!

 Adverse Childhood Experience (ACE) Questionnaire   Finding your ACE Score

While you were growing up, during your first 18 years of life:

1. Did a parent or other adult in the household often...Swear at you, insult you, put you down, or humiliate you?
or
Act in a way that made you afraid that you might be physically hurt?

Yes or No
If yes enter 1 ________

2. Did a parent or other adult in the household often... Push, grab, slap, or throw something at you?
or
Ever hit you so hard that you had marks or were injured?

Yes or No
If yes enter 1 ________

3. Did an adult or person at least 5 years older than you ever... Touch or fondle you or have you touch their body in a sexual way?
or
Try to or actually have oral, anal, or vaginal sex with you?

Yes No
If yes enter 1 ________
4. Did you often feel that... No one in your family loved you or thought you were important or special?
or
Your family didn’t look out for each other, feel close to each other, or support each other?

Yes No
If yes enter 1 ________

5. Did you often feel that... You didn't have enough to eat, had to wear dirty clothes, and had no one to protect you?
or
Your parents were too drunk or high to take care of you or take you to the Doctor if you needed it?

Yes No
If yes enter 1 ________

6. Were your parents ever separated or divorced?

Yes No
If yes enter 1 ________

7. Was your mother or stepmother often... Pushed, grabbed, slapped, or had something thrown at her?
or
Sometimes or often kicked, bitten, hit with a fist, or hit with something hard?
or
Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

Yes No
If yes enter 1 ________

8. Did you live with anyone who was... A problem drinker or alcoholic or who used street drugs?

Yes No
If yes enter 1 ________
​
9. Was a household member depressed or mentally ill
or
did a household member attempt suicide?

Yes No
If yes enter 1 ________

10. Did a household member go to prison?

Yes No
If yes enter 1 ________

Now add up your “Yes” answers: _____
__ This is your ACE Score

The higher your child's or your ACE score is the higher risk there is for social, emotional, behavioral, and/or physical health issues.  Left untreated the problems will increase.  Seeking professional help for a high ACE score is always recommended.

Positive thinking will make your life better. Studies show that encouraging a positive mind can decrease stress, create a greater sense of well being, and improve your health by creating a stronger resistance to the common cold, by reducing the risk of coronary artery disease and by allowing easier breathing for those with lung diseases. Studies also show that thinking positively can generate better coping skills and contribute to more fulfilling relationships.

Our thoughts, feelings, and behavior all affect each other.  If we think negatively, we don’t feel as good about ourselves and our world, and our behavior will reflect that.  If I tell myself I’m worthless and no one likes me, I am sure to feel depressed and might withdraw from others, perhaps even isolating myself at home.  But if we think positively our feelings and behavior will follow.  If I tell myself I have a lot to offer, I will feel happier and may want to interact more with others.

Nine negative thinking patterns, or mistaken ways of thinking, have been identified that are commonly used.  Most of us lean on at least one on a daily basis while others are consumed by all nine every day.

I challenge you to read the list below and circle the negative thinking patterns that you use in your daily life.  You may be surprised by the faulty ways your thoughts are sabotaging you.
 

1. Filtering: You focus on the negative details while ignoring all the positive aspects of a situation.

 

1. Polarized Thinking: Things are black or white, good or bad. There’s no middle ground, no room for mistakes.

 

1. Overgeneralization: You reach a general conclusion based on a single incident or piece of evidence. You exaggerate the frequency of problems and use negative universal labels.

 

1. Mind Reading: You think you have knowledge of how others think and feel about you, and you imagine it is mostly negative.

 

1. Catastrophizing: You expect, even visualize, disaster.  You notice or hear about a problem and start asking ‘What if’ questions: “What if the worst is about to happen to me?”

 

1. Magnifying: You exaggerate the degree or intensity of a problem. You turn up the volume on anything good or bad, thus making it overwhelming.

 

1. Personalization: You assume that everything people do or say is some kind of reaction to you.  You compare yourself to others, seeing how much smarter, better looking, more competent others are than you are.

 

1. Shoulds: You have a list of solid rules about how you and others should act.  People who break the rules make you angry, and you feel guilty if you break your rules.

 

1. Victimization: Everything is always someone else’s fault. I call this “Other Blaming.” You fail to take responsibility for you actions and place the blame on those around you.
   

 
 
How many did you circle?
 
The good news is it is entirely possible for you to rectify your negative thinking. Focus on being aware of when you use them.  Work hard to change them. Cognitive behavioral therapy can help assist you in changing your thought patterns, your emotional reactions, and your behavioral impulses. A cognitive behavioral therapist will point out your negative thought patterns and redirect them towards the positive, thereby improving your feelings, your behavior, and your life.
 
 

This flower (and three others) bloomed on a plant in my home today.  Isn't it lovely?  What is something small you can find to reflect positive today?
​

Today is Monday (again) so let's set our intentions to positive for a good week. Here are some ideas to help you remain in a positive frame of mind this week. 

• Express Gratitude

 

• Let Things Go

 

• Be Kind to Yourself and Others

 

• Smile Often

 

• Change "I Can't" to "I Can"

 

• Work on Your Negative Self Talk or Your Inner Critic 

 

• Create a Positive Mantra and Repeat It Many Times a Day

This maybe a bit after-the-fact but always helpful!

I recently lost my Step-Father and Father within a month of each other.  There has been a lot of grieving and a lot of sadness in my family.  I understand the holidays can be and will be hard for my family this year.  We will surround ourselves with love and attempt to find some joy in this first holiday season without our loved ones.
There are many among us who will also be sad and have a difficult time this holiday season.  The loss of loved ones is one reason for this sadness.  There are also may among us who are suffering due to losses, injuries, sickness, poverty, war, hate crimes, dysfunctional or non-present family and a plethora of other reasons.
 
Grieve and Recognize Your Emotions:
Stress, depression and sadness are common at this time of year.   If you are feeling any of these it’s OK and healthy to recognize your feelings and attempt to manage them. It is normal to feel sadness and grief.  Recognize your emotions and allow yourself to experience emotions.  Crying is healing.  I see many people who tell me they don’t want to cry or don’t think it is OK to cry.  If we weren’t made to cry why do we have tears?  Go ahead and cry if you need to and then remember to care for yourself. Strong emotions rollover us and eventually dissipate.  Remember this.
The stages of grief are; Denial, bargaining “if only I had”, anger, sadness, acceptance.  The stages ae not sequential and each stage can be revisited at any time.

Dysfucnctional Families:
If your family is dysfunctional or negative and you have to be with them over the holidays remember, you can’t change them or control how they act.  However, you can control your reactions and interactions with them.  Put up your boundaries and stick to them.  If someone treats you negatively create some space or some inner peace in your reaction to them.

Don’t Isolate:
Although you may feel like curling into a ball and hiding from the world this will actually make you feel worse and more alone.  Call a friend or family member.  If you feel alone and as though you don’t have anyone to call, go to a support meeting, find somewhere to volunteer, go and listen to some live music.  Studies show being with others can move us out of our negative place.

Find Some Positive Quotes or Positive Energy on The Internet:
Gather positive quotes and take pictures of them on your phone or use sticky notes to post them on your bathroom mirror. When one of my children or foster children was sad or depressed I would sneak into their bathroom and put sticky notes with positive quotes or messages to that child all over the mirror.  Do this for yourself! Watch a positive individual or motivational speaker on the Internet.

Self-Care:
I always repeat to: REMEMBER TO TAKE CARE OF YOURSELF! This is so important. Without self-care we can’t be there for ourselves or for anyone else.  Exercise, get a massage, take a bubble bath, meditate, spend time with your pets.  Whatever makes you feel good and is healthy, do it!
​
Negative Behaviors:
Avoid negative behaviors such as over using substances, self-mutilation or anything else that may be self-sabotaging.  Work hard to replace negative behaviors with healthy ones.
 
Talk to a Professional:
If you have tried all these things and still feel horrible or unable to face the holiday season talk to a professional.  I am always here to help.

