Transgender and Gender-Diverse Children

Transgender and gender-diverse children should ideally receive care from a multidisciplinary team including, at a minimum, a primary care physician and a social worker, psychologist, or psychiatrist. A mental health professional (rather than another type of provider) should diagnose gender incongruence in children and adolescents.

Gender Identity Definitions and Terminology

Assigned sex	The sex and associated gender role assigned to a person at birth
Cisgender	Not transgender / “non-transgender people”
Gender dysphoria	Distress experienced if gender identity is different from assigned sex
Gender identity/ experienced gender	A person’s internal sense of gender
Gender incongruence	Umbrella term used when gender identity differs from what is typically associated with the person’s assigned sex
Gender nonconformity	The extent to which a person’s gender identity or gender expression differs from the cultural norms of the assigned sex
Nonbinary/gender nonbinary	A person who understands their gender as not fitting into a binary definition of “male” or “female.” This is a broad term that includes individuals who may identify as both male and female, neither male nor female, sometimes male and sometimes female, or outside the confines of the two traditional genders.
Transgender and gender diverse	Umbrella term used for persons whose gender identity and/or gender expression differs from what is typically associated with their assigned sex
Transgender male (trans man, female-to-male, trans male)	A person assigned a female sex at birth who has a male gender identity and/or a male experienced gender
Transgender woman (trans woman, male-to- female, transgender female)	A person assigned a male sex at birth who has a female gender identity and/or a female experienced gender
Transition	The process of changing social, physical, or legal characteristics to be consistent with a person’s gender identity; may include but does not require hormonal therapy or surgical modification

Many children may express interests and gender presentations that are not typical of their sex assigned at birth, but only a minority have gender incongruence.
The majority of children and adolescents who have had a diagnosis of gender incongruence established by a multidisciplinary team will continue to express gender incongruence into adulthood.
Gender incongruence does not imply gender dysphoria, and gender dysphoria is not needed to establish gender incongruence. Gender dysphoria is used in the psychiatry literature as the diagnostic term for distress experienced as a result of gender incongruence. However, gender incongruence in and of itself is not a psychiatric diagnosis and should not imply psychiatric pathology.
Decisions regarding social transition of gender in prepubertal youth should be made in conjunction with a mental health professional or other experienced professional.
No hormone treatment is recommended for the prepubertal transgender or gender-nonconforming child.
Once a transgender or gender-diverse child enters puberty, pubertal suppression with gonadotropin-releasing hormone (GnRH) agonists can be considered.
Gender-affirming sex hormones (testosterone for trans males or estradiol for trans females) may be started in adolescents after a multidisciplinary team has diagnosed gender incongruence and confirmed ability of the adolescent to give informed consent. Age 16 years was the traditional age of starting sex hormone therapy, but many providers prescribe sex hormones earlier when appropriate (i.e., at age 13-15 years) to potentially optimize well-being and bone mineral density.

Endocrine Management of Transgender Adolescents

Guidelines from both the Endocrine Society and the World Professional Association for Transgender Health (WPATH) provide criteria for the use of GnRH-agonist therapy and sex hormone therapy in adolescents. In brief, adolescents who have a long-lasting pattern of gender incongruence and who are cognitively and emotionally able to consent or assent to therapy can be considered for puberty suppression with GnRH agonists. Subsequent sex hormone treatment may be provided, potentially starting as early as age 13 to 15 years if agreement exists among the adolescent, parent/guardian, and treatment team, and the adolescent has the mental capacity to give consent.

Whereas GnRH agonists are considered a “reversible” therapy, sex hormone treatment is partly irreversible. Sex hormone therapy in adolescents is typically started in low doses and increased serially to mimic the usual progression of puberty.

Fertility may be affected by administration of sex hormones, and adolescents should be counseled about these risks and referred to a fertility specialist to consider fertility preservation therapy.

Neither GnRH agonists nor sex hormone therapy is recommended for prepubertal children with gender dysphoria.

Research

Landmark clinical trials and other important studies

Research

Psychosocial Functioning in Transgender Youth after 2 Years of Hormones

Chen D et al. N Engl J Med 2023.

In this longitudinal study, researchers evaluated psychosocial functioning among 315 transgender and nonbinary adolescents in the first 2 years after they started gender-affirming hormone therapy. During the study period, appearance congruence, positive affect, and lifestyle satisfaction all increased while depression and anxiety symptoms decreased.

Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation

Turban JL et al. Pediatrics 2020.

In this survey of more than 20,000 transgender adults ages 18−36 years, among adults who desired pubertal suppression as children, those who received it had lower odds of lifetime suicidal ideation than those who wanted suppression but did not receive it. These results suggest that pubertal suppression with gonadotropin releasing hormone agonists is associated with favorable psychological outcomes.

Body Dissatisfaction and Mental Health Outcomes of Youth on Gender-affirming Hormone Therapy

Kuper LE et al. Pediatrics 2020.

In this study of 148 individuals ages 9−18 years receiving gender affirming hormone therapy (pubertal suppression or feminizing or masculinizing hormone therapy), children experienced large improvements in body dissatisfaction, small-to-moderate improvements in symptoms of depression, and small improvements in anxiety after initiation of therapy.