Of late, there has been a seemingly sudden emergence of gender nonconforming persons in the media. Examples include representations in such disparate media as Rolling Stone (Erdely, 2013) and Woman's Day magazines (Kentopp & Yeoman, 2014), South Park animated series (Parker, 2014), and Fox News’ Bill O'Reilly (2014). Furthermore, the emergence or “coming out” of gender nonconformance is occurring at an earlier age than in previous years. Until recently, gender nonconforming individuals, particularly transgender‐identified persons, would often not come out until middle age or older. Severe repercussions, including rejection, and physical and emotional abuse, would occur if one tried to present as one's authentic self (i.e., identified gender; Aramburu Alegría, 2008). This is now changing as gender nonconforming persons become more visible, and there is increased media focus on the population and their needs. As well, increasing acceptance—and debate—at all school levels, including primary through postsecondary schools, has further made the issue more prominent. A myriad of issues can result, including tensions on the designation of gender‐appropriate bathrooms, participation in gender‐specific extracurricular activities, submission of legal documents verifying gender, and notification of other students’ parents (Brill & Pepper, 2008).
As awareness of gender nonconforming persons grows, increasing numbers of children/youth and their families are presenting to healthcare providers with concerns regarding gender nonconformity (Bonifacio & Rosenthal, 2015; Coleman et al., 2011; Drescher & Byne, 2012). Parents/caregivers may ask such questions as, “Is it normal for my son to want his toenails and fingernails painted; is it normal for my daughter to prefer short hair?” There may be concerns if a child prefers cross‐gender friends. To address these concerns, it is paramount that advanced practice nurses, other healthcare providers, and others who work with gender nonconforming persons and their families become more knowledgeable and confident in their abilities to address the unique needs of the population. The aim of this article is to provide foundational knowledge on gender nonconforming and transgender children and youth. Implications for practice and additional resources are provided.
In an article such as this, it is helpful to first present definitions. The definitions as used within are in Table 1. Please note below that the definition for transgender may vary slightly, depending on the source; this is explicated within the table.
Information for this article was obtained through searches on Academic Search Premier, Cinahl, and PubMed. Key words included: gender nonconforming, transgender, puberty suppression, children, youth, families. Information was also obtained through the World Professional Association for Transgender Health (WPATH).
Gender nonconforming children and youth
To contextually discuss gender nonconforming children/youth, first, a discussion on the number of gender nonconforming children/youth is presented. This is followed by a review on the trajectory of nonconforming children/youth. Next is a discussion on family and social networks, followed by a discussion that focuses on community and society. Lastly, information on pharmacologic intervention is provided.
Population estimates of gender nonconformance/transgender children/youth
The prevalence of gender nonconforming children/youth is difficult to ascertain; some estimate it is 0.3%–1.2% of the population (Clark et al., 2014; Gates, 2011). The difficulty in obtaining an accurate number is due to a number of reasons including reluctance to disclose, challenges in defining terms (e.g., gender nonconforming or transgender), or inadequate survey methods. However, The Williams Institute, a think tank and part of the University of California Los Angeles School of Law that is dedicated to research on sexual orientation and gender identity, does provide an estimate on the number of transgender adults. The Institute asserts that 0.3% of the U.S. adult population identifies as transgender (Gates, 2011). Given that gender identity is established in childhood (Brill & Pepper, 2008), one may deduce that at least 0.3% of U.S. children/youth have a transgender identity. With a U.S. population of approximately 320 million (United States Census Bureau, November 2014), 0.3% of the population places the estimate of transgender people at nearly 1 million (960,000).
Another estimate comes from New Zealand. In a survey of more than 8000 high school students, aged approximately 15–16, 1.2% self‐identified as transgender and 2.5% reported being uncertain of their gender (Clark et al., 2014). However, as an indicator of the prevalence of gender nonconforming children, this percentage is likely to be low as not all gender nonconforming children grow to identify as transgender teenagers or adults (Steensma, Biemond, de Boer, & Cohen‐Kettenis, 2010). (Recall that transgender is a subset of gender nonconforming.)
