Transgender and Gender-Diverse

Description

Other Names

The following terms and definitions from the World Professional Association for Transgender Health: Standards of Care, 7th version are used in this module. The evolving vocabularies used by individuals to describe themselves can be found at List of LGBTQ+ Definitions (itspronouncedmetrosexual.com) and Glossary of Terms – Transgender (GLADD).

Female-to-male (FtM): Describes individuals who are changing or who have changed their body and/or gender role from birth-assigned female to a more masculine body or role

Gender: A psychological status that denotes attitudes, feelings, and behaviors within a given culture that are associated with being male or female

Gender binary: A cultural construct that ascribes to the belief there are only 2 genders and these match the sexes male and female

Gender dysphoria: Distress that is caused by a discrepancy between a person’s gender identity and the sex assigned at birth

Gender identity: A person’s intrinsic sense of being male (a boy or a man), female (a girl or a woman), or an alternative gender (e.g., transgender, genderqueer)

Genderqueer: An identity used by individuals whose gender identity does not conform to a binary understanding of gender

Gender non-binary: A gender that is neither solely male or female - gender in varying degrees, fluid, or a gender unattached to the poles of male and female

Gender nonconforming/diverse: Describes individuals whose gender identity, role, or expression differs from what is normative for their assigned sex in a given culture and historical period

Male-to-female (MtF): Describes individuals who are changing or who have changed their body and/or gender role from birth-assigned male to a more feminine body or role

Sex: A biological status categorized as male, female, or intersex, as indicated by factors that include chromosomes, gonads, internal reproductive organs, and external genitalia

Transgender: Describes a diverse group of individuals who cross or transcend culturally defined categories of gender - their gender identity differs to varying degrees from the sex they were assigned at birth

Transition: A period of time when individuals change from the gender role associated with their sex assigned at birth to a different gender role. For many people, this involves learning how to live socially in “the other” gender role; for others, this means finding a gender role and expression that is most comfortable for them. Transition may or may not include feminization or masculinization of the body through hormones.

Diagnosis Coding

The ICD-10 codes under the F64 group describe gender identity disorders. F64 is not billable without an additional digit. See Gender Identity Disorders (icd10.com) for additional coding details.

ICD-10

F64.0, Transsexualism: Severe gender dysphoria, coupled with a persistent desire for the physical characteristics and social roles that connote the opposite biological sex, the urge to belong to the opposite sex that may include surgical procedures to modify the sex organs in order to appear as the opposite sex

F64.1, Dual role transvestism: Disorder characterized by recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing in a heterosexual male. The fantasies, urges, or behaviors cause clinically significant distress or impairment in social, occupational or other areas of functioning

F64.2, Gender dysphoria in children: An intense desire to be the opposite gender, persistence that one is the opposite gender manifesting in childhood. Associated with this desire is the distress of being of a gender that is incongruent with one’s identity.

F64.8, Other gender identity disorders

F64.9, Gender identity disorder, unspecified

Description

For many individuals, gender is assigned at birth based on anatomy and chromosomes. This assignment will help mold gender identity (the innate sense of maleness or femaleness).

Transgender Child
Some individuals' gender identities may not correlate with the assigned birth gender and instead be derived from a combination of biological, cultural, and environmental factors. [Winter: 2016] [Rosenthal: 2014] Terms used to identify this select group of individuals include transgender and gender-diverse. [Coleman: 2011] [Wylie: 2016]

Transgender and gender diverse are not diagnoses. Gender dysphoria, the distress associated with the perceived incongruence of self and gender expression, is a diagnosis and included in the descriptions of ICD10 codes F64.0-9. [Coleman: 2011] Gender dysphoria can be decreased with social transition and treatment including hormone therapy, psychotherapy, and surgery. [Rosenthal: 2014]
The purpose of intervention is to decrease gender dysphoria and promote gender roles and expressions that are affirming to the individual. This can be done by addressing the following domains: [Lancet: 2016]
  • Social
    • Use of the "preferred" name identified to affirm one’s self
    • Use of appropriate pronouns
    • Affirming gender presentation (congruent clothing, behaviors, presentation, use of bathrooms)
  • Psychological
    • Sense of authentic self-identity
    • Access to mental health providers who are knowledgeable about gender-focused therapy and the needs of transgender individuals
  • Medical
    • Gender-affirming hormones that are safely managed
    • Reproductive options
    • Primary care clinicians who are familiar with the needs of transgender individuals
    • Gender-affirming surgeries and procedures
    • Voice and communication therapies
  • Legal
    • Effective anti-discrimination legislation
    • Access to legal providers
    • Legal name change and change of gender designation
    • Right to resignation to the law

Prevalence

Data on transgender and gender diverse children and adolescents are limited. The Williams Institute, using 2016 CDC Behavior Risk Factor Surveillance System survey results, estimated that in the United States 0.6% of adults ≥18 years old (~1.4 million individuals) and 0.7% for children 13-17 years old (~150,000 individuals) self-identified as transgender. [Herman: 2017] [American: 2017]

The DSM-5 reports a prevalence of gender dysphoria as 0.005-0.014% for adults born as males and 0.002-0.003% for adults born as females. Among children, gender-assigned males experience gender dysphoria about 3 times more than gender-assigned females. [American: 2013]

Genetics

The development of gender identity is poorly understood and influenced by the central nervous system, genes, hormones and hormone receptors, and environmental factors. [Lee: 2013] [Hembree: 2017] One study found a 39.1% concordance rate for gender identity disorder in 23 monozygotic twin pairs [Heylens: 2012]; additional twin studies further support that gender identity may be more of a matter of biology than choice. [Coolidge: 2002]

When female-to-male (FtM) or male-to-female (MtF) transgender groups are compared with female or male control groups, no significant differences have been found in karyotypes. [Fernández: 2014] [Fernández: 2014] Gene analysis suggests that beta estrogen receptor (ERbeta) polymorphisms with greater number of repeats could encourage decreased feminization of the female brain and behavior, and there appears to be an increased prevalence of the A2 allele of the CYP17 MspA1 polymorphism (encoding 17alpha-hydroxylase) in FtM compared to control females. [Fernández: 2014] [Fernández: 2015] A related study focusing on MtF compared to control males did not demonstrate a statistically significant relationship of sex hormone-related genes including ERbeta, androgen receptor, or aromatase (the enzyme responsible for converting testosterone to estrogen).