Addiction to Pornography is a real problem in this country.  Although the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) does not identify this as a diagnosable issue the number of people I see in my office, presenting with the issue of not being able to manage their pornography viewing, makes it a very real clinical issue for treatment. I describe it as being a problem when an individual excessively views, downloads, or seeks out pornography.  For this individual pornography is causing problems in family life, relationships, work, or school.  When it becomes so unmanageable that the individual withdraws from other areas of life there is a problem The main relationship becomes one with pornography making him or her unavailable in their relationships.

Sadly, our children are being exposed to pornography at the average age of 11,  usually before they have been sexualized.  I have seen children as young as ten who have pornography related issues. Chlidren first view porn when peers show it to them, when an adult is viewing porn with a child in the vicintiy, or when the child stumbles upon it while on the Internet. When a child is exposed to porn before they are ready to be sexualized they develop an unhealthy and unrealistic view of sexuality.  Intimacy with a person becomes next to impossible.

Once the brain has been exposed to porn it actively seeks more of it.  The effects of pornography on the brain are similar to the effects alcohol or drugs have on the brain.   Pornography feeds the pleasure parts of the brain making the individual crave more. 

Viewing pornography becomes a release from life's daily stressors.  It becomes an unhealthy way of coping with the world.  It allows the individual to escape overwhelming emotions in the same way alcohol, drugs, eating disordered behaviors, and gambling become unhealthy and addictive coping skills.  The problem grows when the individual acts impulsively and compulsively to view porn.

Addiction to pornography can exist alone or with other sexual acting out behaviors.  The brain becomes desensitized to the images being viewed leading the individual to seek more hard core, fantasy driven images.  The individual can become highly involved in this fantasy world leading to seeking out prostitutes, threesomes, bestiality and more and more.  When the individual attempts to bring this into the bedroom, within a relationship, it can be distressing for the partner.

Common problems that may develop with  porn addiction are:

• Failed attempts to cease use
• Spending exorbitant amounts of time viewing porn
• Poor impulse control 
  
• Relational issues
  
• objectifying others in a sexual manner.

The good news is porn addiction is treatable.  With support and a healthy plan for recovery many individuals are able to overcome this problem. By ceasing the behavior the brain will, overtime, re-set allowing the individual to return to a healthy and fulfilling life. Porn addiction can be difficult to deal with without professional help.  If this describes you or someone you love seek help.  The problem is a common one.  You don't have to fight it alone.

It seems that every day the news is filled with more negativity and terrifying events.  Mass shootings, natural disasters, political issues, war, threats of nuclear war.  Before social media, CNN, The Weather channel, and Fox News these events were not brought right into our living room 24 hours a day.  Having the availability of on demand news and the Internet gives us the sense that there is danger as close to home as our living room and sometimes there may be.  We begin to wonder where we can feel safe. Our brains absorb all the negative and tragic events happening all over the world.  This creates a sense of anxiety which lingers over us and can emit negativity from us to those around us.

These are stressful times for all of us.  We are all feeling the impact from what is happening in the world today. The negative events we are hearing about in the daily news are affecting all of us.  For people who already have a high stress load or are already having difficulty coping with other stress the world events can cause more serious mental health issues. Those already suffering with depression, anxiety, Posttraumatic Stress Disorder and other mental health diagnoses may feel an escalation of their symptoms.

What can you do when danger and negativity seem to be looming over your head? 

Think about what you have control over and put your energy into that. 

Ask yourself what you have control over.  Ask yourself if there is anything you can do about all the stress in the world.  Possibly, help close to home if helping in the larger world is not an option for you.
Find a local cause and join in to help.  Find someone close to home who you can provide some support to. 
​
When your brain goes down that rabbit hole of negativity and fear tell yourself to STOP.  Wear a rubber band around your wrist and snap it to tell your brain to STOP.  Or visualize a STOP sign as a signal to the brain to STOP the negative thinking and get you out of that sinking rabbit hole.

When it feels too overwhelming what can you do? 

Reach out and talk about it.  Talk to those around you.  Talk to those you love.  No matter what your values are or when it seems there are others with no values, embrace yours, whatever they are.  We are all humans, no matter what our values, political beliefs, race, culture, religion, age, or sexual orientation.  Try to understand this and believe this.

Be sure to manage your stress and feelings of helplessness. Remember to use healthy coping skills and self-care on a daily basis.  Breathe deeply.  Practice patience and kindness to yourself and those around you.  Be sure you are getting the appropriate amount of sleep.  Do not over use alcohol or other substances as self-medication. Be sure to eat three healthy meals a day.  Avoid processed and fast foods. Eating healthy contributes to a healthy mind.

Spend time with loved ones near and far.  Perhaps join a local support group or an activity group.  Meet and connect with new people.  Find a new hobby and meet people with similar interests.
Try to limit the news to once a day.

When my husband and I felt overwhelmed and helpless to do anything about the world problems we became foster parents.  Our idea was that we could make a difference one child at a time.  Giving children close to home a chance at a some opportunities in our home.

Watching the news over and over contributes to our stress level.  The stories on CNN or Fox news are repeated all day long.  Allow yourself to watch or read the news only once a day.  Restrict your Internet and social media usage to once or less a day to allow you to focus on being positive and productive. Do not use screens at least an hour before bed.

If you find you are so overwhelmed and need to talk to a professional please reach out to me or to someone else. I’d be happy to meet with you in person, through messaging therapy or video session.

We are all in this together!

1. Do you often find yourself preoccupied with sexual thoughts? 

2. Do you hide some of your sexual behavior from others? 

3. Have you ever sought help for sexual behavior you did not like? 

4. Has anyone been hurt emotionally because of your sexual behavior? 

5. Do you feel controlled by your sexual desire? 

6. When you have sex, do you feel depressed afterwards? 



​
A positive response to just one would indicate a need for additional assessment. Two or more indicates sexual addiction.


If you are interested in reading about sexual addiction a good place to start is with Patrick Carne's first book.


Contact Melissa for information on treating a sexual addiction or if you are the partner of someone with a sexual addiction. ​

​

I recently had a conversation with a client, about what success is.  It caused me to realize that the definition of success means different things to different people. I looked up the definition of success in The Cambridge Dictionary and here is what I found:
 
successnoun [ C/U ]
 US ​ /səkˈses/
​
the achieving of desired results, or someone or something that achieves positive results:
 
 
OK, but how do we measure this? Each individual needs to develop their own definition of success.  The client I was referring to has had a good deal of achievement academically and in her career but she does not feel successful.  Probing for why she does not feel successful I discovered she did not have a solid definition of success and did not believe in herself.

Alfred Adler, a contemporary of Freud, defined three life tasks we need to meet to be healthy and productive members of society.  1).  Work (can be unpaid) 2.) Community and 3.) Intimacy.  I believe if you are meeting all three of these life tasks not only are you probably healthy but are a productive member of society.  Does this define success?  I believe it does. Are you meeting all three of these life tasks?
If we all define success differently, how do you define it?  Do you have life goals you strive to meet?  If you meet them does this define success?  I believe it does.

Coach John Wooden defined success as: “Success is peace of mind, which is a direct result of self-satisfaction in knowing you made the effort to do your best to become the best that you are capable of becoming.”

I like that definition of success!

Success is a state of mind.  If you believe and feel successful, have a positive attitude, are happy and content in life, and feel positively about yourself then this can also define success.

Perhaps you have some negative beliefs about yourself which are causing you to feel unsuccessful or incapable of achieving success.  Some examples are, “I am inadequate, I am damaged, I am not good enough”.  These examples of negative core beliefs are formed in childhood, most likely assumptions children come to believe about him or herself when being mistreated by a care giver or parent.  If you recognize these beliefs as a part of your core then this is the area you need to work on before you can feel successful.

Success comes from within ourselves.  We can’t measure success of ourselves in the eyes of others.  We need to feel positive about ourselves and not looking to others to judge us.  Success is not measured by the approval of others.

Setting goals for yourself and achieving them is a way to work towards your own success.  No matter how small the goal may be, when you meet it, this is success!
What is your definition of success?  If, in your life you are not feeling satisfaction for your accomplishments, or, that there are blocks to living the most satisfactory life, let’s talk.

