Advertisement

Psychosocial Overview of Gender-Affirmative Care

  • Jill Wagner
    Correspondence
    Address correspondence to: Jill Wagner, LCSW, Division of Adolescent Medicine, Hasbro Children’s Hospital, 1 Hoppin St, Ste 3055, Providence, RI 02903; Phone: (401) 444-4388
    Affiliations
    Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, Rhode Island

    Division of Adolescent Medicine, Hasbro Children’s Hospital, Providence, Rhode Island
    Search for articles by this author
  • Andrew C. Sackett-Taylor
    Affiliations
    Department of Outpatient Clinical Services, Gándara Mental Health Center, Springfield, Massachusetts
    Search for articles by this author
  • Juanita K. Hodax
    Affiliations
    Department of Pediatrics, University of Washington, Seattle, Washington

    Division of Endocrinology, Seattle Children’s Hospital, Seattle, Washington
    Search for articles by this author
  • Michelle Forcier
    Affiliations
    Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, Rhode Island

    Division of Adolescent Medicine, Hasbro Children’s Hospital, Providence, Rhode Island
    Search for articles by this author
  • Jason Rafferty
    Affiliations
    Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, Rhode Island

    Division of Adolescent Medicine, Hasbro Children’s Hospital, Providence, Rhode Island

    Department of Child Psychiatry, Emma Pendleton Bradley Hospital, Riverside, Rhode Island

    Department of Pediatrics, Thundermist Health Centers, Woonsocket, Rhode Island
    Search for articles by this author

      Abstract

      Transgender and gender-diverse youth and their families are increasingly presenting to adolescent gynecological providers for education, care, and referrals. These youth more often face mental health and social disparities that frequently go unrecognized or unaddressed by providers. A gender-affirmative approach focuses on providing emotional validation, psychological safety, and support to young patients and their families. With better understanding of the unique needs of transgender and gender-diverse populations, gynecological care can be personalized and delivered in a nuanced fashion to better address the sexual and reproductive needs of gender minority patients. In this article we review essential psychological and social considerations in caring for transgender and gender-diverse youth, including concepts relating to gender identity, affirmative approaches, means of assessing for risk and resiliency, and family dynamics. Ultimately, adolescent gynecological providers have an important role in promoting the emotional health and positive development of transgender and gender-diverse youth.

      Key Words

      Case

      A 13-year-old who was assigned female at birth comes to the gynecological clinic for dysmenorrhea stating, “I am genderqueer and go by they/them, thank you. My periods make me really sad and I want them to stop.” Parents report that “Rachel,” who now goes by “Taylor,” gets irritable every month around the time of their menses and they are wondering if it is premenstrual syndrome.

      Introduction

      As transgender and gender-diverse (TGD) youth are increasingly presenting and identifying to medical providers, it is essential that providers from all fields of medicine come to recognize the unique needs and challenges faced by this population. To provide appropriate, patient- and family- centered care, interdisciplinary collaboration between providers in primary care, mental health, reproductive health, and other various specialties is often necessary.
      • Rafferty J.
      • AAP Committee on the Psychosocial Aspects of Child and Family Health
      • AAP Committee on Adolescence
      • et al.
      Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents.
      • Bonifacio H.J.
      • Rosenthal S.M.
      Gender variance and dysphoria in children and adolescents.
      • Edwards-Leeper L.
      • Leibowitz S.
      • Sangganjanavanich V.F.
      Affirmative practice with transgender and gender nonconforming youth: expanding the model.
      The exact number of transgender youth in the United States is unknown, in part because of a lack of large-scale studies and the absence of questions related to gender identity in youth surveys. However, a recent report estimates that the prevalence of youth age 13-17 in the United States who identify as TGD to be approximately 0.7%, which represents an increase from previous estimates.
      • Herman J.
      • Flores A.R.
      • Brown T.N.T.
      • et al.
      Age of individuals who identify as transgender in the United States.
      The reason for this larger estimate is unknown, but it might reflect increased social awareness and access to resources amassed in the past decade, facilitating TGD youth to be more open about their gender identity.
      • Gates G.
      How many people are lesbian, gay, bisexual, and transgender?.
      Studies have consistently shown that TGD youth face a variety of psychosocial challenges at a higher rate than age-matched peers, including depression, anxiety, suicidality, eating disorders, and autism spectrum disorders.
      • Almeida J.
      • Johnson R.
      • Corliss H.
      • et al.
      Emotional distress among LGBTQ youth: the influence of perceived discrimination and victimization.
      • Connolly M.
      • Zervos M.
      • Barone C.
      • et al.
      The mental health of transgender youth: advances in understanding.
      • van Schalkwyk G.I.
      • Klingensmith K.
      • Volkmar F.R.
      Gender identity and autism spectrum disorders.
      • James S.
      • Herman J.L.
      • Rankin S.
      • et al.
      The report of the 2015 U.S. Transgender Survey.
      As such, ensuring that these youth are being properly cared for and connected with needed supports becomes an important role for providers in any setting in which these youth might present.
      Because of the discomfort and dysphoria TGD youth face often centers on reproductive anatomy and function, gynecological practices have become increasingly common sites where gender concerns are first identified.
      • Unger C.A.
      Care of the transgender patient: the role of the gynecologist.
      The American College of Obstetricians and Gynecologists suggests that all obstetrics and gynecology providers be aware of the unique needs of transgender patients and be prepared to treat, support, refer, and provide resources to these individuals and their families.
      Committee on Adolescent Health Care: Committee opinion no. 685: care for transgender adolescents.
      This review provides an introduction for pediatric and adolescent gynecological (PAG) providers to the gender-affirmative care model and outlines the psychological considerations relevant to this diverse population.