Subsequent reviews do not support a consistent relationship between prenatal sex-hormones and gender identity; pubertal hormones play a stronger role. [Fisher: 2017] The role of genetics, as well as neuroanatomical, environmental, social, cultural, and hormonal factors in gender identity, is still being studied.

Prognosis

Good prognostic outcomes are associated with alleviating the distress associated with gender dysphoria and avoiding common related conditions, including HIV, substance abuse, sexually transmitted infections, and mental health disorders. [Lopez: 2017] [Wylie: 2016] [Reisner: 2016] Youth who identify as transgender often have an underlying mood disorder, anxiety disorder, or post-traumatic stress disorder. [Adelson: 2012] Transgender youth often use alcohol and tobacco products starting in early adolescence. [Day: 2017] Improving prognosis often depends on psychosocial support, addressing comorbid conditions, and promoting gender affirmation through hormone therapy and gender-focused psychotherapy. [Coleman: 2011]

Roles Of The Medical Home

Transgender patients have the same medical needs as other individuals, as well as unique needs that are best addressed in a primary care setting. [Bonifacio: 2015] The medical home can function as a hub for referral services, including gender-affirming hormones/surgeries, speech therapy, and other cosmetic procedures. [Daniel: 2015] The medical home should foster a safe and welcoming environment and emphasize an affirmative approach to care.

Primary care clinicians may need to provide letters of support to use gender-affirming restrooms at school, documentation to promote gender marker change on government-issued documentation (driver license, passport, etc.), and letters of medical necessity to insurance companies for appropriate interventions. [Schuster: 2016]

The primary care clinician may be the first medical provider to identify a mood disorder, suicidal ideation, findings of self-harm, substance abuse, and post-traumatic stress. If so, consider treatment with a psychotropic medication and provide prompt referral to a mental health provider. The clinician may detect family discord and refer to mental health resources and support groups.

Patients and families will often have concerns surrounding use of gender-affirming hormone, the steps for transitioning, gender-affirming surgery, and restroom use. Parents may have additional concerns about identifying resources, child safety at school, and mental health. [Lawlis: 2017] The medical home should help with these questions and/or direct the patient and family to appropriate resources. See Transgender and Gender-Diverse, Services & Other Resources) and Sample Letter for Transgender Student Bathroom Access (Medical Home Portal) (PDF Document 138 KB).

Practice Guidelines

Evidence to guide management of gender nonconforming children and young adults is limited but evolving quickly. The American Academy of Pediatrics (AAP), World Professional Association for Transgender Health, Endocrine Society, and American Academy of Child and Adolescent Psychiatry have established guidelines that stress: 1) Care for gender nonconforming youth should be individualized and focus on the medical, psychological, and social needs of the person in question. 2) Treatment should focus on decreasing the damaging effects of gender dysphoria, depression, and other associated co-morbidities. 3) Providers should be willing to refer patients to experienced providers when indicated. [Hembree: 2017]

Levine D.
Office-based care for lesbian, gay, bisexual, transgender, and questioning youth.
Pediatrics. 2013;132(1):198-203. PubMed abstract / Full Text

Coleman E, Bockting W, et al.
Standards of care for the health of transsexual, transgender, and gender-nonconforming people, v.7.
2011; World Professional Association for Transgender Health.; https://www.wpath.org/publications/soc
Guidance related to primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments for transsexual, transgender, and gender nonconforming people.

Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, Rosenthal SM, Safer JD, Tangpricha V, T'Sjoen GG.
Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.
J Clin Endocrinol Metab. 2017;102(11):3869-3903. PubMed abstract / Full Text

Adelson SL.
Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents.
J Am Acad Child Adolesc Psychiatry. 2012;51(9):957-74. PubMed abstract / Full Text

Helpful Articles

PubMed search for articles published within the last year about transgender children and adolescents

Rosenthal SM.
Approach to the patient: transgender youth: endocrine considerations.
J Clin Endocrinol Metab. 2014;99(12):4379-89. PubMed abstract / Full Text

Rosenthal SM.
Transgender youth: current concepts.
Ann Pediatr Endocrinol Metab. 2016;21(4):185-192. PubMed abstract / Full Text

Turban J, Ferraiolo T, Martin A, Olezeski C.
Ten Things Transgender and Gender Nonconforming Youth Want Their Doctors to Know.
J Am Acad Child Adolesc Psychiatry. 2017;56(4):275-277. PubMed abstract

Wylie K, Knudson G, Khan SI, Bonierbale M, Watanyusakul S, Baral S.
Serving transgender people: clinical care considerations and service delivery models in transgender health.
Lancet. 2016;388(10042):401-411. PubMed abstract / Full Text
Full text is free, but log-in is required.

Fisher AD, Ristori J, Morelli G, Maggi M.
The molecular mechanisms of sexual orientation and gender identity.
Mol Cell Endocrinol. 2017. PubMed abstract

Clinical Assessment

Screening

Patients need to undergo preventive services (pap smears, mammograms, colonoscopies, prostate exams, etc.) based on their organ inventory and according to current screening guidelines.

For The Condition

Surveillance for gender nonconforming identity, gender dysphoria, and related issues can be accomplished with a detailed social history, including a thorough HEEADSSS assessment.
  • HEEADSSS Assessment Guide (USU) (PDF Document 1017 KB) provides examples of open-ended questions about home; environment, education, and employment; eating; peer-related activities; drugs; sexuality; suicide/depression; and safety from injury and violence
Use open-ended questions:
  • "By what name do you want me to call you?”
  • “What are your pronouns?”
Screening questions for gender dysphoria:
  • “Do you identify as a boy, girl, or something else?”
  • “Do you feel you are a different gender from the way others have thought of you since you were born?”
  • “Are there any parts of your body that make you unhappy or that you wished you did not have?”
  • “Have you thought about your body having certain characteristics or traits of another gender?”
Questions to help understand existing gender dysphoria:
  • “What about your body bothers you the most? The least?”
  • “Describe how you feel when you are not perceived by others as the gender you identify with the most?”

Of Family Members

While screening of family members is not necessary for identifying gender nonconforming behavior or gender dysphoria, it can provide clues to the family dynamic and information related to mental health disorders.

