Supporting the Health and Well-Being of Transgender Students

Abstract

Throughout the United States, there has been a rise in public discourse about transgender people and transgender issues. Much of this attention stems from passed and proposed anti-LGBTQ (lesbian, gay, bisexual, transgender, queer or questioning) legislation, including “bathroom bills” that would require transgender people to use public facilities corresponding with the sex designated on their birth certificates. With the recent discussion and legislation impacting school-aged children and adolescents, what does this mean for school nurses and how can they care and advocate for their transgender students? In this article, we aim to empower school nurses to join the discussion, advocate for inclusive and equitable school policies, and deliver gender-affirming care to transgender students. We will explain transgender identities; transgender-related stigma, prejudice, discrimination, and health concerns; gender-affirming approaches in caring for transgender youth; and implications for school nurses. School nurses play a key role in creating a space that is welcoming and affirming where transgender students can thrive.

Throughout the United States (US), there has been a rise in public discourse about transgender people and transgender issues. Much of this attention stems from passed and proposed anti-LGBTQ (lesbian, gay, bisexual, transgender, queer or questioning) state and local legislation, including “bathroom bills” that would require transgender people to use public facilities (bathrooms and locker rooms) corresponding with the sex designated on their birth certificates, not their gender identity. Some politicians claim that bathroom bills are necessary in order to keep women and children safe by preventing sexual violence in public bathrooms perpetrated by men posing as women (Campaign for Houston, 2015; Shabad, 2016; The Pat McCrory Committee, 2016). Organizations like the National Task Force to End Sexual and Domestic Violence Against Women and National Network to End Domestic Violence have issued statements against these claims and in support of equal and full access for the transgender community (2016). However, preliminary findings from the 2015 US Transgender Survey (2016) of over 27,000 transgender adults revealed that transgender people face extensive victimization when trying to use public bathrooms. Additionally, findings show that 59% of transgender adults avoided using the bathroom at work or school; 12% were harassed, attacked, or sexually assaulted in public bathrooms; 9% were denied access to the appropriate bathroom; and 8% reported a kidney or urinary tract infection because they avoided using public bathrooms due to fear of harassment or discrimination (National Center for Transgender Equality, 2016).

On May 13, 2016, the U.S. Department of Justice and Education provided guidance to schools in order to ensure the civil rights of transgender students (Department of Justice, 2016). This guidance states that any school receiving federal funding may not discriminate against transgender students and that gender identity is protected under Title IX (Department of Justice, 2016). With the recent discussion and legislation impacting school-aged children and adolescents, what does this mean for school nurses and how can they care and advocate for their transgender students? We recognize that for some nurses, this topic may be uncomfortable to navigate, understand, and discuss, especially given the dearth of nursing curriculums designed to address caring for transgender individuals. In this article, we aim to provide a foundation and context to empower school nurses to join the discussion, advocate for inclusive and equitable school policies, and deliver gender-affirming care to transgender students. Furthermore, we will explain transgender identities and the variation and expansiveness of language and terms related to this topic (Table 1), as they can sometimes be intimidating. We will also explain transgender-related stigma, prejudice, discrimination, and health concerns; gender-affirming approaches for transgender youth; and implications for school nurses. While we cannot speak to every state and local bill passed or currently under review, we will supply resources that can give additional direction and specifics for local and state ordinances.

Table 1.

Terminology and Definitions.

Term	Definition
Cisgender	Individuals with a gender identity that is aligned with the sex they were assigned at birth
Cross-sex hormone therapy	The administration of exogenous cross-sex hormones, which results in development of secondary sex characteristics to affirm one’s gender identity. Also referred to as gender-affirming hormones
Gender	The attitudes, feelings, and behaviors that a given culture associates with a person’s biological sex (male or female)a
Gender dysphoria	The discomfort or distress that is associated with a discrepancy between a person’s gender identity and that person’s sex assigned at birth—and the associated gender role and/or primary and secondary sex characteristicsa
Gender expression	The outward manner in which an individual expresses or displays their gender. This may include choices in clothing and hairstyle or speech and mannerismsb
Gender identity	One’s sense of oneself as male, female, both, neither, or something else
Genderqueer	A person whose gender identity falls outside of the gender binary (i.e., identifies with neither or both genders)a
Gender nonconforming	Persons with a gender expression that is at odds with cultural gender expectations
Intersex	A range of conditions associated with atypical development of physical sex characteristics. Intersex individuals may be born with chromosomes, genitals, and/or gonads that do not fit typical female or male presentations.c
Queer	The term queer is an umbrella term used to describe sexual orientation, gender identity, and gender expression. In the past, queer was considered a pejorative term, but, in recent years, it is used in a positive manner.c
Sex	Assigned at birth based on the assessment of external genitalia, chromosomes, or gonads
Gender affirmation surgery	Surgery to change primary and/or secondary sex characteristics to affirm a person’s gender identity
Transition	Period of time when individuals change from the gender role associated with their sex assigned at birth to a different gender role. For many people, this involves learning how to live socially (social transition) in another gender role; for others, this means finding a gender role and expression that are most comfortable for them. Medical transition may or may not include feminization or masculinization of the body through hormones or other medical procedures.
Transgender	An adjective and an umbrella term inclusive of diverse communities of people whose gender identity or gender expression differs from the sex that was assigned at birth. A transgender man, or female to male, is someone with a male gender identity and was assigned female at birth; a transgender woman, or male to female, is someone with a female gender identity and was assigned male at birth.

