Caring for Transgender & Gender-Diverse Youth
Other Names
Key Points
Gender nonconformity is when gender identity differs from cultural norms. Gender dysphoria is the discomfort caused by the difference between a person’s gender identity and the sex assigned at birth. Some gender nonconforming people experience gender dysphoria, but not all. A portion of transgender and gender-diverse youth develop gender dysphoria during adolescence.
Not all transgender and gender-diverse patients follow the typical insistent, consistent, and persistent pattern. A range of outcomes exists for children presenting as gender-diverse, including progressing through puberty and identifying as a gender-diverse adolescent. Others may identify as a cisgender person with variations in sexual orientation. 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), gender dysphoria in childhood only persists into adulthood for about 15% of children. [Hembree: 2017]
Often a positive experience begins as the patient walks through the door. Front desk staff can ask: How do you like to be called? What is your name? What are your pronouns? Using a gender-neutral approach when developing forms and including an “other” option when asking patients to identify their gender is inclusive. Many electronic medical records have ways to store the individual’s affirmed gender and sexual orientation so that clinical staff can use the patient’s desired terminology. Most important is that health care professionals use culturally appropriate language and uphold safety, dignity, and respect toward our transgender and gender-diverse population. [Coleman: 2022]
Early involvement with a provider skilled in gender-focused therapy is encouraged during the initiation of a social transition and for those experiencing gender dysphoria. Mental health support is important to address any active mental health/behavioral concerns that may impact a person’s ability to provide informed consent. Many institutions require a letter of support from a mental health provider before initiating gender-affirming hormones or surgical procedures. It is important to recognize gender dysphoria is not a mental health disorder. Although studies show a higher prevalence of depression, anxiety, and other mental health disorders in transgender and gender-diverse individuals, elevated rates have been linked to complex trauma, discrimination, societal stigma, internalized transphobia, and violence. [Peterson: 2021] In fact, psychiatric symptoms lessen with appropriate gender-affirming care. [Aldridge: 2021] [Grannis: 2021] [Almazan: 2021]
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. Puberty blockers are 100% reversible.
In general, gender-affirming hormone therapy is appropriate in patients who have progressed through puberty or been on puberty blockers for at least 1 year, demonstrate gender dysphoria, and wish to express physical attributes that are congruent with their identified gender. Current endocrinology guidelines recommend starting gender-affirming hormones after 16 years of age, ideally after living in their desired gender for at least a year. Individuals should be physically and mentally well. Working with a mental health provider may be appropriate. Starting hormone therapy may require a letter of support from a mental health provider who has identified that the patient's gender dysphoria is causing distress and that the hormone therapy may help lessen this distress. See Responsibilities of Hormone-Prescribing Physicians (WPATH) (
78 KB) and
Criteria for Hormone Therapy (WPATH) ( 80 KB).
Gender-affirming surgeries are appropriate for patients who desire masculinizing or feminizing characteristics. WPATH recommends that the individual be the age of majority for most surgical interventions. Chest masculinization surgery may be performed in transmasculine individuals before age 18. Gender-affirming surgeries include chest masculinization surgery (often called top surgery), vaginoplasty or phalloplasty (bottom surgery), and other interventions, including vocal cord surgery (rare), facial feminization, liposuction, lipofilling, pectoral implants, and various reconstructive procedures.
Providers should be aware of their state's stance on gender-affirming care. As of January 2023, over 120 bills are being introduced in over 20 states to limit gender-affirming care access, prevent children from using gender-affirming names/pronouns in schools, limit participation in athletic programs, and prevent legal name/gender marker changes. Some of these bills have been signed into law as of February 9, 2023. Health care clinicians are at the front lines of providing care to this marginalized group. Many of these laws will likely contribute to the mental health challenges for transgender and gender-diverse youth. Health care providers are encouraged to familiarize themselves with active laws, identify out-of-state resources if possible, advocate against hurtful/unnecessary legislature, and provide an affirming clinical space for this group.
Practice Guidelines
Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, et al.
Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.
Int J Transgend Health.
2022;23(Suppl 1):S1-S259.
PubMed abstract / Full Text
American Psychological Association.
Guidelines for psychological practice with transgender and gender nonconforming people.
Am Psychol.
2015;70(9):832-64.
PubMed abstract / Full Text
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
Rafferty J.
Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.
Pediatrics.
2018;142(4).
PubMed abstract / Full Text
Assessment
Most children begin showing gendered behavior and using affirming pronouns between 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 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] Some transgender children consistently, persistently, and insistently express an opposite gender identity and feel that their gender differs from their assigned sex.