For Complications

Presentations

Most typically developing children begin showing gendered behavior and using gender pronouns between the ages of 2-4 years old. This is the same time that gender-affirming behavior usually begins. Gender atypical behavior is common among young children and may be part of normal development. Many children will "experiment" with gender expression and may dress as the opposite gender or engage in cross-gender play. Most children will declare gender identity that is consistent with their birth-assigned sex by the time they are about 5 years old. This identity will persist throughout the child's lifespan. [Drescher: 2012] Transgender children consistently, persistently, and insistently express an opposite-gender identity and feel that their gender is different from their assigned sex.

Puberty often serves as a time to identify one's ultimate identity. Although some transgender teens are comfortable with their bodies, transgender teens are more likely to experience gender dysphoria than their gender-diverse peers. These individuals may undergo a social transition by adopting preferred pronouns, a new name, and gender-affirming attire. [Drescher: 2012]

For the majority of children who present as transgender or gender diverse in early childhood, gender dysphoria will not persist into adolescence, or it will lessen or even dissipate after puberty. However, about 15% will continue to experience gender dysphoria through puberty and it may increase in intensity. There is no evidence-based protocol for managing the gender diverse child. [Leibowitz: 2012]

The range of outcomes for children presenting as gender diverse include:
  1. A gender diverse child progresses through puberty to be a transgender adolescent. These adolescents present with all variations of sexual orientation.
  2. A gender diverse child progresses through puberty and eventually identifies as a cisgender gay, lesbian, bi/pan-sexual identified adolescent.
  3. A gender diverse child progresses through puberty and identifies as a gender-queer/questioning adolescent.
  4. A gender diverse child progresses through puberty and identifies as a cisgender straight-identified adolescent.
Some adolescents begin to identify as transgender or gender diverse after puberty and having completed development of secondary sex characteristics. Many of these adolescents have undergone little concerning social transition. These individuals pose a significant challenge to care providers concerning gender-affirming medical management.

Diagnostic Criteria

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) provides 1 overarching diagnosis of gender dysphoria with separate criteria for children, adolescents, and adults. [American: 2013]

For adolescents and adults, a gender dysphoria diagnosis involves a difference between one's experienced/expressed gender and assigned gender, significant distress or problems with daily functioning, and gender dysphoria lasting at least 6 months and shown by at least 2 of the following:
  1. A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics
  2. A strong desire to be rid of one's primary and/or secondary sex characteristics
  3. A strong desire for the primary and/or secondary sex characteristics of the other gender
  4. A strong desire to be of the other gender
  5. A strong desire to be treated as the other gender
  6. A strong conviction that one has the typical feelings and reactions of the other gender
In children, a gender dysphoria diagnosis involves at least 6 of the following and an associated significant distress or impairment in function, lasting at least 6 months.
  1. A strong desire to be of the other gender or an insistence that one is the other gender
  2. A strong preference for wearing clothes typical of the opposite gender
  3. A strong preference for gender-affirming roles in make-believe play or fantasy play
  4. A strong preference for the toys, games, or activities stereotypically engaged in by the other gender
  5. A strong preference for playmates of the other gender
  6. A strong rejection of toys, games, and activities typical of one's assigned gender
  7. A strong dislike of one's sexual anatomy
  8. A strong desire for the physical sex characteristics that match one's experienced gender
Children who meet criteria for gender dysphoria may or may not continue to experience it into adolescence and adulthood. Some research shows that children who had more intense symptoms and distress, who were more persistent, insistent, and consistent in their gender-affirming statements and behaviors, and who used more declarative statements, such as "I am a boy (or girl)" rather than "I want to be a boy (or girl)," were more likely to become transgender adults. [Steensma: 2013]

Medical Conditions Causing Transgender and Gender-Diverse

A subject of research is whether biological disorders of sexual development, such as congenital adrenal hyperplasia, 5 alpha-reductase deficiency, or complete androgen insensitivity, contribute to differences in sexual orientation or gender identity. [Fisher: 2017]

Although more children with congenital adrenal hyperplasia experience gender dysphoria (3%) than in the general female population (0.002-0.003%), the numbers are small, and 95% of children with congenital adrenal hyperplasia raised as females later identify as cis-gender females, even though a much larger proportion of these children are inclined to play with male children doing activities more commonly associated with boys. [Callens: 2016] There is much greater variability in the 5 alpha-reductase deficiency population, with over half reporting a change in gender identity from female to male during puberty. Children with complete androgen insensitivity usually identify as female. [Fisher: 2017]

Retrospective studies indicate that about 3% of adults with disorders of sexual development recall experiencing childhood gender dysphoria and then changed gender. [Fisher: 2017] Most researchers in this field support the idea that each child with a disorder of sexual development will have a unique path and should have individualized multidisciplinary support. [Fisher: 2016] [Callens: 2016]

Comorbid Conditions

Autism
There has been a described co-occurrence of gender identity disorder in patients with autism spectrum disorder. Clinicians should be aware of this potential co-occurrence and the challenges it creates for clinical management. [de: 2010]

Disordered weight management
Transgender youth report more unsafe weight management behaviors than cisgender youth. These behaviors include fasting for more than 24 hours, diet pill use, and laxative abuse. [Guss: 2017] Additionally, transgender men have an increased risk of developing midline fat distribution after starting androgen therapy.

HIV/STI
Transgender youth are at increased risk of acquiring HIV and other sexually transmitted infections. HIV and STIs disproportionately affect transgender women when compared to transgender men. [Rosenthal: 2014]

Homelessness/unemployment/education
In 2015, the U.S. Transgender Survey examined the experiences of 27,715 transgender persons; 30% of the respondents reported experiencing homelessness during their lifetime and 12% reported homelessness in the year prior to completing the survey. Additionally, up to 32% of youth identified leaving school due to mistreatment. Unemployment rates were double the weighted national average. [James: 2016]

Homicide and violence
In 2011, youth who identified as transgender or gender diverse reported rates of harassment (78%), physical assault (35%), and sexual violence (12%) while attending K-12 education. [James: 2016] In the United States, homicide rates of transfeminine black and Latina individuals were higher than that of cisgender counterparts. [James: 2016]

Substance abuse/tobacco use
Transgender youth are 3 times more likely to use substances than their non-transgender peers. [Day: 2017]

Suicide
Rates of suicide, suicide attempts, and suicidal thoughts are elevated when compared to the general population. Family support and school safety are considered major protective factors. [Adelson: 2012]

Unipolar depression
Individuals who identify as transgender have an increased risk of having major depression requiring medical intervention. [Wylie: 2016]

Pearls & Alerts

Gender identity can change with time

Only 15%-30% of children who identify as transgender or gender diverse will continue with this identity after puberty. [Hembree: 2017]

No pattern predicts gender dysphoria

Not all transgender and gender diverse patients follow the typical insistent, consistent, and persistent pattern. Many of these patients develop gender dysphoria during adolescence.