^aAmerican Psychological Association & National Association of School Psychologists (2015).

^bCenter of Excellence for Transgender Health (June, 2016).

^cAmerican Psychological Association (2015b).

^dColeman et al. (2012).

Transgender: Meaning and Prevalence

First, it is important to understand what transgender means and distinguish terminology often used with this term. The term transgender is an umbrella term inclusive of diverse communities of people. Transgender, or trans, describes an individual when their sex assigned at birth does not correspond to their gender expression or gender identity (Institute of Medicine, 2011). Gender identity is an individual’s sense of being male, female, both, or neither (American Psychological Association, 2015a). Gender expression describes a person’s physical appearance, clothing choice, and behaviors used to express aspects of gender identity or role (American Psychological Association, 2015a). Conversely, cisgender individuals’ gender identity and sex assigned at birth align. The term cisgender should be used versus saying that an individual is not transgender. Sex assignment, sex, or natal sex is determined at birth based on external genitalia, and sometimes genetics, and is often categorized as male, female, or intersex (American Psychological Association, 2012). Transgender girls were assigned male at birth and identify as girls; they are girls. Transgender boys were assigned female at birth and identify as boys; they are boys. Using the term transgender as an adjective is appropriate—the school nurse cares for transgender students including transgender boys and girls. However, using it as a noun or verb is often viewed as disrespectful and incorrect—this school policy is for transgenders/transgendered. Trans persons with a gender expression that is at odds with cultural gender expectations are self-identified as gender nonconforming (Grant et al., 2011). Both transgender and cisgender people can be gender nonconforming or gender conforming.

The term transgender is part of the LGBTQ acronym; an acronym is used to describe sexual orientation and gender identity—two very different concepts. LGBTQ is a more inclusive acronym than the commonly used and familiar, LGBT. The “Q” can represent both queer and questioning individuals. The terms lesbian, gay, bisexual, and sometimes queer are used to classify sexual orientation, which describes intimate human relationships, including sexual, romantic, or both types of connections (Institute of Medicine, 2011). In addition to sexual orientation, the term queer is an umbrella term used to describe gender identity or gender expression (American Psychological Association, 2015b). In the past, queer was considered a pejorative term, but in recent years, it is used in a positive manner. When individuals use “Q” for questioning, it may be associated with sexual orientation, gender identity, or gender expression. Teens and preteens are often exploring and discovering their sexual orientation as they navigate feelings of attraction for others. It is not uncommon for adolescents to use the term questioning to describe their romantic or sexual attractions. Gender identity and expression are often understood at a much younger age due to a myriad of factors which we will discuss in more detail within the Gender Identity and Development section. The terms we describe here and in Table 1 are community-driven, and the descriptions may vary or evolve over time. We will address how to navigate fluctuations in these terms and the development of new language in subsequent sections of this article.

With social consciousness, visibility, and acceptance of transgender people increasing, more children and adolescents are asserting their gender identities. They are coming out as transgender at various ages during the course of normal child and adolescent development. Currently, the number of transgender children and adolescents is unknown; however, in March 2016, an estimated 300,000 transgender people aged 13 and above lived in one of the 15 states introducing antitransgender legislation (Herman, Mallory, & Wilson, 2016). This is an incomplete picture of the number of school-aged transgender people, but there are approximately 1.4 million transgender adults in the US (Flores, Herman, Gates, & Brown, 2016). This figure may be as high as 2.3 million, with younger adults aged 18–24 years being more likely to identify as transgender as compared to older adults (Flores et al., 2016). The size of the transgender population is likely underestimated due to the array of prejudice, stigma, and discrimination transgender people experience, which causes individuals to avoid self-identifying as transgender (Grant et al., 2011; Institute of Medicine, 2011; Reisner et al., 2016).

Stigma, Prejudice, Discrimination, and Health

The transgender community represents one of the most marginalized and stigmatized groups in the United States (Grant et al., 2011). Discrimination and prejudice experienced by transgender persons is associated with negative social outcomes, such as higher rate of homelessness (Grant et al., 2011), living under the poverty level (Conron, Scott, Stowell, & Landers, 2012), sexual and physical assaults (Grant et al., 2011; Lombardi, Wilchins, Priesing, & Malouf, 2001), and they are twice as likely to be unemployed (Grant et al., 2011). The National Transgender Discrimination Survey (NTSD), a landmark study of 6,450 transgender adults, revealed that 53% of transgender adults reported being verbally harassed and 44% were denied equal treatment or service in public accommodations (Grant et al., 2011). Contemporary, empirically based knowledge regarding transgender children and adolescents experiencing discrimination is scant (Institute of Medicine, 2011); however, it is quickly growing (Reisner et al., 2016; Wilson, Chen, Arayasirikul, Raymond, & McFarland, 2016; World Professional Association for Transgender Health, 2016). While there is a dearth of knowledge in this population, we can learn a great deal from what is known about transgender adults experiencing discrimination.

