Sexual and Gender Minority Youth
Gender identity emerges in the late preschool years as an inherent sense of being a girl, or female, or a boy, or male, or some blend of or alternative to male/female. Understanding and awareness of gender identity, especially when gender identity differs from the gender assigned to an individual at birth, may emerge at later stages as the individual gains context and language to explore, express and integrate their identy.
Sexual orientation is distinct from gender identity, but the 2 are related and often conflated. Sexual orientation is a person's sexual and/or emotional attraction to others. Young children may be aware of their sexual orientation, but it emerges around puberty for many. Like gender identity, an individual's awareness and understanding of their sexual orientation may occur at different stages of life. Both gender identity and sexual orientation may be experienced as fluid.
School-aged children with gender non-conforming behavior or non-heterosexual orientation may provoke parental concern or peer marginalization. The pediatric primary care clinician plays a key role in providing education, support, and gender-affirming care for these children and their families.
Sexual and gender diversity
- Sex assigned at birth - the terms “male” and “female” are designated at birth based on the appearance of external genitalia. In cases in which there are variations in chromosomal, gonadal or phenotypic sex characteristics (i.e., a difference of sex development or “DSD” or intersex variation) a child is still typically designated male or female, though increasingly there are options to designate a nonbinary gender marker at birth.
- Gender Role – socially and culturally defined patterns of behavior, dress, speech, and relating to others
- Gender Identity – internal, innate sense of being male, female, in between, or fluid – forms between age 3-5 years
- Gender expression - how individuals choose to present themselves including clothing, hairstyles, physical appearance, and behavior. Gender expression can also be fluid and may not align with cultural norms associated with designated sex at birth or gender identity (e.g., boys wearing dresses).
- Sexual orientation: immutable, stable, and resistant to conscious control
- Sexual identity: how an individual defines their sexuality – may develop in early childhood; more often at puberty
- Sexual behavior: how a person is sexual with others or themselves. Sexual behavior may differer from sexual identity and also from romantic interest or behavior.
Gender identity and sexual orientation intersect with other aspects of identity, including race/ethnicity, socioeconomic status, religion or spirituality, ability, immigration status, and others. Gender and sexual minority youth may experience acceptance or rejection for who they are and whom they love at the level of their parents and family, culture, neighborhood, school peers, and larger community.
Gender Dysphoria is defined in DSM-5 as "an individual's affective/cognitive discontent with the assigned gender". This is in contrast with the preceding (DSM-IV) diagnosis of Gender Identity Disorder which focused on gender identity itself rather than the dysphoria associated with the incongruence between assigned gender and experienced gender.
(Non-heterosexual orientation was included as a disorder in previous editions fo the DSM. That is no longer the case, and there is no equivalent for gender dysphoria related to sexual orientation).
Gender Dysphoria must be diagnosed to support medical or surgical transition, but gender dysphoria may abate or resolve with transition as the individual is able to fully live their gender identity. Being transgender and having Gender Dysphoria are NOT synonymous.
Parents and others wonder, when a child expresses clearly that they are a gender other than that assigned at birth, if this expression just a phase. This question has significant implications for medical interventions supporting gender transition.
Recent data from the longitudinal Trans Youth Project report on the persistence of transgender idenity in children. The study followed rates of retransition and current gender identies of 208 transgender girls and 109 transgender boys who had a mean age of 8.1 years at study start. At 5 years after initial social transition (see below), 94% identified as binary (boy or girl) transgender youth, 3.5% as non-binary, and 2.5% as cisgender (Olson et al, 2022). This indicates that transgender identity is stable through childhood for the great majority of children, but that a small percentage will retransition.
Levels of gender-affirming care
The pediatric clinician should be prepared to educate parents and patients on available options for gender-affirming care.
Levels of affirmation
- Social - Real life experience in the desired gender role. This may include using preferred pronouns and chosen name, as well as gender-affirming dress, hairstyle, and behaviors.
- Hormonal Treatment – GnRH Analogs (Puberty Suppression); Testosterone/Estrogen (See Salas-Humara et al, 2019, for details)
- Gender Affirming Surgeries (See Salas-Humara et al, 2019, for details)
- Legal: name and legal sex change; reissuance of birth certificate
Parenting practices and mental health in sexual and gender minority youth
Gender and sexual minority youth experience the same mental health disorders as do all children and adolescents. There is some debate as to whether gender and sexual minority youth have higher rates of anxiety, depression, disordered eating, or substance abuse than do their peers. These mental health conditions occur at higher rates in samples of patients presenting for clinical care but rates may differ in community samples.