History & Examination

The history and examination of patients often begin during the initial patient encounter by getting an understanding of their gender journey. This includes:
  • Social transition: Where is the patient with regards to social transition? Are they using gender-affirming pronouns? Are they using their desired name? Is physical presentation congruent with desired expression?
  • Psychosocial support: Who are their sources of support? Are they involved with community support groups? Do they have family/friends who can provide support through a social/medical transition?
  • Mental health therapy: Is the patient seeing anyone for gender-focused therapy. Would this individual provide a letter of support to help facilitate the medical transition?
In addition, it is important to ask questions about the patient’s desire to transition in order to document gender dysphoria and ascertain their goals:
  • How many years has gender dysphoria been present?
  • Can the patient describe their attitudes about pubertal changes?
  • What are the patient’s feelings about their birth-assigned sex?
  • Does the patient desire hormones, surgery, both, neither?

Family History

Family conditions that may confer increased risk for the adolescent or young adult taking hormone therapy include obesity, heart disease, and osteoporosis.

For transgender women undergoing estrogen therapy, it is prudent to ask questions related to clotting disorders, venous thromboembolism, breast cancer, and prostate cancer.

For transgender men, it is important to ask questions related to type 2 diabetes mellitus, breast cancer, and cervical cancer.

Current & Past Medical History

Key items to assess include:
  • Mood
  • Thoughts of self-harm or suicidal ideation
  • History of abuse and post-traumatic stress
  • History of a blood clot
  • Hypertension
  • Diabetes (type 2)
  • Obesity and weight trends
  • History of smoking and other substance use
Before prescribing hormones, be sure to perform an initial evaluation that includes discussion of a patient's physical transition goals, health history, risk assessment, and relevant laboratory tests.

Developmental & Educational Progress

Appropriate developmental screens should be performed if there is concern of autism spectrum disorder or other mental health conditions. Asking about academic performance could help identify barriers and difficulties at school, such as bullying.

Maturational Progress

An understanding of the patient's sexual maturity can help guide the use of puberty-blocking agents and the use of gender-affirming pharmacologic therapy. Understanding the patient's sexual history can help guide the need to screen for sexually transmitted infections and high-risk sexual behavior.

Social & Family Functioning

Assessing extended-family dynamics and psychosocial support is useful to identify needs or barriers to receiving care and transitioning successfully to adulthood.

Physical Exam

A physical exam does not have to be performed at the initial encounter but should be performed prior to the initiation of puberty blockers or gender-affirming hormones. The physical exam may be especially distressing for this population. It is often useful to introduce the need for a physical examination during the initial encounter to help the patient prepare. It can also help to ask the patient when they prefer to do the exam (e.g., beginning or end of appointment).

General

Affect, weight, fitness, grooming, skin care, and body habitus may each reflect the healthiness of habits and adaptation.

Vital Signs

Check blood pressure and heart rate. Monitor for hypertension in patients taking gender-affirming hormone therapy.

Growth Parameters

Record height and weight, BMI, and BMI percentile for preferred gender and age. Monitor these parameters in patients who are undergoing pubertal suppression. Monitor weight, especially in patients who are undergoing androgen therapy.

Skin

Examine skin for body hair distribution, acne, acanthosis nigricans, facial hair, and hair loss. Look for signs of cutting on arms and thighs.

HEENT

Examine for signs of conjunctival injection, which may indicate marijuana use.

Mouth/Teeth

Assess for enamel erosion or parotid hypertrophy, which may be evidence of purging behavior.

Chest

Examine breast for pubertal staging in assigned females and for evidence of gynecomastia in transgender women taking estrogen. Transgender men may often use a chest binding device under their clothes to conceal breast tissue.

Abdomen

Evaluate for enlarged liver in individuals taking hormone therapy.

Genitalia

Examine for any evidence of genital lesions or vaginal discharge, which may be associated with a sexually transmitted infection.

Testing

Laboratory Testing

Laboratory testing is usually performed every 6 months while initiating hormone therapy, then annually once secondary sex characteristics are achieved: [Hembree: 2017]
  • Total testosterone, free testosterone, estradiol for patients undergoing gender-affirming hormone therapy
  • Comprehensive metabolic panel (CMP) to evaluate liver enzymes while on hormone therapy and potassium if being treated with spironolactone
  • Complete blood count (CBC) to evaluate for polycythemia while on while on testosterone therapy
  • Lipid panel to evaluate for hyperlipidemia while on hormone therapy
  • Vitamin D to evaluate need for supplementation to reduce potential risk of developing osteoporosis while taking puberty blockers
  • Follicle-stimulating hormone/luteinizing hormone (FSH/LH) in prepubertal and early patients being treated with sex hormone suppression therapy, such as gonadotropin-releasing hormone (GnRH) agonists (leuprolide acetate, histrelin, etc.)

Imaging

A bone age may be useful in determining pubertal development prior to initiating sex hormone suppression. A bone densitometry (DEXA) scan may help determine bone mineral density in individuals who have been receiving puberty blockers for more than 1 year.

Genetic Testing

Karyotypes and other genetic studies are not currently indicated for people with gender dysphoria.

Subspecialist Collaborations & Other Resources

Adolescent Medicine (see Services below for relevant providers)

Often functions as the provider to evaluate transgender individuals and screen for high-risk sexual behavior and other biopsychosocial issues common in adolescents. Adolescent medicine provider may initiate gender-affirming hormone therapy and monitor labs.