      Gender-Affirmative Care Model

      The gender-affirmative care model recognizes gender diversity as a normal part of human development, not to be pathologized or labeled as a “disorder.” It uses strengths-based terminology outlined in Table 1 and the principles outlined in Table 2. Providers using the gender-affirmative care model differentiate between gender identity and assigned sex, understanding that gender identity is one’s inner sense of self, which arises from many factors, including biology, socialization, and culture, and is distinct from assigned sex, which is the label “male” or “female” given to babies at birth on the basis of the external physical sex characteristics present. Gender identity can be stable or fluid across time, and it might or might not conform to binary constructions of what it means to be either a man or a woman.
      Fenway Health
      Glossary of Gender and Transgender Terms.
      Last, this model incorporates the existence of psychological comorbidities as a response to external factors, such as stigma and rejection, rather than intrinsic to the TGD youth’s gender identity.
      • Rafferty J.
      • AAP Committee on the Psychosocial Aspects of Child and Family Health
      • AAP Committee on Adolescence
      • et al.
      Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents.
      • Edwards-Leeper L.
      • Leibowitz S.
      • Sangganjanavanich V.F.
      Affirmative practice with transgender and gender nonconforming youth: expanding the model.
      • Hidalgo M.A.
      • Ehrensaft D.
      • Tishelman A.C.
      • et al.
      The gender-affirmative model: what we know and what we aim to learn.
      Table 1Relevant Terms and Definitions to Gender-Affirmative Care.
      • Rafferty J.
      • AAP Committee on the Psychosocial Aspects of Child and Family Health
      • AAP Committee on Adolescence
      • et al.
      Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents.
      Fenway Health
      Glossary of Gender and Transgender Terms.
      Committee on Health Care for Underserved Women: committee opinion no. 512: health care for transgender individuals.
      TermDefinition
      Assigned sexDesignation of a person at birth, usually male or female, typically on the basis of anatomy, genetics, and biology
      Gender identityA person’s innate, internal sense of being female, male, a combination of both, somewhere in between, or neither
      Gender expressionHow a person presents their gender socially, such as with clothing, hairstyle, and social roles
      Gender perceptionThe way others interpret a person’s gender expression
      Gender-diversePeople with gender behaviors, appearances, or identities that are incongruent with those culturally assigned to their birth sex. Use of this term acknowledges and includes the vast diversity of gender identities that exists
      TransgenderA subset of gender-diverse youth who generally identify and express a gender inconsistent with sex assigned at birth, which tends to remain persistent, consistent, and insistent over time. Includes binary identities (transgender male, transgender female), as well identities falling outside of a binary construct of gender (nonbinary, genderqueer, gender fluid)
      CisgenderA person who identifies and expresses a gender consistent with the sex they were assigned at birth
      AgenderA person who does not identify as having a particular gender
      Asserted and affirmed genderA person’s gender identity, or gender experience, as it is communicated to (asserted) and validated from others (affirmed) as authentic
      These terms are considered strengths-based because they emphasize people’s self-determination and autonomy.
      Table 2Relevant Components and Informing Psychological Concepts to Gender-Affirmative Care.
      ConceptDefinition
      Components of the gender-affirmative care model
      • Rafferty J.
      • AAP Committee on the Psychosocial Aspects of Child and Family Health
      • AAP Committee on Adolescence
      • et al.
      Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents.
      • Edwards-Leeper L.
      • Leibowitz S.
      • Sangganjanavanich V.F.
      Affirmative practice with transgender and gender nonconforming youth: expanding the model.
      • Hidalgo M.A.
      • Ehrensaft D.
      • Tishelman A.C.
      • et al.
      The gender-affirmative model: what we know and what we aim to learn.
       NonpathologizingTransgender and gender-diverse identities and expressions are not mental disorders. These variations are considered a normal part of human development and diversity
       Culturally sensitiveRepresentations of gender vary across cultures, therefore gender diversity should be understood through a cultural lens
       Fluid and nonbinaryGender identity might be fluid across time and might not reflect a binary conceptualization of gender
       MultifacetedGender emerges as an interplay of biology, development, socialization, and culture
       Conceptualizing mental healthIf mental health concerns exist, they are most often a response to external factors, such as stigma and victimization, rather than being inherent to the youth’s gender
      Relevant psychological concepts to gender-affirmative care
       EmpathyFrom self-psychology, the capacity of the provider over time to think and feel oneself into the inner life of another person with an objective perspective. It can be used to appreciate the struggle and reality of an experience different from one’s own
       ContainmentThe atmosphere created within the therapeutic relationship that conveys a sense of safety, allowing patients to more comfortably move through their emotions, particularly those that are more difficult
       Psychological safetyAn environment, team, or relationship of support that encourages authenticity and risk-taking, without fear of consequences or retaliation, and thereby has the potential to promote learning, development, and growth
       Zone of proximal developmentA concept from education suggesting that in the process of learning there are tasks that are too challenging and others that are not challenging enough. Teachers, or providers, play a central role in understanding how much to challenge each person and family to promote critical reflection and learning
      Pediatric providers following a gender-affirmative care model validate a youth’s asserted gender identity as well as the related emotions, uncertainties, and aspirations of the youth and their family. This creates a nonjudgmental environment that supports gender exploration, development of the child’s self-worth, all while minimizing stigma and strengthening connections to family, peer, and community supports.
      • Bonifacio H.J.
      • Rosenthal S.M.
      Gender variance and dysphoria in children and adolescents.
      • Hidalgo M.A.
      • Ehrensaft D.
      • Tishelman A.C.
      • et al.
      The gender-affirmative model: what we know and what we aim to learn.
      Gender, like other aspects of one’s identity, is revealed as a child develops cognitively and in response to their overall self-awareness.
      • Martin C.L.
      • Ruble D.N.
      Patterns of gender development.
      In general, TGD youth have an awareness of their gender similar to their developmentally-matched peers at corresponding points throughout childhood development.
      • Olson K.R.
      • Key A.C.
      • Eaton N.R.
      Gender cognition in transgender children.
      Gender affirmation is often an important aspect of a TGD youth’s experience, and the provider’s ability to affirm a patient’s gender can have implications for their mental health and well-being. Children who are socially affirmed in their asserted gender demonstrate no significant increase in the rates of depression and anxiety compared with their age-matched population averages,
      • Olson K.R.
      • Durwood L.
      • DeMeules M.
      • et al.
      Mental health of transgender children who are supported in their identities.
      and youth who are able to use their asserted name in multiple contexts have lower rates of depression than youth who were restricted from doing so.
      • Russell S.T.
      • Pollitt A.M.
      • Li G.
      • et al.
      Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth.
      • Olson-Kennedy J.
      • Warus J.
      • Okonta V.
      • et al.
      Chest reconstruction and chest dysphoria in transmasculine minors and young adults: comparisons of nonsurgical and postsurgical cohorts.
      Furthermore, emerging research suggests that youth who are supported in pursuing medical interventions have reduced dysphoria and improved psychological functioning and life satisfaction.
      • Olson-Kennedy J.
      • Warus J.
      • Okonta V.
      • et al.
      Chest reconstruction and chest dysphoria in transmasculine minors and young adults: comparisons of nonsurgical and postsurgical cohorts.
      • de Vries A.L.
      • McGuire J.K.
      • Steensma T.D.
      • et al.
      Young adult psychological outcome after puberty suppression and gender reassignment.
      • Edwards-Leeper L.
      • Spack N.P.
      Psychological evaluation and medical treatment of transgender youth in an interdisciplinary “Gender Management Service” (GeMS) in a major pediatric center.
      In contrast, there is consensus that interventions aimed at preventing children from expressing or affirming their gender identity, known as “conversion” or “reparative” therapy, are ineffective and harmful, and thus deemed inappropriate as an intervention for TGD youth.
      Substance Abuse and Mental Health Services Administration
      Ending Conversion Therapy: Supporting and affirming LGBTQ youth. HHS Publication No. (SMA) 15-4928.
      • Haldeman D.C.
      The practice and ethics of sexual orientation conversion therapy.
      World Professional Association for Transgender Health Board of Directors
      De-psychopathologisation statement released.
      PAG providers have a role in supporting and educating youth and families as they consider various options for gender affirmation. Some individuals might be interested in pursuing multiple available interventions, and others might feel affirmed in their gender while using very few. As we move away from a binary (“male” or “female”) understanding of gender and encounter more youth with nonbinary, fluid, and genderqueer identities, the range of gender expression and goals for affirmative care will likely show wide variation.
      • Richards C.
      • Bouman W.P.
      • Seal L.
      • et al.
      Non-binary or genderqueer genders.
      PAG providers can also deliver advanced expertise to help manage menstrual dysphoria for those experiencing menstruation, prevent unintended pregnancy, and educate patients on fertility preservation options when they are considering certain hormonal and surgical interventions that might reduce or eliminate fertility potential.
      Committee on Adolescent Health Care: Committee opinion no. 685: care for transgender adolescents.
      A recent study of TGD adolescents showed that fertility was often not discussed with their providers, and many expressed interest in learning more about their options before exploring relevant gender-affirming treatments.
      • Chen D.
      • Matson M.
      • Macapagal K.
      • et al.
      Attitudes toward fertility and reproductive health among transgender and gender-nonconforming adolescents.