Discrimination and Health

The health of transgender people is at risk due to exposure to discrimination, which shape the environments where they live, learn, and work (Grant et al., 2011; Meyer, 2003). Experiences of discrimination contribute to negative physiological outcomes in transgender adults, such as disproportionate levels of anxiety (Reisner, Vetters, et al., 2015), depression (Bockting, Miner, Swinburne Romine, Hamilton, & Coleman, 2013; Brown & Jones, 2016; Reisner, Vetters, et al., 2015), substance abuse (Benotsch et al., 2013; Grant et al., 2011), suicidal ideation and attempts (Grant et al., 2011; Reisner, Vetters, et al., 2015), and self-harm (Reisner, Vetters, et al., 2015) as compared to their cisgender counterparts. Furthermore, gender nonconforming trans adults experience higher rates of discrimination and are more likely to attempt suicide, abuse drugs or alcohol, and smoke as compared to their gender-conforming counterparts (Miller & Grollman, 2015; Reisner, Greytak, Parsons, & Ybarra, 2015). In fact, the suicide rate for transgender adults is 41%, a rate that far exceeds the rate for the gay and lesbian population (10–20%) and the general public (4.6%; Herman, Haas, & Rodgers, 2014).

Transgender adults endure discrimination within health-care environments (Bradford, Reisner, Honnold, & Xavier, 2013; Cicero & Black, 2016; Grant et al., 2011; Lambda Legal, 2010). They encounter numerous barriers in health care such as the paucity of knowledgeable providers, lack of insurance coverage, and stigma and discrimination from healthcare providers and staff (Bradford et al., 2013; Grant et al., 2011; Sanchez, Sanchez, & Danoff, 2009). The NTSD reported that 19% of transgender adults were refused medical care, 28% were subjected to harassment, 33% postponed needed medical care, and 33% delayed or did not get preventative health care due to discrimination experienced by providers (Grant et al., 2011). Similar findings were reported in smaller cross-sectional and community-based convenience samples across the US (Bradford et al., 2013; Clements, Katz, & Marx, 1999; Kenagy, 2005; Kenagy & Bostwick, 2005). Unfortunately, avoiding care was also associated with several modifiable health indicators such as smoking, inactivity, and increased body weight in trans men (Reisner, Gamarel, Dunham, Hopwood, & Hwahng, 2013). Furthermore, the perceived experiences of discrimination were more frequent when providers were aware of their patients’ transgender identity (Bradford et al., 2013; Cruz, 2014; Grant et al., 2011; Shires & Jaffee, 2015), and when providers refused to care for transgender adults, their suicide attempt rates increased from 41% over 60% (Herman et al., 2014).

School Environments

For transgender students (kindergarten to 12th grade), schools can be a hostile learning environment and a source of stress, producing lifelong implications (Kosciw, Greytak, Bartkiewicz, Boesen, & Palmer, 2012; Kosciw, Greytak, Palmer, & Boesen, 2014; McGuire, Anderson, Toomey, & Russell, 2010; Reisner, Greytak, et al., 2015). The prevalence and impact of school-related bullying and harassment are well documented, but recent reports indicate that transgender youth experience disproportionate levels of bullying, harassment, physical attacks, and other types of peer victimization (Greytak, Kosciw, & Boesen, 2013; Grossman & D’Augelli, 2006; Grossman, D’Augelli, & Salter, 2006; Grossman et al., 2009; Kosciw et al., 2014; Reisner, Greytak, et al., 2015). Additionally, transgender students experience higher rates of discrimination than their lesbian, gay, and bisexual peers (McGuire et al., 2010), which may disrupt or delay education and career obtainment and development (Grant et al., 2011; Grossman et al., 2009). These experiences are also associated with increased odds of substance use such as alcohol, cigarettes, marijuana, and non-marijuana illicit drugs among transgender youth (Reisner, Greytak, et al., 2015). The 2013 National School Climate Survey (NSCS) provides insight into school victimization by contextualizing the experiences of nearly 8,000 “LGBT” students between the ages of 13 and 21, of which 1,822 identified within the transgender spectrum (Kosciw et al., 2014). Experiences of harassment were pervasive for transgender students, as 37.8% felt unsafe, 55.2% were verbally harassed, 22.7% were physically harassed, and 11.4% were physically assaulted due to their gender expression (Kosciw et al., 2014). Additionally, 56.4% heard negative remarks about their gender expression, and nearly a third heard negative remarks about transgender people (Kosciw et al., 2014). Over 56% of the students surveyed did not report the harassment because (1) they doubted staff would effectively address the situation, (2) they felt the situation would become worse, (3) they perceived their experiences were not severe enough, or (4) they were concerned about how the school personnel would react to the report (Kosciw et al., 2014). Trans students who reported higher levels of victimization in school environments were 3 times as likely to have missed school in the past month as compared to their peers experiencing lower levels of victimization (Kosciw et al., 2014). These findings also align with local community research studies (Grossman et al., 2009; McGuire et al., 2010).

Schools can be a negative environment for transgender students because many school policies do not include protections based on gender identity and expression (Kosciw et al., 2012, 2014; McGuire et al., 2010). Policies providing these protections can present a framework for those working with trans students because teachers and school personnel are also perpetrators of harassment and violence within school environments, including refraining from intervening in peer-based victimization (Grant et al., 2011; Grossman et al., 2009; Kosciw et al., 2014). The NSCS discovered over 55% of students reported hearing negative remarks about gender expressions from their teachers or other school staff (Kosciw et al., 2014). Two examples of how school employees inflicted additional distress are using student’s birth name and pronouns rather than their preferred name and pronouns that are aligned with their gender identity, and coaching trans students to act and dress aligned with their birth gender (Grossman et al., 2009; Kosciw et al., 2012, 2014). As a result of the discrimination faced in school environments, transgender students will avoid gym class, cafeterias, school buses, hallways, locker rooms, bathrooms (Grossman et al., 2009; Kosciw et al., 2014). Unfortunately, when harassment is severe, absenteeism becomes a coping mechanism (Kosciw et al., 2014).

