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REVIEW

CURRENT
OPINION Statement on gender-affirmative approach to care
from the pediatric endocrine society special
interest group on transgender health
Ximena Lopez a, Maja Marinkovic b, Toni Eimicke c, Stephen M. Rosenthal d,,
and Jerrold S. Olshan e,, on behalf of the Pediatric Endocrine Society
Transgender Health Special Interest Group

Purpose of review
The purpose of this Position Statement is to emphasize the importance of an affirmative approach to the health
care of transgender individuals, as well as to improve the understanding of the rights of transgender youth.
Recent findings
Transgender youth have optimal outcomes when affirmed in their gender identity, through support by their
families and their environment, as well as appropriate mental health and medical care.
Summary
The Pediatric Endocrine Society Special Interest Group on Transgender Health joins other academic societies
involved in the care of children and adolescents in supporting policies that promote a safe and accepting
environment for gender nonconforming/transgender youth, as well as adequate mental health and medical
care. This document provides a summary of relevant definitions, information and current literature on which
the medical management and affirmative approach to care of transgender youth are based.
Keywords
adolescents, children, pediatric endocrine society, transgender

INTRODUCTION population, there are gaps in our scientific knowl-

The purpose of this Position Statement is to empha-
size the importance of an affirmative approach to the
health care of transgender individuals, as well as to
improve the understanding of the needs and rights of
transgender youth. The Endocrine Society (with the
Pediatric Endocrine Society as a cosponsor) and the
World Professional Association for Transgender
Health provide detailed clinical practice guidelines
&&
elsewhere [1 ,2]. The need for this Statement
emerged in light of controversies in the medical
community around the approach to mental health
and medical care of transgender youth, including the
risks involved in this care, and around support of
transgender rights. This document provides a sum-
mary of relevant definitions, information and cur-
rent literature on which the medical management
and affirmative approach to care of transgender
youth are based.
LIMITATIONS
It is important to underscore that despite our sup-
port and willingness to provide the best care for this
edge and a paucity of robust, scientifically validated
information. Therefore, current practices are fluid
and may continue to change. Moreover, some
medical treatments approved in countries around
the world are not available in the United States
or Canada, limiting our ability to adopt them.
Furthermore, the increasing recognition of this
a
Department of Pediatrics, University of Texas Southwestern Medical
Center, Dallas, Texas, bDepartment of Pediatrics, University of California,
San Diego, California, cThe Barbara Childrens Hospital at Maine Medical
Center, Portland, Maine, dDepartment of Pediatrics, Benioff Childrens
Hospital, University of California, San Francisco, California and
e
Department of Pediatrics, Tufts University School of Medicine, Portland,
Maine, USA
Correspondence to Ximena Lopez, MD, Department of Pediatrics,
University of Texas Southwestern Medical Center, 5323 Harry Hines
Blvd, Dallas, TX 75390-9063, USA. Tel: +1 214 648 3501;
e-mail: Ximena.Lopez@utsouthwestern.edu

Stephen M. Rosenthal and Jerrold S. Olshan contributed equally to the
article.
Curr Opin Pediatr 2017, 29:000000
DOI:10.1097/MOP.0000000000000516

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KEY POINTS
 Sex chromosomes and/or genitalia do not determine
ones gender identity.
 Transgender youth are a vulnerable population at high
risk for discrimination and with an elevated prevalence
of depression, anxiety and suicide.
 Transgender children and adolescents have optimal
outcomes when affirmed in their gender identity,
through support by their families and their environment
and through access to gender-affirming
medical treatments.
 Puberty suppression and cross-sex hormone therapy are
recommended in adolescents that meet eligibility
criteria and that have undergone an appropriate
mental health assessment.
 Transgender students need school support, including
the use of restrooms consistent with their
gender identity.
entity is resulting in the emergence of younger
patients, in which our limited knowledge increases
our uncertainty as to what is best for these
children and families and how to implement effec-
tive assistance. These realities highlight the need
for prospective, long-term outcomes studies to opti-
mize care.
THE CONCEPT OF GENDER IDENTITY
The Pediatric Endocrine Society Special Interest
Group on Transgender Health supports the concept
that sex chromosomes and/or genitalia do not deter-
mine ones gender identity.