      Components of Gender Affirmation

      In the process of gender affirmation and exploration, interventions might be necessary, at developmentally appropriate times, to help the youth feel more aligned with their gender identity. Because gender identities are diverse and personal, as are the options for interventions, decisions regarding whether all, some, or none of the interventions are used will vary from patient to patient and over time.
      • Rafferty J.
      • AAP Committee on the Psychosocial Aspects of Child and Family Health
      • AAP Committee on Adolescence
      • et al.
      Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents.
      • Hembree W.C.
      • Cohen-Kettenis P.T.
      • Gooren L.
      • et al.
      Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society Clinical Practice Guideline.
      World Professional Association for Transgender Health
      Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People.
      Some broad categories of gender affirmation include:
      • Social affirmation refers to the reversible process of affirming one’s gender through outward expression (hair style, clothing), name and pronoun use, and participation in gendered spaces (ie, use of bathroom, participation on gendered sports teams, etc). Social affirmation can also involve the use of various devices such as breast binders or padding, packers, stand-to-pee devices, and tucking devices.
        Fenway Health
        Glossary of Gender and Transgender Terms.
        World Professional Association for Transgender Health
        Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People.
      • Legal affirmation refers to the process of legally changing name and/or gender marker on official documents, such as birth certificate, license, passport, etc. This process varies from state to state and often requires the support of a physician (for detailed information on state-by-state requirements: https://transequality.org/documents).
      • Medical affirmation involves the use of medication and hormonal interventions at some point around or after the onset of puberty to either halt unwanted characteristics associated with assigned sex, or produce physical changes that more closely align with the youth’s gender identity. Medical interventions include puberty blockers (gonadotropin-releasing hormone analogues), sex hormones (testosterone, estradiol, progesterone), and hormonal birth control methods, ranging from completely reversible (puberty blockers and birth control) to partially reversible (sex hormones). Of particular interest to PAG providers is the use of hormonal birth control methods for individuals assigned female at birth to reduce dysphoria related to menstruation and/or prevent unwanted pregnancy, which might not align with the goals of transgender men.
        Committee on Adolescent Health Care: Committee opinion no. 685: care for transgender adolescents.
        For additional information on medical affirmation see the subsequent review to be published in this journal.
      • Surgical affirmation refers the use of nonreversible surgical interventions to better align one’s body with their gender identity. Surgical interventions include, but are not limited to, gender-affirming top surgeries (chest reconstruction or augmentation), bottom surgeries (genital reconstruction or removal of sex organs), and facial feminization surgeries.
        World Professional Association for Transgender Health
        Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People.
        Most surgical interventions for youth populations, when indicated, are done on a case-by-case basis after careful consultation with primary care, mental health, and specialty providers, as well as the youth and their parents/guardians. For additional information on surgical affirmation see see the subsequent review to be published in this journal.