Puberty often serves as a time to identify and express one's identity. Individuals may transition socially by adopting desired pronouns, a new name, and wearing gender-affirming attire. [Drescher: 2012] Some adolescents begin to identify as transgender or gender-diverse after puberty and with the development of secondary sex characteristics. These adolescents can pose a significant challenge to clinicians providing gender-affirming medical management because many individuals have not undergone much social transition, and their needs for mental health and other comorbidities are evolving.
Gender dysphoria is distress associated with the perceived incongruence of self and gender expression. For most transgender or gender-diverse children who experience gender dysphoria in early childhood, this distress may lessen or resolve by adolescence. However, about 15% will continue to experience gender dysphoria through puberty, and it may increase in intensity. Gender dysphoria may develop if the individual experiences a lack of acceptance in a social setting, such as school. Transphobia, discrimination, and violence often worsen gender dysphoria and exacerbate mental health crises. Many transgender and gender-diverse people can “experience stigma, prejudice, discrimination, harassment, abuse, and violence resulting in social, economic, and legal marginalization, poor mental health and physical health, and even death.” [Coleman: 2022] Although some transgender teens are comfortable with their bodies, transgender youth are more likely to experience gender dysphoria than their gender-diverse peers.
Initial Encounter
- Social transition: Where is the patient with regard to social transition? Are they using gender-affirming pronouns? Are they using their desired name? Is physical presentation congruent with desired expression? Do their family and friends also use their desired names and pronouns?
- Psychosocial support: Do they feel supported by their loved ones? 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 therapist provide a letter of support to help facilitate a medical transition?
- 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?
Physical Exam
Diagnostic Criteria for Gender Dysphoria
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.
- A strong desire to be of the other gender or an insistence that one is the other gender
- A strong preference for wearing clothes typical of the opposite gender
- A strong preference for gender-affirming roles in make-believe play or fantasy play
- A strong preference for the toys, games, or activities stereotypically engaged in by the other gender
- A strong preference for playmates of the other gender
- A strong rejection of toys, games, and activities typical of one's assigned gender
- A strong dislike of one's sexual anatomy
- A strong desire for the physical sex characteristics that match one's experienced gender
- A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics
- A strong desire to be rid of one's primary and/or secondary sex characteristics because of a marked incongruence with one’s personal or expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
- A strong desire for the primary and/or secondary sex characteristics of the other gender
- A strong desire to be of the other gender (or some alternative gender different from one’s designated gender)
- A strong desire to be treated as the other gender
- A strong conviction that one has the typical feelings and reactions of the other gender
Screening
-
HEEADSSS Assessment Guide (USU) ( 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.
- "Hi, my name is Dr. Smith, and I prefer she/her/hers pronouns. What name would you prefer to be called?”
- “What are your pronouns?”
- "Do you feel you are a different gender from how others have thought of you since you were born?”
- “If you were to use a bathroom at school or in public, would you use the women’s, men’s, or gender-neutral bathroom?”
- “Do you feel this is in line with your gender identity?”
- “Are there any parts of your body that make you unhappy or that you wish you did not have?”
- “Have you thought about your body having certain characteristics or traits of another gender?”
- “Have you ever tried on clothes from the opposite gender and felt less discomfort with your body?”
- “What about your body bothers you the most? The least?”
- “How do you feel when others do not perceive you as the gender you identify with the most?”
Genetics
Prevalence
Monitoring for Associated Conditions
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] For screening and management information, see Autism Screening and Autism Spectrum Disorder.
If family dynamics are not supportive of a child who is gender diverse, that child is at increased risk for child abuse and exposure to trauma or increased stress at home. SEEK Parent Screening Questionnaire (PSQ-R) is a free parent questionnaire with scoring instructions that screens for child maltreatment and toxic stress using 15 yes/no questions. Toxic Stress Screening may also be helpful.
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. See Screening for Eating Disorders and refer to Nutrition Assessment Services (see ID providers [1]) if there are concerns.
Human immunodeficiency virus (HIV)/sexually transmitted infection (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 before 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] For screening and management information, see Substance Use Disorders.
Suicide
Rates of suicide, suicide attempts, and suicidal thoughts are elevated compared to the general population. Among adolescents (11-19 years), 51% of transmales, 30% of transfemales, 42% of non-binary, and 28% of those questioning their gender identity attempted suicide in the past year before completing the Profiles of Student Life, Attitudes and Behaviors Survey. Among non-transgender adolescents who completed the survey, 18% of females and 10% of males had attempted suicide in the past year. [Toomey: 2018] Family support and school safety are major protective factors. [Adelson: 2012] Suicide-Screening Questions (ASQ) is a free, 5-question screening tool with scoring instructions. When the ASQ is positive, a follow-up assessment is necessary, and then decide if inpatient care or an outpatient safety plan will be adequate. See Suicidality & Self-Harm.
Major depression
Individuals who identify as transgender have an increased risk of having major depression requiring medical intervention. [Wylie: 2016] For screening and management information, see Depression.
