The Lesbian, Gay, Bisexual, and Transgender (LGBT) community has built tremendous momentum in raising awareness of its presence in our communities, and in the past several decades we have seen the positive impacts that LGBT and ally groups have made on society. However, despite these great strides, the community is still significantly marred by stigma, hate, and isolation and is often susceptible to the immense burden of grouping a diverse population under one common flag. In the past decade, the transgender community has made some of the most significant strides in bringing about awareness and acceptance of individuals who may not identify with their assigned birth genders or with society’s binary construct of gender. Increasing evidence has shown that children and youth who struggle with gender identity benefit from compassionate and informed care. With appropriate management, health care providers can help to safely affirm and assist children and youth who identify as transgender in navigating their individual journeys while minimizing physical and mental health risks.
When treating children and adolescents whose gender identity differs from their assigned sex at birth, correct use of terminology is important. Box 3.1 defines some of the more common terms currently used in the field. However, it important to note that language related to gender identity may vary and may not have the same meaning to all individuals. Some individuals may find certain terms outdated or even offensive, whereas others may still prefer the use of them to describe their experience. It is therefore important for clinicians to preemptively ask patients and their families which terms they prefer, especially with regard to identity and use of pronouns.
|Sex||Birth classification, generally as male and female, based on gender-specific anatomy (internal and external reproductive organs), chromosomal classification.|
|Intersex||Used to describe an individual with ambiguous gender-specific anatomy and/or chromosomal makeup.|
|Gender||Social and psychological constructs and expectations held for individuals based on their assigned sex.|
|Gender Identity||The internalized sense of gender, this may correlate with assigned sex (cisgender), conflict with assigned sex (transgender), or be represented in varying degrees (see below).|
|Gender Expression||External expression of gender identity; clothing, hair, and behavior (including voice, body morphology), as well as the use of preferred names and pronouns.|
|Sexual Orientation||A person’s physical, romantic, emotional, and sexual attraction to another person. A person can be lesbian, gay, straight, bisexual, or queer based on their gender identity.|
|Transgender||A person whose gender identity and expression differ from their assigned sex at birth.|
|Cisgender||A person’s whose gender identity and expression match their assigned sex at birth.|
|Gender Nonconforming||Term often used to describe when aspects of one’s gender expression does not conform to the social expectations of femininity or masculinity. Gender nonconforming individuals can identify as transgender or cisgender.|
|Nonbinary Identities (can include various terms including “nonbinary,” “genderqueer,” “neutrois”)||A person whose gender identity does not meet conventional expectations of gender in a binary form (e.g., male vs. female). Gender identity can be fluid, identifying with aspects of either gender, or neither.|
|Transitioning||Refers to the process by which a person begins to alter their sex and begin expressing their gender identity. This is a complex process that involves social transitioning (living socially as their identified gender), may include medical interventions such as pubertal suppression, cross-sex hormone therapy (see below), or gender-confirming surgery (see below).|
|Cross-Sex Hormone Therapy (also referred to as Gender Affirming Hormone Therapy)||The use of feminizing hormones on a biologic male, or the use of masculinizing hormones on a biologic female.|
|Gender-Confirming Surgery (also referred to as Gender Affirming Surgery)||A series of surgical procedures performed with a goal of adopting a person’s preferred sexual anatomy. This may include masculinizing or feminizing cosmetic procedures as well.|
Trends in Gender Nonconforming Behavior and Gender Variance
Transgender youth make up a unique and vulnerable population that requires comprehensive treatment approaches and considerations. There is currently more literature studying and describing the adult lesbian, gay, and bisexual population, with limited data on youth populations. This is especially true with regard to research related to transgender youth and their health outcomes. Given that the percentage of individuals who identify as LGBT in the community is small, studies also tend to have small population sizes and/or are case studies. In 2016 the Williams Institute published a study looking at data from the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System and estimated that 0.6% of adults in the United States identify as transgender. An earlier study based on a smaller data set at the state level had estimated that the prevalence of transgenderism within the United States was 0.3%. In addition to increasing efforts in gathering data on the transgender community, it is also possible that increased acceptance and visibility of transgender individuals in society may also be contributing to more transgender individuals identifying themselves as such on survey data. To estimate prevalence in youth populations, it is even more difficult because the data are limited to even smaller data sets. We must also consider the likelihood that transgender youth are less willing to identify themselves in surveys as a result of fear related to confidentiality issues or because many youth are still exploring their gender identity and may not be sure how to answer the survey question related to gender and identity.