      Psychosocial Needs of TGD Youth

      TGD youth who present for care might be experiencing a variety of social and emotional stressors. The minority stress theory provides a helpful framework for understanding the ways in which external stressors in response to one’s minority identity can affect an individual’s overall sense of safety and well-being and can contribute to an array of social and emotional concerns.
      • Meyer I.H.
      Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence.
      • Hendricks M.L.
      • Testa R.J.
      A conceptual framework for clinical work with transgender and gender nonconforming clients: an adaptation fo the minority stress model.
      Table 3 provides an overview of the principles of minority stress theory as it pertains to TGD individuals. In addition, trauma-informed care centered on safety, trust, choice, collaboration, and empowerment provides an approach to build resiliency and autonomy.
      • Butler L.D.
      • Rinfrette E.S.
      Trauma-Informed care and mental health.
      Table 3Components of the Minority Stress Theory.
      • Meyer I.H.
      Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence.
      • Hendricks M.L.
      • Testa R.J.
      A conceptual framework for clinical work with transgender and gender nonconforming clients: an adaptation fo the minority stress model.
      ComponentMinority Stress Theory
      External eventsEvents that occur in response to the knowledge or perception of one’s minority status. For transgender individuals this can be in the form of discrimination, rejection, or violence. These events result directly in creating stress in an individual’s life
      Expectation of stressIndividuals come to expect and anticipate external stress. This vigilance can become another source of stress and might result in avoidance (such as avoiding medical care in the case of transgender individuals) or concealment of one’s minority identity. The act of hiding one’s identity can cause additional distress
      InternalizationIndividuals begin to internalize negative attitudes and prejudices about themselves. For gender-diverse individuals, this can lead to internalized transphobia, resulting in mental health sequelae and difficulties coping with external stress
      ResiliencyMinoritized individuals develop resiliency and coping strategies for responding to external stress through membership within a group of similar people (in this case transgender and gender-diverse individuals) where they experience a sense of unity and solidarity.
      In terms of external stressors, TGD youth experience higher rates of emotional, physical, and sexual violence, within families, in intimate relationships, and in their communities.
      • Lombardi E.L.
      • Wilchins R.A.
      • Priesing D.
      • et al.
      Gender violence: transgender experiences with violence and discrimination.
      • Goldenberg T.
      • Jadwin-Cakmak L.
      • Harper G.W.
      Intimate partner violence among transgender youth: associations with intrapersonal and structural factors.
      Familial rejection and violence is a contributing factor to the high prevalence of TGD youth homelessness and involvement in the child welfare system, where they are at risk for additional victimization in systems that are often not equipped to meet their needs.
      • Keuroghlian A.S.
      • Shtasel D.
      • Bassuk E.L.
      Out on the street: a public health and policy agenda for lesbian, gay, bisexual, and transgender youth who are homeless.
      • McCormick A.
      • Schmidt K.
      • Terrazas S.
      LGBTQ youth in the child welfare system: An overview of research, practice, and policy.
      • Mottet L.
      • Ohle J.
      Transitioning our shelters: a guide to making homeless shelters safe for transgender people.
      Homelessness and engagement in child welfare systems have been linked to TGD youths’ increased engagement in survival sex and sex trafficking, where they face additional health risks, such as exposure to HIV and other sexually transmitted diseases.
      • Tomasiewicz M.L.
      Sex trafficking of transgender and gender nonconforming youth in the United States.
      TGD youth in schools experience high rates of bullying and harassment, resulting in more frequent absences, perceived lack of safety, and risk of dropping out.
      • James S.
      • Herman J.L.
      • Rankin S.
      • et al.
      The report of the 2015 U.S. Transgender Survey.
      • Kosciw J.
      • Greytak E.
      • Giga N.
      • et al.
      The 2015 National School Climate Survey: the experiences of lesbian, gay, bisexual and transgender youth in our nation’s schools.
      TGD youth also experience increased frequency of school discipline, which has been shown to be associated with higher rates of involvement with the juvenile justice system, a system in which transgender youth are disproportionately represented and are often at risk for further victimization.
      • McCarter S.
      The school-to-prison pipeline: a primer for social workers.
      • Marksamer J.
      And by the way, do you know he thinks he’s a girl? The failures of law, policy and legal representation for transgender youth in juvenile delinquency courts.
      • Hunt J.
      • Moodie-Mills A.C.
      The unfair criminalization of gay and transgender youth: an overview of the experiences of LGBT youth in the juvenile justice system.
      In light of the multitude of external stressors these youth face, it is not surprising that TGD youth have been shown to have higher rates of depression, anxiety, substance use, suicidality, and self-harm.
      • Connolly M.
      • Zervos M.
      • Barone C.
      • et al.
      The mental health of transgender youth: advances in understanding.
      • Grossman A.H.
      • D’Augelli A.R.
      Transgender youth and life-threatening behaviors.
      • Olson J.
      • Schrager S.M.
      • Belzer M.
      • et al.
      Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria.
      • Day J.K.
      • Fish J.N.
      • Perez-Brumer A.
      • et al.
      Transgender youth substance use disparities: results from a population-based sample.
      Eating disorders are also common among TGD youth, with an increased risk for youth who were assigned female at birth.
      • Diemer E.W.
      • White Hughto J.M.
      • Gordon A.R.
      • et al.
      Beyond the binary: differences in eating disorder prevalence by gender identity in a transgender sample.
      Additionally, there is evidence that there is an increase in the occurrence of autism spectrum disorders among TGD individuals, although this relationship is not well understood.
      • van Schalkwyk G.I.
      • Klingensmith K.
      • Volkmar F.R.
      Gender identity and autism spectrum disorders.
      Recent Youth Risk Behavior Survey data from 10 states and 9 urban school settings that included gender identity in their surveys provides a snapshot of self-reported rates of these concerns, which are outlined in Table 4.
      • Johns M.M.
      • Lowry R.
      • Andrzejewski J.
      • et al.
      Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students — 19 states and large urban school districts, 2017.
      As outlined in minority stress theory and the affirmative care model, this increase in experiences of mental health concerns is not inherent to having a TGD identity, but rather it is a primary comorbidity and/or a response to adverse external factors, such as those previously outlined, alongside discomfort with one’s body.
      • Almeida J.
      • Johnson R.
      • Corliss H.
      • et al.
      Emotional distress among LGBTQ youth: the influence of perceived discrimination and victimization.
      • Edwards-Leeper L.
      • Spack N.P.
      Psychological evaluation and medical treatment of transgender youth in an interdisciplinary “Gender Management Service” (GeMS) in a major pediatric center.
      • Clements-Nolle K.
      • Marx R.
      • Katz M.
      Attempted suicide among transgender persons: the influence of gender-based discrimination and victimization.
      Table 4Recent Youth Risk Behavior Survey 2017 Data Comparing Rates of Victimization, Substance Use, and Suicidality Among Cisgender and Transgender Students.
      Health Risk Behaviors or ExperiencesCisgender MenCisgender WomenTransgender Youth
      Felt unsafe at or traveling to/from school4.6 (4.0-5.2)7.1 (6.3-8.0)26.9 (21.4-33.1)
      Threatened or injured with a weapon at school6.4 (5.8-7.0)4.1 (3.6-4.6)23.8 (20.0-28.1)
      Ever forced to have sexual intercourse4.2 (3.6-4.9)10.5 (9.5-11.6)23.8 (19.0-29.3)
      Bullied at school14.7 (13.8-15.7)20.7 (19.6-21.8)34.6 (29.8-39.8)
      Cigarettes, lifetime use23.2 (21.0-25.6)22.0 (19.9-24.3)32.9 (26.4-40.2)
      Alcohol, lifetime use53.3 (51.3-55.4)62.8 (60.9-64.6)70.0 (63.7-75.6)
      Marijuana, lifetime use34.1 (31.9-36.4)38.0 (35.7-40.3)43.8 (36.9-51.0)
      Cocaine, lifetime use4.3 (3.5-5.3)2.6 (2.2-3.0)27.2 (22.8-32.0)
      Felt sad or hopeless20.7 (19.8-21.7)39.3 (38.0-40.7)53.1 (47.7-58.4)
      Considered attempting suicide11.0 (10.2-11.9)20.3 (19.3-21.3)43.9 (38.3-49.7)
      Made a suicide plan10.4 (9.4-11.4)16.0 (15.2-16.8)39.3 (33.1-45.8)
      Attempted5.5 (4.9-6.1)9.1 (8.3-10.1)34.6 (27.1-42.9)
      Data are presented as percentage (95% confidence interval).
      Adapted from Johns et al.
      • Johns M.M.
      • Lowry R.
      • Andrzejewski J.
      • et al.
      Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students — 19 states and large urban school districts, 2017.
      It is also important to understand that TGD individuals might face additional psychological stress due to other marginalized identities they have, such as race, class, and ability. The 2015 US Transgender Survey showed that, compared with other TGD respondents, TGD individuals of color had higher unemployment rates and higher rates of HIV, undocumented individuals had more experiences of violence and poverty, and TGD individuals with disabilities had higher rates of poverty, psychological distress, and suicide attempts.
      • James S.
      • Herman J.L.
      • Rankin S.
      • et al.
      The report of the 2015 U.S. Transgender Survey.
      When faced with these myriad psychosocial challenges, the presence of resilience plays a key role in promoting positive outcomes and healthy development. Interviews with sexual and gender minority youth and service providers competent in working with such populations, revealed 5 processes by which youth counter experiences of emotional pain inflicted by external adversities. These include: navigating safety across contexts, asserting personal agency, seeking and cultivating meaningful relationships, “unsilencing” marginalized identities, and engaging in collective healing and action.
      • Asakura K.
      Paving pathways through the pain: a grounded theory of resilience among lesbian, gay, bisexual, trans, and queer youth.
      PAG providers can recognize and foster the potential for resiliency among TGD youth through regularly assessing safety, promoting the adolescent’s involvement in care, and using strength-based language and approaches.
      For PAG providers working with TGD youth, it is important to understand the increased nature and context of risk faced by this population, mechanisms for assessing and screening for such risks, and also interventions that recognize and build upon the youth’s strengths and resiliency. Because TGD populations face distinct vulnerabilities and have needs specific to their experience as a member of that group, PAG providers should familiarize themselves with minority stress theory and elements of trauma-informed care. Psychosocial screening should occur regularly and frequently, including suicidal risk, substance use, victimization, and sexual health assessments. Meaningful and effective interventions usually occur through interdisciplinary and interagency collaboration, including qualified mental health providers, family and peer support groups, community-based agencies, and at times, child protection services.

