Fear and discrimination against homosexuality and transsexual people are still unknown and scary in some countries after more than four decades of progressive changes in psychiatric science and civil rights across countries [1]. In these countries, discrimination toward Lesbian, Gay, Bisexual, Transgender, Queer, & Intersex Life (LGBTQs) and their families still exists. Transgenderism, trans, and transsexual mean a desire to live and be accepted as a member of the opposite sex, which is usually accompanied by a feeling of discomfort about one’s anatomical sex and a desire for sex reassignment surgery and hormonal treatment [2]. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-Fifth Edition) [3], the diagnostic name of “gender identity disorder” has been replaced with “gender dysphoria” [3]. A person learns from childhood to think, feel, and behave according to the sex he/she was created. This natural process may take a different path when the person considers himself/herself a member of the opposite sex, thinks that there is a mistake in his/her birth gender, and tries to correct this mistake by changing his/her gender [4]. People who are called “transsexual” have a strong desire to be similar to people of the opposite sex and like to be accepted by the public as the same gender they consider themselves to belong to [5]. According to the World Health Organization (WHO), people with gender identity change and other gender minorities are estimated to make up about 0.3~0.5% (25 million people) of the world’s population. Gender dysphoria has been found in 4% of men and 1.5% of women. About 3% for boys and less than 1% of girls have a desire to be a member of the opposite sex [2]. The exact prevalence of gender identity disorder remains unclear. It seems to be more common in men than in women (1 in 30,000 men vs. 1 in 100,000 women) [6].

Given that people normally perceive members of the community belong to only two gender groups, it is not surprising that some parents reject their children as soon as they find out about their gender choice due to shame and embarrassment. Conservatives and religious societies have negative reactions to sexual variations. In these societies, transsexual persons and LGBTQI are considered to be pathological and need to be medically treated [1]. Parents’ first reactions to their child’s transsexualism are associated with concerns. They try to get information about this issue [7]. Mothers are always exposed to secondary stigma related to their children due to having transsexual children [8]. Parents with transsexual children often experience psychological reactions and feelings of shame, blame, and self-stigma [9].

Some parents seek treatment and counseling to solve their children’s problems, to try to make them conform to society’s standards, and keep the family system stable at their will [10]. In countries with a Muslim majority and conservative groups, male gender is valued more than the female. A child showing masculine behaviors is encouraged. However, if a male child shows feminine behavior, he will be rejected by the people around him. For this reason, these people might be rejected by the family and other people or harassed. In a society like Iran where there is no desire to recognize the wishes and needs of transsexual people, a negative public view can lead to rejection and harassment [4,11]. According the Islamic Penal Code of the Islamic Republic of Iran Article 237, homosexual acts of a male person in cases other than livat (sexual intercourse male to male) and tafkhiz (defined as various forms of homosexual sexual activity either between men or women) such as kissing or touching as a result of lust shall be punishable by thirty-one to seventy-four lashes of ta’zir punishment of the sixth grade [12]. Some of these people are not satisfied with the sex reassignment surgery. To avoid committing a crime that can lead to jail sentence, they have to submit to sex reassignment surgery. This practice affects all family members, especially the mother [10].

The mother bears the most blame and humiliation due to her child’s gender dysphoria [11]. Transsexual people need family support and integration into the society. Family rejection and neglect of transsexual people may lead to drug use and suicide [13-14] and unprotected sexual relations [15]. Moreover, family support can lead to more resilience in these people and decrease distress levels [16]. Fear and stigma toward LGBTQ people are widely rooted in religious, political, and cultural values and beliefs of society members [17-18].

Studies conducted in Iran have shown that mothers are always blamed and humiliated for their children’s psychological and educational problems [19]. Motherhood is very difficult in a world that demands “normalcy”. At times, psychological distress and dysphoria can get out of family control and disrupt homeostasis [20]. However, depending on the type of problem, blames and insults directed at mothers are different. A mother living with a child who has changed gender for some reason has to care for the child. She also faces many adversities and problems caused by negative public views and criticisms of her parenting style. Mothers who have transexuals adult children might hide themselves because of the negative view of the conservative and strict Iranian society. They mostly do not talk about their psycho-social problems. Their problems need to be recognized in order to help them and their parent-child relationship. Thus, this study aimed to explore psychosocial experiences of mothers with transsexual adult children.