What is clear, however, is that mental health disorders and high-risk behaviors including suicidal acts and runaway status are significantly higher in gender and sexual minority youth who experience parental and/or peer rejection.
Parental acceptance of their transgender, gender diverse, or sexual minority child, including usage of their child’s chose name and pronouns, significantly reduces risk of depression, suicidal ideation, and suicidal behaviors.
Family connectedness and the experience of home as a safe, non-judgmental space are also protective factors.
Gender-Affirming Care in Pediatrics
Ask appropriately about gender identity and pronouns, as well as partners:
- “Are you dating anyone?” instead of “do you have a boyfriend/girlfriend?”
- “My pronouns are she/her. What pronouns would you like me to use for you? Would you prefer I use a different pronoun in front of your parents?”
- “What name would you like me to use? Would you prefer I use a different name in front of your parents?”
If you make a mistake with regard to pronouns or names, acknowledge it, apologize, and move forward.
Review confidentiality with the adolescent and parents.
Monitor pubertal progression.
- Monitor your patient’s feelings about the experience of puberty.
- Recognize that gender identity exists on a continuum, and that your transgender or gender diverse patient may want to pursue multiple available interventions or just a few.
- Prescribe contraceptive options to manage monthly bleeding.
- Pubertal suppression can be started at Tanner Stage 2 (see Salas-Humeira 2019 and Weisselberg 2019, below).
Consider environmental changes to the office space
- Display and share symbols and images that accept and affirm the identity of SGM youth, such as the GLSEN poster pictured here.
- Consider labeling restrooms “all gender” restrooms.
- Ensure that intake forms, screening measures, and any documents you use in your practice are affirming to gender and sexual minority patients.
When to refer to specialty care
Referrals to refer to specialty care adolescent medicine, endocrinology, or multidisciplinary gender clinics should be made if your patient is seeking medical or surgical gender affirming care, including puberty suppression.
Assess and treat mental health concerns according to your scope of practice. Refer to mental health professionals should be made if your patient presents with self-harm, suicidal ideation, substance use, or disordered eating.
Mental Health in LGBTQ+ Youth: Pediatric Mental Health Minute Series
Trevor Project Coming Out Handbook
Amaze.org Sexual Orientation, Behavior and Identity
Lurie Children's Gender Development Program
Gender Spectrum: Supportive Parenting
Gender and Sexuality Definitions - Vanderbilt University
Gender Odyssey Gender Odyssey is an annual international conference focused on the needs and interests of transgender and gender diverse children of all ages, their families and supporters, and the professionals who serve them.
Green, A. E., Price-Feeney, M., & Dorison, S. H. (2021). Association of Sexual Orientation Acceptance with Reduced Suicide Attempts Among Lesbian, Gay, Bisexual, Transgender, Queer, and Questioning Youth. LGBT Health, 8(1), 26–31. https://doi.org/10.1089/lgbt.2020.0248
Mizock, L. (2017). Transgender and Gender Diverse Clients with Mental Disorders: Treatment Issues and Challenges. Psychiatric Clinics of North America, 40(1), 29–39. https://doi.org/10.1016/j.psc.2016.10.008
Olson, K. R., Durwood, L., Horton, R., Gallagher, N. M., & Devor, A. 2022. Gender Identity 5 Years After Social Transition. Pediatrics 150 (2).
Rafferty, J. (2018). Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. 142(4), 14.
Salas-Humara, C., Sequeira, G. M., Rossi, W., & Dhar, C. P. (2019). Gender affirming medical care of transgender youth. Current Problems in Pediatric and Adolescent Health Care, 49(9), 100683.
Wagner, J., Sackett-Taylor, A. C., Hodax, J. K., Forcier, M., & Rafferty, J. (2019). Psychosocial Overview of Gender-Affirmative Care. Journal of Pediatric and Adolescent Gynecology, 32(6), 567–573. https://doi.org/10.1016/j.jpag.2019.05.004
Weiselberg, E.C., Shadianloo, S., & Fisher, M. (2019). Overview of care for transgender children and youth. Curr Probl Pediatr Adolesc Health Care , 49: 100682