      “Coming out”

      “Coming out” is the process of navigating a series of decisions to share or disclose one’s gender identity with a person or group. Studies show that TGD youth who report higher rates of being “out” tend to exhibit more positive outcomes, including better academic performance, higher self-esteem, and lower rates of anxiety and depression.
      • Russell S.T.
      • Fish J.N.
      Mental health in lesbian, gay, bisexual, and transgender (LGBT) youth.
      • Bockting W
      • Coleman E
      Developmental stages of the transgender coming out process: toward an integrated identity.
      However, that is not true for everyone because “coming out” might increase one’s risk of experiencing social prejudice and stigmatization.
      • Greenfield J.
      Coming out: the process of forming a positive identity.
      • Levitt H.M.
      • Ippolito M.R.
      Being transgender: the experience of transgender identity development.
      Disclosure is never a one-time event as TGD individuals are often “out” in some contexts, but nondisclosed in others. Selecting when and where to come out is highly dependent on safety, comfort, trust, and readiness.
      • Bockting W
      • Coleman E
      Developmental stages of the transgender coming out process: toward an integrated identity.
      • Seelman K.
      • Colón-Diaz M.
      • LeCroix R.
      • et al.
      Transgender noninclusive healthcare and delaying care because of fear: connections to general health and mental health among transgender adults.
      The degree to which a TGD individual is accepted as a member of their self-identified gender identity is often an important consideration.
      • Levitt H.M.
      • Ippolito M.R.
      Being transgender: the experience of transgender identity development.
      Approximately 61% of TGD youth are not “out” to anyone in their family, and nearly the same percentage are nondisclosed to health care providers. Yet, more than two-thirds reported being “out” to some or all of their peers, and nearly all were “out” to their gender and sexual minority peers. This suggests that many TGD youth find safety and support in their peer communities, but also shows many are not accessing reliable resources when it comes to health screening and interventions because of nondisclosure in medical settings, thus providing rationale for professional education and quality improvement.
      • Seelman K.
      • Colón-Diaz M.
      • LeCroix R.
      • et al.
      Transgender noninclusive healthcare and delaying care because of fear: connections to general health and mental health among transgender adults.
      • Kahn E.
      • Johnson A.
      • Lee M.
      • et al.
      LGBTQ Youth Report.
      A quarter of TGD individuals report fear of discrimination by their provider as a reason to avoid disclosure or delay care. In this same population, approximately the equivalent number had care refused to them or experienced verbal harassment after a provider learned of their gender identity.
      • Grant J.
      • Mottet L.A.
      • Tanis J.
      • et al.
      Injustice at every turn: a report of the National Transgender Discrimination Survey.
      Overall, trust and openness in clinical settings can be fostered through genuine, nonjudgemental dialogue, and efforts to make the environment more welcoming and safe for TGD populations. This might include: posting welcoming symbols, identifying gender-neutral bathrooms, making brochures and media available on relevant issues, asking about and using asserted names and reflecting these names within the electronic medical record, and ensuring all levels of staff are trained on gender-affirming care.
      • McClain Z.
      • Hawkins L.A.
      • Yehia B.R.
      Creating welcoming spaces for lesbian, gay, bisexual, and transgender (LGBT) patients: an evaluation of the health care environment.
      • Gay and Lesbian Medical Association
      Creating a Safe Clinical Environment for Lesbian, Gay, Bisexual, Transgender, and Intersex (LGBTI) Patients.
      • Deutsch M.B.
      • Green J.
      • Keatley J.
      • et al.
      Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group.

