Keywords

Pediatric Gender Identity: Consultation on Matters of Identity, Transgender Concerns, and Disorders/Differences of Sex Development

Broadly, gender identity refers to a person’s sense of self as a gendered (or not) individual. A person’s “gender identity” is distinct from other constructs such as biological “sex” characteristics (e.g., chromosomes, internal/external anatomy, and hormonal activity), sexual orientation (the gender that a person is romantically or sexually attracted to), and gender assignment (the gender that parents and/or medical professional assigns to an infant at birth, typically based on the appearance of the genitals). Most people are cisgender; that is, they develop a gender identity consistent with their initial gender assignment. In most, but not all cultures, gender has typically been confined to the gender binary (i.e., the two primary categories of female/male), with transgender referring to a person assigned one of those categories at birth (e.g., male) who identifies as the other category (e.g., female). Recently, the dichotomy of the gender binary has been questioned by both research findings and sociocultural movements such as LGBTQ activism (Hyde, Bigler, Joel, Tate, & Anders, 2018), resulting in an expansion of categories recognized (by some individuals and groups) to include a number of other identities including bi-gender, gender nonconforming (GNC), and genderqueer (gender terminology quickly changes; a number of websites provide definitions, e.g., https://www.apa.org/pi/lgbt/programs/safe-supportive/lgbt/key-terms.pdf).

Indeed, there is a paradigm shift in expression of gender identity underway in the United States and other countries. At the time of writing this chapter, New York City and four states offer a gender X designation on birth certificates, and three states plus Washington, DC, offer gender-neutral driver licenses (Trotta, 2018). A recent large-scale study of US adults from 19 states analyzed 2014 data and found the prevalence of adults identifying as transgender (0.6% of the sample, 1,400,000 total persons) had doubled over the past 10 years, with 18–24-year-old adults (the youngest age group) more likely to identify as transgender (Flores, Herman, Gates, & Brown, 2016). A population-based study of high school students found that 2.7% identified as “transgender, genderqueer, genderfluid, or unsure about [your] gender identity”; those youth identifying as such reported compromised physical and mental health (Rider, McMorris, Gower, Coleman, & Eisenberg, 2018).

Pediatric psychologists consulting in inpatient and outpatient medical settings are likely to encounter youth who experience gender identity in a variety of ways. Given that youth may not easily disclose to others, providing appropriate and effective consultative services is critical. In this chapter we briefly review gender identity development, gender dysphoria, and current terminology relevant to gender. We then discuss assessment of gender concerns, as well as assessment of relevant psychosocial risk and resiliency factors, and highlight potential interventions, with a focus on transgender individuals and youth with a disorder/difference of sex development (DSD).

Gender Identity Development

Gender identity is most appropriately conceptualized as a multidimensional construct, including aspects such as gender typicality (whether behaviors/interests conform to gender stereotypes), gender contentedness (the degree to which a person feels glad to be their gender), and pressure to conform to gender stereotypes (Egan & Perry, 2001; Yunger, Carver, & Perry, 2004). Importantly, these dimensions can operate independently of each other. For example, a person can have interests that are atypical of their gender yet be content in their gender. Extensions of the multidimensional model now include the potential for determining the degree to which an individual feels similar or dissimilar to both genders (Martin, Andrews, England, Zosuls, & Ruble, 2017). Research investigating the multidimensional model of gender identity (Egan & Perry, 2001) suggests that different aspects of gender identity interact to pose different risks for adjustment. For example, preadolescents’ perceived gender atypicality most strongly predicted later internalizing behaviors when youth also reported high pressure to conform to gender stereotypes (Yunger et al., 2004). Research has identified both psychosocial and biological influences on gender identity development. For example, the development of cognitive gender schemas is thought to influence gender identity, framing children as active participants in this identity development through information processing activities. Social influences include early socialization, modeling and reinforcement for gender-typical behaviors by family and peers, as well as the perceived and experienced costs/benefits of belonging to a “social category.” Biological theories emphasize the influence of prenatal sex hormones on both gendered behavior and identity (de Vries, Kreukels, Steensma, & McGuire, 2014; Ruble, Martin, & Berenbaum, 2006).