Trajectory of gender nonconforming children/youth
Children as young as age 2 or 3 may begin displaying gender nonconforming behavior. It is not uncommon for children of both sexes to role‐play or dress‐up as the opposite gender. Typically, this is transient and does not indicate a predilection for persistent cross‐gender expression or identification (Brill & Pepper, 2008; de Vries & Cohen‐Kettenis, 2012; Menvielle, 2012). However, some children do continue to persist in their cross‐gender expression, and among them are children who persist in their cross‐gender identification (i.e., transgender; Menvielle, 2012; Wallien & Cohen‐Kettinis, 2008). At this juncture, the standard of care is that the child is supported and not shamed, and that gender variant behavior be allowed (Bonifacio & Rosenthal, 2015; Coleman et al., 2011; Olson & Garofalo, 2014). Parents and caregivers are encouraged to follow the child's lead. As most gender nonconforming children do not grow to be gender dysphoric adolescents, watchful waiting is advised (de Vries & Cohen‐Kettenis, 2012; Menvielle, 2012).
Nonetheless, most families would benefit from talking with healthcare providers and counselors who are experienced in working with gender nonconforming children, and referral to such resources is advised (Bonifacio & Rosenthal, 2015; Brill & Pepper, 2008). Families will need the support of professionals in making decisions regarding whether, and to what extent, the child should socially transition. Decisions regarding a name change, modification of gender status on legal documents and at school, clothing, etc. will need to be made (de Vries & Cohen‐Kettenis, 2012). Further, the counsel of those experienced with gender issues can help rule out psychopathology in children/youth who persist in cross‐gender expression or identification (Drescher & Byne, 2012).
Children who present to clinicians with persistent cross‐gender expression and/or identification may be diagnosed with gender dysphoria (Zucker et al., 2013). Most children diagnosed with gender dysphoria do not grow to be adults with gender dysphoria (i.e., transgender adults). Current research suggests that children diagnosed with gender dysphoria are more likely to grow to be gay or lesbian, without gender dysphoria. A smaller number grow to be cisgender (i.e., nontransgender) heterosexual adults (Steensma et al., 2010; Wallien & Cohen‐Kettinis, 2008).
In contrast, children who do persist in cross‐gender identification and expression into adolescence (i.e., transgender identification) are unlikely to return to their natal gender in their identity. Further, they are likely to experience extreme psychological distress at the onset of puberty and the development of secondary sex characteristics (Menvielle, 2012; Steensma et al., 2010). At this developmental stage, the natal sex becomes especially salient, and mental health is further compromised. The distress associated with the development of natal sex secondary characteristics places transgender youth at an increased risk for depression, self‐harm, substance abuse, suicidal ideation, and suicide (Grossman & D'Augelli, 2007).
Family and social networks
Parents’ reactions to their children generally include anxiety over the stigma of gender variance, and anticipated complications with extended family and friends (Menvielle, 2012). Similarly, Johnson and Benson (2014) describe the stigma and negative, often accusatory, response of others when parents support their child's cross‐gender behavior. Further, parents/guardians have considerable unease related to gender uncertainty in their child, and whether or not their child will persist in cross‐gender expression and/or identification or revert back to the sex assigned at birth (Edwards‐Leeper & Stack, 2012).
Perhaps not surprisingly, family rejection and nonsupport of the gender nonconforming child is common. In a study of 55 transgender youth aged 15–21, Grossman and colleagues (2005) found that participants reported that approximately 50% of their parents were nonsupportive of their gender transition. Further, the research suggests that the likelihood of abuse is increased as the degree of gender nonconformity increases (Grossman, D'Augelli, & Salter, 2006). Given the high rate of family rejection, transgender youth are at increased risk of homelessness. Often concomitant with homelessness is a high rate of substance abuse, unemployment, sex work, and violent victimization (Clements‐Nolle, Marx, & Katz, 2006; Grossman & D'Augelli, 2007).
The effects of a gender nonconforming child/youth on siblings can be variable (Edwards‐Leeper & Stack, 2012). Siblings may be the most supportive members of the family; on the other hand, having a gender nonconforming sibling may be devastating. Consideration needs to be given to siblings as decisions regarding social transition (of the gender nonconforming child/youth) are made. Siblings may experience significant stress related to the attention placed on their gender nonconforming sibling. Siblings of gender nonconforming children/youth may experience teasing from their peers. As well, they may experience grief as their sibling transitions from one gender to the other (Brill & Pepper, 2008).