      Family Support

      Parental and caregiver support has been shown to play a critical role in TGD youths’ social and emotional well-being. Specifically, parental support has been linked to increased life satisfaction, decreased depression and anxiety, decreased suicidality and fewer attempts, increased self-esteem, and decreased substance use, compared with youth facing parental rejection.
      • Travers R.
      • Bauer G.
      • Pyne J.
      • et al.
      Impacts of strong parental support for trans youth: a report prepared for Children’s Aid Society of Toronto and Delisle Youth Services.
      • Ryan C.
      • Russell S.T.
      • Huebner D.
      • et al.
      Family acceptance in adolescence and the health of LGBT young adults.
      • Simons L.
      • Schrager S.M.
      • Clark L.F.
      • et al.
      Parental support and mental health among transgender adolescents.
      Even when there might be different perspectives or levels of understanding between parents and youth around gender, support can come in various forms, including being able to communicate openly, actively listen, and attempt to understand each other.
      Although parents and caregivers play an important role in the lives of TGD youth, they face their own challenges and dilemmas that can affect their ability to support and accept their child. Lack of information about TGD identities, personal beliefs, stigma, and fear of judgment from other parents and family members can be barriers to parental acceptance.
      • Malpas J.
      Between pink and blue: a multi-dimensional family approach to gender nonconforming children and their families.
      • Brill S.A.
      • Pepper R.
      The transgender child.
      Parents have fears about their child’s own personal safety and might worry that being “too accepting” could set their child up for future harm and stigmatization.
      • Malpas J.
      Between pink and blue: a multi-dimensional family approach to gender nonconforming children and their families.
      • Wren B.
      “I can accept my child is transsexual but if I ever see him in a dress I’ll hit him”: dilemmas in parenting a transgendered adolescent.
      Parents also experience a wide range of emotions in response to their child’s TGD identity, including shock, confusion, denial, anger, and loss.
      • Malpas J.
      Between pink and blue: a multi-dimensional family approach to gender nonconforming children and their families.
      • Brill S.A.
      • Pepper R.
      The transgender child.
      • Wren B.
      “I can accept my child is transsexual but if I ever see him in a dress I’ll hit him”: dilemmas in parenting a transgendered adolescent.
      The needs of parents and family members should be considered when working with TGD youth. Parents need access to accurate and up-to-date information related to gender diversity and options for care.
      • Riley E.A.
      • Sitharthan G.
      • Clemson L.
      • et al.
      The needs of gender-variant children and their parents: a parent survey.
      Parents typically benefit from being given space to process their own emotions related to their child’s gender identity and might require referrals to individual therapy or parent support groups.
      • Malpas J.
      Between pink and blue: a multi-dimensional family approach to gender nonconforming children and their families.
      • Wren B.
      “I can accept my child is transsexual but if I ever see him in a dress I’ll hit him”: dilemmas in parenting a transgendered adolescent.
      • Riley E.A.
      • Sitharthan G.
      • Clemson L.
      • et al.
      The needs of gender-variant children and their parents: a parent survey.
      Family therapy might also be indicated to provide more direct structure and support around strengthening family bonds, providing space for the child and parents’ needs to be heard and addressed, and working collaboratively through the gender affirmation process.
      • Malpas J.
      Between pink and blue: a multi-dimensional family approach to gender nonconforming children and their families.
      • Coolhart D.
      • Shipman D.L.
      Working toward family attunement. Family therapy with transgender and gender-nonconforming children and adolescents.
      Siblings also experience their own emotional responses, which might include grief, resentment, embarrassment, and feeling neglected by parents, and can benefit from participation in family therapy as well.
      • Brill S.A.
      • Pepper R.
      The transgender child.
      • Coolhart D.
      • Shipman D.L.
      Working toward family attunement. Family therapy with transgender and gender-nonconforming children and adolescents.
      PAG providers are in an essential position to assess personal and familial psychosocial needs and challenges, and then facilitate connections and referrals to counseling, mental health, and community-based supports. Table 5 provides additional resources for families tz in better understanding their TGDfamily member.
      Table 5Resources for Families and Clinicians Relevant to Gender-Affirmative Care and Mental Health.
      TermResource
      HealthyChildren.org (American Academy of Pediatrics), support resources for families of TGD youthhttps://www.healthychildren.org/English/ages-stages/gradeschool/Pages/Support-Resources-for-Families-of-Gender-Diverse-Youth.aspx
      TGD Youth Mental Health (target audience is clinicians)Janssen A, Leibowitz S: Affirmative Mental Health Care for Transgender and Gender-diverse Youth. Switzerland, Springer International Publishing, 2018
      Mental healthYarbough E: Transgender Mental Health. Washington, DC, APA Publishing, 2018
      Family support and mental healthNealy EC: Transgender Children and Youth: Cultivating Pride and Joy with Families in Transition. New York, NY, WW Norton & Company, 2017
      Personal and professional gender exploration workbookTesta RH, Coolhart D: The Gender Quest Workbook. Oakland, CA, New Harbinger Publications, 2015
      Terms, depictions, metaphorsMays J, Hill MR. The Gender Book (mostly available free online, www.thegenderbook.com)
      Suicide and crisis hotlines, other resources for families from “PFLAG”https://pflag.org/hotlines
      Gender spectrumhttps://www.genderspectrum.org
      TGD, transgender and gender-diverse.
      At times, varying levels of acceptance and understanding can lead to conflict and disagreement that can have implications for obtaining consent for minors for various gender-affirming interventions. PAG providers should be familiar with local laws and regulations around consent for aspects of care, including gender-affirmative care interventions, sexual health counseling and screening, contraception, and mental health and substance use services.
      Lamda Legal
      Transgender Rights Toolkit: a legal guide for trans people and their advocates.

      Conclusion

      PAG providers need to be aware of the unique psychosocial challenges that TGD youth face, because PAG clinics are settings where concerns around gender identity are relevant and likely to be discussed. PAG providers should be familiar with the principles of the gender-affirmative care model, which includes meeting TGD youth and families where they are to assess and provide relevant risk assessment, support, referrals, and education. It has been shown that when TGD youth can identify at least 1 supportive person in their life, distress and associated psychological comorbidities decrease.
      • McConnell E.A.
      • Birkett M.
      • Mustanski B.
      Families matter: social support and mental health trajectories among lesbian, gay, bisexual, and transgender youth.
      Therefore, increasing provider awareness and creating a nonjudgemental clinic space can go a long way in promoting the health of TGD youth.