Gender identity develops over time (de Vries et al., 2014; Ruble et al., 2006). Male versus female gender behavior differences are present at birth; newborn girls spend longer time looking at interpersonal features of stimuli than do boys. Infants as young as 3–4 months old distinguish between male and female features, and by 2 years of age children understand gender labels. Three-year-old children can usually identify their own gender and are more likely to play with gender-typical toys. The degree to which an individual engages in sex-typical behavior is relatively constant from toddlerhood through adolescence (de Vries et al., 2014). Gender variant behavior often is first noticed in early childhood and may range from children playing with gender-atypical toys and dressing in atypical clothing to children expressing a desire to be the other gender, intense anatomic dysphoria, or insisting that they are the other gender.

Gender dysphoria (GD) is diagnosed when there is (1) “marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration,” and (2) this incongruence is associated with clinically significant distress (American Psychiatric Association, 2013, pp. 452–453). The majority of children with GD no longer meet criteria by the time they reach adolescence or adulthood (Ristori & Steensma, 2016); childhood GD intensity, older age at GD diagnosis, female assignment at birth, and early cross-gender identification predict persistent GD into adolescence (Steensma, McGuire, Kreukels, Beekman, & Cohen-Kettenis, 2013). Childhood GD has a high association with a lesbian, gay, or bisexual orientation (Ristori & Steensma, 2016). Adolescents presenting with GD typically report significant gender variant behavior occurred earlier in childhood, although a more recent “late-onset” GD first presenting in adolescence has been reported (Cohen-Kettenis & Klink, 2015).

Transgender/GNC Youth and Psychosocial Functioning

There is a rapidly growing body of literature describing the mental health disparities experienced by transgender and GNC youth. The documented increased risk for mental health problems has been linked to the dysphoria/distress experienced when one’s gender assignment does not match their gender identity as well as the stress experienced from societal discrimination and prejudice (e.g., Cass’ Minority Stress Model; Hatzenbuehler & Pachankis, 2016).

ADHD and ASD

Higher rates of externalizing disorders such as ADHD and ASD have been found in the transgender population. In a recent study of a large sample of transgender youth (588 transgirls and 745 transboys), Becerra-Culqui et al. (2018) observed increased rates of ADHD in transgender children (15%) and adolescents (19.5%) compared to epidemiological estimates ranging from 5 to 10% in the general population. Indeed, ADHD was the most common mental health diagnosis observed in the child sample; however, the reason for this phenomenon is unknown. ADHD is associated with increased risk taking and impulsive behavior; thus clinicians should be aware of the presence of ADHD and work with trans youth to manage symptoms as it could lead to health risks, e.g., sexually transmitted infections (STIs) or substance use.

In the same study, 7% of the transgirls and 3% of transboys met criteria for ASD (versus 1% of the general population). It is important to note that this study did not perform a full diagnostic assessment for ASD and solely utilized a standardized diagnostic interview; however, other studies have observed similar increased rates of ASD in transgender youth (e.g., de Vries, Noens, Cohen-Kettenis, van Berckelaer-Onnes, & Doreleijers, 2010). Theories posited to explain the co-occurrence of ASD and GD include the male brain theory, fetal testosterone exposure, lack of attention paid to social constructs and schemas like gender, or that the social impairment experienced by those with GD (e.g., social isolation) may mimic symptoms of high functioning ASD (Glidden, Bouman, Jones, & Arcelus, 2016). Although these individuals present as more complex, they should not be excluded from receiving transgender-related medical treatment if deemed appropriate and gender dysphoria should not be seen/treated as a symptom of ASD.