The presence of family support can make a critical difference toward optimal health outcomes in gender nonconforming children and youth. In a study of 66 transgender youth/young adults, aged 12–24, greater resilience, fewer symptoms of depression, and general higher quality of life were demonstrated in youth who have the support of family (Simons, Schrager, Clark, Belzer, & Olson, 2013). Accepting and viewing children and youth in their authentic expression of themselves, as opposed to an individual who must conform can lead to improved emotional health and social interactions. A decrease in resilience and quality of life has been found to occur when children and youth are perceived to be reflections of their parents/guardians, as opposed to unique individuals in their own right (Singh, Meng, & Hansen, 2012).
Community and society
Moving through society likewise brings challenges to gender nonconforming children/youth and their families. Safety is a salient issue in day‐to‐day life. Experiences at K‐12 school regularly include harassment and bullying (Grant et al., 2011). Further, even well‐intentioned schools with antibullying policies often lack knowledge on gender identity and gender nonconformity (Brill & Pepper, 2008). Issues such as which bathroom to use, if/when other parents should be told, and participation in sports/extracurricular activities are commonplace, and parents/guardians of gender nonconforming children/youth are often at a loss as to how best to advocate for their child (Jean [first name only provided to protect identity], personal communication, September 3, 2014). As gender nonconforming youth venture out into social situations, they are at increased risk of victimization, including physical harm. These risks are particularly heightened for gender nonconforming persons of color (Grant et al., 2011).
Accessing health care presents a challenge for families of gender nonconforming children/youth. Providers are generally not prepared to care for the complexities with which members of this population may present. Studies show that providers have little knowledge on gender variance issues, and instruction in the curriculum is lacking. Parents/guardians are often left to their own devices in seeking compassionate and competent care (Brill & Pepper, 2008; Eliason, Dibble, & DeJoseph, 2010; Grant et al., 2011).
Gender dysphoria and pharmacologic intervention
Prior to the development of natal secondary sex characteristics, gonadotropin‐releasing hormone (GnRH) agonists (e.g., leuprolide acetate, histrelin) to suppress puberty are recommended for youth diagnosed with gender dysphoria. These medications suppress the production of estrogen or testosterone by shutting down the hypothalamic‐pituitary‐gonadal axis (Bonifacio & Rosenthal, 2015; de Vries & Cohen‐Kettenis, 2012; Olson & Garofalo, 2014). Treatment is initiated at Tanner stages 2–3. The effects of puberty blockers are reversible. The positive effects of puberty blockers are twofold: first, they “buy time,” allowing the youth to further explore and make sense of an authentic gender identity; and second, early suppression of natal sex characteristics will enable the individual to transition more easily into the identified gender as a young adult. Feminine features are reduced in the female‐to‐male person, and masculine features are reduced in the male‐to‐female. Further, emotional functioning is improved, and comorbidities often are significantly alleviated, or altogether eliminated, when gender transition begins in transgender‐identified youth (Edwards‐Leeper & Spack, 2012). In a prospective study with 70 youth aged 11–17, diagnosed with gender dysphoria, significant improvement in psychosocial functioning and a decrease in depression was observed following approximately 2 years of puberty suppression (de Vries, Steensma, Doreleijers, & Cohen‐Kettenis, 2011). Similarly, in a longitudinal study over 18 months with 201 youth treated with GnRH agonists, significant psychosocial functioning was demonstrated (Costa et al., 2015).
Despite their efficacy in preventing the distressing development of biological secondary sex characteristics and in improving overall function, the administration of puberty blockers is not without debate. Critics argue that psychological and sexual identity development may be stunted (Korte et al., 2008). Additional concerns include the delay in the development of bone mass and growth (Olson & Garofalo, 2014). There remains much to be known about the long‐term effects of puberty suppression; however, a recent study comparing executive function in 20 youth diagnosed with gender dysphoria and treated with GnRH agonists for approximately 1 ½–20 untreated youth diagnosed with gender dysphoria found no difference in performance (Staphorsius et al., 2015). Other recent studies have found that although bone growth is slowed by puberty suppression, it resumes at age‐appropriate levels following the discontinuation of GnRH agonists (Olson & Garofalo, 2014).
