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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000435340.48589.8a
AJN Reports

Helping Transgender Children and Teens

Jacobson, Joy

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At a critical time in young lives, school nurses can make a difference.

One afternoon in early 2012, Michelle Rini's 11-year-old son, Sebastian, came home from school and announced that he wanted to have a sex-change operation. Rini had always seen her son as more sensitive than other boys, but he hadn't seemed girlish; in fact, he'd shown a preference for stereotypically male toys such as action figures. She asked him, gently, if he might be gay. No, Sebastian said. He wasn't gay. He was a girl.

Figure. A boy at a c...
Figure. A boy at a c...
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Soon Sebastian asked family and friends to call her Hannah, and Rini found a therapist specializing in gender dysphoria near their home in Pawtucket, Rhode Island. She dressed as a girl at home, but when it was time for summer camp, the Rinis decided Hannah would go as Sebastian because Sebastian was the name they'd used to sign her up for it. That decision produced much anxiety in Hannah, though, and her parents had to pull her out of camp early.

They saw no point in causing their child further torment; and Hannah began sixth grade as a girl, where she encountered “zero teasing,” her mother said. Hannah began taking puberty-suppressing hormones, followed shortly thereafter by an estrogen regimen that will allow her to go through puberty at the same rate as other girls her age. During that time, Hannah used the nurse's bathroom at school, a safe place for her.

But midway through the year that nurse moved on. Rini went to the school one day, and the new nurse asked her to come into her office and shut the door. “I want you to know,” the school nurse told Rini, “I'm the mother of an adult transgender child, and I'm here to lend support if needed.”

Hannah's grade-school nurses, teachers, and superintendents universally accepted and worked to accommodate her. Only recently has she had an experience of bullying from a peer. As Hannah at age 12 prepares to enter junior high, her mother is hopeful that the new school will give her daughter the support she needs.

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Transgender teens and adults face significant health and social risks. According to the 2011 National School Climate Survey, which tracks the experiences of homosexual and transgender youths in U.S. schools, 64% of middle and high school students identifying as gay, lesbian, bisexual, or transgender reported being verbally harassed in the year prior because of their gender expression. The National Transgender Discrimination Survey from the National Center for Transgender Equality and the National Gay and Lesbian Task Force found that 51% of transgender adults whose families had rejected them had attempted suicide. And the Centers for Disease Control and Prevention put the rates of new HIV infections in 2009 at 0.9% among male U.S. residents, 0.3% among female residents, and 2.6% among transgender people.

To address these and other concerns, the National Association of School Nurses (NASN) issued a position statement, Sexual Orientation and Gender Identity/Expression (Sexual Minority Students), recommending that school nurses propose school policies that ensure the safety of these students, help them understand their particular health risks, and provide care that meets their needs (go to

The NASN tapped Beverly Bradley, a longtime member who worked in California during the early years of the AIDS crisis, to be the lead author of the position statement. In a recent interview Bradley cited many reasons such a statement was needed, prime among them the need for safe havens for students bullied in schools. But school nurses hold a wide range of personal views on sexuality and gender, she said. “For some people, part of their belief system is that people choose to be homosexual or bisexual, and there's something wrong with them if they are transgender. But you have to rethink your belief system and put it aside for the good of the client.”

Bradley said that most school nurses function outside of clinical settings—sometimes, a school nurse's supervisor is an educator and not a clinician—and some small school districts haven't developed firm procedures for handling all students, making it even more crucial that the NASN provide guidance. Yet just because a position statement has been issued doesn't mean all school nurses will follow it, Bradley said. “There's no way to enforce it. But the standards are a terribly important place to start.”

A recent lawsuit in Colorado shows how attitudes inform practice and how new regulation is sometimes required to change it. The school district in Fountain, Colorado, determined in 2012 that six-year-old Coy Mathis, a gender-nonconforming girl, should use the school nurse's bathroom and not the girls’ room. Coy's parents filed a complaint with the Colorado Civil Rights Division; it ruled in June that the school erred in creating “an environment that is objectively and subjectively hostile, intimidating or offensive.” The Maine Supreme Court is deciding a similar case: that of Nicole Maines, a male-to-female transgender teen who as a fifth grader was told to use the staff bathroom after the grandparent of a fellow student complained when Maines used the girls’ room.

Last summer the California legislature passed Assembly Bill 1266 and Governor Jerry Brown signed it; it is the first state law allowing public school students to use facilities and to participate in school programs, including team sports, according to their gender identity rather than their biological sex.

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Katy Tierney, an NP at the Center for Metabolic Services at the Hospital of Central Connecticut, spends most of her time working with patients with diabetes. But roughly 200 of her patients see her for cross-sex hormone therapy (the youngest is 16, the oldest over 80). “Not a day goes by that I'm not thankful I live in this time,” Tierney said of her work with transgender patients.

She doesn't treat many adolescents but her patients have told her of the harms that can come from delaying transition. “It's hard to mature and relate to other people,” she said of teens who don't express their gender identity. She said too that puberty blockers, although expensive and not always covered by insurance, buy adolescents some time. “But it takes a forward-thinking child and family and community for that to happen. When it does, how amazing that a family can truly listen to their child and allow them to be who they are.”

Beverly Bradley might also say it requires forward-thinking nurses. During the first wave of the HIV epidemic, Bradley stood up to a school superintendent who was discriminating against an HIV-positive teacher. But she didn't act alone. Now she suggests that school nurses do as she did, forging cross-disciplinary ties to act in the best interests of students and staff. “I cultivated relationships with the local academy of pediatrics and also with the adolescent specialist in pediatrics and the public health officials. Then when establishing protocols it wasn't just a school nurse, whining, on her soapbox. I had their backing.”

Crossover Kids is a 17-minute documentary about the “gender journey” of Coy Mathis and several other young people whose parents, clinicians, teachers, and others supported them (it's available on YouTube: A teenager named Eli describes why she took estrogen at age 15 and underwent sex-reassignment surgery at age 17—one of the youngest people to do so. “I couldn't participate with the girls and I was always singled out,” she says of her experience in middle school. Now, she feels “natural.”

That natural feeling is what Michelle Rini wants most for her daughter. The Rinis understood that going ahead with hormone therapy would have permanent consequences: Hannah would develop in many ways as a girl, but she would also be infertile. Rini discussed the pros and cons with Hannah and believes she understands, as much as a 12-year-old can. “We just don't want her to have to fight to be who she wants to be.”—Joy Jacobson

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American Academy of Pediatrics. Office-based care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics 2013;132(1):e297-e313. The academy recommends that primary care providers allow transgender teens to express “their feelings of gender dysphoria and desires to transition.”

Spack, NP. Management of transgenderism.JAMA 2013;309(5):478-84. An endocrinologist reviews hormone and surgical treatments and the role of psychiatry, and a patient discusses her transition from male to female.

Know Your Rights: A Guide for Trans and Gender Nonconforming Students, from the American Civil Liberties Union and the Gay, Lesbian and Straight Education Network, addresses students’ concerns: how to talk to teachers and peers, handle bullying and discrimination, and understand laws protecting gender expression.

The Center of Excellence for Transgender Health at the University of California, San Francisco, offers guidance to patients, parents, and providers on when hormone therapy is appropriate for those under age 18 and how to get treatments covered by insurance.

The World Professional Association for Transgender Health works to advance “health, research, education, respect, dignity, and equality for transgender, transsexual, and gender-variant people in all cultural settings.”

© 2013 Lippincott Williams & Wilkins. All rights reserved.