I am a week late as National Eating Disorders Awareness Week was last week!  However, I think we need to be aware of the dangers and seriousness of eating disorders all year long.

Eating Disorders are a serious mental illness which can be fatal. Eating disorders are not passing phases or fads. The sooner someone is able to receive treatment for an Eating Disorder the better the chances for recovery will be.  Eating Disorders are persistent and ongoing patterns of unhealthy eating or dieting behaviors which cause severe health and emotional problems for those suffering with the disorders. 
There are three basic categories of Eating Disorders; Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder.  There are also some subcategories of these disorders.

An individual who suffers with Anorexia will restrict food intake and refuse to maintain a normal body weight.  These individuals are terrified of gaining weight and spend most of their time thinking about how to avoid calorie intake. 

Individuals who suffer with Bulimia have binge eating episodes during which the individual eats an excessive amount of food in a short amount of time.  This is then followed by trying to compensate for the high number of calories consumed by purging.  Purging can be by vomiting, laxatives, compulsive exercise, enemas, or diuretics.

An individual with an eating disorder has social difficulty with peers, partners, and family because this individual is in a serious relationship with ED (their eating disorder).  This individual may think about eating or not eating up to 90% of the time making them unavailable to others in their life.

Treatment for eating disorders is available through outpatient therapy, intensive outpatient programs, and residential programs.  Treatment will focus on reestablishing health and identifying the root causes of the eating disorder. Effective treatment will also involve the family who has been effected by the eating disorder.  Coexisting disorders may include anxiety and depression.
​
If you know someone suffering hep them to get help the sooner the better.  

​​Melissa Muller is a Licensed Mental Health Counselor in St. Augustine, FL.  Melissa works with families, adolescents, couples and individuals.  Melissa has specializations in treating adolescents, eating disorders, trauma, and sexual addictions. In addition she enjoys working with the LGBT community.  She often works with families in the crisis of divorce to make the transition as healthy as possible for both the children and the adults in the family.

Call for your appointment today (904) 770-7587

In my counseling practice and in my personal life I am frequently in contact with people who have lost someone or something through death, break up, natural disasters or other factors.  At some point in our lives we all experience loss.  Some losses will be more difficult than others.  Some losses take less time to recover from than others.  The pain of some losses never goes away.  In the last year, I have worked with individuals experiencing grief and loss, had people in my personal life experience grief and loss, and experienced it myself. 

Although all situations take a different path to grief we all experience grief and loss in a similar way, painfully.  Grief is a universal emotion.  All people go through it in a similar manner; no matter where you are from, the color of your skin, your religious beliefs, or your political views we share this same process. Loss can be: a loss of a friend through a disagreement, a break up with a partner, the death of a friend, a parent, child, or a loved one. 

Loss and grief can come from natural disasters such as the hurricane that recently devastated the town I live in.  Following the storm there was a collective grief.  So many experienced so much loss but had the opportunity to come together, understand each other’s grief, and mourn as a unit.  In this aspect grief had a positive effect on the town and relationships between neighbors. Loss and grief can be a lonely process or a collective process.  The better support system available to an individual who is grieving the less likeliness of feeling alone.

There are stages of grief and loss which all people go through.  Let’s use an example of a break up.  Two of my loved ones recently experienced relationship break ups.  Being close to both of them I watched them each go through the painful process and provided support to them as they moved through the stages. 

The stages of grief and loss, presented by Elisabeth Kübler-Ross in 1969, are:  1. Denial and isolation 2.  Anger 3.  Bargaining 4.  Sadness 5. Acceptance.  The stages are not necessarily sequential and once you get through them you might return to any of the stages.

As an example, we will use Suzy.  Suzy’s partner of five years recently broke up with her seemingly out of nowhere. She found out he had been seeing another woman.  When the break up happened, Suzy initially did not believe it.  (Denial and isolation).  She tried desperately to talk to her partner, who only kept telling her this was what he wanted.  She took to her bed and cried.  She called out of work and remained in bed, crying for three days.  She did not want to see or talk to anyone other than her best friend whom she spent hours talking to on the phone.

After several days, Suzy began to think about what she could have done differently so the break up wouldn’t have happened.  She even tried to make a pact with God that if her partner returned to her she would never ask God for anything again.  (Bargaining).

Soon, Suzy became angry (Anger).  She couldn’t believe he actually broke up with her.  What a jerk!  This is who she was supposed to have spent the rest of her life with.  How could he have hurt her so badly?  What did she do to deserve this?  How could he have been cheating on her?  Suzy became so angry she thought about ways she could get back at him.  Anger took over her mind and she had difficulty focusing on anything else.

After a few days of anger, Suzy became overwhelmingly sad (Sadness).  She was so sad she could barely move.  She cried constantly and felt as though her heart had been ripped out of her chest and stomped on.  She howled when she cried.  She clutched her dog closely and sobbed into his fur.  This alternated with the anger she had towards her ex-partner.  Most days she wanted to be alone and isolated herself.
One day, Suzy woke up feeling better.  “I got this” she said to herself.  “I don’t need that jerk anymore”.  Suzy had come to accept that the breakup had happened and that her life was not over (Acceptance).  She could and would move on.

Although Suzy had gone through the stages of grief and loss she did go back and forth between the anger and the sadness for several more months especially when something reminded her of her ex.  After several months, she was ready to date again and began to look forward.

Loss is usually something we cannot prepare for but by keeping ourselves as mentally and physically healthy as we can we will ensure when we meet up with loss we will have adequate coping skills to help us through the process. It helps to know the stages of grief and loss because when we go through them we will understand all people have to deal with loss at some point.  We are never alone in our grief.  If you are grieving reach out to those who care about you.  We all go through it and we can all take our turn supporting those who are grieving. 

​​Melissa Muller is a Licensed Mental Health Counselor in St. Augustine, FL.  Melissa works with families, adolescents, couples and individuals.  Melissa has specializations in treating adolescents, eating disorders, trauma, and sexual addictions. In addition she enjoys working with the LGBT community.  She often works with families in the crisis of divorce to make the transition as healthy as possible for both the children and the adults in the family.

Call for your appointment today (904) 770-7587.

I work a lot with youth and adolescents who say they are transgender. As we all know, Transgender is a big buzz word today. Sorting through what is going on with the child and his or her mental health issues is important.
 
Families struggle with this issue. A lot of the time the youth or adolescent has mental health issues which may include anxiety, depression, and suicidal behavior. These kids come to me with low self-esteem and low self-worth. It is important to look at the root of these issues. For some kids gender issues may be a phase, with some it may not be. The immediate issue is stabilizing the mental health problems and providing support to the family.
 
This article from GenderSpectrum.org, is a good one for families who have a youth or adolescent who has gender issues which are affecting their mental health. 

Gender is more complex than most of us have been taught. Gender is made up of three parts: (1) gender biology (our bodies or biological sex – our sex assigned at birth based on appearance of genitals), (2) gender expression (how we dress and act), and (3) Gender identity (how we feel inside). For most kids, these three facets of gender line up and the kids are typically gendered boys or girls (cisgender). For other kids, however, these three facets of gender align differently; these kids are Gender-expansive, which includes transgender kids.

Although our society teaches us that there are only two genders—male and female--there are really many genders. Not all children fit neatly into a male or female gender identity. For some children, the sense of being “both” or “neither” best describes their reality. Some of these kids speak of being more of one some days and more of the other on different days; these children might best be described as gender fluid. These are all normal variations in human gender and do not mean something is wrong with a child. A child’s gender is not what others tell them, but who they know themselves to be.
​
Even though we as parents have great influence over our children, parents can’t change a child’s true gender identity or expressions of their gender. However, we can help our children to have a healthy, positive sense of themselves in relation to their gender.

​When we talk about “family,” we are not referring only to people related by genetics. Families can come in all configurations, including adoptive or foster parents, grandparents, extended family, mentors, or one’s chosen family made up of close friends. Many youth have been rejected by their genetic and adoptive families and need support from other adults. Similarly, “parenting” can be done by a variety of adults in a child’s life, not just by legal parents or guardians. Thus our resources in this section, and in our work in general, are for all types of “family” and all adults who “parent” a child.