Terms Related to Gender-Affirming Care
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 that 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 or a clinical symptom that is characterized by a sense of alienation to some or all of the physical characteristics or social roles of one’s assigned gender
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 nor female - gender in varying degrees, fluid, or a gender unattached to the poles of male and female
Intersex: Atypical, congenital variations in the reproductive tract, “genital ambiguity”
Sex: A biological status categorized as male, female, or intersex, as indicated by factors that include chromosomes, gonads, internal reproductive organs, and external genitalia
Transition: The period 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 most comfortable for them. Transition may or may not include feminization or masculinization of the body through hormones.
Outcomes
Gender-Affirming Care
- Social
- Use the individual’s desired name and pronouns identified to affirm one’s self.
- Affirm gender presentation (congruent clothing, behaviors, presentation, use of bathrooms).
- Psychological
- Support a sense of authentic self-identity.
- Provide access to mental health providers who are knowledgeable about gender-focused therapy and the needs of transgender individuals.
- Medical
- Provide access to safely managed gender-affirming hormones (generally via referral).
- Discuss and plan for reproductive options.
- Refer to appropriate specialists for gender-affirming surgeries and procedures.
- Refer to speech and language specialists for voice and communication therapies.
- Facilitate transition to adult primary care clinicians who are familiar with the needs of transgender individuals.
- Legal
- Advocate for effective anti-discrimination legislation and access to legal providers.
- Ask about legal name and gender designation changes.
Family
138 KB). Primary care clinicians may need to provide documentation to promote a
gender change on government-issued documentation (driver's license, passport,
etc.). [Schuster: 2016]
Endocrine
- Record height and weight, BMI, and BMI percentile for desired gender and age. Monitor these parameters regularly in patients undergoing pubertal suppression and hormone therapy. Switching to a gender-appropriate growth chart can be helpful once the initiation of gender-affirming hormones begins. While there is no consensus on when switching growth charts is appropriate, many providers will compare affirmed growth charts to natal growth charts after a year of gender-affirming hormones.
- Note changes in affect, weight, fitness, changes in muscle mass, fat distribution, grooming, skincare, and body habitus, which may each reflect the healthiness of habits and adaptation. Be aware that those undergoing androgen therapy as testosterone can experience weight gain and increased visceral fat.
- Examine skin for body hair distribution, acne, androgenic alopecia, acanthosis nigricans, facial hair, and hair loss. Examine breast for pubertal staging in assigned females and evidence of gynecomastia in transgender women taking estrogen. Transgender men may often use a chest binding device under their clothes to conceal breast tissue. You may need to ask the patient to remove their chest binding since binding can lead to skin breakdown and infection. Additionally, breast cancer screening guidelines should be followed for those receiving estrogen.
Prescribing Gender-Affirming Hormones
- History of a blood clot or venous thromboembolism
- Hypertension
- Diabetes (type 2)
- Obesity and weight trends
- History of smoking and other substance use
- History of breast, cervical, or prostate cancer
- The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed).
- Gender dysphoria emerged or worsened with the onset of puberty.
- Any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment.
- The adolescent has given informed consent, and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process. [Coleman: 2022]
- Expected time course of physical changes in response to gender-affirming hormone therapy WPATH Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 Appendix C
- 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 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.). Monitoring estrone to estradiol ratio is not supported by current published evidence.
Suppressing Puberty
Therapy for Transgender Females
Therapy for Transgender Males
Therapy Costs
Maturation/Sexual/Reproductive
- Discuss unwanted/wanted effects of puberty (e.g., menses, spotting, erections)
- Discuss sexual orientation, history of sexual encounters, and use of contraception. It is important to stress the need for use of contraception in adolescents who are thinking of potentially becoming sexually active. Understanding the patient's sexual history can help guide the need to screen for sexually transmitted infections and high-risk sexual behavior.
- Discuss future childbearing/rearing (fertility). 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.
- 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.
- Examine for any evidence of genital lesions or vaginal discharge, which may be associated with a sexually transmitted infection.
- 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, which can lead to rashes, discomfort, or tissue damage. 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 genitalia, including "tucking" the penis between one's thighs as well as displacing the testicles into the inguinal canal. Evaluating for hernia or areas of skin breakdown around the testicles is also important if the patient has tried to tuck their testicles.
Cardiology
- Estrogen use has been shown to increase the risk of venous thromboembolic events. This risk may be amplified in smokers, obese individuals, and those with known thrombophilia disorders.
- Estrogen use increases the 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. It can increase thirst in patients.
- 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 a family history of hypertension or who have polycystic ovarian syndrome may be at increased risk of hypertension.
- Check blood pressure and heart rate. Monitor for hypertension in patients taking gender-affirming hormone therapy.