The American Psychological Association defines
gender as a nonbinary construct that allows for a
range of gender identities and that a persons gender
identity may not align with sex assigned at birth
&
[3 ]. Gender identity is the innermost concept of self
as male, female, a blend of both or neither. It also
encompasses how individuals perceive themselves
and what they call themselves.
Sex is not equivalent to gender identity. Sex,
typically but not always, categorized as male or
female, is determined by factors that include
chromosomes, gonads, internal reproductive organs
and external genitalia.
Sex and gender identity align in the majority of
the population. When they do not, individuals may
categorize themselves as transgender. Transgender
refers to a transient or persistent identification with
a gender that is different from the gender implied by
the birth sex assignment.
2 www.co-pediatrics.com
Copyright 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Sexual orientation and gender identity are often
conflated, but are distinct aspects of human devel-
opment. Just as nontransgender (sometimes referred
to as cis-gender) persons can be heterosexual,
homosexual or bisexual, the same holds true for
transgender individuals.
GENDER DYSPHORIA IN TRANSGENDER
YOUTH
Gender dysphoria, defined in the diagnostic and
statistical manual of mental disorders (DSM)-5,
refers to the discomfort or distress that may occur
when ones gender identity does not match the sex
assigned at birth [4]. Gender dysphoria may or may
not be present in transgender individuals [4], as
it may improve or even disappear with a gender
affirmative approach or treatment such as social
transition (change in clothing, attire, name and
pronouns), parental and social support, as well as
hormonal therapy with or without surgical inter-
&&
vention [5,6,7 ,811].
MENTAL HEALTH CARE OF
TRANSGENDER YOUTH
There are no data (ND) to support the use of rep-
arative or conversion therapy with the intention of
changing ones gender identity or sexual orien-
tation. Furthermore, the American Psychological
Association, the American Psychiatric Association
and the American Academy of Pediatrics, reject this
form of therapy and support a more trans-affirma-
&
tive model of care [3 ,12,13].
Although rates of depression are two to three
times higher in transgender youth vs. nontransgen-
&
der peers [14 ], and the suicide attempt rate among
transgender adults is reported to be as high as 41%
[15], there are data to suggest that much of the
psychiatric comorbidity derives from discrimi-
nation, peer rejection and lack of social support
[16]. On the other hand, the best predictor of
positive psychological outcomes is parental support
[17], and a recent study published in the journal
Pediatrics showed that young transgender children
that underwent a social transition have rates
of depression comparable with nontransgender
&
children [18 ].
It is important to note that not all young gender-
nonconforming children will persist as such into
adolescence, and that there might be different paths
of gender development and degrees of complexity
&
[19,20 ]. This has raised the concern about support-
ing an early social transition in young children who
may not persist into adolescence. However, previous
studies may have underestimated or misunderstood
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Statement on gender affirmative approach from the PES Lopez et al.
the likelihood of long-term persistence. Commonly
used terms include persisters for those individuals
for whom gender dysphoria persists into and
beyond adolescence and desisters for those indi-
viduals for whom it does not. A key issue is that
criteria for gender identity disorder from earlier
versions of the DSM on which the studies were based
included diagnosis on the basis of gender atypical
expression alone, which may or may not be inde-
pendent of gender identity. Some have suggested
that the proportion of persisters would likely be
higher by applying current gender dysphoria criteria
and, for example including individuals who contin-
ued to express a desire to be of the opposite sex or to
believe that they were the opposite sex, regardless of
gender-stereotypical behaviors per se. A second
methodologic criticism is that most of the youth
studied had not actually been followed into adult-
hood, suggesting that with longer follow-up, the
number of apparent desisters might be lower. It
seems clear, however, that most (>90%) children
whose gender-variant identity persists into adoles-
cence develop an adult transgender identity
&&
[7 ,21,22]. In these cases, puberty, with attainment
of secondary sex characteristics, is often a source of
significant distress [22].
