Paeds · adolescent-and-young-adult-medicine
Gender diversity and gender-affirming paediatric care
Also known as Transgender and gender-diverse youth care · Gender dysphoria in children and adolescents · Pubertal suppression and GnRH analogues · Gender-affirming hormones in adolescents · Affirmative model of gender care · Gender incongruence in young people
Fellowship-level approach to caring for trans and gender-diverse children and adolescents: separating gender identity, expression, dysphoria and orientation; the affirmative, exploratory, biopsychosocial model; staged, reversible-first care from exploration through social transition, pubertal suppression with GnRH analogues at Tanner 2, and gender-affirming hormones; eligibility, consent and bone-health considerations; and regional differences between the international (Endocrine Society/WPATH), North American (AAP), UK (Cass) and ANZ models.
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Red flags
- Acute suicidality precipitated by unwanted endogenous puberty or family rejection - safety first, before any gender-specific planning
- Any offer of, or referral for, gender identity conversion efforts - these are harmful, unethical and must never be provided
- Commencing GnRH analogues without multidisciplinary assessment, comorbidity treatment, assent and informed consent
- Missing the Tanner 2 window so pubertal suppression becomes suppression of an established puberty rather than prevention
- Family rejection treated as a parenting preference rather than a major driver of harm
- Neglecting bone-density monitoring, calcium and vitamin D, and fertility counselling during medical transition
- Assuming every gender-diverse presentation is permanent and binary, or dismissing an adolescent's stable identity as social contagion
Life stages
Care settings
Clinical exam formats
Board mappings
- Adolescent Medicine
- Development and Behaviour
- Ethics and Professionalism
- General and Community Paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 12: Communication with patients, families, and health professionals
- Renewed curriculum for first-year trainees from 2027 — Learning goal 14: Professional behaviour and ethical conduct
- Renewed curriculum for first-year trainees from 2027 — Learning goal 15: Essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 17: Adolescent health
- Clinical Applications
- Long Cases
- Communication
- Psychosocial presentations
- 8. Safeguarding
- 10. Growth and pubertal development
- 11. Adolescent medicine
- 1. Professional values and behaviours
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- History taking and management planning
- Adolescent and psychosocial scenarios
- General Pediatrics Content Outline — Domain 4: Psychosocial Issues
- General Pediatrics Content Outline — Domain 6: Growth and Puberty
- General Pediatrics Content Outline — Universal Task 5: Communication
- General Pediatrics Content Outline — Domain 9: Ethics
- Patient Care 2: Diagnostic and therapeutic decision making
- Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication
- Professionalism 1: Professional Behavior and Ethical Principles
- Systems-Based Practice 2: System Navigation for Patient-Centered Care
- Communicator
- Collaborator
- Professional
- Health Advocate
- Pediatrics: Foundations EPA #8 — Communicating assessment findings and management plans to patients and/or families
Overview & Definition
A twelve-year-old tells you, through tears, that their body is about to betray them. Puberty has started. They know, with a clarity that unsettles the adults around them, that the changes coming are wrong. Your job in the next forty minutes is to keep them safe, to understand whether this is a persistent gender identity or something more fluid, to assess the rest of their life, and to set up a plan that does no harm. That is the whole topic. [1] [16]
Gender diversity is the ordinary fact that human beings vary in their internal sense of gender. Some of that variation causes no distress at all; some of it causes profound distress when a young person's identity and their body or social role do not align. That distress is gender dysphoria — a clinical term for suffering, not a label for a person. The newer term gender incongruence, used in ICD-11, deliberately describes the mismatch without calling it a mental disorder. [3] [15]
The four words that examiners test most are easy to conflate and must be held apart. Gender identity is the internal sense of self as girl, boy, both, neither, or somewhere else. Gender expression is how that is shown outwardly — name, pronouns, hair, clothing, voice. Gender dysphoria is the distress that arises when identity and body or social role clash. Sexual orientation is who a person is attracted to, and it is independent of the other three. A transgender girl can be straight, bisexual, asexual or lesbian; her gender and her orientation are separate questions. [1] [15]
The care model that follows from all of this is affirmative (it supports the young person's stated identity rather than fighting it), exploratory (it is open, non-directive and developmentally informed, never pushing a child toward or away from transition) and biopsychosocial (it situates gender inside the whole of the young person's life). It is not the old "watchful waiting," which historically meant withholding affirmation, and it is never, under any circumstances, conversion effort. [1] [8]
References16ShowHide
- [1]Rafferty J Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics, 2018.PMID 30224363
- [2]Hembree WC, Cohen-Kettenis PT, Gooren L, et al Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, 2017.PMID 28945902
- [3]Coleman E, Radix AE, Bouman WP, et al Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health, 2022.PMID 36238954
- [4]de Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 2014.PMID 25201798
- [5]Tordoff DM, Wanta JW, Collin A, et al Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care. JAMA Netw Open, 2022.PMID 35212746
- [6]Chen D, Berona J, Chan YM, et al. Psychosocial Functioning in Transgender Youth after 2 Years of Hormones. N Engl J Med, 2023.PMID 36652355
- [7]Turban JL, King D, Carswell JM, Keuroghlian AS Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation. Pediatrics, 2020.PMID 31974216
- [8]Turban JL, Beckwith N, Reisner SL, Keuroghlian AS Association Between Recalled Exposure to Gender Identity Conversion Efforts and Psychological Distress and Suicide Attempts Among Transgender Adults. JAMA Psychiatry, 2020.PMID 31509158
- [9]Jowett S, Mathews B Current legal and clinical framework for treatment of trans and gender diverse youth in Australia. J Paediatr Child Health, 2020.PMID 32914910
- [10]Vlot MC, Klink DT, den Heijer M, et al Effect of pubertal suppression and cross-sex hormone therapy on bone turnover markers and bone mineral apparent density (BMAD) in transgender adolescents. Bone, 2017.PMID 27845262
- [11]Thompson L, Sarovic D, Wilson P, et al. A PRISMA systematic review of adolescent gender dysphoria literature: 3) treatment. PLOS Glob Public Health, 2023.PMID 37552651
- [12]Tornese G, Di Mase R, Munarin J, et al. Use of gonadotropin-releasing hormone agonists in transgender and gender diverse youth: a systematic review. Front Endocrinol (Lausanne), 2025.PMID 40438403
- [13]Steensma TD, McGuire JK, Kreukels BPC, Beekman AJ, Cohen-Kettenis PT Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc Psychiatry, 2013.PMID 23702447
- [14]Tollit MA, Pang KC, Telfer M, et al What are the health outcomes of trans and gender diverse young people in Australia? Study protocol for the Trans20 longitudinal cohort study. BMJ Open, 2019.PMID 31690608
- [15]Chew D, Tollit MA, Poulakis Z, et al. Youths with a non-binary gender identity: a review of their sociodemographic and clinical profile. Lancet Child Adolesc Health, 2020.PMID 31978373
- [16]Shumer DE, Spack NP Current management of gender identity disorder in childhood and adolescence: guidelines, barriers and areas of controversy. Curr Opin Endocrinol Diabetes Obes, 2013.PMID 23221495