As a member of a multidisciplinary clinic that cares for gender-nonconforming (GN) youth, I frequently field questions from providers about how to handle gender identity concerns in the primary care setting. The specific health care needs of these youth matter as GN youth are at increased risk of self-harm, suicide attempts, mood disorders, eating disorders, substance use, and low school performance.1, 2 These increased risks appear to be related to the rejection and stigma associated with gender nonconformity that can extend to the health care setting.
More than 50% of transgender adults report experiences of discrimination in health care.3 The literature suggests that creating a supportive and affirming environment for GN youth may decrease these risks. If we can do just that during their health care visits, we can make a positive impact on our patients.
A review of terminology and clarification of the difference between biologic sex, gender identity, gender expression, and sexual orientation are necessary before discussing the care of GN youth. Biologic sex is typically assigned at birth and is determined by a person’s chromosomes, hormones, and anatomy. Sex most commonly is female or male. For a minority of the population, there may be disorders or differences of sex development in which the development of chromosomal, gonadal, or anatomic sex is atypical. Examples of these conditions are congenital adrenal hyperplasia and androgen insensitivity syndrome. Gender includes the behavioral, cultural, and psychological characteristics associated with femaleness or maleness.2 Gender identity is a person’s innate sense of feeling male, female, or somewhere in between. Individuals who have a gender identity that is congruent with their assigned sex are referred to as cisgender; those who have a gender identity that does not align with their birth sex are often referred to as transgender. Gender expression is how people choose to present themselves to the world. A person’s gender may or may not be consistent with his/her internal gender identity. For example, an individual may be female biologically (XX chromosomes, with a uterus, ovaries, and vagina) and self-identify as female, but express herself in a masculine way by having her hair cut short and wearing more masculine clothing.
Gender dysphoria occurs when an individual experiences psychological distress caused by the incongruence between his/her biologic sex and his/her internal gender identity, and this mismatch leads to clinically significant distress or impairment in daily functioning. Gender dysphoria is a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It has replaced the earlier diagnosis of gender identity disorder in the DSM-IV. The new diagnosis focuses on the distress related to an incongruence between gender identity and biologic sex and does not label it as pathologic. Gender-nonconforming individuals do not follow other people’s ideas or stereotypes about how they should look or act based on the sex they were assigned at birth. It is important to note that an individual’s gender identity is separate from sexual orientation. Sexual orientation describes an individual’s pattern of sexual and physical attraction. An individual may be attracted to members of the same sex (homosexual, lesbian, gay), opposite sex (heterosexual), or both sexes (bisexual). Increasingly youth are using a variety of terms to describe their gender (for example, genderqueer, asexual, gender fluid) and sexual orientation (for example, pansexual, asexual). These terms may have different meanings for different youth, and it is important to respectfully ask and clarify what these terms mean to each individual patient.
Trajectory of gender identity
Experimenting with gender expression and gender roles is a normal part of childhood. The majority of young children with nonconforming gender identification will not persist with this identification through adolescence. Some of these children will go on to have a nonheterosexual sexual orientation when they are older. While it can be difficult to predict the trajectory of cross-gender identification in early childhood, those with a persistent, insistent, and consistent cross-gender identification in childhood are more likely to experience gender dysphoria and continue with a transgender identity into adulthood. Adolescence is a particularly difficult time for GN youth. The development of secondary sex characteristics that are not consistent with an individual’s identified gender, in addition to the psychosocial challenges of adolescent development, can lead to increased suicidal thoughts, self-harm behaviors, anxiety, isolation, and risk-taking behaviors. Gender dysphoria that increases with the onset of puberty rarely subsides with time.
Approach to GN patients in practice
Research is ongoing related to best practices for the care of GN youth. Clinical guidelines and standards of care have been published and endorsed by organizations including the Endocrine Society, Pediatric Endocrine Society, World Professional Association for Transgender Health, and the American Academy of Pediatrics. My recommendations for the care of GN youth are based on these guidelines.