Anxiety and Depression

The occurrence of internalizing disorders in transgender youth has been well established. Becerra-Culqui et al. (2018) found anxiety to be the second most common diagnosis in children and adolescents with GD (15% and 38%, respectively). Chodzen, Hidalgo, Chen, and Garofalo (2018) found that internalized transphobia (i.e., the shame one feels about their identity) positively predicted a diagnosis of generalized anxiety disorder in a sample of adolescent with GD. Indeed, many youths with GD describe having few friends and self-isolate due to shame and fear. Among adolescents with GD, depression is the most common mental health diagnosis, occurring in over half of the adolescent sample (Becerra-Culqui et al., 2018). Transgender and GNC youth are at increased risk for self-harm, suicide ideation, and suicide attempts. A recent large-scale study comparing rates of suicide attempts between transgender youth and cisgender youth found 50.8% of transmen and 29.9% of transwomen had attempted suicide compared to 17.6% for cisgender females and 9.8% for cisgender males (Toomey, Syvertsen, & Shramko, 2018). Notably, risk for suicide attempts doubles if families moderately reject a trans family member and the risk triples if there is a high amount of rejection (Klein & Golub, 2016). Factors found to protect against poor mental health outcomes in this population include positive self-esteem, supportive family and peer relationships, and community connections (Johns, Beltran, Armstrong, Jayne, & Barrios, 2018). Other studies have noted the positive effects of social transition (e.g., allowing youth to wear what they choose) and other people using youth’s preferred name (Durwood, McLaughlin, & Olson, 2017; Russell, Pollitt, Li, & Grossman, 2018). Supportive environments and especially parental support can reduce risk for internalizing symptoms to levels found in the general population (Ryan, Russell, Huebner, Diaz, & Sanchez, 2010).

The CL psychologist is unlikely to receive a consultation for gender identity specifically unless they are working within a clinic that serves this population. However, nonspecialized practitioners are likely to interface with these youth under a variety of circumstances. Psychologists should be aware that consultation requests received for such concerns as “behavioral problems,” “family stress,” “suicide attempt,” etc., may include a gender identity component. Given the high rate of occurrence of mental health issues in these youth, it is important that psychological consultation services in medical settings establish sensitive assessment strategies to identify and competently address these issues.

Disorder(s)/Differences of Sex Development (DSD)

DSD are defined as congenital conditions in which a person’s sex chromosomes, internal or external reproductive anatomy, or gonads have developed atypically (Lee, Houk, Ahmed, & Hughes, 2006). Incidence of DSD is estimated to be 1:4500–5000 live births (Sax, 2002). DSD are classified into three categories based on karyotype (Table 1) and range in acuity from presenting as a medical emergency, e.g., salt-wasting Congenital Adrenal Hyperplasia (CAH), to conditions for which no medical or surgical care is required, e.g., mild hypospadias. DSD often co-occur with other congenital anomalies that may pose greater mortality risk (e.g., congenital heart disease). DSD are most commonly diagnosed during the neonatal period when the infant’s genitalia are first clearly visualized, and gender assignment may be delayed while further diagnostic workup proceeds including karyotyping and other genetic testing, imaging studies of internal structures, and lab work detailing sex hormone levels. Assignment of infant gender in such cases takes into consideration a variety of factors: medical diagnosis, implications for hormone therapy, fertility potential, genital appearance, surgical options, predicted gender identity given diagnosis (when evidence is available), and caregiver preference (Lee et al., 2006). Other common diagnostic time points include surgical exploration of an inguinal hernia in girls, atypical or absent pubertal development, or fertility challenges; thus, psychologists may be supporting patients and families across the developmental span in coping with a new diagnosis.

Table 1 Categories of disorders/differences of sex development
Full size table

Medical care related to DSD often involves hormone therapy to influence genital development or steroids (in the case of CAH). Surgical treatment may be indicated in some conditions, e.g., if atypical gonadal development or placement increases cancer risk, or when the formation of urogenital structures block urine or menstrual fluid flow. Surgery may also occur to change the appearance of atypical genitals. These procedures are commonly initiated by the parents of infants, but have become the focus of controversy of advocacy and human rights groups due to the inability of the infant to consent to these irreversible and “not medically urgent” procedures (Human Rights Watch, 2017). Of note, many persons/families affected by these conditions reject the term DSD, expressing concerns that the term medicalizes, pathologizes, or stigmatizes the condition. Some individuals prefer condition-specific terminology (e.g., CAH), or prefer the term “intersex,” which has a stronger association with identity and the gender spectrum (Johnson et al., 2017). As with transgender pronouns, asking individuals and families what term they prefer is the recommended patient-centered approach.