Referral to a mental health provider with experi-
ence in gender identity concerns is strongly recom-
mended to guide families in a variety of ways, such
as: helping youth understand and reflect on their
gender issues and choices, helping youth and family
with difficult decisions such as potential benefits
and risks of social transition and medical interven-
&
tion [23,24 ], providing counseling at times of fam-
ily conflict and distress, assisting with advocacy in
schools and other community settings, helping
youth and families navigate and problem-solve
social challenges, assessing for and treating mental
health and developmental morbidities and asses-
sing for risk, and to provide continuity of care
throughout a childs gender exploration and hor-
monal treatment.
MEDICAL CARE OF TRANSGENDER
YOUTH
Medical intervention before adulthood in transgen-
der adolescents is recommended by the Endocrine
Society, the Pediatric Endocrine Society and the
World Professional Association of Transgender
Health as standard of care for selected patients that
have undergone an appropriate psychological
&&
assessment [1 ,2]. It is important to emphasize
that little is known of the potential long-term
risks, particularly because the literature reports
mostly short-term outcomes and the number of
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individuals studied has been small. A multidiscipli-
nary approach that includes mental health experts is
strongly recommended to assess for readiness for
medical intervention and to monitor the effects of
this treatment. This protocol includes puberty sup-
pression with gonadotropin-releasing hormone
(GnRH) agonists after initiation of puberty (Tanner
stage II for breast or testicular development), fol-
lowed by cross-sex hormones (estrogen or testoster-
one), sometimes referred to as gender-affirming
hormones, around age 16 (though many experts
agree that there may be compelling reasons not to
wait until age 16 years in some adolescents). Puberty
suppression has the purpose of delaying the devel-
opment of secondary sex characteristics while
providing time for continued exploration of the
adolescents gender identity, as well as allowing
for gender continuity in those who have already
socially transitioned. GnRH agonists have been used
by pediatric endocrinologists for more than 30 years
for patients with precocious puberty, and its safety
and efficacy profile in that population is well known
[2528].
It is important to counsel all patients and their
families on fertility, which is likely to be comprom-
ised if GnRH agonists are started in early puberty
(Tanner stage IIIII), and endogenous puberty is not
allowed to complete. Before starting treatment,
sperm and oocyte retrieval and banking can be
offered to those who are post pubertal, but due to
significant barriers these might not be an option for
all patients. For sperm banking, enough endogenous
puberty needs to have occurred to produce sperm
(mid-to-late pubertal stages), and it is generally not
covered by insurance. Oocyte retrieval is an invasive
procedure with limited clinical and research experi-
ence in minors and also not covered by insurance.
Research is underway to determine if prepubertal
gonadal tissue can be differentiated in tissue culture
to result in mature sperm or oocytes.
Cross-sex hormone therapy has the purpose of
inducing secondary sex characteristics that enable
the individual to present in accordance with their
affirmed gender identity. Testosterone induces ame-
norrhea in postmenarchal transmen; however, it is
important to counsel transmen that testosterone
alone is not a reliable contraceptive, as there are
a number of cases of unplanned pregnancy that
have occurred while on treatment. Planned preg-
nancy and uneventful child birth after interrup-
tion of testosterone treatment have been reported
[29]. Estrogen treatment may lead to sterility, and
implications for fertility as well as other repro-
ductive options need to be thoroughly discussed
with the patient and legal guardian(s). In our
limited experience, adolescent patients and parents
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Endocrinology and metabolism
generally prioritize treatment that will help affirm
patients gender identity over attaining or preserv-
ing fertility.
Long-term data from transgender patients
treated as adults show that this therapy seems to
be well tolerated, and there are ND to suggest that
use of estrogen or testosterone, when used at physio-
logic doses, leads to a cancer risk higher than
expected for the average adult man, in the case of
transmen, or the adult woman, in the case of trans-
women [3032]. The thromboembolic risk was sig-
nificant with ethinyl estradiol preparations [32]
but is lower with the current oral and patch 17-
beta estradiol formulations [30,31]. There is a theor-
etical concern that testosterone may worsen
the cardiovascular profile of transmen. Although
severely underpowered, a recent study on overall
mortality in transgender individuals showed that
transmen, followed for an average length of
18 years on testosterone treatment, did not have a
significant increase in mortality due to cardiovas-
cular events [32].