As mentioned, studies looking specifically at prevalence rates in youth populations remain limited. One study done in New Zealand surveyed 8500 youth and found that 1.2% of respondents identified as transgender. Interestingly, the study also had options for students to indicate if they were not sure of their gender (2.5%) or if they did not understand the question (1.7%). In their 2016 review, Connolly et al. looked at the existing data on transgender youth. They found variance in the reported prevalence of youth who identify as transgender, between 0.17% and 1.3%. It is important to note that these studies relied on a binary system of describing gender (male or female) and were not inclusive of other gender-fluid identities. Previous studies, such as the one published in 2009 by Almeida et al., found that in a sample of more than 1000 students in Boston, 1.6% identified as transgender. Gender clinics specializing in gender nonconforming and transgender youth have also seen a significant increase in referrals in recent years, and the number of total gender clinics has also grown.
In 2015, the US Transgender Survey aimed to better understand the experience of the transgender community by surveying 27,000 transgender adult respondents in the United States. Although the survey focused on adults, it asked a number of questions regarding the individual’s childhood experiences. In this portion of the survey, 54% of respondents recalled being verbally harassed in their K-12 experience, 24% were physically attacked, and 13% were sexually assaulted because of their gender identity. Of the respondents who disclosed their gender identity to their families, 10% experienced violence from one or more family members and 8% were kicked out of the home. Mental health concerns were also brought to light in this survey, because 39% of respondents reported experiencing serious psychological distress in the past month, 40% reported a suicide attempt in their lifetime, and 7% reported a suicide attempt in the past year.
The most current version of the Diagnostic and Statistical Manual of Mental Disorders, the DSM 5, describes the diagnosis of Gender Dysphoria as “the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender.” This more recent diagnosis marked a change from the previous version of the DSM-IV, which diagnosed transgender individuals with Gender Identity Disorder (GID). By changing the terminology and omitting “disorder” from the diagnosis, there was a shift in the paradigm with regard to what it means to be transgender. There is now less of an emphasis on an individual being disordered, and there is more of a focus on the distress that some individuals may experience as a result of being transgender. An important take away point from this change in nomenclature is that the term Gender Dysphoria does not simply refer to behavior that is nonconforming with stereotypical gender roles, but rather, it describes an individual’s distress or impairment as a result of the incongruence between their experienced and assigned gender. The main purpose for changing the terminology was to refine the diagnosis and to help avoid stigma against patients. In the past, it has been easy to misinterpret the former diagnosis of GID to mean that transgender individuals are inherently mentally ill or that their identity can be changed through treatment as in any other disorder.
In the DSM 5 criteria for Gender Dysphoria a distinction is made between Gender Dysphoria in Childhood and Gender Dysphoria in Adolescents and Adults ( Box 3.2 ). In the criteria for Gender Dysphoria in Childhood , there must be a desire or insistence that the individual is of the other or an alternative gender. Some children present voicing a strong insistence that they are the other gender, and they may exhibit their distress as a result of this in the form of behavioral problems or temper tantrums when those around them treat them as their assigned gender. On the other hand, some children exhibit interests that might challenge our society’s expectations for their assigned gender (e.g., a natal boy who likes to play dress up in princess gowns, or a natal girl who may refuse to wear a dress or play with dolls) but continue to insist that their gender identity is in line with their assigned gender.
A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least six of the following (one of which must be Criterion A1):
A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender).
In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.
A strong preference for cross-gender roles in make-believe play or fantasy play.
A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender
A strong preference for playmates of the other gender
In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities.
A strong dislike of one’s sexual anatomy.
A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.
The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.