      References

        • Rafferty J.
        • AAP Committee on the Psychosocial Aspects of Child and Family Health
        • AAP Committee on Adolescence
        • et al.
        Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents.
        Pediatrics. 2018; 142: e20182162
        • Bonifacio H.J.
        • Rosenthal S.M.
        Gender variance and dysphoria in children and adolescents.
        Pediatr Clin North Am. 2015; 62: 1001
        • Edwards-Leeper L.
        • Leibowitz S.
        • Sangganjanavanich V.F.
        Affirmative practice with transgender and gender nonconforming youth: expanding the model.
        Psychol Sex Orientat Gend Divers. 2016; 3: 165
        • Herman J.
        • Flores A.R.
        • Brown T.N.T.
        • et al.
        Age of individuals who identify as transgender in the United States.
        The Williams Institute, Los Angeles, CA2017
        • Gates G.
        How many people are lesbian, gay, bisexual, and transgender?.
        The Williams Institute, UCLA School of Law, Los Angeles, CA2011
        • Almeida J.
        • Johnson R.
        • Corliss H.
        • et al.
        Emotional distress among LGBTQ youth: the influence of perceived discrimination and victimization.
        J Youth Adolesc. 2009; 38: 1001
        • Connolly M.
        • Zervos M.
        • Barone C.
        • et al.
        The mental health of transgender youth: advances in understanding.
        J Adolesc Health. 2016; 59: 489
        • van Schalkwyk G.I.
        • Klingensmith K.
        • Volkmar F.R.
        Gender identity and autism spectrum disorders.
        Yale J Biol Med. 2015; 88: 81
        • James S.
        • Herman J.L.
        • Rankin S.
        • et al.
        The report of the 2015 U.S. Transgender Survey.
        National Center for Transgender Equality, Washington, DC2016
        • Unger C.A.
        Care of the transgender patient: the role of the gynecologist.
        Am J Obstet Gynecol. 2014; 210: 16
      1. Committee on Adolescent Health Care: Committee opinion no. 685: care for transgender adolescents.
        Obstet Gynecol. 2017; 129: e11
        • Fenway Health
        Glossary of Gender and Transgender Terms.
        Fenway Health, Boston, MA2010
      2. Committee on Health Care for Underserved Women: committee opinion no. 512: health care for transgender individuals.
        Obstet Gynecol. 2011; 118: 1454
        • Hidalgo M.A.
        • Ehrensaft D.
        • Tishelman A.C.
        • et al.
        The gender-affirmative model: what we know and what we aim to learn.
        Hum Dev. 2013; 56: 285
        • Martin C.L.
        • Ruble D.N.
        Patterns of gender development.
        Annu Rev Psychol. 2010; 61: 353
        • Olson K.R.
        • Key A.C.
        • Eaton N.R.
        Gender cognition in transgender children.
        Psychol Sci. 2015; 26: 467
        • Olson K.R.
        • Durwood L.
        • DeMeules M.
        • et al.
        Mental health of transgender children who are supported in their identities.
        Pediatrics. 2016; 137: e20153223
        • Russell S.T.
        • Pollitt A.M.
        • Li G.
        • et al.
        Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth.
        J Adolesc Health. 2018; 63: 503
        • Olson-Kennedy J.
        • Warus J.
        • Okonta V.
        • et al.
        Chest reconstruction and chest dysphoria in transmasculine minors and young adults: comparisons of nonsurgical and postsurgical cohorts.
        JAMA Pediatr. 2018; 172: 431
        • de Vries A.L.
        • McGuire J.K.
        • Steensma T.D.
        • et al.
        Young adult psychological outcome after puberty suppression and gender reassignment.
        Pediatrics. 2014; 134: 696
        • Edwards-Leeper L.
        • Spack N.P.
        Psychological evaluation and medical treatment of transgender youth in an interdisciplinary “Gender Management Service” (GeMS) in a major pediatric center.
        J Homosex. 2012; 59: 321
        • Substance Abuse and Mental Health Services Administration
        Ending Conversion Therapy: Supporting and affirming LGBTQ youth. HHS Publication No. (SMA) 15-4928.
        Substance Abuse and Mental Health Services Administration, Rockville, MD2015
        • Haldeman D.C.
        The practice and ethics of sexual orientation conversion therapy.
        J Consult Clin Psychol. 1994; 62: 221
        • World Professional Association for Transgender Health Board of Directors
        De-psychopathologisation statement released.
        World Professional Association for Transgender Health, Minneapolis, MN2010
        • Richards C.
        • Bouman W.P.
        • Seal L.
        • et al.
        Non-binary or genderqueer genders.
        Int Rev Psychiatry. 2016; 28: 95
        • Chen D.
        • Matson M.
        • Macapagal K.
        • et al.
        Attitudes toward fertility and reproductive health among transgender and gender-nonconforming adolescents.
        J Adolesc Health. 2018; 63: 62
        • Hembree W.C.
        • Cohen-Kettenis P.T.
        • Gooren L.
        • et al.
        Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society Clinical Practice Guideline.
        J Clin Endocrinol Metab. 2017; 102: 3869
        • World Professional Association for Transgender Health
        Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People.
        World Professional Association for Transgender Health, Minneapolis, MN2011
        • Meyer I.H.
        Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence.
        Psychol Bull. 2003; 129: 674
        • Hendricks M.L.
        • Testa R.J.
        A conceptual framework for clinical work with transgender and gender nonconforming clients: an adaptation fo the minority stress model.
        Prof Psychol Res Pr. 2012; 5: 460
        • Butler L.D.
        • Rinfrette E.S.
        Trauma-Informed care and mental health.
        Directions in Psychiatry. 2011; 31: 197
        • Lombardi E.L.
        • Wilchins R.A.
        • Priesing D.
        • et al.
        Gender violence: transgender experiences with violence and discrimination.
        J Homosex. 2001; 42: 89
        • Goldenberg T.
        • Jadwin-Cakmak L.
        • Harper G.W.
        Intimate partner violence among transgender youth: associations with intrapersonal and structural factors.
        • Keuroghlian A.S.
        • Shtasel D.
        • Bassuk E.L.
        Out on the street: a public health and policy agenda for lesbian, gay, bisexual, and transgender youth who are homeless.
        Am J Orthopsychiatry. 2014; 84: 66
        • McCormick A.
        • Schmidt K.
        • Terrazas S.
        LGBTQ youth in the child welfare system: An overview of research, practice, and policy.
        • Mottet L.
        • Ohle J.