Gender Identity and Development

Biophysiological, family structure, cultural, and community-level factors impact how children express and identify their gender (Bem, 1981; Hidalgo et al., 2013; Kohlberg, 1966; Malpas, 2011). Psychologists posit that cultural norms influence our beliefs, understanding, and expectations of gender expression, as gender is socially constructed (Bem, 1981; Brill & Pepper, 2008; Ehrensaft, 2012; Kohlberg, 1966; Malpas, 2011; Sherer, Baum, Ehrensaft, & Rosenthal, 2015). When children express and/or identify in ways that do not conform, they often receive explicit or implicit messages from family and community members that their behavior and/or expression is wrong (Bandura & Walters, 1977; Link & Cullen, 1990; Malpas, 2011). As a result, transgender children and adolescents may form negative self-esteem and expect rejection from others, which cause negative health outcomes, such as depression, anxiety, self-harm, and suicide (J. Olson, Schrager, Belzer, Simons, & Clark, 2015). Additionally, the existing and vast diversity of gender identities is disregarded when gender is viewed as a binary with preset trajectories for boys and girls (Brill & Pepper, 2008; Ehrensaft, 2012).

Gender identity and gender expression are continually evolving, representing the fluidity and complexities of gender. Researchers in the Netherlands studying the largest cohort of transgender children advise that there are multiple developmental pathways for transgender children (Steensma & Cohen-Kettenis, 2015). Child developmental psychologists provide three broad categories reflecting the multitude of ways children present and express their gender identity (Brill & Pepper, 2008; Ehrensaft, 2016). Children may present with features from multiple categories or move between categories (Ehrensaft, 2016). These broad categories are not indented to represent an all-encompassing rigid classification system, but rather they are helpful in understanding a variety of gender presentations in children and adolescents. Table 2 provides nursing considerations for each categories discussed below: insistent, consistent, and persistent; creative gender expression; and nonbinary gender identity and expression.

Table 2.

Gender Presentation Categories and Nursing Considerations.

Category	Common Presentation	Nursing Considerations
Insistent, consistent, and persistent cross-sex gender identity	Early verbal statements of “I am a boy” or “I am a girl” Early onset gender expression consistent with cross-sex gender identity Gender dysphoria and rejection of genital body parts, often but not always prior to onset of physical pubertal changes Anxiety, anger, and reclusive behavior that resolves when gender identity is affirmed Relatively fixed gender identity and expression as boy or girl from very young ages	Listen and do not ignore what these children are saying about their gender. Assess and provide support/referrals for parent/guardians. Carefully assess children with chronic behavioral problems for any struggles with gender expression or identity.
Creative gender expression	Creative gender expression (hair, clothes, and play), yet have a gender identity that matches the gender assigned at birth Does not experience gender dysphoria or distress from assigned sex or gendered body parts May be annoyed that because of their creative gender expression, people see them as the opposite gender	Assess and intervene if child is experiencing bullying due to gender expression. Remain cognizant of the differences between gender identity, gender expression, and sexual orientation—do not assume a certain trajectory just because of a creative gender expression.
Nonbinary gender identity and gender expression	Statements include “I’m a boy on the outside and a girl on the inside” or “I am not a boy or a girl.” Gender identity and expression does not fall into male/female binary. Authentic gender is fluid and may change throughout life.	Follow the lead of the child or adolescent about their gender identity and expression. Provide safe spaces to use the bathroom if gender-neutral facilities are not available. Assess and intervene if child is experiencing bullying due to gender identity or expression.

Note. Adapted from Brill and Pepper (2008) and Ehrensaft (2016).

Insistent, Consistent, and Persistent

All prepubertal children play with gender expression and explore gender roles—from playing “house” to “dress up.” This behavior is often temporary, but, for some children, it persists over time and is closely connected to their sense of identity and gender expression. These children will insist that they are the opposite sex with such expressions as “I am a boy” or “Me girl.” Often these expressions, or assertions of gender identity, will occur as early as 2 or 3 years old, but it may transpire at any age (Ehrensaft, 2016; Malpas, 2011). Children will be consistent with their cross-sex gender identity and also express their gender in ways traditionally associated with the opposite sex (Brill & Pepper, 2008; Ehrensaft, 2016). As this assertion persists, children may inquire about when they will receive genitalia aligned with their cross-sex gender identity (Ehrensaft, 2012). Children with an insistent, consistent, and persistent cross-sex gender identity and expression will most likely identity as transgender through adolescence and into adulthood (Steensma, Biemond, de Boer, & Cohen-Kettenis, 2011). Furthermore, youth in this category often struggle with severe gender dysphoria, which is defined by the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) as distress related to gender identity being incongruent with one’s body and the sex assigned at birth. Additionally, youth may exhibit anxiety, anger, reclusive behavior, or other behavioral problems, especially at the onset of puberty (Malpas, 2011; J. Olson et al., 2015). These behaviors most often resolve immediately when their gender identity is affirmed (K. R. Olson, Durwood, DeMeules, & McLaughlin, 2016).