- It may be beneficial to get a baseline electrocardiogram and electrolytes in patients taking QT/QTc prolonging 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.
- Ensure routine labs are followed with the specialist or in the medical home.
Hematology/Oncology
Endocrine
- 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.
- Individuals with risk factors such as obesity, family history, or polycystic ovarian syndrome may be at increased risk of type 2 diabetes.
- Individuals can still ovulate for 1 to 5 cycles after initiating testosterone therapy. [Taub: 2020]
Gender Affirmation Surgery
- 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
- Breast/chest surgery: subcutaneous mastectomy, creation of a male chest (wider areolae/nipple position). Many centers will consider chest masculinization surgery prior to age 18 years.
- 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
Mental Health/Behavior
Developmental & Educational Progress
Social & Family Functioning
- The Gender Creative Child: A 304-page book that explains the rapidly changing cultural, medical, and legal landscape of gender and identity - by Diane Ehrensaft, PhD (2016)
- 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
Transition
Services and Referrals
Provides information about hormone therapy, prescribes relevant hormones, and monitors growth and sexual characteristics. Refer patients as needed for evaluation and treatment of endocrine conditions that may develop with the use of hormone therapy, such as diabetes. Assists with monitoring bone health for those taking puberty blockers, adjusts hormone treatment, and evaluates overall growth bone health.
Provides counseling regarding diet and assists with diagnosis of associated eating disorders.
Assists with pitch, resonance, intonation, range, and volume of the voice.
Often initiates gender-affirming hormone therapy and monitors labs. Often functions as the provider to evaluate transgender individuals and screen for high-risk sexual behavior and other biopsychosocial issues common in adolescents.
Refer patients as needed for evaluation and treatment of cardiovascular disease that may develop with the use of hormone therapy.
Refer patients as needed for evaluation and treatment of hepatic complications that may develop with the use of hormone therapy.
Refer patients as needed for evaluation and behavioral treatment of problematic family interactions. 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.
Refer if child abuse is suspected.
Identify and refer to surgeons comfortable and experienced with the desired surgical approaches.
Refer for gender-affirming cosmetic procedures.
Assists with managing psychotropic medications for associated mood disorders, anxiety disorder, substance abuse, and post-traumatic stress disorder.
Resources
Information & Support
Clinical diagnosis and management information: Transgender and Gender-Diverse Youth (FAQ)
Answers to questions families often have about caring for their transgender or gender-diverse child.
Working with Insurance Companies
Letters of Medical Necessity and appealing funding denials.
For Professionals
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 nonprofit 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 ( 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) ( 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."
For Parents and Patients
Support
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.
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)
An on-line 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 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.
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.
Gender Change and ID Documents (NCTE)
Information about the legal name change process in each state; 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.
General
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).
Tools
The Genderbread Person ()
A popular infographic that breaks down gender identity, gender expression, biological sex, and sexual orientation into an
easy to understand visual.
HEEADSSS Assessment Guide (USU) ( 1017 KB)
Examples of open-ended questions the clinician can ask adolescents about Home, Education/Employment, Eating, Activities, Drugs,
Sexuality, Suicide/Depression, and Safety.
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.
Sample Letter for Transgender Student Bathroom Access (Medical Home Portal) ( 138 KB)
A sample letter requesting that a transgender student is given appropriate boys', girls', or staff bathroom access at school.
Services for Patients & Families in Idaho (ID)
| Service Categories | # of providers* in: | ID | NW | Other states (5) (show) | | NM | NV | OH | RI | UT |
|---|---|---|---|---|---|---|---|---|---|---|
| Adolescent Medicine | 1 | 1 | 2 | 1 | 8 | 2 | ||||
| Child Abuse/Neglect/Violence | 13 | 25 | 84 | 14 | 25 | 142 | ||||
| General Counseling Services | 1 | 3 | 209 | 1 | 30 | 362 | ||||
| Nutrition Assessment Services | 3 | 1 | 2 | 6 | ||||||
| Pediatric Cardiology | 2 | 4 | 17 | 5 | ||||||
| Pediatric Endocrinology | 1 | 4 | 6 | 1 | 13 | 4 | ||||
| Pediatric Gastroenterology | 1 | 3 | 6 | 1 | 19 | 4 | ||||
| Pediatric Plastic Surgery | 3 | 5 | 4 | 3 | 4 | 5 | ||||
| Pediatric Surgery [Discontinued] | ||||||||||
| Psychiatry/Medication Management | 2 | 49 | 79 | 56 | ||||||
| Speech - Language Pathologists | 4 | 22 | 13 | 4 | 31 | 69 | ||||
For services not listed above, browse our Services categories or search our database.
* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.
Studies
Transgender Youth (ClinicalTrials.gov)
Studies looking at better understanding, diagnosing, and treating this condition; from the National Library of Medicine.
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