Parents have a very powerful role to play in a gender-expansive youth’s life. Research has shown that supportive parenting can significantly affect our children’s positive outlook on their lives, their mental health and their self-esteem. On the other hand, rejecting parenting practices are directly correlated to gender-expansive and transgender youth being more depressed and suicidal. Research shows that the most crucial thing we as parents can do is to allow our children to be exactly who they are.
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Every family is unique, with different family dynamics, as well as cultural, social, and religious influences. Some families have to consider their child’s physical safety in their communities more than others, but all families have to weigh the effects of their parenting approach on their child’s long term psychological well-being.

Parenting practices that are based on affirming a child’s own sense of gender strengthen a child’s self-esteem and sense of self worth. While some of the parenting practices discussed in this section may be challenging for some parents to implement, it is important to take whatever steps you can to demonstrate to your child that you are with them on this journey.

Create a supportive family environment: The ability to make the home a sanctuary of security and support for your child is the single most important factor in promoting lifelong health and well- being for your child. Such an environment creates a buffer for your child from the hardships they may face outside of the home. Creating such a space may not come easily for you, particularly if you are struggling with accepting your child’s gender identity or expression. If so, seek help from an empathetic, knowledgeable friend, family member, support group, therapist or other source of support.

Require respect within the family: With immediate and extended family, it is imperative that you require and accept only kindness and respect for your child. While you may not be able to change people’s opinions, you can certainly dictate how you expect others to behave and speak around you and your child. It can be scary to make this demand of family members, yet many parents report that once they’ve taken a stand on their child’s behalf, they feel a great sense of relief and empowerment.

Express love and support for your child’s gender expression: What does this look like? It means allowing them to choose, without pressure or unspoken messages, the clothes they wish to wear, how and with whom they play, their favorite toys, the accessories they favor, the manner in which they wear their hair, and the decorations and images with which they surround themselves. It means helping them prepare for any negative reactions they may encounter outside the home by practicing their responses with them and making sure, when appropriate, that there is a safe adult for them to turn to in case they need assistance. It means discussing any negative or conflicting feelings you are struggling with over their gender identity or expression with other adults, not with your child.

Allow zero tolerance for disrespect, negative comments or pressure: A concrete way to demonstrate ongoing support and acceptance for your child is to tolerate absolutely no negative comments about your child, from anyone, whether your child is with you or not. This means following up with the people who make such comments in a firm way that makes clear your commitment to your child’s well-being. It may also mean needing to follow up with other parents or the school about the comments made by other parents or children.
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Maintain open and honest communication with your child: Stay open about this journey, both your child’s, and your own. By demonstrating to them that you are a partner in this process, and showing a genuine sense of interest in how they see themselves, what they think, what they are experiencing, you show that you are there for them. This open level of communication will also help you evaluate your child’s level of stress or distress, and whether they may need additional outside support or intervention.

​When their authentic sense of self is not recognized and affirmed, it undermines a child’s self-esteem and feelings of self-worth. It should not be surprising that many children who end up in the foster care system, run away, or become homeless are gender-expansive and transgender; rejected at home, they find themselves with few options for support. Refusing to accept one’s child as they are and behaving in an unkind, punitive, or disrespectful manner communicates to your child a lack of value or worth.

As you read the list of behaviors below, try to also have compassion toward yourself. Many parents have employed these practices at one time or another. What is important is to commit to communicate your love and support for your child from this point forward. We can only start from where we are.

Physical or verbal abuse: One of the most damaging things you can do is verbally or physically abuse your child. It won’t get them to change, and it places them at a far greater risk of suicide. Even if you have the feelings internally, work to keep them there, rather than outwardly demonstrating your struggle to your child.

Exclusion from family activities: The urge to avoid being embarrassed by your gender-expansive child may not seem blatant to you, but it sends a message of shame and implies core change is required in order to be a member of the family. Insisting your child “dress properly” or “act normally” makes your child feel that the comfort of others trumps their own sense of well-being and security.

Blocking access to supportive friends or activities: Preventing your child from seeing gender-expansive friends and allies or participating in supportive activities will only generate a sense of isolation and significantly increase risk factors. Blocking your child’s access not only cuts them off from a critical support system, it also stigmatizes other people like your child.

Blaming the child for the discrimination they face: Saying that a child deserves any mistreatment that they encounter simply for being who they are is incredibly dangerous, an implicit message that they are to blame for the cruelty of others.

Denigration and ridicule: When you speak or treat your child with disrespect, or allow others to, it shows them that they cannot count on you for the love and protection they desperately need.

Religious or faith-based condemnation: Telling a child that God will punish them greatly increases health and mental health risks, and can remove a vital source of solace.

Distress, denial, and shame: When a child sees that they are causing you great distress and shame, they internalize this pressure. It is damaging to openly communicate your denial of their gender identity or expression.

Silence and secrecy: Insisting your child remain silent about their gender identity or expression tells them that there is something inherently wrong them. If you are keeping your child’s gender identity or expression a secret because you are worried about their safety, think about ways you can balance keeping your child safe with your safety concerns while still letting them know that you support them (see Safety Considerations below).
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Pressure to enforce gender conformity: Even when motivated by a desire to protect your child, asking them to mask who they are sends the harmful message that there is something fundamentally wrong with them.

Young Children
If your child has identified as the opposite gender since early childhood, it is unlikely they will change their mind. Most people have some sense of their gender identity between the ages of two and four years old. For most, this awareness remains stable over time. For example, a 12 year old child who was assigned a male gender at birth, but has consistently asserted “I am a girl” since the age of three, will most likely remain transgender throughout life.

There are cases when a young child who strongly identifies with the opposite gender does change their mind. The most common time for this to occur is about 9-10 years old. There is insufficient research to know if these children later identify as gender-expansive or transgender adults. So, it is unclear if this change indicates that the child has learned to hide their true self, or if it was indeed just a childhood phase.

Teens
Another typical time for gender identity to come into question is at puberty. Many teens who have never exhibited anything outside the norm in their gender expression or identity, start feeling differently as puberty approaches. This can be very confusing for parents who “didn’t see this coming.” Since adolescence is a time of exploration and change in general, it can be hard for parents to know if this is just a teenage phase, or whether their child is “really” gender-expansive or transgender. Again, look to the concept of insistence, consistence and persistence to determine if a child is truly gender-expansive or transgender. This may mean you won’t have an answer for quite a long time.
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Though these are two common times for gender identity to come up for children, they are certainly not the only times. A child at any age, even to adulthood, can start feeling differently about their gender identity or expression.

​Parents have a variety of responses to their gender-expansive or transgender children, and none of them are “right” or “wrong.” Feelings of embarrassment, denial, anger, fear, doubt, grief, and worry are normal, as are feelings of acceptance, understanding, support, pride and joy. Many parents feel a combination of positive and negative feelings. This is a hard road for parents, and even though we may not have chosen this for our child or ourselves, it is our road to navigate. You are not alone in your feelings or in your experience of raising a gender-expansive child. It can be very helpful and comforting to seek support from other parents or from a mental health professional.

Feelings of guilt
It is common for parents to blame themselves when a child falls outside of gender norms. They ask themselves, “Is it my fault somehow?” “Where did I go wrong?” Mothers may feel they were too permissive. Fathers may be angry and refuse to accept their gender-expansive child, especially if this child was born a boy.
Current research supports the theory that gender is “hard-wired” in the brain from birth. Gender diversity is not an illness or a result of poor parenting. It is not the result of divorce or an indication of child abuse. Gender diversity is not caused by liberal, or permissive parenting, or by a parent who secretly wished their child were the ‘opposite’ sex. It is normal. You did not cause this or do anything wrong.

Feelings of loss
Another common feeling is that of loss. Families, parents, and siblings may feel a sense of grief at the idea they are “losing” their son or daughter, their brother or sister. Even though the child is alive and well, a socially recognized gender change can elicit strong feelings of losing the person we thought we knew. We may experience periods of sadness, anger, and mourning as we (or our other children) come to terms with our child’s authentic identity.