Gender Creative Expression

Many children will engage in gender creative expressions temporarily or even long term, but not all will have a cross-sex gender identity (Ehrensaft, 2016; Malpas, 2011). Gender creative children exhibit a gender expression that does not conform to social norms and expectations (Ehrensaft, 2016). They are cisgender children, having a gender identity that aligns with their sex assigned at birth. The number of gender creative children may be larger than those who would be classified as transgender (Ehrensaft, 2016). Examples of creative gender expressions include clothing, hairstyles, communication patterns, and behaviors that do not conform to expectations based on birth sex (Ehrensaft, 2016). Gender creative children may experience discomfort if others assume they are the opposite sex (Ehrensaft, 2016). For example, a teacher using female pronouns to address a male student with a creative gender expression (longer hair, wears a dress, and carries a purse) may inflict unnecessary harm. Often, but not always, children in this category may later identify sexually as gay, lesbian, or queer (Ehrensaft, 2016). School nurses should remain cognizant of the difference between gender identity, gender expression, and sexual orientation and not assume any trajectory is standard for children who do not conform to social gender norms.

Nonbinary Gender Identity and Expression

For some children, both their gender expression and gender identity are nonconforming to social norms based on their sex assigned at birth (Brill & Pepper, 2008; Ehrensaft, 2016). Neither their gender identity or expression will fall into traditional binary conceptions of male or female (Ehrensaft, 2016). Often children with nonbinary gender identity and expression are articulate about their unique gender identity and express themselves in an infinite number of ways (Brill & Pepper, 2008; Ehrensaft, 2016). Children may make statements such as “I’m a girl on the outside and a boy on the inside” or “I am not a boy or a girl” (Ehrensaft, 2016). The child’s gender identity is fluid and may change throughout the life course (Brill & Pepper, 2008). Nonbinary youth may also be referred to as gender expansive or gender variant (Brill & Pepper, 2008; Ehrensaft, 2016). Additionally, adolescents may self-identify as agender, genderqueer, or gender fluid and may express their gender identity with gender-neutral pronouns such as they, them, and their. Youth within this category may not self-identity as transgender, as this term does not adequately covey the fluidity of their gender identity and expression.

Gender-Affirming Interventions

The Society of Adolescent Health and Medicine (Reitman et al., 2013) and the American Academy of Pediatrics (2015) suggest that because gender identity and expressions vary widely, affirming a child’s articulation of their authentic gender is paramount for healthy growth and development. Careful assessment for gender dysphoria is important because youth experiencing this require interventions in order to prevent mental health sequelae such as anxiety, depression, self-harmful behaviors, and suicidality (Coleman et al., 2012). Treatment for gender dysphoria occurs through gender-affirming interventions, which are defined as steps taken to align social and physical gender presentations and characteristics with one’s authentic gender identity. Gender-affirming interventions fall into four main categories: social transition, puberty suppression, cross-sex hormones, and gender-affirming surgeries. Interventions will depend upon the child’s pubertal development stage: prepuberty (no pubertal development), early puberty (Tanner Stage 1 and 2), or late puberty (Tanner Stage 3–5). Table 3 provides an overview of gender-affirming interventions and nursing considerations according to pubertal stage.

Table 3.

Stages of Pubertal Development and Gender-Affirming Interventions.

Stage	Gender-Affirming Interventions	Nursing Considerations
Prepubertal: No pubertal changes	Social transition	No medical interventions are necessary at this stage. Anticipatory guidance regarding stages of puberty and referrals to gender specialists as needed
Early puberty: Tanner Stage 1 and 2	Social transition Puberty suppression	Youth with exacerbated gender dysphoria due to puberty may experience high rates of anxiety, depression, and suicidality. Mental health assessment and referrals to gender specialists are warranted.
Late puberty: Tanner Stage 3–5	Social transition Cross-sex hormone therapy Gender-affirming surgeries	Adolescents who received puberty blockers may be moving through tanner stages in their affirmed gender. Adolescents who have not received blockers have various secondary sex characteristics that may cause severe gender dysphoria. It may be difficult to socially transition safely at this stage without medical or surgical intervention, due to visible secondary sex characteristics that do not match gender identity and expression. Sexual health education and screening that considers all gender identities and sexual orientations is paramount. Older adolescents who have experienced rejection from family due to gender identity and/or expression may struggle to maintain basic survival needs such as housing and food.

Social Transition

Social transition for children and adolescents involves changing their name, pronouns, clothing, hairstyle, or activities in order to align with their gender identity. Social transition can take place at any stage of pubertal development, but it is the only intervention recommended for prepubertal youth (Coleman et al., 2012). Social transition alone is usually inadequate for early pubertal or late pubertal youth due to the development of secondary sex characteristics which will exacerbate gender dysphoria (Coleman et al., 2012). Socially transitioned youth may change their names and gender markers on legal documents or school records, as well as participate on sports teams and extracurricular actives (e.g., Girl Scouts or Boy Scouts) that align with their gender identity. Children and families often benefit from support groups as they navigate this transition (see Table 4 for family resources). Before socially transitioning, transgender youth should be assessed for mental health implications because there are extremely high rates of anxiety, depression, and self-harmful behaviors found among youth who have not been affirmed in their authentic gender (J. Olson et al., 2015; K. R. Olson, 2016; Sherer, 2016). Notably, a study focused on the mental health of 73 prepubescent, socially transitioned transgender children, ages 3–12 years old, found developmentally normative levels of depression and anxiety when these trans children were allowed to express their gender identity in everyday life (K. R. Olson et al., 2016).

Table 4.

Resources for Nursing Professionals, School Staff, Families, Health-Care Providers, and Transgender Individuals.