In addition to the desire to be the other or some alternative gender, to meet criteria for Gender Dysphoria in childhood, a child must have six out of eight criteria that include various preferences in types of play and activities, clothing, roles in pretend play, and gender of their playmates. Two of the eight criteria refer to either a dislike of their sexual anatomy or a desire for the primary/secondary sex characteristics of their experienced gender.
The requirements for diagnosis in adolescents differ slightly from the diagnosis of children. To make the diagnosis in adolescence, two out of the following six criteria must be met: a marked incongruence between one’s experienced gender and assigned gender; a strong desire to be rid of their primary/secondary sex characteristics because of the incongruence; a strong desire for the primary/secondary sex characteristics of the other gender; a strong desire to be a different gender from their assigned gender; a strong desire to be treated as the other gender; or a strong conviction that one has the feelings and reactions of the other gender.
The aforementioned criteria must be present for at least 6 months for Gender Dysphoria to be formally diagnosed in either childhood or in adolescence, and they must be associated with marked distress or impairment in functioning. It is possible for a child or adolescent to identify as another gender, and some patients may even consider themselves transgender without there being associated distress or impairment. These individuals do not meet criteria for Gender Dysphoria , but it is important to acknowledge that this does not mean that the individual’s gender identity is any less valid, nor does it mean that they may not need mental health care services. Many gender-nonconforming youth who do not have gender dysphoria may still be subject to stressors such as teasing or bullying around their gender expressions that can lead to the development of problems such as school avoidance, anxiety, and/or depression.
As previously mentioned, understanding the true prevalence of transgenderism and gender dysphoria has been challenging because there is limited research in this area. Most of the data that exist have been subject to both selection and recall bias as a result of how samples are chosen and the need to rely on self-reporting. Individuals may not be comfortable identifying themselves as a gender minority, which leads to an underestimation of the prevalence of this patient population. Early estimates in children and adolescence have been based more on behavior, making them more difficult to interpret because exhibiting behavior that is more typical of the other gender does not equate to having a transgender identity or meeting criteria for Gender Dysphoria . Some of these earlier estimates used the Child Behavior Checklist (CBCL), which contains questions for parents to indicate whether their child behaves like the opposite sex or wishes to be of the opposite sex. Zucker et al. found that using the CBCL, when asked, mothers reported the following: their child behaves like the opposites sex (for natal boys 3.8% sometimes, 1% often; for natal girls 8.3% sometimes, 2.3% often) and their child wishes to be the opposite sex (for natal boys 1% sometimes, 0% often; for natal girls 2.5% sometimes, 1% often). A large Dutch twin study also looked at parental endorsement of cross-gender behavior and identification and found similar results (for natal boys at 7 years old 3.4% behaving like the other gender and 1% wishing to be the opposite sex, at 10 years old 2.4% behaving like the opposite sex and 1% wishing to be the opposite sex; for natal girls at 7 years old 5.2% behaving like the opposite sex and 1.7% identifying as the opposite sex, and at 10 years old 3.4% behaving like the opposite sex and 0.9% identifying as the opposite sex). Again, we would like to emphasize that it is hard to interpret these data because cross-gender behavior is not necessarily a surrogate for Gender Dysphoria .
Social transitions in prepubertal youth
Social transition can refer to various decisions and choices one can make to show themselves as the gender they identify as. This can include changing one’s name to one that is more stereotypically associated with their experienced gender, changing the use of pronouns or changing the way they express their gender in a way that fits their experienced gender. One who is or has socially transitioned may make some of the aforementioned choices in some or in all settings. As visibility has increased around transgender identities, there has been a growing number of families that present to gender clinics and specialists looking for guidance in making some of these decisions at an early age.
There is controversy surrounding the best approach for working with children with gender dysphoria. As such, there are a number of different treatment approaches that specialists have taken in caring for young patients. Families sometimes present very anxious about their child’s behaviors when they are outside of the social norms for what is expected of the child’s assigned birth gender. A very frequent concern and question that many parents have is if it is too early in development for their child to truly know their gender identity. Current psychological theories do point to children having an early awareness of their gender identity and having an ability to label themselves as being a boy or girl as young as 2 or 3 years of age. However, parents often raise concerns that their child may change their mind and they worry about the damage that could be done if a “wrong” decision is made with regard to their child’s transition.