As shown in Table 1, participants’ age ranged from 36 to 62 years. Seven participants had a high school diploma. Four had a bachelor’s degree. Six were illiterate. Results concerning participants’ employment status indicated that 11 persons were housewives and 6 persons were employed. Regarding the number of children of each participant, the highest number was 5 and the lowest number was 1. Ten persons lived in Tehran and 7 lived in other cities. Three mothers had children with male to female (MtF) gender identity and 14 mothers had children with female to male (FtM) gender identity. Four mothers attended face-to-face interviews and 13 mothers who lived in other cities or could not attend face-to-face interviews were interviewed by phone. Themes, main categories, and subcategories extracted from the data on psychological challenges of mothers with transsexual children are detailed in Table 2.

Results of the present study showed that having a transsexual child in the first place was a trauma for family members, especially the mother in Iranian society. The lack of adequate information about these children, the lack of family and government support, and most importantly, social stigma and public attitudes cause negative reactions and feelings of mothers. Thus, mothers of transsexual children experience sadness, discomfort, and psychological problems. Frigerio et al. have examined the experience of Italian parents with a transsexual child and concluded that this issue is something impossible to understand for parents of teenagers [22].

The present study showed that mothers of transsexual children reported that they were sad. This finding was consistent with results reported by Johnson and Benson [10]. In their case study, they showed that a single mother in a rural area of the United States who had a child with FtM gender identity always received ironic messages from those around her for having such a child and that people judged her parenting styles. Thus, she was always sad [10].

Participants of this study stated that they had feelings of shame and tried not to reveal that they had transsexual children. Similarly, Russell et al. [23] have reported that parents of children with a transsexual identity often experience negative emotions such as withdrawal and shame. Moreover, Johnson and Benson [10] have shown that mothers of transsexual children try to make their children get accepted by the community and subsequently seek treatment and support for children. These mothers often faced disagreements and lost their ties with family members and friends. These problems were linked to their parenting styles. Thus, they became confused, disappointed, and depressed [10]. In another study, Kuvalanka et al.[19] showed that some mothers were blamed by others for having trans children.

Transsexual people try to engage in social activities after a gender change surgery. They try to prove and confirm themselves in the community. Thus, they may pay a ransom and engage in risky behaviors such as smoking and drug use, fights, and beatings to present themselves as men or women in society [4]. One of the most important concerns of mothers with transsexual children was the fear of suicide of their children. These mothers also experienced public rejection and fear of child suicide. Accordingly, Russell et al. [23] have concluded that if parents do not support children with gender identity inconsistency, children might face negative consequences such as depression and suicidal thoughts. Most of these frustrations stem from public rejection, uncertain job prospects, and inability to marry and have children. In a similar vein, Hill and Menvielle [24] have found that parents express concern about their child’s well-being and safety in the future. The attention of parents, especially the mother, to the transsexual child and the presence of a sibling who had been the only daughter or son in the family for years and now showing up as a sibling of the same sex can cause jealousy and sometimes resentment between the sibling and the trans person. Thus, parents may reject their trans child to save face or keep the matter a secret from relatives and friends. Likewise, other studies [25,26] have found that family acceptance has a positive effect on emotions and behavioral health of transsexual youth, including self-esteem against drug abuse and suicidal thoughts. Jin et al. [26] have also shown that young transsexual women who receive adequate support from their mothers have lower levels of suicidal ideation compared to daughters of mothers who are not supportive.

Results of the present study indicated that families of transsexual children were rejected ad blamed by relatives and neighbors. Johnson and Benson [10] also showed that after the mother persuaded family members to accept her transsexual child, she tried to persuade first-degree relatives who did not accept her transsexual child and started to oppose and blame parents of the trans child and limit or cut off their relationships.