Psychiatrist, Child-18 (MD) (see Services below for relevant providers)

Assists with managing psychotropic medications for associated psychiatric disorders, such as mood disorders, anxiety disorder, substance abuse, and post-traumatic stress disorder

Psychologist, Child-18 (PhD, PsyD) (see Services below for relevant providers)

Provides gender-focused psychotherapy and other therapy as needed. Refer to mental health providers known to be gender-affirming; avoid mental health providers who purport to "fix" gender identity

Pediatric Endocrinology (see Services below for relevant providers)

Assists with monitoring bone health for those taking puberty blockers, adjusts hormone treatment, and evaluates overall growth

Nutrition Assessment Services (see Services below for relevant providers)

Provides counseling regarding diet and assists with diagnosis of associated eating disorders

Speech - Language Pathologists (see Services below for relevant providers)

Assists with pitch, resonance, intonation, range, and volume of the voice

Treatment & Management

How should common problems be managed differently in children with Transgender and Gender-Diverse?

Growth Or Weight Gain

Masculinizing hormone therapy with testosterone can promote weight gain and increase visceral fat. Switching to a gender appropriate growth chart once the initiation of gender-affirming hormones begins can be helpful.

Development (cognitive, motor, language, social-emotional)

A percentage of children with autism identify as transgender; evaluate for autism spectrum disorder if any "flags" arise.

Prescription Medications

The use of GnRH agonists in adult men with prostate cancer has been associated with prolonged QT/QTc interval. There is no existing data for adolescents and young adults. Take special care in patients taking QT/QTc prolonging medications such as antidepressants, antiepileptics, opioids, and anticholinergic medications. It may be beneficial to get a baseline electrocardiogram and electrolytes in patients taking QT/QTc prolonging medications.

Common Complaints

All of the typical complaints that occur with cisgender adolescents (bullying, anxiety, depression, abdominal pain, headache) may likely occur. Additionally, patients may experience discomfort or rash from the use of chest binders. Spironolactone may increase thirst. Hormones may exacerbate (or cause) irritability and mood swings.

Pearls & Alerts

Affirming self-image

Transgender and gender-diverse youth often disguise their anatomy to promote a more affirming self-image. A transgender boy may use a binder to make breast tissue less obvious. Prosthetic devices known as "packers" are often used to resemble male genitalia. These devices may also allow a transgender boy to urinate while standing. Transgender girls may go to extremes to hide male genital including "tucking" the penis between one's thighs as well as displacing the testicles into the inguinal canal.

Fertility counseling

Adolescents rarely think about having children later on in life. It is important to discuss fertility and childbearing when counseling these patients, including reproductive options prior to the initiation of gender-affirming therapy. This includes harvesting and freezing of eggs and sperm. It is important to document that this conversation took place.

Systems

Pharmacy & Medications

The primary care clinician may refer transgender patients to a specialty team for management. The following provides guidance for prescribers of feminizing/masculinizing medications: Treatment goals, possible outcomes, and realistic expectations should be discussed with each patient. Most physical changes, whether feminizing or masculinizing, occur over 2 years. The amount of physical change and the exact timeline of effects can be highly variable. The following tables may be helpful: Suppressing Puberty
Gonadotropin-releasing hormone (GnRH) agonist delay the development of secondary sexual characteristics. Puberty blockers can be started in patients who are at sexual maturity rating 2 to 3. This includes agents like leuprolide acetate (Lupron Depot intramuscular injection every 3 months, Eligard subcutaneous injection every 4 months) and Vantas (a subcutaneous implantable rod effective for 12 months). Puberty blockers are 100% reversible. Consider referral to an endocrinologist or specialized adolescent medicine provider for assistance in treatment and monitoring.

Therapy for Transgender Females
Gender-affirming hormone therapy is appropriate for patients who have progressed through puberty (or who have been on puberty blockers for at least 1 year), demonstrated gender dysphoria, and wished to express physical attributes that are congruent with their identified gender. Hormone regimens for transgender MtF include various derivatives and vehicles of estrogen. The goal of estrogen therapy is to achieve estradiol levels within the physiologic range for an assigned female. Estrogen can be delivered as daily oral estradiol or through an estradiol patch (transdermal delivery) that is replaced every 3-5 days. Parenteral preparations of estrogen are available as estradiol valerate or cypionate. Doses for these preparations vary based on weekly or bi-monthly dosing. The use of estrogen therapy is often not sufficient to suppress testosterone levels and anti-androgens, GnRH agonists and spironolactone (100-400mg/day), are often used. [Hembree: 2017] More information about side effects will be found in the relevant systems below.

Therapy for Transgender Men
Gender-affirming hormone therapy is appropriate in patients who have progressed through puberty (or who have been on puberty blockers for at least 1 year), demonstrated gender dysphoria, and wished to express physical attributes that are congruent with their identified gender. Hormone regimens for transgender FtM include various derivatives and vehicles of testosterone. Traditionally, parenteral testosterone enanthate or cypionate is used. Dosing varies based on the use of intramuscular or subcutaneous injections. Transdermal preparations of testosterone include testosterone gel or transdermal patch. The goal of testosterone therapy is to achieve physiologic testosterone levels for an assigned male. [Hembree: 2017] More information about side effects will be found in the relevant systems below.

Subspecialist Collaborations & Other Resources

Adolescent Medicine (see Services below for relevant providers)

Often initiates gender-affirming hormone therapy and monitor labs.

Pediatric Endocrinology (see Services below for relevant providers)

Assists with monitoring bone health for those taking puberty blockers and adjusts hormone treatment.

Cardiology

For patients undergoing feminizing hormone therapy (MtF):
  • Estrogen use has been shown to increase the risk of venous thromboembolic events. This risk is amplified in smokers, obese individuals, and those with known thrombophilia disorders.
  • Estrogen use increases risk of cardiovascular events in patients older than 50 with known cardiovascular risk factors. Oral estrogen has been shown to increase triglycerides and increase LDL cholesterol.
    • The risk for venous thromboembolic events and cardiovascular events is increased with the additional use of third-generation progestins.
    • The use of transdermal estrogen does not have as much impact on lipid profiles as oral estrogen.
  • Estrogen use can increase blood pressure; however, the long-term clinical significance of this is unknown.
  • Spironolactone is used as an androgen-blocking agent and may be useful for patients who are hypertensive.
For patients undergoing masculinizing hormone therapy (FtM):
  • Testosterone decreases HDL cholesterol and has varying effects on LDL and triglycerides. High levels of testosterone outside the normal male range have been associated with poor lipid profiles.
  • Testosterone may increase the risk of cardiovascular disease in patients with underlying risk factors.
  • Individuals with risk factors such as family history of hypertension or who have polycystic ovarian syndrome may be at increased risk of hypertension.