There have been a number of studies that have looked at the development of youth that exhibit gender nonconforming behaviors at an early age. Overall, these studies show that a significant percentage of these youth “desist” in their presentations and ultimately identify as their assigned gender at birth. Studies show variable rates of persistence in children identifying as the other gender, ranging from 2% to 39%. Of note, very few studies use the most up-to-date DSM 5 definition of Gender Dysphoria . More recent research has looked into the differences that exist between the groups of children that “persist” and those that do not. In a prospective study of 77 children referred for Gender Dysphoria , Wallien and Cohen-Kettenis showed that those children who persisted had a much higher incidence of being assigned a formal diagnosis of GID (as defined by DSM-IV at the time of the study), more gender variant behavior, and a higher intensity of dysphoria in childhood. Steensma et al. followed 127 adolescents and found that “persisters” tended to be more explicit in their belief that they were the other sex and had higher intensity of gender dysphoria in childhood, more gender variant behavior, and more dissatisfaction with their bodies compared with children that did not remain persistent.
The aforementioned findings have led many parents and providers to adopt the now commonly used phrase of looking for an “insistent, consistent, and persistent” pattern to help determine which children may be more likely to persist in their presentation through adolescence and adulthood. This concept has been further validated by researchers such as de Vries et al., who showed that in a cohort of 55 adolescents belonging to a Dutch gender clinic, all of the patients were children who continued to identify as transgender in young adulthood. Interestingly, review of persistence and desistance studies reveals that the rates of persistence have increased to a range of 12% to 39% compared with studies published before the year 2000 which showed lower persistence rates of 2% to 9%. Some have theorized that this may be a result of changes in our societies with more individuals identifying as transgender because of less stigma and social pressures.
Role of the Mental Health Professional in the Assessment and Treatment of Adolescents with Gender Nonconforming Behavior
Assessment of co-occurring psychiatric conditions
With suicide currently as the second leading cause of death in US youth, it is important to remember that sexual and gender minority youth are at a particularly higher risk for suicidal ideation, self-injurious behavior, and suicide attempts. Mental health can be a stigmatized subject, and transgender youth may have difficulty fully disclosing their concerns with providers. Major contributors to this are social factors such as a higher risk of bullying and victimization as a result of disclosure. Seventy-five percent of sexual and gender minority youth experience bullying and are afraid or may not feel supported if they disclose this at home or in their school community. Bullying and victimization at school and home put transgender youth at a particularly high risk for running away behavior, which contributes to their overrepresentation in the homeless youth population. Without a stable environment in which to develop, these youth are at risk for comorbid depression, anxiety, substance use (sexual minorities have the greatest risk of reporting lifetime substance use problems, especially sexual minority women of color), use of illegally obtained street-hormones, engaging in prostitution and “survival sex,” and associated physical health concerns such as communicable diseases.
A number of studies have looked at the presence of mental health comorbidities in youth with gender dysphoria. In one study, 44% of youth followed in a multidisciplinary gender clinic had a significant psychiatric history, 58% had been diagnosed with depression, 16% with generalized anxiety, 21% had a history of self-mutilation, and 9% had at least one previous suicide attempt. A Dutch study found that out of 120 children referred to a gender clinic, 52% had a mental health diagnosis other than GID (the term used at the time) and a higher incidence of internalizing disorders (e.g., anxiety and mood disorders) compared with externalizing disorders (e.g., disruptive behavioral disorders): 37% versus 23%. Similarly, a study performed in the Gender Identity Development Service (GIDS) in London examined adolescents with gender dysphoric features and also found higher rates of internalizing symptoms compared with externalizing symptoms.
Reisner et al. showed that transgender youth have significantly more comorbid psychiatric conditions when compared with cisgender controls. In their study, youth who identified as transgender were more likely to be diagnosed with a depressive disorder (50.6% vs. 20.6%) or anxiety (26.7% vs. 10%), to have presence of suicidal ideation (17.2% vs. 6.1%), presence of self-injurious behavior (16.7% vs. 4.4%), a history of inpatient psychiatric treatment (22.8% vs. 11.1%), or to report being in an outpatient psychiatric treatment at the time of the study (45.6% vs. 16.1%). In this study, there were no significant differences in the aforementioned mental health conditions between transgender males and females.