Negative public attitude was one of the themes identified in this study. Participants often complained about public attitudes, their harsh blame and mockery, and harassment of their transsexual child because of their clothing style. Similarly, previous studies have revealed that some people might provide encouragement and support about wearing a disguise, whereas others have hostile behavior along with ridicule and even blame the mother, with maternal blame having a gender bias [19,24]. Interestingly, Gonzalez et al. [27] have shown that with political and social changes in society, views towards (GLBTQIs) individuals and families play a key role in supporting their members.

Rejection of transsexual students by school officials and parents of other students is a social crisis and stigma that stems from an unawareness of transsexualism. Findings of the present study showed that some families decided to migrate to other countries or larger cities in the country to decrease negative public views and blame. Sometimes they forced their children to migrate alone. Kuvalanka et al. reported similar results about the migration of families with transsexual families to other cities [19]. Moreover, after revealing gender identity, families react differently according to their race, ethnicity, and immigration status. Moreover, media play a very important role in shaping public attitudes. Counselors and psychologists can also help transsexual people and their families [27].

However, other studies have reported conflicting results about immigration to other countries. Western culture is very different from Iranian culture in terms of public attitudes toward transsexual people. In western cultures, families try to provide comprehensive support for their children with the help of support groups. Their focus is on their child rather than on public attitudes. However, in Iran, public attitudes and preserving the reputation of families are more important than anything else.

Since gender dysphoria has replaced gender identity disorder in psychiatric textbooks, preventing prejudice among mental health professionals and developing new education curriculum are necessary, especially in Muslim countries. In addition, raising awareness by mental health experts, through the media, or government institutions is of great importance. The existence of clinics to increase awareness among parents and the existence of a positive therapeutic environment and family therapy are very helpful for families of transsexual children [28]. A systematic review by Malpas et al. [29] showed that preventive and family therapy programs are very effective for families with trans children. They have pointed out that in addition to educating families and supporting them, advocacy plays a very important role in the acceptance of families, ultimately increasing public support for them [29]. In conservative societies with a more closed culture such as Muslim and Middle Eastern societies, social networks and non-governmental organizations (NGOs) are very effective in helping mothers and families with transsexual children. Mothers who participated in this study were very upset that they could not hang out with others and that they were socially isolated. In all human societies, accessing education and information about transsexual people can help these people and their families [30]. Thus, holding training programs about transsexualism and cultural values by health care professionals and increasing information and receiving information through the Internet can be very helpful in increasing support for families with transsexual children [10]. In summary, results of this study are helpful for emphasizing the importance of what needs to be improved to support parents with transsexual adult children.

One of the limitations of the present study was that participants hardly trusted the interviewer. Many times interview appointments were canceled or interviews were refused. Thus, the data collection process took a long time. Accordingly, future studies need to focus on problems faced by transsexual children and their families and examine children with gender identity change who have not yet undergone surgery and problems faced by their families. Future research should address concerns and experiences of siblings. In addition, fathers were not present in the research. Some of the husbands of these women left the house because of their child’s problem and blamed the mother. Hence, interviewing fathers is very important. Also, it seems necessary to examine the role of organizations supporting trans people in Iranian society.

The present study reveals that mothers of transsexual children are likely to suffer a lot because of their child’s gender change. Mothers are lonely. They face negative and harsh judgments from family and other people. These are often beyond their tolerance. Furthermore, worries about the child’s future and the risk of child suicide are other challenges faced by these mothers. Raising awareness and unbiased treatment of trans people without blaming mothers for an incident (that sometimes nature plays a greater role than nurture and parenting) can play a significant role in reducing these challenges. Findings of the present study can help mental health professionals and officials of the national health system to organize mental health programs such as; family-based interventions and manfulness reeducation stress based on needs and experiences of mothers with transsexual children. One of the main concerns of trans’ siblings is about the role of heredity, which mainly stems from misconceptions.