DSD and Psychosocial Functioning

Most individuals with DSD maintain their assigned gender throughout their lifetime, although higher rates of both gender change and nonbinary gender identification (compared to the general population) have been documented (e.g., 3% gender change, 4% nonbinary gender; Kreukels et al., 2018). Findings from studies on more general psychological functioning and quality of life are mixed, with some reporting overall good psychological adjustment, while others note significant psychiatric and social concerns (e.g., Engberg et al., 2017; Meyer-Bahlburg, Khuri, Reyes-Portillo, & New, 2016; Nordenström, 2015). The adjustment of caregivers has also been explored, particularly during infancy, with many caregivers of infants with a DSD reporting high levels of distress (e.g., Pasterski, Mastroyannopoulou, Wright, Zucker, & Hughes, 2014).

Gender Identity: Consultation and Assessment

Given the psychosocial risk associated with GD, it is recommended that evaluations of preadolescents and older patients should routinely include an assessment of gender identity. Normalizing approaches can decrease fear and stigma related to disclosure. For example, a question such as “some children see themselves as a girl, some see themselves as a boy, and some see themselves as both of those or something entirely different—how do you see yourself?” conveys that a range of responses are acceptable. If youth appear to be unclear or questioning their gender identity, their uncertainty and level of confusion and/or distress can be queried. It is important to remember that youth may be questioning, or identify as nonbinary or transgender, without notable distress. Assessing level of distress is important as dysphoria contributes to negative mental health outcomes such as suicide attempts. Questions assessing this include the following: “How do you feel about your body?” “What would you change about your body if anything?” “Are there specific times when you feel worse about your body or gender? What makes it worse?”

Assessment via clinical interview should include eliciting an individual/family’s gender narrative or gender journey. Gender is a multifaceted, internal, social construct and every journey is unique; many youth are eager to share the details of their story, which can help in building rapport. One aspect of establishing a diagnosis of GD is establishing a developmental timeline in order to establish consistency, insistency, and persistency. Two particular factors have been shown to predict stability of transgender identity into adolescence and adulthood: intensity of GD and tendency to discuss gender cognitively rather than affectively (“I am a boy” versus “I feel like a boy”; Steensma et al., 2013). Both factors can be assessed through the gender narrative. If gender identity appears to be a large aspect of the case conceptualization or referral question, self-report rating scales of body image/dissatisfaction and gender identity can also be used, such as the body image scale (for older children/adolescents; Lindgren & Pauly, 1975), the transgender congruence scale (validated for 18 and older but appropriate for older adolescents; Jones, Bouman, Haycraft, & Arcelus, 2018), the multidimensional gender identity scale (for children/adolescents; Egan & Perry, 2001), and the gender identity interview (Zucker et al., 1993; for review see Zucker, 2005), all of which are brief enough for the medical consultation setting. Patients may be more forthcoming if these areas are explored without parental presence. Parental input will likely be required for younger patients, which can be facilitated via a parent-report measure assessing child gender identity (Johnson et al., 2004). Of note, these measures have limited evidence supporting psychometric validity and reliability (this research is ongoing), particularly when used within the DSD population.

Beyond gender, consultations with patients reporting gender concerns and/or DSD condition should include the areas of functioning typically assessed in behavioral health consultations, such as family, school and peer functioning, and overall emotional/behavioral functioning (see the Assessment chapter). Peer victimization has been shown to influence the relationship between gender atypicality and psychosocial adjustment (Smith & Juvonen, 2017). Thus, the quality of peer relationships should be carefully assessed. Finally, given the high rates of self-harm, suicidal ideation, and suicide attempts in these populations, particularly in transgender youth, a thorough risk-safety assessment should be performed. Risk factors that should be assessed include parental support, peer support, school support, degree of affirmation, co-occurring depression, substance use, previous self-harm or suicide attempts, and family history of suicide. Conversely, protective factors should also be assessed including level of acceptance and support (parental, peer, school, societal), as well as access to and utilization of mental health services. For transgender youth, initiating transition may also be protective.

