Overview of the management of gender nonconformity in children and adolescents
- Johanna Olson-Kennedy, MD
Johanna Olson-Kennedy, MD
- Assistant Professor of Clinical Pediatrics
- University of Southern California, Keck School of Medicine
- Michelle Forcier, MD, MPH
Michelle Forcier, MD, MPH
- Associate Professor of Pediatrics
- Warren Alpert School of Medicine, Brown University
- Section Editors
- David Brent, MD
David Brent, MD
- Section Editor — Childhood Mental Disorders
- Professor of Psychiatry, Pediatrics and Epidemiology
- University of Pittsburgh School of Medicine
- Mitchell Geffner, MD
Mitchell Geffner, MD
- Section Editor — Pediatric Endocrinology
- Professor of Pediatrics
- Keck School of Medicine, University of Southern California
- Diane Blake, MD
Diane Blake, MD
- Section Editor — Adolescent Medicine
- Professor of Pediatrics
- University of Massachusetts Medical School
Children generally are assigned a gender at birth based upon genital anatomy or chromosomes. For most children, gender assignment correlates with gender identity, which is the innate sense of maleness or femaleness. However, some children have a gender identity that does not correlate with assigned gender. These children are called gender nonconforming, gender variant, or sometimes transgender (table 1). (See "Overview of gender development and clinical presentation of gender nonconformity in children and adolescents", section on 'Terminology'.)
The trajectory of gender nonconformity in childhood is unpredictable; some children with gender nonconformity will grow up to be transgender adults and some will grow up to be cis-gendered adults (ie, adults in whom gender identity matches genital anatomy). (See "Overview of gender development and clinical presentation of gender nonconformity in children and adolescents", section on 'Trajectory'.)
This topic will provide an overview of the management of gender nonconformity in children and adolescents. Gender development and the clinical presentation of gender nonconformity in children and adolescents are discussed separately. (See "Overview of gender development and clinical presentation of gender nonconformity in children and adolescents", section on 'Referral'.)
There is little evidence to guide the management of gender nonconformity in children and adolescents and opinions about the best treatment vary [1,2]. Most experience comes from case series of adults who underwent sex reassignment surgery . However, as the number of multidisciplinary centers providing treatment for gender-nonconforming youth increases, information about outcomes in this population is increasing [4-11]. (See "Transgender women: Evaluation and management".)
Clinicians have differing views on whether gender nonconformity should be regarded as a normal variation of gender expression, a medical condition, or a psychiatric disorder . In the absence of a clear understanding of the etiology of gender nonconformity, these views influence the management approach. Approaches to treating gender-nonconforming children and adolescents have been outlined by the Endocrine Society, the American Academy of Child and Adolescent Psychiatry, and the World Professional Association for Transgender Health [2,13,14]. Our approach is generally consistent with the recommendations in these guidelines.
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- GUIDING PRINCIPLES
- TYPES OF INTERVENTIONS
- Mental health interventions
- Phenotypic interventions
- - Social transition
- - Hormonal interventions
- - Surgical interventions
- APPROACH IN PREPUBERTAL CHILDREN
- General suggestions
- Social transition
- Indications for referral
- APPROACH IN PUBERTAL CHILDREN AND ADOLESCENTS
- Approach for youth with nonbinary gender identity
- OVERVIEW OF HORMONAL INTERVENTIONS FOR ADOLESCENTS
- Potential indications
- Counseling and consent
- Availability of care
- Suppression of endogenous puberty
- - Rationale
- - Timing
- - Regimen
- - Potential adverse effects
- - Monitoring
- Treatment with cross-gender hormones
- - Rationale and eligibility
- - Timing
- - Male-to-female
- - Female-to-male
- - Monitoring
- SURGICAL INTERVENTIONS
- SUMMARY AND RECOMMENDATIONS