A number of studies have also been done looking at suicidality. One study interviewed a sample of youth and young adults who identified as transgender and found that 45% seriously thought of suicide, with even higher rates reported by those that identified as having experienced verbal or physical abuse by parents, and 26% reported a history of a suicide attempt.
A retrospective analysis by the GIDS in London also showed that youth with gender dysphoric features often have high rates of bullying (47%), low mood or depression (42%), and self-harm behavior (39%). Their study also compared youth aged 5 to 11 years and youth aged 12 to 18 years and showed that puberty was a time of increased distress with even higher rates of depression, self-harm, and suicidal thoughts in the younger age group. In a study published by Olson et al., 20% ( n = 96) of youth aged 12 to 24 years of age seeking care in a transgender youth clinic had Beck Depression Inventory rating scale scores in the moderate to extreme range, 51% had a history of suicidal thoughts, and 30% had a history of a suicide attempt.
Similarly, in a comprehensive review by Connolly et al., the authors found that transgender youth were more likely to be depressed than their cisgender peers, with up to 50.6% of youth diagnosed with depression. They also showed that transgender youth were at a higher risk for attempted suicide and suicidal ideation, with rates reported in some studies as high as 19.8% and 56%, respectively. In their 2016 study looking at the prevalence of suicidal thoughts and behaviors in children (aged 3 to 12 years) seen in a gender identity clinic, Aitken et al. noted that children referred to gender clinics had more behavior problems and had poorer peer relations than a nonreferred group of children. The referred group was also more likely to talk about killing themselves (22.7%), more likey to be deliberately harming themselves and attempting suicide (18.6%). There appeared to be an age relationship: as children got older, the gender-referred group was 15 times more likely to talk about suicide.
It is no surprise that social supports and perception of safety play a significant role in the well-being of transgender youth, and assessment of this is important when conducting a mental health evaluation. LGBT youth who report low levels of support from their families, communities, or social relationships are more likely to report depressive symptoms and suicidality. In their 2014 study of LGBT youth in Boston, Duncan and Hatzenbuehler found a correlation between suicidal ideation and suicide attempts in LGBT youth who lived in neighborhoods that had high rates of LGBT-related hate crimes.
Lastly, Connolly et al. also reported a higher prevalence of eating disorders among transgender adolescents, with overall rates as high as 15.8%. The authors revealed that 13.5% of youth reported using diet pills and 15.1% described purging behaviors.
Exploration of gender identity/expression
At the time of assessment, a diagnosis of Gender Dysphoria may or may not be made depending on whether the child or adolescent meets criteria for the diagnosis. Regardless of the formal diagnosis that is made, the mental health provider’s role is also to help children and adolescents further explore and discern their gender identity and gender expression. Some youth may not show much desire to “explore,” because they may express certainty about their gender identity. Conversely, other children and adolescents present to the mental health provider with difficulty in articulating their internal sense of their gender identity. This is often the case for those individuals who may not identify in the binary (male vs. female) sense of gender. Some children present identifying neither as male nor female and, when asked, may find difficulty in labeling their gender identity. Adolescents who feel certain with their gender identity may still desire counseling regarding ways to express their gender. Great care must be taken in eliciting conversations about gender identity. Some youth may choose to not to disclose their gender identity or express their gender the way they truly wish to out of fear of bullying or harassment. In other cases, it may be the parents who wish to limit certain expressions out of safety fears for their child.
There is a lot of controversy surrounding models of care for prepubertal youth who have gender variant behaviors. Past approaches have included efforts to help youth be more comfortable with their assigned gender at birth through different interventions, such as promoting interactions with same-sex peers, relationships with the same-sex parent, and encouraging more typical behaviors of the assigned sex at birth. The rationale behind these approaches are to help hasten desistence, which is based on previous literature that suggests that many prepubertal youth who have gender nonconforming behaviors desist through development and eventually stop identifying as the opposite gender thereby minimizing the potential risks of being rejected by peers and family and developing symptoms of anxiety or depression. It is important to note that these approaches lack strong evidence and have not been studied in randomized controlled trials designed to show efficacy. As noted earlier, the literature that exists on rates of persistence and desistance has a number of limitations. The biggest concern related to this approach is the potential risk of harm that could occur in the individual who does not desist, but rather persists. The approach sends a message of lack of acceptance or tolerance, and this type of rejection may be at the core of some of the disparities in mental health seen in transgender youth.