Although many studies demonstrate that HRT
and gender-affirming surgery lead to improved gen-
der dysphoria and quality of life in adults [6,3335],
a long-term follow-up study revealed persistence of
psychiatric comorbidity and death from suicide in
transgender patients after gender-affirming surgery
[36]. However, the authors comment that the results
should not be interpreted such that sex reassign-
ment increases morbidity and mortality given that
the overall mortality rate was only significantly
increased for the group operated on before 1989;
therefore, the results might be explained by
improved health care for transgender adults during
the 1990s, along with improved societal attitudes
toward gender nonconforming individuals. Another
limitation of this study is that this group was com-
pared with nontransgender controls. A more appro-
priate control group would have been transgender
individuals who did not undergo gender reassign-
ment surgery, which may have revealed worse out-
comes without treatment.
A recent long-term study of 55 transgender ado-
lescents who underwent puberty suppression and
cross-sex hormones followed by gender-affirming
surgery in early adulthood, showed complete
resolution of gender dysphoria, and psychological
outcomes that were similar or better than nontrans-
gender, age-matched young adults. In addition,
none of these patients regretted their decision to
&&
transition [7 ].
Sexually transmitted infections, including HIV,
are more prevalent in the transgender population,
possibly related to the lack of family and/or social
&
support [37 ,38]. Attention to high-risk behaviors
4 www.co-pediatrics.com
Copyright 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
that merit screening for these should be part of the
routine care of this population.
SCHOOL SUPPORT FOR TRANSGENDER
YOUTH
In our experience, transgender children and adoles-
cents often suffer from discrimination if they do not
always have a supportive environment in school.
Lack of support is prevalent and this severely com-
plicates and limits our ability to properly assist this
population that in turn is more at risk to develop
psychological, physical and social complications
described in this document.
The Pediatric Endocrine Society Special Interest
Group on Transgender Health supports the United
States Department of Education and the Department
of Justice guidance on the rights of transgender stu-
&
dents released on May of 2016 [39 ], which recom-
mends that students use the restroom that is
consistent with their gender identity. School support
in acknowledging a young persons true gender iden-
tity is crucial for their long-term well being. When
transgender children and adolescents present accord-
ing to their gender identity but are forced to use the
restroom that matches their genitalia, they are often
harassed both physically and verbally, and in some
cases are questioned or pulled out. Although some
schools have provided accommodations to use a staff
(gender neutral) restroom, this leads to segregation
and other psychological and medical problems,
including being questioned by peers and school staff
not aware of their transgender status, sanctions for
being late because the allowable restroom is often not
close to the classrooms, avoidance of using the rest-
room resulting in refusing to drink fluids and with-
holding urination potentially leading to urinary tract
infections, as well as school avoidance.
Almost universally, transgender students do not
want to bring attention or expose themselves pub-
lically; on the contrary, they want to be accepted like
any other youth. There are no reported cases in which
allowing a transgender child to use the bathroom
that matches their gender identity has led to inap-
propriate self-exposure or sexual advances. Self-
exposure, voyeurism and sexual assault already con-
stitute criminal offenses and policies supporting the
rights of transgender individuals do not change that.
CONCLUSION
In conclusion, transgender youth have optimal out-
comes when affirmed in their gender identity,
through support by their families and their environ-
ment, as well as appropriate mental health and
medical care. For this reason, the Pediatric Endocrine
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MOP 290412
Statement on gender affirmative approach from the PES Lopez et al.
Society Special Interest Group on Transgender Health
joins other academic societies involved in the care
of children and adolescents in supporting policies
that promote a safe and accepting environment for
gender nonconforming/transgender youth, as well as
adequate mental health and medical care.
Acknowledgements
We would like to thank the members of the Pediatric
Endocrine Society Transgender Health Special Interest
Group for their contributions to this document.
Financial support and sponsorship
None.
Conflicts of interest
S.M.R. has been a consultant to AbbVie Inc. X.L. has
participated in an Advisory Board for Abbvie Inc., M.M.
has participated in an Advisory Board for Abbvie Inc.,
T.E. has not conflicts of interest. and J.S.O. have no
conflicts of interest.
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