Subspecialist Collaborations & Other Resources

Adolescent Medicine (see Services below for relevant providers)

Often functions as the provider to evaluate transgender individuals and screen for high-risk sexual behavior and other biopsychosocial issues common in adolescents. Adolescent medicine provider may initiate gender-affirming hormone therapy and monitor labs.

Pediatric Cardiology (see Services below for relevant providers)

Refer patients as needed for evaluation and treatment of cardiovascular disease that may develop with the use of hormone therapy.

Gastro-Intestinal & Bowel Function

For patients undergoing feminizing hormone therapy (MtF):
  • Estrogen use has been associated with elevated liver enzymes. There is a rare risk of hepatotoxicity.

For patients undergoing masculinizing hormone therapy (FtM):
  • Testosterone use has been associated with elevated liver enzymes.
  • Oral methyltestosterone has been associated with hepatic dysfunction and hepatic malignancies.

Subspecialist Collaborations & Other Resources

Pediatric Gastroenterology (see Services below for relevant providers)

Refer patients as needed for evaluation and treatment of hepatic complications that may develop with the use of hormone therapy.

Endocrine/Metabolism

For patients undergoing feminizing hormone therapy (MtF):
  • Estrogen therapy may increase the risk of developing type 2 diabetes, especially among patients with a known family history of type 2 diabetes or metabolic syndrome.
  • Estrogen use increases risk of developing hyperprolactinemia during the first year of treatment.
  • High-dose estrogen therapy can enhance clinical features of a preexisting prolactinoma that were previously not clinically evident.
For patients undergoing masculinizing hormone therapy (FtM):
  • Individuals with risk factors such as obesity, family history, or polycystic ovarian syndrome may be at increased risk of type 2 diabetes.

Subspecialist Collaborations & Other Resources

Pediatric Endocrinology (see Services below for relevant providers)

Refer patients as needed for evaluation and treatment of endocrine conditions that may develop with the use of hormone therapy, such as diabetes.

Mental Health/Behavior

Masculinizing hormone therapy may increase risk of hypomanic, manic, or psychotic symptoms in patients with related psychiatric disorders. There appears to be a direct association with supraphysiologic blood levels of testosterone.

Monitor for school bullying, child abuse, school failure, eating disorders, and mood or anxiety disorders that can occur in youth with gender dysphoria or during and after the transition process. The primary care clinician can advocate and intervene on the youth's behalf, when indicated, or refer to mental health specialists for more support.

Consider use of anti-depressants and other psychotropic medications as indicated for co-morbid mental health disorders. See Depression, Treatment & Management and Anxiety Disorders, Treatment & Management for more specific treatment information.

Subspecialist Collaborations & Other Resources

Psychiatrist, Child-18 (MD) (see Services below for relevant providers)

Assists with managing psychotropic medications for associated mood disorders, anxiety disorder, substance abuse, and post-traumatic stress disorder.

Mental Health Counselor (LPC, LCPC, CMHC) (see Services below for relevant providers)

As with any patient, refer as needed for evaluation and behavioral treatment of mental health disorders.

Hematology/Oncology

For patients undergoing masculinizing hormone therapy (FtM), therapy involving testosterone or other androgenic steroids increases the risk of polycythemia. Very little is known about cancer risks and protective factors.

Subspecialist Collaborations & Other Resources

Pediatric Hematology/Oncology (see Services below for relevant providers)

Refer patients as needed for evaluation and treatment of blood disorders, such as polycythemia.

Maturation/Sexual/Reproductive

Patients undergoing hormone therapy should be counseled about reproductive options prior to the initiation of gender-affirming therapy. This includes harvesting and freezing of eggs and sperm. Patients should be referred to a reproductive endocrinology clinic to discuss the options, processes, and costs if future fertility is desired.

Subspecialist Collaborations & Other Resources

Pediatric Endocrinology (see Services below for relevant providers)

Provides information about hormone therapy, prescribes relevant hormones, and monitors growth and sexual characteristics.

Surgery

Gender Affirmation Surgery
Surgery is a broad topic that is evolving rapidly and exceeds the scope of this module. A current literature review when considering referring or advising patients related to gender-affirming surgery is encouraged. For transgender women, surgical procedures may include:
  • Breast/chest surgery: augmentation mammoplasty (implants/lipofilling)
  • Genital surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, vulvoplasty
  • Non-genital, non-breast surgical interventions: facial feminization surgery, liposuction, lipofilling, voice surgery, thyroid cartilage reduction, gluteal augmentation, hair removal
For transgender men, surgical procedures may include:
  • Breast/chest surgery: subcutaneous mastectomy, creation of a male chest (wider areolae/nipple position)
  • Genital surgery: hysterectomy/oophorectomy, reconstruction of the fixed part of the urethra to extend urethra, which can be combined with a metoidioplasty or with a phalloplasty (employing a pedicled or free vascularized flap), vaginectomy, scrotoplasty, and implantation of erection and/or testicular prostheses
  • Non-genital, non-breast surgical interventions: voice surgery (rare), liposuction, lipofilling, pectoral implants, and various aesthetic procedures
The World Professional Association for Transgender Health: Standards of Care, 7th version summarizes surgical interventions on pages 57-65. Not all transgender individuals will express the same surgical needs.

Subspecialist Collaborations & Other Resources

General Pediatric Surgery (see Services below for relevant providers)

Identify and refer to surgeons comfortable and experienced with the desired surgical approaches.

Pediatric Plastic Surgery (see Services below for relevant providers)

Refer for gender-affirming cosmetic procedures.

Funding & Access to Care

The cost of puberty blockers ranges from $1,500 - $7,000 for injectable GnRH agonists (Lupron Depot is effective for 3 months; Eligard is effective for 4 months) to about $4,000 for implantable histrelin rods (good for 1 year or more). Intramuscular testosterone generally costs about $100 for a 10-dose supply. Estrogen is available is different modalities (oral, injectable, patch), but a 3-month supply can cost anywhere from $10 to $30. While many insurance companies are starting to cover medications for transgender and gender diverse individuals, supporting documents from a physician may be necessary.

Family

At each encounter, consider asking parents about how the family is functioning and coping with their gender-diverse child. Make recommendations for family or couples therapy as appropriate. Helpful educational books could include:

Subspecialist Collaborations & Other Resources

Psychologist, Child-18 (PhD, PsyD) (see Services below for relevant providers)

Refer patients as needed for evaluation and behavioral treatment of problematic family interactions.