Other approaches have taken a “watchful waiting” stance, where risks of transitioning are taken into consideration given potential negative reactions or responses from others. In this approach, parents may have their child wait before undergoing a social transition until further development into puberty, while still trying to balance an accepting approach. Some approaches try to balance this by encouraging acceptance and tolerance of any behaviors or interests that are considered gender nonconforming, but potentially limiting expression or deferring timing of social transitions when accounting for potential risks.
Finally, the affirmative model focuses on building resilience and positive self-esteem, and youth desiring a social transition are affirmed and supported in their attempts to transition. More recent research has looked at prepubertal transgender youth who have undergone social transition. Compared with cisgender controls, affirmed transgender youth seem to have no significant differences in depressive symptoms and only mild elevation in anxiety ratings that are not considered clinically concerning.
Controversy remains among multiple professional societies regarding the acceptability of allowing a child to transition to their self-affirmed gender. However, what is agreed upon is that decisions around social transitions must be tailored to various factors, including the temperament of the child, the level of social supports, acceptance and understanding of those around the child, and of course, the child’s desires. Some children desire a social transition early and want to disclose their identity as transgender to many of their peers and those around, whereas other children may want to defer transitioning due to anxieties or fears of being stigmatized, harassed, or bullied and may express their gender identity only in limited settings.
Support for both the child/adolescent and parents
Families may bring their child to the mental health professional for a variety of reasons. Many families are concerned about whether their child truly is transgender and wonder if this may be “just a phase.” Other families may be convinced that their child is transgender and may have worries and anxieties around how to help their child face potential obstacles and barriers, such as teasing and bullying, or the fear of their child being assaulted or discriminated against. Still other families may present hoping that the mental health professional can in some way change the development of the child such that he or she no longer has cross-gender expressions or identification. Mental health professionals need to be prepared for the variety of presentations from families and how to best address their concerns, while maintaining what is in the best interest of the child.
In working with parents of gender nonconforming and transgender youth, it is important to realize that without working and addressing the parents’ concerns and questions, one may inadvertently push the family away from coming in to get the help that may be needed for the child. Eliciting parent expectations and concerns is key early on in therapeutic work to help shape and determine how the provider may proceed in working with both the child and the family. Coolhart and Shipman describe a model for working with families therapeutically where the tasks in therapy are divided into two stages: the first being assessing and increasing family “attunement” (their level of understanding and peace with the child’s gender identity and expression) and the second being helping explore and support options for gender expression or transition. Parents who may feel that their concerns or viewpoints are not being heard or taken into consideration may result in the parents preventing their child from getting the help or support that they need.
Furthermore, it should be noted that just because the child may be gender nonconforming or identify as transgender, it may not be necessary for the child to receive mental health treatment.
It is important to recognize that the “diagnosis” that is often being evaluated for is Gender Dysphoria focusing on the distress and impairment that can often occur in a transgender individual’s life. The clinician is not diagnosing the child’s gender identity, although parents may be looking for the clinician to provide them with reassurance that their child is or is not transgender. Psychotherapy is no longer an absolute requirement for access to interventions for transitioning, such as hormone therapy or surgery as outlined in the World Professional Association for Transgender Health (WPATH) standards of care. Depending on the individual child and the family, there will be different needs, and the flexibility of the mental health care provider is important in working with these families. The WPATH standards of care outline some potential roles that mental health care providers may play in working with gender nonconforming and transgender youth. These potential roles include ( Box 3.3 ): directly addressing gender dysphoria, providing family counseling, helping youth explore their gender identity, assessing and treating any coexisting mental health concerns, referring for physical interventions (puberty suppression and gender-affirming hormones), educating and advocating for the child and their family, and providing or referring youth and their families to peer support resources.