Organization	Description
Beyond Gender Project	Resources that help explain the complicated idea of gender, information on social and medical transitioning, and information about advocacy and current issues. www.beyondgenderproject.org
Gender Spectrum	Resources to empower your relationships, work, and interactions with youth and children, including how-to guides, sample training materials, and tools necessary to create gender inclusive environments. www.genderspectrum.org
GLSEN	The leading national education organization focused on ensuring safe and affirming schools for lesbian, gay, bisexual, transgender, queer or questioning students. www.glsen.org
National Center for Transgender Equality	Resources on laws and policies affecting transgender people, including legal name and gender marker changes and educational materials. www.transequality.org
The National LGBT Health Education Center	Webinars, video training, learning modules, continuing education, and resources. www.lgbthealtheducation.org
Trans Lifeline	A hotline staffed by transgender people primarily for transgender people experiencing a crisis. www.translifeline.org The United States: (877) 565–8860 and Canada: (877) 330–6366
UCSF Center of Excellence for Transgender Health	Guidelines for the care of transgender and gender nonbinary People. www.transhealth.ucsf.edu/protocols Learning center topics include routine care, cultural competency, mental health, policy; primary care guidelines; online training; and education. https://goo.gl/a8Dcno
World Professional Association of Transgender Health (WPATH)	An interdisciplinary professional and educational organization devoted to transgender health. WPATH also provides the standards of care for the health of transsexual, transgender, and gender nonconforming people. www.wpath.org

Puberty Suppression

Often, the onset of puberty exacerbates gender dysphoria because the development of secondary sex characteristics do not represent the child’s gender identity (American Psychiatric Association, 2013; Coleman et al., 2012; Hembree et al., 2009). In order to prevent the development of secondary sex characteristics and gender dysphoria, puberty can be suppressed with the administration of a Gonadotropin-releasing hormone (GnRH) analogue. Puberty suppression is ideally initiated no later than Tanner Stage 2 (Rosenthal, 2014), and may be given as a subcutaneous injection at varying time intervals (daily to every 3 or 4 months), or provided by a time-release implant that is surgically inserted to the under-side of the upper arm and may last 1–3 years (Center of Excellence for Transgender Health, 2016). School nurses would not be administering puberty suppression medications, but parents may ask them about the proper technique to deliver subcutaneous injections. The number of transgender youth prescribed puberty suppression medications in the United States is not known. The effects of puberty suppression using GnRH analogues is completely reversible once the medication is stopped. Guidelines from the Endocrine Society (Hembree et al., 2009) recommend maintaining pubertal suppression until the age of 16 without adding cross-sex hormones. However, this practice is quickly becoming outdated, and transgender youth are often started on cross-sex hormones when it is developmentally appropriate, as opposed to a chronological age (Center of Excellence for Transgender Health, 2016).

Cross-Sex Hormone Therapy (CSHT)

Puberty suppression medications will temporarily repress the development of natal secondary sex characteristics, but the initiation of CSHT is necessary for pubertal development aligned with one’s gender identity. CSHT, or gender-affirming hormones, involves the administration of exogenous cross-sex hormones such as estrogen and testosterone. Feminizing CSHT consists of estrogen (administered as a patch, pills, or injection) plus an androgen blocker, which is usually spironolactone pills, although GnRH analogues may also be maintained for this purpose (Center of Excellence for Transgender Health, 2016; Hembree et al., 2009; Rosenthal, 2014). Masculinizing CSHT consists of testosterone given as a subcutaneous or intramuscular injection (Center of Excellence for Transgender Health, 2016; Hembree et al., 2009; Rosenthal, 2014).

Gender-affirming hormones are safe in adolescents and rarely produce adverse effects (Center of Excellence for Transgender Health, 2016; Rosenthal, 2014). Hormone dosing is titrated to the desired effect and will be dependent on (1) the stage of pubertal development and (2) previous or concurrent use of puberty suppression medication (Center of Excellence for Transgender Health, 2016; Hembree et al., 2009; Rosenthal, 2014). Youth who receive puberty suppression before the development of secondary sex characteristics will progress through all stages of puberty aligned with their gender identity once CSHT is initiated (Center of Excellence for Transgender Health, 2016). CSHT cannot alter the development of secondary sex characteristics associated with one’s natal sex, such as facial hair for young transgender women or breast development for transgender young men (Coleman et al., 2012; Hembree et al., 2009).

Gender-Affirming Surgeries

Gender-affirming surgeries are considered on a case-by-case basis for youths under the age of 18, experiencing severe gender dysphoria and receiving CSHT (Center of Excellence for Transgender Health, 2016). Surgeries may include but are not limited to chest reconstruction (bilateral mastectomy and/or chest contouring) for transgender males or genital surgery (vaginoplasty) for transgender females. Although not often considered a surgery, many transgender girls will pursue laser or electrolysis for permanent hair removal (Center of Excellence for Transgender Health, 2016). Other surgical interventions are generally not performed until after the age of 18 (Coleman et al., 2012; Hembree et al., 2009). Surgical recovery times vary and may last between 6 and 12 weeks. In the rare instance that a high school-aged transgender student does undergo a gender-affirming surgery, postoperative guidelines are provided by the University of California, San Francisco (UCSF) Center of Excellence for Transgender Health (Center of Excellence for Transgender Health, 2016). Additional resources are provided in Table 4.