Living with uncertainty
One of the biggest challenges to raising gender-expansive kids is learning to live with uncertainty. When a child is not clearly identifying as male or female, even parents who want to be supportive can find themselves thinking, “(j)ust decide already, one way or another!” A lack of consistency in their child’s gender expression can leave parents wondering just who their child “really” is. Parents feel more empowered to help their child if they know where their child will end up.

Gender identity is not always “one or the other.” We need to recognize that not every child is on the path to choosing a male or female gender identity. Many children (and adults) feel like they are both genders, neither gender, or go back and forth. They have already arrived at their final destination, which is a space outside typical gender constructs. Or, they may still be figuring it out. We won’t know until our child knows and can communicate this to us, and that may take many years. It is important for us to follow their lead, and let them figure out who they are at their own pace.

Finding language that works for your child and yourself can be a big help in dealing with uncertainty. With older children, this can mean discussing together how they would like for you to refer to them, both directly as well as when you are speaking with others. Some families take the approach of working around pronouns by just using the child’s name. Others use gender neutral pronouns such as “they” or “ze.” Developing stock responses that don’t include male or female pronouns can also be helpful: “My kid is just being their true self!”

Examining Our Own Gender Stories
Everyone has a gender story, including us parents. Every person in our society has been affected by gender norms, either positively or negatively, in their lives. If we make our gender stories part of our family conversations, then gender identity and expression becomes about all of us, not just about the one child who is “different.”

Gender norms and expectations are different now than when we were growing up and will continue to change. Many teens and young adults today define their genders in ways we didn’t even know existed. It is important for parents to accept this new frontier of gender identity and gender expression and to take the time to think about how our children’s experiences relate to our own experiences growing up.

What assumptions do we make about gender based on how we were raised and the messages we received? Are these the only way to think about gender? How have gender norms affected us in ways we do or don’t want them to affect our kids? These exercises will help us in understanding our child’s gender story, as well as our own, which can only help us be better parents.

​Sometimes the gender diversity of a family member can create a sense of perpetual crisis in a family. Because of society’s discomfort with gender diversity, we may unconsciously bond with our cisgender children more than our gender-expansive child. By doing this, we may inadvertently place siblings in a position of choosing loyalties to us or to their gender-expansive sibling. Alternately, we may focus on the exceptional needs of a gender-expansive child, overlooking the sibling as a result.

A sibling may act out in an effort to gain our attention, possibly in ways that are hurtful to their gender-expansive sibling. For example, the sibling may “out” or disclose personal information about the gender-expansive sibling at inappropriate times or in a disrespectful manner.

Gender diverse children may be teased and bullied, even by their siblings. Siblings may participate because they feel pressure from their peers to ostracize or be critical of their gender-expansive sibling. On the other hand, siblings often feel obliged to defend their gender-expansive sibling from bullying by others. Siblings may be teased and bullied themselves.
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One strategy to avoid the division between gender-expansive kids and their siblings is to make sure we discuss gender as it relates to all people (see Examining Our Own Gender Stories above). This not only avoids treating the gender-expansive child as if they are the “problem,” but also helps support siblings in their experiences as well.

​It can be nerve-wracking and scary to bring up the topic of our child’s gender with family and friends. Even if our closest friends and immediate family members are aware of our child’s gender expression and identity, it may be hard to see people that either didn’t previously know about our child’s gender, and may not be supportive.

There is not just one way to deal with this situation, of course, as every family and group of friends are different. Remember that family members and friends are at different places in their understanding of gender identity and gender expression; recognize that while we’ve had some time to think about this (and think about it, and think about it…), this may be completely new to them, as it was to us at some point in time. They also aren’t around our children as much as we are, and may not see what we see in our kids.

One strategy is to call or write to family and friends before seeing them. Let them know about your child’s gender and that you are fully supportive of your child. Of course, it’s natural for them to have questions; let them know they are welcome to ask you anything in private, but they should not talk about it in front of your child. Let them know that regardless of their personal feelings about your child’s gender and/or your parenting choices, that you expect them to be kind and respectful to your child. We have collected some sample letters that parents/caregivers have sent to family members and friends to assist you in this communication.

Spend some time identifying your expectations, then be very explicit about what you are requesting of them. For example, you’d like them to use your child’s preferred pronoun and name; you’d like them to avoid negative comments about their hair, clothes, toys, etc. If presents are being exchanged, you’d like them to give what your child actually wants to play with and not what they think your child should play with.

Remind your family and friends that your child is more than just their gender and they should see and relate to your whole child. If they are nervous, tell them what your child’s current interests are so they will have some safe topics to discuss. Direct them to the Gender Spectrum website, or offer some articles or books for them to read so they can learn more about gender-expansive kids. The Transgender Child is a good primer on the topic. Share articles that explain gender and kids so you don’t have to be the expert.

The more you learn to speak with confidence and pride about your child, the easier it will be for others to accept your child and your parenting. People look to you for their lead on how to respond or react to your child. You have nothing to apologize or be ashamed about. Remember, it’s your job to take care of your child, not the needs of other adults. A desire to help other people feel comfortable is natural. Yet if you find yourself doing so by denying or dismissing your child’s authentic self, it can be quite hurtful. For example, if an acquaintance or new person you meet asks about your dress-wearing boy, rather than making comments such as, “Oh yes, that is my son. He’s just pretending to be a princess today,” consider simply saying, “Yes, that’s my son,” or even “Isn’t it great that he’s not afraid to be himself.” Your priority is your child’s well-being.

​Raising gender-expansive and transgender kids comes with constant decisions about when and how to share information. Each situation and each family is different. Some kids are completely open and tell everyone they meet about their gender, while others don’t ever want to mention the word “gender.” Some gender-expansive and transgender kids conform to societal norms of gender expression, while others are so clearly a combination of genders, that there is no option of being private.

Are you obligated to disclose if your child is going on a playdate? What if they are sleeping over at a friend’s house? Going to a school dance? A school overnight trip? In fact, there are no rules about when you must share information about your child. What type of body your child has is no one else’s business. Other people don’t have to tell us what’s in their child’s pants, why do we have to tell them what’s in our child’s pants? The only considerations we need to think about are what’s best for our child in each situation.

Remember that once you share your child’s gender information, you can’t un-share it. Even if a child is OK with being open when they are little, their needs around privacy may change as they grow older.

For additional information on privacy considerations, we encourage you to visit our Resources section.

​Children not fitting into typical gender boxes are often the victims of mistreatment or even violence. Caregivers to gender-expansive children bear a burden to ensure the physical and emotional safety of these kids in the face of that general reality.

Our role as parents is to love and accept our child, and we will help them learn how to deal with a world that sometimes doesn’t understand them. Without alarming them, we can help prepare our children for unwanted questions or comments by helping them come up with respectful replies that maintain their boundaries; this way, they won’t be left on their own to come up with a response on the spot.

We also need to teach our children how to access the support they need if it feels like things are becoming unsafe. We each know our own communities best, so we each need to decide if our children are in physical danger by expressing their gender in public, and weigh this physical danger against the emotional harm of not allowing our child to be their true selves outside of the home.

This can be tricky territory- our own discomfort, as well as a desire to protect our children, may lead us to decide to allow one set of behaviors in the home, and another set outside the home. But there is a cost to this choice: to your child’s sense of self, and potentially their experience of your support and acceptance.

There are a number of safety considerations for you to consider – remembering to place your child’s needs at the forefront of your decision making process is the first step to protecting them.

​When a person changes outwardly from one gender to another and lives in accordance with their gender identity, it is called going through transition, or transitioning. Transition can occur in two ways: social transition through non-permanent changes in clothing, hairstyle, name and/or pronouns, and medical transition through the use of medicines and/or surgeries to promote gender based body changes..

There is no rule of thumb for when a transgender child should be allowed to transition socially and/or medically. There usually comes a time when your child’s discomfort or suffering is so obvious that despite your concerns, it is critical for them to live in the world as they choose. But how do you know when that is? How long after they tell you about their desire should you wait to allow them this form of expression?