        Transitioning our shelters: a guide to making homeless shelters safe for transgender people.
        National Gay and Lesbian Task Force, Washington, DC2003
        • Tomasiewicz M.L.
        Sex trafficking of transgender and gender nonconforming youth in the United States.
        Loyola University School of Law Center for the Human Rights of Children, Chicago, IL2018
        • Kosciw J.
        • Greytak E.
        • Giga N.
        • et al.
        The 2015 National School Climate Survey: the experiences of lesbian, gay, bisexual and transgender youth in our nation’s schools.
        GLSEN, New York, NY2015
        • McCarter S.
        The school-to-prison pipeline: a primer for social workers.
        Social Work. 2017; 62: 53
        • Marksamer J.
        And by the way, do you know he thinks he’s a girl? The failures of law, policy and legal representation for transgender youth in juvenile delinquency courts.
        Sex Res Soc Policy. 2018; 5: 72
        • Hunt J.
        • Moodie-Mills A.C.
        The unfair criminalization of gay and transgender youth: an overview of the experiences of LGBT youth in the juvenile justice system.
        Center for American Progress. 2012; 29: 1
        • Grossman A.H.
        • D’Augelli A.R.
        Transgender youth and life-threatening behaviors.
        Suicide Life Threat Behav. 2007; 37: 527
        • Olson J.
        • Schrager S.M.
        • Belzer M.
        • et al.
        Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria.
        J Adolesc Health. 2015; 57: 374
        • Day J.K.
        • Fish J.N.
        • Perez-Brumer A.
        • et al.
        Transgender youth substance use disparities: results from a population-based sample.
        J Adolesc Health. 2017; 61: 729
        • Diemer E.W.
        • White Hughto J.M.
        • Gordon A.R.
        • et al.
        Beyond the binary: differences in eating disorder prevalence by gender identity in a transgender sample.
        Transgend Health. 2018; 3: 17
        • Johns M.M.
        • Lowry R.
        • Andrzejewski J.
        • et al.
        Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students — 19 states and large urban school districts, 2017.
        MMWR Morb Mortal Wkly Rep. 2019; 68: 67
        • Clements-Nolle K.
        • Marx R.
        • Katz M.
        Attempted suicide among transgender persons: the influence of gender-based discrimination and victimization.
        J Homosex. 2006; 51: 53
        • Asakura K.
        Paving pathways through the pain: a grounded theory of resilience among lesbian, gay, bisexual, trans, and queer youth.
        J Res Adolesc. 2017; 27: 521
        • Russell S.T.
        • Fish J.N.
        Mental health in lesbian, gay, bisexual, and transgender (LGBT) youth.
        Annu Rev Clin Psychol. 2016; 12: 465
        • Bockting W
        • Coleman E
        Developmental stages of the transgender coming out process: toward an integrated identity.
        in: Ettner R. Monstrey S. Evan Eyler A. Principles of Transgender Medicine and Surgery. The Haworth Press, New York, NY2007: 185-208
        • Greenfield J.
        Coming out: the process of forming a positive identity.
        in: Makadon H.J. Mayer K.H. Potter J. Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. American College of Physicians, Philadelphia, PA2008: 45-74
        • Levitt H.M.
        • Ippolito M.R.
        Being transgender: the experience of transgender identity development.
        J Homosex. 2014; 61: 1727
        • Seelman K.
        • Colón-Diaz M.
        • LeCroix R.
        • et al.
        Transgender noninclusive healthcare and delaying care because of fear: connections to general health and mental health among transgender adults.
        Transgend Health. 2017; 2: 17
        • Kahn E.
        • Johnson A.
        • Lee M.
        • et al.
        LGBTQ Youth Report.
        Human Rights Campaign, Washington, DC2018
        • Grant J.
        • Mottet L.A.
        • Tanis J.
        • et al.
        Injustice at every turn: a report of the National Transgender Discrimination Survey.
        National Center for Transgender Equality and National Gay and Lesbian Task Force, Washington, DC2011
        • McClain Z.
        • Hawkins L.A.
        • Yehia B.R.
        Creating welcoming spaces for lesbian, gay, bisexual, and transgender (LGBT) patients: an evaluation of the health care environment.
        J Homosex. 2016; 63: 387
        • Gay and Lesbian Medical Association
        Creating a Safe Clinical Environment for Lesbian, Gay, Bisexual, Transgender, and Intersex (LGBTI) Patients.
        Gay and Lesbian Medical Association (GLMA), San Francisco, CA2003
        • Deutsch M.B.
        • Green J.
        • Keatley J.
        • et al.
        Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group.
        J Am Med Inform Assoc. 2013; 20: 700
        • Travers R.
        • Bauer G.
        • Pyne J.
        • et al.
        Impacts of strong parental support for trans youth: a report prepared for Children’s Aid Society of Toronto and Delisle Youth Services.
        Trans Pulse, Toronto, ON2012
        • Ryan C.
        • Russell S.T.
        • Huebner D.
        • et al.
        Family acceptance in adolescence and the health of LGBT young adults.
        J Child Adolesc Psychiatr Nurs. 2010; 23: 205
        • Simons L.
        • Schrager S.M.
        • Clark L.F.
        • et al.
        Parental support and mental health among transgender adolescents.
        J Adolesc Health. 2013; 53: 791
        • Malpas J.
        Between pink and blue: a multi-dimensional family approach to gender nonconforming children and their families.
        Fam Process. 2011; 50: 453
        • Brill S.A.
        • Pepper R.
        The transgender child.
        Cleiss Press, San Francisco, CA2008
        • Wren B.
        “I can accept my child is transsexual but if I ever see him in a dress I’ll hit him”: dilemmas in parenting a transgendered adolescent.
        Clinical Child Psychol Psychiatry. 2002; 7: 377
        • Riley E.A.
        • Sitharthan G.
        • Clemson L.
        • et al.
        The needs of gender-variant children and their parents: a parent survey.
        Int J Sex Health. 2011; 23: 181
        • Coolhart D.
        • Shipman D.L.
        Working toward family attunement. Family therapy with transgender and gender-nonconforming children and adolescents.
        Psychiatr Clin North Am. 2017; 40: 113
        • Lamda Legal
        Transgender Rights Toolkit: a legal guide for trans people and their advocates.
        Lambda Legal, New York, NY2016
        • McConnell E.A.
        • Birkett M.
        • Mustanski B.
        Families matter: social support and mental health trajectories among lesbian, gay, bisexual, and transgender youth.
        J Adolesc Health. 2016; 59: 674