Implications for School Nurses

School nurses are in a unique position to provide gender-affirming care in order to improve the safety, well-being, and health of transgender students. They can expect to work with transgender students presenting in a myriad of ways depending on age, gender identity, and gender expression. School nurses interacting with transgender students may be able to notice and carefully assess students presenting with mental health concerns or experiencing discrimination, harassment, or family rejection related to their gender identity, as well as those who may be struggling with their gender identity or gender expression. School nurses may also be able to assess and intervene if a transgender student is experiencing bullying due to a nonconforming gender identity or expression. This mistreatment may come from both peers and school personnel. Some schools attempt to establish safe spaces or identity LGBTQ-friendly staff by displaying rainbow and safe space stickers. Transgender students report that these visual cues are helpful in identifying safe spaces and solidarity, but they are not as inclusive or enough for transgender identities (Wolowic, Heston, Saewyc, Porta, & Eisenberg, 2016). Transgender students experienced staff members knowledgeable about gay and lesbian identities, but they were lacking knowledge on transgender identities and nonconforming gender presentations (Wolowic et al., 2016). Staff displaying rainbow and safe space stickers would benefit from training programs that include content on gender identities and gender presentations as well as sexual orientations.

Gender-affirming communication approaches are necessary when caring for transgender students (Table 5). Congruence between body language and verbal communication is critical (The National LGBT Health Education Center, 2016). It may not always be possible to know how a student identifies, which name and pronouns to use in order to affirm their gender identity or gender expression, or if they are struggling with their gender identity (The National LGBT Health Education Center, 2016). School nurses may feel uncomfortable for not knowing or awkward asking students about their gender identity, but transgender students will welcome the exploration during a respectful private conversation (The National LGBT Health Education Center, 2016). Ask the student how they would like to be addressed and clarify which name and pronouns to use (The National LGBT Health Education Center, 2016). Listen to the language transgender students use when describing themselves, including their identities and sexual orientation (The National LGBT Health Education Center, 2016). Mirror this language, and if unfamiliar terms are used, ask them to explain what the terms mean to them (The National LGBT Health Education Center, 2016). As you execute gender-affirming communication techniques, be cognizant that terms, names, and pronouns may evolve over time. Furthermore, you may mistakenly use the wrong name or pronoun, expect it (The National LGBT Health Education Center, 2016). Apologize, move on, and try to be conscious of your communication approaches moving forward. Developing trust and rapport with transgender students may take longer to establish, but they will appreciate your good intentions and sincerity.

Table 5.

Key Communication Approaches for Working With Transgender Students and Families.

Circumstance	Communication Approaches
Greetings and names	It is not always possible to know someone’s gender identity by their name or how they look or sound. It can be uncomfortable to be confused about someone’s gender identity. It can also feel awkward to ask someone what is their gender. If you are unsure about a person’s gender identity, or how they wish to be addressed, ask politely for clarification.a How would you like to be addressed? What name would you like me to use? Is it okay to call you [insert name]? Do you have another name you like to go by? Use the names and pronouns indicated by the student, even when they are not present. Make a note in the student’s record about which name and pronouns to use. Don’t be afraid to politely correct school staff and faculty members if they are using the wrong names and pronouns. When referring to them, please use [insert name] and [insert pronouns].
Pronouns	Transgender individuals may use a wide range of gender-specific language, including pronouns. Pronouns include the common she/her/hers and he/him/his, as well as less common pronouns such as they/them/theirs and ze/hir/hirs. Never refer to someone as “it” or “he–she”.b I wanted to check in before I assumed—what are your pronouns? I have never used those pronouns before, so I apologize if I make a mistake. Can you help me pronounce them properly? Here’s how to use the subject, objective, and possessive form of a few pronouns:b He/him/his: He is in the waiting room. The nurse is ready to see him. The book is his. She/her/hers: She is in the waiting room. The nurse is ready to see her. The book is hers. They/them/theirs: They are in the waiting room. The nurse is ready to see them. The book is theirs. Ze/hir/hirs: Ze is in the waiting room. The nurse is ready to see hir. The book is hirs.
Making mistakes	You may mistakenly use the wrong name or pronoun, expect it. Apologize, move on, and try to be conscious of your communication approaches moving forward.c I apologize for using the wrong pronoun/name. I did not mean to disrespect you.
Before calling parents or guardians	First, it is important to talk to the student about their homelife. Explain the purpose of your call to their parents or guardians, if possible. Ask the student how they are referred to at home, or, for guidance, on which names and pronouns to use for them when speaking with their parents or guardians. The student’s preference at school may be different than the language used by their parents or guardians at home. You do not want to inflict any unnecessary harm, but affirming the student’s gender or gender expression is important. Always follow the student’s recommendations regarding which name and pronouns to use when speaking with their parents or guardians. Remember, using “they” is not only grammatically correct, it may circumvent any conflicting communication approaches When I call [insert name], what name and pronouns should I use when referring to you? Good afternoon, this is the school nurse and I am calling about your child [insert name provided by youth], who is not feeling well today. They are currently resting in my office.
Legal documents and school records	Names and gender markers on legal documents and school records may not match what the student uses. Changing names and gender markers can be a complicated process which varies from state to state. Avoid asking the student what is their “real” namec What is the name on your official transcript or school record? What is the name on your health insurance? Could your records be under a different name?
Anatomy	Ask students directly what language they are comfortable and uncomfortable with regarding their anatomy. Let students use their own terminology. Ask them to explain what their terms mean to them. Listen and echo back the language heardd I’d like to be respectful, what language should I use as it relates to your body parts, genitals, reproductive organs, and so on?
Physical assessments	Address sensitive topics carefully, yet treat as routine. Chief complaint may not be the main reason for the visit. Transgender individuals may be very uncomfortable with physical exams that involve their genitalia—be extra sensitivee Do you have any other problems or questions, or want anything else checked out while you are here? What can I do to make you more comfortable? Would you like someone else in the room?
	Transgender people express the same range of sexual behavior and identity as cisgender people. It is important to assess which body parts are involved during sexual activities for both the student and their partner(s). Explain why you are inquiring about their sexual behaviors.e I’m going to ask you some questions I ask everybody about their sexual health. It is helpful for me to know the answers to these questions so that I can provide the best care for you. What term (if any) do you prefer that I use to best describe your sexual orientation? For example, do you consider yourself gay, lesbian, bisexual, heterosexual (straight), something else, or are you not sure? It’s okay if you prefer not to use labels, do you want to share about the type of people you’re attracted to? Have you been sexually involved with anyone during the past year, including oral, vaginal, or anal sex, or other kinds of sexual practices? During sexual activity, what body parts are involved and how are they used? How does your current/previous partner(s) identify?
Avoid asking unnecessary questions	Only ask for information that is required for you to care for the student. Ask yourself:c What do I know? What do I need to know in order to care for the student? How can I ask in a sensitive way? Have I explained to the student why I am asking certain questions? Unhelpful and disrespectful questions and comments: When did you decide to be a man/woman? Do you want THE surgery? What is your real name/gender? You are so attractive, why would you want to … ? Can I see what you looked like before? You aren’t a real boy/girl. When did you know you wanted to change? Referring to cisgender people as “normal.” Using the term transgender as an adjective is appropriate—the school nurse cares for transgender students including transgender boys and girls. Using the term transgender as a noun or verb is often viewed as disrespectful and incorrect—this school policy is for transgenders/transgendered.