In making this decision, two concerns typically rise to the surface: “Will my child be safe if I let them do this?” and “Wouldn’t it be better just to make them wait?” The most useful way to answer these questions is to first evaluate whether your child currently feels safe and satisfied, or if instead they are suffering. If your child is suffering it is important to weigh the potential dangers that await them if they were to transition, compared to the dangers associated with their current depression.   What is clear is that children who receive the support of their families have the best outcomes in terms of their future health and well-being.

​Depending on the religion or religious community, acceptance of gender diversity can vary tremendously. It can be helpful to take stock of your religious community’s influences. List the overt messages and messengers about gender and sexual orientation issues, as well as how LGBT people tend to be characterized. You might be able to identify people who you perceive as “safe.” Approach these members first about your situation and seek their counsel on how to approach others.

It is also important to remember that gender diversity cuts across all racial, cultural and religious lines. With sensitive exploration, you may find people in your religious community who are more tolerant than others. Some people find they can educate their present religious community about gender. Other families find they need to seek new religious communities that are more welcoming of their family. In the process of supporting your child, you may well lose important people in your life, but more than likely you will also gain some important new people to replace them.

Choosing a School or College

Choosing a school or college with our kids is an important decision. Talk to the administrators or admissions staff about gender diversity to determine if the school will be a good fit for your child. For a more in depth assessment on choosing a school or college, please visit our Resources section.

Working with the School

Forming a positive relationship with school administrators and staff, whether you are new to a school or returning, it vital to the safety and success of your gender-expansive child. You will need to be proactive. You cannot assume that schools with general anti-bullying policies will be responsive to the needs of your child. Be sure to approach the school as partners, not as adversaries. Assume they have positive intentions; the vast majority of educators are interested in the well-being of the students and families they serve. However, most have little or no training about working with gender-expansive children. It may be that you will need to help them by providing resources, materials, and examples of other schools that have successfully met the needs of gender-expansive students.

Most schools have written or unwritten aspirations around inclusion and diversity; bring these into your discussions to show you want what is best for the whole school community. You may be hopefully working with these teachers and administrators for many years, and not only around issues of gender, so the goal is to forge a positive collaboration. You can use our outline, “Initial School Meeting” as a guide.

Even before your child starts at a school, you can start preparing. Many schools do professional development during the few weeks before school starts. Ask for gender training to be included in this professional development, so teachers feel prepared to deal with your gender-expansive or transgender child. Even if you are the first family at the school with a gender-expansive child, you certainly won’t be the last. Point out that it is in the best interest of all of the students, not just your student, for the staff to be trained, as gender affects every child and the school wants to create a gender-inclusive environment. The good news is that resources exist to help educate schools, including our own Gender Spectrum Trainings.

Safety in School

It is well documented that a safe environment optimizes a child’s ability to learn. A child cannot effectively learn when they live in fear of discrimination. All children, including gender-expansive and transgender children, deserve a safe school environment, free from bullying, teasing and violence, and it is the school’s legal responsibility to maintain that environment. Your child’s gender identity or gender expression in no way excuses mistreatment by other students, staff or parents. While it is important to work in partnership with the school, your child’s physical safety  and emotional well-being are non-negotiable. School districts and individual school administrators can be held liable under various federal, state and local laws for failing to protect students from harassment based on gender identity. From the beginning, if you believe your child is being mistreated based on gender, document those concerns and share them with the school leader. Make it clear that while you wish to work with the school, you will take whatever steps necessary to keep your child safe.

If you’ve tried to work with the school and they are unresponsive or unreasonable, you may need legal advice (see Legal Considerations).

Bullying in School

Bullying is a serious problem for any student. Most schools recognize this fact, and many are adopting programs and policies to create environments that do not allow or tolerate bullying. Bullying can take the form of one or more students directly teasing, taunting, or threatening another. Bullying comes in other, more indirect forms as well. A student may experience intentional social isolation perpetrated by their peers, and sometimes even reinforced by teachers and/or the administration.

Often, bullying is related to gender expression, even if on the surface it appears to be motivated by something else. For instance, a boy may be taunted as “gay,” not because he is in fact gay, but because his gender expression falls outside the society’s norms of masculinity. Your school may not specifically name gender expression or gender identity as reasons for bullying, but it does not mean that they will not respond proactively. Further education about gender diversity is often needed for teachers and school administrators to respond most effectively.

Other School Issues

Along with a child’s general safety and well-being, there are several specific areas that will require your attention. These include how your child will be referred to (name and pronouns), and listed on school records, how your child’s privacy will be protected, will you child be allowed to use the restroom and locker room aligned with their gender identity, and participation in overnight trips, sports or clubs.

As students get older, they must navigate school dance, crushes, and gossip. Talking about these situations ahead of time with your child will help them be prepared.

Our “Gender Support Plan” is a great tool to help you in these discussions with your school. This resource, as well as many others, can be found in the Resources section of this website.

​Many of the same situations that arise in school situations arise in out-of-school activities as well, such as privacy considerations, restrooms and locker rooms, and overnight sleeping arrangements.

Just as with schools, most adults who run these activities have no experience with gender-expansive or transgender kids.

Sometimes, camp or outside activities are opportunities for gender-expansive kids to see what it is like to present as the opposite gender, if they are not already doing so at home and at school.

Depending upon what documentation you need to register your child, you can think about registering them as their preferred gender. If you don’t have documentation, look into obtaining a state I.D. to use instead of a birth certificate, as in some states it is much easier to change a gender marker in the state system than it is on a birth certificate.

Some families choose to be completely open with camps and activities about their child’s gender and some don’t share any information at all. Another approach is to tell only the camp leader(s) and ask them not to disclose this private information to staff or campers. If you do choose to share your child’s gender information, take the same approach with camp staff and coaches as with schools—assume positive intent and work to educate their staff. Proactively speak with the camp leaders about potential issues before they arise, and ask if they are willing to have their staff receive gender training.

Changing bodies to match gender identity

Gender-expansive and transgender kids do not have to change their bodies in order to change their gender expression or identity. Some choose to make no changes to their bodies at all, while others know that they must change their bodies to feel complete. One of our roles as parents is to help our children figure out what road is right for them.

Keep the lines of communication open and explore options together. Discussing what you learn together can work to make the whole family better informed as well as allow for ample adjustment time. However, keep in mind that a parent and child may have very different ideas of an appropriate timetable. Don’t feel rushed into making decisions about permanent changes, but also keep in mind that your child may feel rejected by you if these critical life decisions are delayed indefinitely.

Children’s emotions around medical care

For many kids, going to the doctor can be traumatic. For gender-expansive or transgender kids, physical examinations of their bodies can feel especially invasive because if forces them to face a body they want to be different. Or, it can feel hard to explain their gender expression to a doctor who doesn’t understand.

Choosing Medical Professionals

It is important to find a medical professional who understands children and gender, or who is at least willing to educate themselves. Interview potential medical providers and find out about their experience in working with gender-expansive or transgender children. Ask about how they see their role in your child’s gender journey, and make sure they won’t be another adult trying to put your child into a gender box.

If your child is going down the road of physical transition, you don’t have to only work with an endocrinologist. Any physician, including your pediatrician or family practitioner, can help a child with start their physical transition with hormone “blockers” and/or cross-hormones.

If no one in your area is qualified, try to find someone who is willing to learn. We can help connect them to experienced physicians who can consult with them about the process. Unfortunately, many physicians are intimidated by this relatively new area of practice, or disagree with treating transgender children. Sometimes, families end up having to travel to established gender clinics in order to receive treatment for their child.

As with any relationship with a medical professional, it is important to be an active participant in your child’s care and monitor the physician-client relationship on an ongoing basis.

Need some help finding a medical professional? Gender Spectrum has connections to many professionals who are committed to affirmative care and support of gender diverse youth. If you need referrals for medical, mental health, legal or educational support, contact us at and we will connect you to professionals who can help you find appropriate referrals.

​Should We Seek Mental Health Support?