Child Abuse Counseling (see Services below for relevant providers)

Refer if child abuse is suspected.

Transitions

When it is time for an adolescent to transition to an adult health care provider, the most important information to summarize for the new clinician, along with any chronic health conditions/events, is the list of current medications with doses, contact information for the therapist (if there is one) and other providers involved in the patient’s care, an organ inventory if surgery has been performed, and a brief discussion of the patient’s desired gender journey.

Frequently Asked Questions

When is it appropriate for a patient to start puberty blockers?

Patients with documented gender dysphoria who wish to halt the progression of puberty and potentially ameliorate gender dysphoria can start puberty blockers to prevent the further development of secondary sex characteristics. Puberty blockers are appropriate in patients who have achieved sexual maturity rating 2 and no later than sexual maturity rating 3. Puberty blockers are 100% reversible.

When can a patient start gender-affirming hormones?

Gender-affirming hormone therapy is appropriate in patients who have progressed through puberty (or who have been on puberty blockers for at least 1 year), demonstrated gender dysphoria, and wished to express physical attributes that are congruent with their identified gender. Starting hormone therapy requires a letter of support from a mental health provider who has identified that the patient's gender dysphoria is causing extreme distress and that the hormone therapy may help lessen this distress.

What proportion of children who like to dress or play like the "opposite" sex end up transgender?

While many children enjoy playing in non-gender conforming ways (e.g., girls playing with trucks) and wearing non-gender conforming clothing (e.g., boys wearing princess dresses), only about 15% of children with gender dysphoria ultimately identify as transgender.

When can a patient undergo surgical procedures?

Gender-affirming surgeries are appropriate for patients who desire masculinizing or feminizing characteristics. WPATH recommends that the individual be the age of majority for many surgical interventions. Gender-affirming surgeries include breast/chest surgery, genital surgery, and other interventions including voice surgery (rare), liposuction, lipofilling, pectoral implants, and various aesthetic procedures.

How can we set up our clinic to be more welcoming to gender diverse youth? Has anyone figured out how to manage gender identity in the electronic medical record?

A welcoming clinical environment is important to establish a therapeutic relationship. Often, a positive patient experience begins right as the patient walks through the door. It is important for front desk staff to be sensitive to all aspects of one’s affirmed gender. Questions like: “How do you like to be called?” or “Please share your name, your pronouns, your grade in school, etc.” help identify useful information including the patient’s chosen name and affirmed gender. Clinics should consider using a gender-neutral approach when developing forms and include an “other” option when asking a patient to identify their gender. Many electronic medical records have made an effort to help identify a gender; Epic has integrated fields for gender identity and sexual orientation.

When is it appropriate to have children with gender dysphoria and transgender youth undergo a mental health evaluation?

Many institutions may require a letter of support from a mental health provider prior to the initiation of gender-affirming hormones or surgical procedures. A mental health evaluation is important for any mental health disorders, as these may hinder a patient’s ability to provide informed consent for medical treatment. Early involvement with a provider who is skilled with gender-focused therapy is encouraged during the initiation of a social transition.

Issues Related to Transgender and Gender-Diverse

Funding & Access to Care

Appealing Funding Denials

Resources

Information for Clinicians

Acknowledging Gender and Sex (UCSF)
An online course for clinicians to create a welcoming environment for transgender people; Center of Excellence for Transgender Health, University of California San Francisco.

National LGBT Health Education Center (Fenway Institute)
Provides educational programs, resources, and consultation to health care organizations with the goal of optimizing quality, cost-effective health care for lesbian, gay, bisexual, and transgender (LGBT) people.

World Professional Association for Transgender Health (WPATH)
A non-profit organization for professionals that focuses on best practices and supportive policies to promote health for transgender, transsexual, and gender-variant people in all cultural settings.

Taking Routine Histories of Sexual Health (PDF Document 952 KB)
A 38-page booklet with recommendations for learning about the sexual health and behavior of patients, includes considerations for special populations; National LGBT Health Education Center and the National Association of Community Health Centers (2014).

Position Statement on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage (WPATH) (PDF Document 246 KB)
An 8-page statement citing the importance of coverage for transgender patients that includes medically prescribed sex reassignment or gender-affirming services; World Professional Association for Transgender Health.

Glossary of Terms – Transgender (GLADD)
Definitions of common, problematic, and preferred terminology related to transgender topics.

List of LGBTQ+ Definitions (itspronouncedmetrosexual.com)
An A-Z list of terms with definitions that "resonate with at least 51 out of 100 people."

Helpful Articles

PubMed search for articles published within the last year about transgender children and adolescents

Fisher AD, Ristori J, Morelli G, Maggi M.
The molecular mechanisms of sexual orientation and gender identity.
Mol Cell Endocrinol. 2017. PubMed abstract

Rosenthal SM.
Approach to the patient: transgender youth: endocrine considerations.
J Clin Endocrinol Metab. 2014;99(12):4379-89. PubMed abstract / Full Text

Rosenthal SM.
Transgender youth: current concepts.
Ann Pediatr Endocrinol Metab. 2016;21(4):185-192. PubMed abstract / Full Text

Turban J, Ferraiolo T, Martin A, Olezeski C.
Ten Things Transgender and Gender Nonconforming Youth Want Their Doctors to Know.
J Am Acad Child Adolesc Psychiatry. 2017;56(4):275-277. PubMed abstract

Wylie K, Knudson G, Khan SI, Bonierbale M, Watanyusakul S, Baral S.
Serving transgender people: clinical care considerations and service delivery models in transgender health.
Lancet. 2016;388(10042):401-411. PubMed abstract / Full Text
Full text is free, but log-in is required.

Clinical Tools

Assessment Tools/Scales

The Genderbread Person (PDF Document)
A popular infographic that breaks down gender identity, gender expression, biological sex, and sexual orientation into an easy to understand visual.

Toolkits

Trans Toolkit for Employers (Human Rights Campaign)
A toolkit and video for employees and employers to make workplaces transgender inclusive.

National Transgender HIV Testing Toolkit (CoE)
Five modules that reflect the most current HIV prevention research and best practices for serving trans and gender non-binary people; Center of Excellence for Transgender Health at the University of California, San Francisco.