^aThe National LGBT Health Education Center (n.d.-a).

^bThe National LGBT Health Education Center (2016).

^cThe National LGBT Health Education Center (n.d.-a).

^dHagen and Galupo (2014).

^eThe Fenway Institute (n.d.).

The level of family acceptance and support of transgender students will vary significantly. A study of 66 transgender youths, ages 12–24 years old, found parental support was significantly associated with higher life satisfaction and fewer depressive symptoms (Simons, Schrager, Clark, Belzer, & Olson, 2013). In contrast, when family rejection related to gender identity occurs, it is associated with increased odds of substance misuse and suicide attempts (Klein & Golub, 2016). With unsupportive family members, transgender students may struggle to maintain their basic and psychological needs such as housing, food, security, safety, and positive self-esteem (Grossman, D’Augelli, Howell, & Hubbard, 2006; Koken, Bimbi, & Parsons, 2009; Wilson et al., 2015). Assessing for these basic needs is critically important, as meals offered in school settings may be their only source of nutrition. However, transgender students may avoid cafeteria settings due to discrimination and therefore may be malnourished, which will impact their school performance and development. School nurses assessing for these circumstances have an opportunity to intervene and work closely with family, community members, and other health professionals in providing a network of resources for students needing gender-affirming interventions. Social, peer, and family support as well as gender-affirming approaches are known pathways to reduce psychological distress and increase life satisfaction (Bockting et al., 2016; K. R. Olson et al., 2016; Simons et al., 2013).

As states and local jurisdictions pass anti-LGBTQ bills, bathrooms and locker rooms may pose as a source of discrimination and peer victimization. Well-intended schools may provide transgender-only bathrooms or identify gender-neutral bathrooms that may be in remote areas of the building. Both scenarios create unsafe conditions for transgender students, as others will be able to identify them as trans or remotely located bathrooms produce accessibility challenges and consequences for being tardy to class. Additionally, transgender students may avoid these spaces, which will create bowel and bladder dysfunctions (National Center for Transgender Equality, 2016). School nurses can provide a safe space for bathroom and locker room use, advocate for accessibly located bathrooms, and support the establishment of gender-neutral bathrooms for all students. Transgender students may seek care from school nurses, presenting with symptoms such as headaches, stomach pain, or anxiety-related symptoms. Assessing for the underlying cause verses only treating the symptoms may help school nurses identify unsafe and harmful conditions for transgender students. Performing physical examinations, taking sexual health histories, and providing sexual health education and screening should be tailored to the student’s current anatomy and sexual interest, behavior, and orientation. Additionally, school nurses should familiarize themselves with community resources for caring for transgender youth and their families. Each organization listed in Table 4 provides resources designed for multiple audiences such as families, school staff, health-care providers, and transgender individuals. Local resources may be identified by contacting your nearest LGBTQ Center, most often found in metropolitan areas.

Conclusion

School nurses play a key role in creating a space that is welcoming and affirming where transgender students can thrive. Given the high prevalence of transgender-related discrimination and victimization in school settings, it is critical for school nurses to intervene and address all safety and health concerns. Furthermore, by using Nursing’s Code of Ethics (Bell, 2015) as a framework, school nurses have an ethical responsibility to maintain a safe and healthy environment for all students, regardless of whether they agree or condone transgender identities. School nurses can advocate or provide educational trainings to school employees, so that they not only understand but also use gender-affirming approaches when teaching transgender students. Understanding varying gender identities and expressions, and the appropriate gender-affirming approaches will help cultivate a supportive, compassionate, and caring environment.

Author Biographies

Ethan C. Cicero is a Robert Wood Johnson Foundation Future of Nursing Scholar and a PhD student at Duke University School of Nursing.

Linda M. Wesp is a Jonas Nurse Leader Scholar, PhD student at the University of Wisconsin College of Nursing, and a family nurse practitioner.