Although the effects of GnRH agonists are reversible, many youth who start these agents go on to cross‐sex hormones. With the initiation of cross‐sex hormones, fertility will be impacted and thus, fertility should be discussed prior to the institution of GnRH agonists (Bonifacio & Rosenthal, 2015). Persons who wish to preserve fertility should be referred to reproductive specialists for possible egg preservation (in the natal female) or sperm banking (in the natal male).
Cross‐sex hormones and gender‐affirming surgery
If gender dysphoria persists, transition continues with the implementation of cross‐sex hormones (e.g., testosterone, estrogen) and the discontinuation of GnRH agonists, typically at approximately age 16 (Bonifacio & Rosenthal, 2015; Coleman et al., 2011; Olson & Garofalo, 2014). For natal males who identify as female, this includes feminizing hormones and an antiandrogen (e.g., spironolactone). For natal females who identify as male, this includes testosterone to masculinize (Bonifacio & Rosenthal, 2015). At approximately age 18, youth may be eligible for gender‐affirming surgeries, for example, mastectomy in the female‐to‐male individual, and breast augmentation in the male‐to‐female person. (For a detailed discussion on cross‐sex hormones, including dosing, the reader is referred to Bonifacio & Rosenthal, 2015.)
Implications for practice
The complexities of providing holistic care to gender nonconforming children/youth and their families are best met through an interdisciplinary approach (Bonifacio & Rosenthal, 2015; Coleman et al., 2011). Consultation with and/or referral to providers who are knowledgeable about transgender health care and specialize in endocrinology and mental health is advised. Support groups for families of gender nonconforming children/youth can provide an additional avenue through which members can express thoughts, concerns, frustrations, and successes. Through these measures, a network of support is available to both healthcare providers and families.
Primary care providers should have a familiarity with resources, including how to locate appropriate specialists to whom to refer the patient and family, and websites and other materials to further educate oneself and families. The WPATH website offers assistance in locating providers knowledgeable in transgender health. Table 2 lists this website along with other resources that offer education for providers and families.
Upon first being approached by parents/guardians with questions and concerns regarding their child's gender‐nonconforming behavior, a provider may experience a drop in confidence over the situation. However, by recalling the trajectory of gender nonconformance, providers may be better able to tailor interview questions. (Please see Table 3 for key points.) For very young children, reasonable questions may include identifying what the behavior includes and how long it has been observed, including any suicidal ideation or attempts at self‐mutilation (or suggestion of such). These questions also pertain to older children and youth, along with questions regarding any distress related to impending puberty. In all cases, assess for the presence of bullying, victimization, or other safety concerns, including those that may arise within the family.
Of primary importance to patients and their families is the knowledge that they are being heard and will continue to be heard and supported by their healthcare providers. Establishing a safe and welcome environment is paramount. This can easily be achieved by posting symbols or signage that indicate receptivity to caring for transgender individuals. Examples include the rainbow flag and Human Rights Campaign insignia/logo (Human Rights Campaign; http://www.hrc.org/hrc‐story/about‐our‐logo). The practice of transgender health is rapidly growing; often, providers are learning the process and options just as families are. Families realize this and strive to work with professionals to provide holistic care for their gender nonconforming/transgender children to achieve the best possible outcomes in this challenging situation.
Gender nonconforming/transgender children and youth are presenting to providers in increasing numbers. At home and in society, these children and youth and their families experience many challenges, and the risk of depression, self‐harm, and victimization is high (e.g., Brill & Pepper, 2008; Clements‐Nolle et al., 2006; Grossman & D'Augelli, 2007; Grossman, D'Augelli, Howell, & Hubbard, 2005). Yet, supportive families and school environments are protective factors that can make the difference between thriving and tragedy. In collaboration with primary care providers, specialists experienced in working with gender nonconforming/transgender children and youth can provide guidance with watchful waiting and gender‐affirming care. By providing a receptive and nurturing environment, establishing an effective interdisciplinary team, and incorporating a familiarity with the trajectory of gender nonconformance and resources, primary care providers can elevate the health of this under‐served and stigmatized population.
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