Children who fall outside of typical gender norms don’t automatically need to see a therapist. Gender diversity is not a mental illness that needs to be treated. If your child is generally content and functioning like most other children their age, they don’t need to be in therapy. On the other hand, if your child is depressed, anxious, or distressed due to their experience of their gender or due to other peoples’ reactions to their gender identity and expression, then they may need some extra support.

Raising a gender-expansive child is complicated in a world that doesn’t yet understand gender diversity. The constant decisions—large and small—we need to make can be exhausting. Should my child wear that outfit to school? Should I tell this person before we get together with them? Should I correct people if they assume my child is a different gender than they identify with? Will my child be safe and supported at school? The pressure to be an expert on gender and kids can feel overwhelming. Because of this, oftentimes parents will seek therapy for themselves in order to gain some support around parenting issues related to their child’s gender.

Whether you seek professional help or not, it is important to keep the lines of communication open between you and your child around gender issues. Talk about your own experiences with gender norms so your child understands that everyone has a gender story, not just gender-expansive people. If it’s not already part of your pattern, try to raise the issue of gender with your child occasionally so that your child doesn’t think it’s a forbidden or uncomfortable topic for you to discuss. Point out and appreciate gender diversity in other kids or adults so your child understands that there is a variety of gender identities and expressions, not just two. Most of all, make sure your child knows that if they are teased or questioned excessively about their gender that it is not because there is anything wrong with them, but instead it is because other people don’t understand that there are other ways to be boys, girls, both or neither.

How Do I Choose a Mental Health Provider?

Once you have determined that you will seek a therapist’s support, you must then identify a professional who will be most appropriate for the needs of your child and family. By no means are all therapists well informed on issues of gender as they relate to children and youth. As you seek the services of professionals, ask them what their experience is working with transgender or gender-expansive youth. A bad therapist can do more harm than good.

If you cannot find a qualified therapist in your area, consider finding someone you are comfortable with and who is open to learning; they can then consult with another therapist who has experience around issues related to gender and youth. Contact us for more information.

Ongoing monitoring of the therapy relationship is important. If the therapist is for your child, keep the lines of communication open between you and your child, as well as between you and the therapist. You want to make sure the environment remains supportive and affirming for your child.

Need some help finding a mental health professional? Gender Spectrum has connections to many professionals who are committed to affirmative care and support of gender diverse youth. If you need referrals for medical, mental health, legal or educational support, contact us and we will connect you to professionals who can help you find appropriate referrals.

​Deciding Whether to Seek Legal Help

Parents of gender-expansive or transgender kids may have some legal considerations to contend with, such as identity documents, health insurance, discrimination, and custody. Many of the legal issues faced by parents with gender-expansive children can be resolved through education and training.

Discrimination: Keep in mind that most institutions have little or no experience responding to gender-expansive or transgender kids. Rather than anything malicious, they may simply be unaware of the challenges being faced by your child, and don’t know how to respond more effectively. Sometimes the easiest and most efficient way to garner the support you seek is to approach the individuals involved directly, armed with the most up-to-date information and laws. If you can’t resolve the issues, you may want to consider seeking legal advice.

Identity Documents: What name should I use to register my child for school? What if I am asked to provide legal documentation that does not match my child’s gender expression? Should I legally change my child’s name and/or gender? While legal name changes give you a great deal of leverage to ensure your child is referred to consistent with their gender identity, some parents are not able or ready to take this step. Many have found it helpful to approach the school, program, agency or organization in which their child is involved and simply request that their child be referred to by their preferred name. There are no laws preventing schools and other organizations from calling children by their chosen name. Much of the time all it takes is a little education to help them understand that it is the right thing to do.

Custody Issues: Many lawyers and judges have no experience with the issues related to gender and children. If your child lives in two households and you are experiencing disagreement about your child’s gender status and what is best for your child, obtain therapy and/or mediation as your first steps. Try to reach an understanding outside of the courtroom about how to proceed with parenting your child. This may mean having to make compromises, especially if your child is young; though perhaps not ideal, it likely preferable to going to court and facing a potentially negative outcome.

If your family is already in the family courts system, you should immediately seek the counsel of an attorney familiar with issues and rights related to gender-expansive and transgender identities. It is also advisable to secure the professional support of doctors and therapists who can speak to the court about gender-expansive and transgender children and what they think is in the best interest of your child with regard to gender expression.

Choosing a Legal Provider

If you are in a situation where you need an attorney, especially for a family law case, it is imperative that you find one that has experience in dealing with gender-expansive or transgender children. There is too much at stake in custody cases to take unjustified risks or an unwise approach to a case based on inexperience. Gender Spectrum can connect you to experienced attorneys who can provide advice to you and/or your attorney around the issues of gender.

Need some help finding an attorney? Gender Spectrum works closely with the National Center for Lesbian Rights, the ACLU, and the Transgender Law Center, as well as other legal advocates who are committed to support of gender diverse youth. If you need referrals for legal support, contact us and we will connect you to professionals who can help you find appropriate referrals.

​​Melissa Muller is a Licensed Mental Health Counselor in St. Augustine, FL.  Melissa works with families, adolescents, couples and individuals.  Melissa has specializations in treating adolescents, eating disorders, trauma, and sexual addictions. In addition she enjoys working with the LGBT community.  She often works with families in the crisis of divorce to make the transition as healthy as possible for both the children and the adults in the family.

Call for your appointment today (904) 595-6840.

In my work I frequently work with individuals who have made the discovery that their partner has a sexual addiction.  This news is extremely traumatic and explosive.  The individual suddenly realizes their relationship is not the relationship they thought it was.  The partner is not who you thought he or she was.  This has a significant impact on the relationship, the couple, the family, and anyone else involved with the couple.  It may feel like a bomb has exploded in the family.

Sally had been married to Paul for twenty years when she came home one day and discovered him watching pornography and masturbating.  Paul swore to Sally that he had only recently begun this behavior because their sex life had diminished.  Sally accepted this and tried harder to be more involved sexually with Paul.  However, her trust for Paul had diminished and she was on the lookout for any other sexual acting out behavior by Paul.  Within a month, Sally came home and saw Paul’s computer open and a website for prostitutes pulled up.  She then went into his email and saw Paul had been corresponding with not one but many different women about getting together for sex.  Sally felt like she had been punched in the stomach and began to wretch.  She felt dizzy and had to sit on the floor.  Later, when she confronted Paul he told her had hadn’t actually had sex with any of these women but was only talking to them. She tried to believe him because she wanted it to be true.  Again, Paul blamed Sally for having withdrawn from him sexually.  Sally’s entire world had changed by the time she reached out to me in desperation.

The discovery of a sexual addiction is a traumatic experience for the partner. It brings major turmoil to the relationship.  The partner experiences extreme shame, broken trust, anger, hostility, and a possible desire for retribution. What does one tell the children?  What do the children already know?  Basically, the family’s world has imploded.

When the discovery of a sexual addiction hits the couple is thrown into turmoil.  Common feelings are anxiety, depression, self-doubt, anger, and a complete loss of trust.  Sexually, there is also a major impact.  I see a lot of partners who believe if they have as much sex as possible with the partner he or she won’t stray or need anything outside of the relationship.

Debbie was broken when she discovered her husband's sexual addiction.  The last thing she wanted to do was be sexual with her husband.  But she did, on a daily basis.  She believed if she had as much sex as her husband needed then he wouldn’t stray again.  During these times Debbie felt sexual aversion, shame, developed body image issues, but felt obligated and continued to be sexual with her husband. 

What Debbie and other partners of individuals with sexual addictions did not understand was that the sexual addiction had nothing to do with her.  It had roots in her husband's childhood.  It was something that had become out of control.  She did not understand the shame, guilt, and self-hatred her partner had as a result of the sexual addiction. 

 Joe’s wife Michelle had a sex and love addiction. Joe discovered Michelle was maintaining several. Long term, extramarital relationships.  Joe had not learned self-care or how to set boundaries in childhood.  Joe refused to do anything for himself that involved self-care because he was worried if he left Michelle home alone she would act out sexually.  Paul sacrificed his needs, choices, and behavior for Michelle’s.  He hired a private investigator, put a tracker on Michelle’s phone, and fastidiously watched the phone records.  He believed he could control his wife’s addiction.