Other

Sample Letter for Transgender Student Bathroom Access (Medical Home Portal) (PDF Document 138 KB)
A sample letter requesting that a transgender student is given appropriate boys', girls', or staff bathroom access at school.

Information & Support for Families

Family Diagnosis Page

Information on the Web

Transgender Youth and Schools

Schools in Transition: Guide for Supporting Transgender Students in K-12
Considerations and practical tips by age and topic (dress codes, names & pronouns, bullying, sex-separated facilities, etc.) for school teachers and administrators to support safe environments for transgender students (68 pages); by American Civil Liberties Union, Gender Spectrum, and other partners.

LGBT Youth & Schools Resources (ACLU)
A library of resources for school administrations and gender nonconforming students with information about harassment, free speech, privacy, suicide prevention, and more; American Civil Liberties Union.

Know Your Rights! A Guide for LGBT High School Students (ACLU)
A 7-page electronic resource with information for students about Title IX, privacy, freedom of speech, and more; American Civil Liberties Union.

Teaching Transgender Toolkit
Best practices, lesson plans, and resources for those who wish to facilitate training about transgender people, identities, and experiences; written by Dr. Eli R. Green, founder of The Transgender Training Institute, available for a fee.

LGBT Resource Center (University of Utah)
Information, support, events, and more for University of Utah students, staff, faculty, and alumni.

Legal Changes to Identity Documents

Gender Change and ID Documents (NCTE)
Find out how to get a legal name change where you live and update your name/gender on state and federal IDs and records; National Center for Transgender Equality.

How Do I Change My Gender on Social Security Records? (SSA)
Required documents and processes; Social Security Administration.

Gender Designation Change for Passports (U.S. Dept of State)
Requirements and answers to frequently asked questions about gender changes on U.S. passports.

Transgender Parents

Protecting the Rights of Transgender Parents and Their Children
A guide for parents who have transitioned or come out as transgender and are facing challenges to their legal status as parents; American Civil Liberties Union and National Center for Transgender Equality.

Transgender Youth and Families

Center of Excellence for Transgender Health (CoE)
Information, programs, and services for transgender individuals; Center of Excellence for Transgender Health, University of California, San Francisco.

Facts for Families: Transgender and Gender Diverse Youth (AACAP)
An introduction for families about gender diversity; American Academy of Child & Adolescent Psychiatry.

How I Help Transgender Teens Become Who They Want to Be (TED Talk)
A TED talk (approx. 17 minutes) by Dr. Norman Spack at Boston's Children Hospital about his experience as one of the few doctors in the United States to treat minors with hormone replacement therapy.

Gender Revolution: A Journey with Katie Couric (NGS)
A documentary that explores gender identity; National Geographic Society.

Where's My Book?: A Guide for Transgender and Gender Non-Conforming Youth, Their Parents, & Everyone Else
A 390-page book to help transgender youth through puberty. Explains the basics of gender identity, sexual orientation, puberty, puberty blockers, hormone treatments, and gender-affirming surgeries - by Dr. Linda Gromko (2015).

The Gender Creative Child
A 304-page book for parents and professionals that explains the rapidly changing cultural, medical, and legal landscape of gender and identity - by Diane Ehrensaft, PhD (2016).

Support National & Local

National Center for Transgender Equality
A social justice organization devoted to ending discrimination and violence against transgender people by promoting education about national issues of importance to transgender people.

GLAAD
Works with the media to fairly and accurately tell the stories of transgender lives. Focuses on tough issues to shape the narrative and provoke dialogue that leads to cultural change.

Transgender Law Center
Trans-led organization that is grounded in legal expertise and committed to racial justice and community-driven strategies to keep transgender and gender-nonconforming people thriving.

PFLAG
Committed to advancing equality through its mission of support, education, and advocacy. Strives to unite people who are lesbian, gay, bisexual, transgender, and queer (LGBTQ) with families, friends, and allies.

Equality Utah
Non-profit organization dedicated to education, advocacy, and political action.

Utah Pride Center
Information, support, events, and more for the LGBTQ community.

Services for Patients & Families in Utah

Select services for a different state: ID, MT, NM, NV, RI

Adolescent Medicine

See all Adolescent Medicine services providers (2) in our database.

Child Abuse Counseling

See all Child Abuse Counseling services providers (46) in our database.

General Pediatric Surgery

See all General Pediatric Surgery services providers (1) in our database.

Mental Health Counselor (LPC, LCPC, CMHC)

See all Mental Health Counselor (LPC, LCPC, CMHC) services providers (80) in our database.

Nutrition Assessment Services

See all Nutrition Assessment Services services providers (23) in our database.

Pediatric Cardiology

See all Pediatric Cardiology services providers (3) in our database.

Pediatric Endocrinology

See all Pediatric Endocrinology services providers (3) in our database.

Pediatric Gastroenterology

See all Pediatric Gastroenterology services providers (2) in our database.

Pediatric Hematology/Oncology

See all Pediatric Hematology/Oncology services providers (1) in our database.

Pediatric Plastic Surgery

See all Pediatric Plastic Surgery services providers (4) in our database.

Psychiatrist, Child-18 (MD)

See all Psychiatrist, Child-18 (MD) services providers (22) in our database.

Psychologist, Child-18 (PhD, PsyD)

See all Psychologist, Child-18 (PhD, PsyD) services providers (143) in our database.

Speech - Language Pathologists

See all Speech - Language Pathologists services providers (65) in our database.

For other services related to this condition, browse our Services categories or search our database.

Authors & Reviewers

Initial Publication: February 2018; Last Update: June 2018
Current Authors and Reviewers (click on name for bio):
Author: Adam W. Dell, MD
Contributing Author: Jennifer Goldman-Luthy, MD, MRP, FAAP
Reviewer: Nicole Mihalopoulos, MD, MPH
Authoring history
(Limited detail is available on authoring dates before 2014.)
AAuthor; CAContributing Author; SASenior Author; RReviewer

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Approach to the patient: transgender youth: endocrine considerations.
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Transgender youth: current concepts.
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Ten Things Transgender and Gender Nonconforming Youth Want Their Doctors to Know.
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Serving transgender people: clinical care considerations and service delivery models in transgender health.
Lancet. 2016;388(10042):401-411. PubMed abstract / Full Text
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