Discovering your partner has a sexual addiction is a traumatic event.  Believing life was one thing and discovering it is something else is shocking.  It is common for these individuals to experience symptoms of Acute Stress Disorder and Post-traumatic Stress Disorder.  In one study, 70 % of these individuals showed these symptoms.  Different factors may contribute to how severe these symptoms are including; past history of trauma, level and length of deception, public embarrassment, and others.

Sexual addiction is a stigma.  It is not something that is accepted and supported in our society.  When someone loses a partner to death the support system surrounds the partner with love and support.  When the discovery of a sexual addiction happens, it isn’t discussed or brought to the open.  Other’s may talk negatively about it, there may be public shaming.  This leaves the family isolated and embarrassed.
When partners of individuals with sexual addictions arrive at my office they often feel broken.  Many times they come in with the partner whom they want fixed. They are unaware that they also need support and guidance in working through the storm.  When I work with partners of individuals who are sexually addicted we work to create boundaries.  We look at the individual’s history of boundaries.  Did he or she learn to create them or were boundaries never respected?  Was self-care taught?  Is there any self-care today?  I work with individuals to learn to develop a healthy support system and a healthy set of boundaries.  Partners of individuals with sexual addictions cannot take responsibility for their partner’s sexual addiction.  Their behavior is their own to control. 

Fernando’s partner George was addicted to pornography and masturbation.  Fernando did his best to control George’s behavior.  He monitored the computer and the Internet.  He was scared to leave George in the evenings and sacrificed his own social life and self-care.  What Fernando didn’t understand was that he could not control George’s behavior.  George needed to take responsibility for himself.  I worked with Fernando to establish boundaries for what he would do if George continued in his addiction.  Fernando was able to establish a self-care plan and to let go of the control he was trying to have over George.

In therapy some of the items partners and I work on include; letting go of trying to control the addiction, creating boundaries, developing a self-care plan, putting one’s needs as primary, and issues from family of origin that may be contributing to the couple’s problems. 

I welcome partners of sexually addicted individuals into my practice and enjoy helping them along the healing process.  Sometimes couples do not survive the trauma of addiction but other times couples are able to heal from the sexual addiction, when both work on their individual parts and then as a couple,  coming through as a strong individuals and as a unit.  This is rewarding work!
​
(All of the names and stories have been changed for this article.)

​​Melissa Muller is a Licensed Mental Health Counselor in St. Augustine, FL.  Melissa works with families, adolescents, couples and individuals.  Melissa has specializations in treating adolescents, eating disorders, trauma, and sexual addictions. In addition she enjoys working with the LGBT community.  She often works with families in the crisis of divorce to make the transition as healthy as possible for both the children and the adults in the family.

Call for your appointment today (904) 595-6840.

We all need to work together to prevent the ones we love and those we are close to from following through with suicide.  If you have lost someone by suicide you know the extreme pain it brings to those around the one who took his or her life. 

Suicide claims more deaths than automobile crashes.  Suicide is the third leading cause of death in ages 10 to 14 and the fourth ages 14 and up.  In 2013 (the last recorded year for suicides) there were 41,149 deaths by suicide.

These are factors that increase an individual’s chance of considering and following through with a suicide:

• A history of prior attempts leaves one more susceptible to future attempts.

 

• A family history of suicide breaks the taboo of taking one’s life.  It makes it the option an easier choice.

 
 

• Substance abuse increases the odds of suicide.  Alcohol lowers one’s inhibitions, impairs judgement and increases impulsivity.  Many people take their lives when intoxicated.

 

• A history of depression or other mental health issues raises the risk of suicide.

 

• Isolation from others and lack of support make suicide a viable option. No support system means there is no one there to help.

 

• Access to lethal means to harm oneself (guns, pills etc.).  Combine this with impulsivity and the risk increases.

 

• Feelings of hopelessness.  When one loses hope for the future suicide is an easier choice.

 
Warning Signs Include:

• Talking about feelings of hopelessness or wanting to die.

 

• Talking about feeling unbearable pain.

 
 

• Researching ways to kill oneself.

 

• Obtaining lethal means to harm oneself.

 
What can you do to help someone you are concerned about? 

• Talking to the individual is the best help you can offer.  Don’t be afraid to ask the individual if he or she is considering suicide.  Offer to assist the individual to obtain help

 

• Listen to what the individual is telling you and respond with empathy and compassion. Reassure them there is hope.

 
 

• Assist them in calling the National Suicide Hotline: (800) 273-8255

 

• If they state they are going to harm themselves, take them to a hospital for professional help.

Suicide is preventable if we all work together to be alert and caring to those around us.  Be on alert today and always for possible suicide!

​Melissa Muller is a Licensed Mental Health Counselor in St. Augustine, FL.  Melissa works with families, adolescents, couples and individuals.  Melissa has specializations in treating adolescents, eating disorders, trauma, and sexual addictions. In addition she enjoys working with the LGBT community.  She often works with families in the crisis of divorce to make the transition as healthy as possible for both the children and the adults in the family.

Call for your appointment today (904) 595-6840.

Guilt is something we feel badly for having done, it is about our behavior.  If we were late picking up our child, we may feel guilty about it.  If we had an argument with our spouse we may feel guilty about our part.

Shame is when we feel badly about ourselves as individuals. We think we aren’t loveable, are unworthy, or aren’t good enough. 

Individuals who experience shame learned when they were children from their caretakers they were bad.  When a child is mistreated by a caretaker the child believes that if the child was not a bad person the caretakers would have provided the love, care, and affection that the child needed.  It is easier for the child mind to create the belief that the child is unlovable, bad, or unworthy.  This is where the shame was created.

When we carry shame into adulthood, we may view situations through our wounded, child eyes. We make attempts to hide the true, bad self from others so they will not discover how unlovable, how bad, or how unworthy we really are.  Attempts to hide this can be seen as manipulation, or drama to those in our lives.

The good news is that shame and guilt are feelings that can be managed and changed using cognitive behavioral therapy (CBT).  CBT works to change the negative thoughts about oneself to be more positive, which affects the way we feel about ourselves, reducing the shame and guilt.  The result is feeling better about ourselves and feeling more positive about interacting with others.

​​Melissa Muller is a Licensed Mental Health Counselor in St. Augustine, FL.  Melissa works with families, adolescents, couples and individuals.  Melissa has specializations in treating adolescents, eating disorders, trauma, and sexual addictions. In addition she enjoys working with the LGBT community.  She often works with families in the crisis of divorce to make the transition as healthy as possible for both the children and the adults in the family.

Call for your appointment today (904) 595-6840.

I am often asked if I work with couples.  I do indeed and I enjoy it!  I work with all types of couples at various stages of difficulties or couples who simply want to strengthen their relationship.  There are many presenting reasons couples arrive at my office. 

Issues that may be affecting the couple:
·         Constant arguing,
·         Infidelity in the relationship,
·         Loss and grief,
·         Considering separating,
·         Sexual issues, and/or
·         Stage of life crisis.

Sometimes, but not often, I get a couple who comes in seeking premarital counseling. These couples are fun to work with because they are excited for their new venture.

I try to meet the couple at their level of conflict and dive in with them into the process of healing or growing together.  The couple is always the client, not either individual.  I work towards the betterment of the relationship, hopefully, they do too.
When a couple is in my office it is imperative that they both work hard to improve their relationship.  Things we may work on together include:
·         Communication,
·         Strengthening the relationship,
·         Problem solving,
·         Resolving conflict, and/or
·         Developing deeper intimacy.

I often give some homework between sessions.  One assignment is from the book by Gary Chapman, The Five Love Languages.  This is a wonderful, easy to read book. The book explains ways we each want to give and receive love.  It is an easy read and may help you and your partner figure out how to keep each other’s love tanks full!  Try this on your own!

It is important to remember that all relationships are hard work and reaching out for help can be a positive.