Of note, a psychosocial evaluation of youth and families with DSD or GD should be conducted with the standard pediatric psychology focus on resiliency  factors. Though these populations are at higher risk for mental health difficulties, they should not be treated as innately pathological. Especially with GD, mental health professionals have often been rightfully perceived as functioning as “gatekeepers” to patients’ access to life-saving treatments (e.g., hormonal therapies). Assessment of individuals requesting transition is now conceptualized as an avenue to confirm diagnosis of GD, evaluate knowledge and informed consent capabilities, and ultimately lead to appropriate referrals for medical and mental health interventions. The pediatric psychologist consultant should play an active role in facilitating referral to appropriate and competent providers.

Psychosocial Interventions for Transgender/Gender Nonconforming Youth

Addressing Mental Health Concerns

The American Psychological Association (APA) has produced competency guidelines for psychologists treating individuals who identify as transgender or gender nonconforming (American Psychological Association, 2015). Affirmative care is the current primary therapeutic framework with transgender/gender nonconforming youth, which supports variability in gender expression based on research suggesting that lack of acceptance poses significant psychosocial risk (Edwards-Leeper, Leibowitz, & Sangganjanavanich, 2016; but see Berenbaum, 2018, for cautions related to this approach). Though there are currently no specific evidence-based therapies for this population, there are numerous evidence-based therapies used in the treatment of depression and anxiety that are appropriate for their clinical concerns. For example, a transgender youth who is afraid to go out in public may benefit from exposure therapy. A transgender youth with depression and/or self-harm may benefit from cognitive-behavioral therapy or dialectical behavior therapy. Given that many transgender youths are in situations that cannot be changed (e.g., being misgendered in public), many may benefit from acceptance and commitment therapy which strives to acknowledge emotional situations while promoting value-based behavior.

Addressing Family Dynamic Issues

In addition to treating mental health difficulties, there are other tasks therapists can help transgender patients complete that have been shown in the research to have positive effects on well-being. As stated earlier, there is an increased risk for depression and suicide if families reject their children after coming out. Pediatric psychologists embedded in medical settings are uniquely positioned to facilitate family sessions that foster healthy, positive communication in addressing barriers in accepting and supporting their transgender child, including informing them of the damaging effects of rejection and the positive effects of their understanding and acceptance. One study found that supportive parents, defined in this study as those providing help, advice, and confidant support, increased transgender individual’s life satisfaction, lowered the burden of being transgender, and reduced depressive symptoms (Simons, Schrager, Clark, Belzer, & Olson, 2013).

Additionally, data has shown that using affirmed name and pronouns reduces depressive symptoms, suicidal ideation, and behaviors. Russell et al. (2018) found that by adding one additional setting where a youth’s chosen name and pronouns were used reduced depressive symptoms by five points (0–60 scale), suicidal ideation by 29%, and suicide behaviors by 56%. Providers should review their institutional policies regarding names and pronouns and advocate for patients to be referred to by their preferred name and pronouns when in the medical setting. Some electronic medical records have included a nickname or AKA in addition to legal name as well as a gender marker in addition to sex. Of note, it is important to ask a patient’s permission before changing the chart (“Would you like me to make a note in your chart of your preferred name and pronouns? This way other staff will know how to refer to you”). Not all patients and families will be ready to socially transition in the medical setting.

In line with this research, Durwood et al. (2017) observed that socially transitioned youth (e.g., out and asking to be affirmed in multiple settings) showed no significant differences in self-worth or depressive symptoms when compared to cisgender peers. A very individualized approach is critical when working with youth who experience GD and desire social transition (Edwards-Leeper et al., 2016). The psychologist provider role can include exploring motivations and expectations for transition, identifying the range of possibilities for initiating or progressing transition, bolstering peer and family support, and problem-solving to optimize a healthy and safe social transition. Transition ideally begins in the home with caregivers and immediate family and then extends to other settings such as school or work. Social transition requires that schools allow transgender patients to go by affirmed name and pronouns, use affirmed gender facilities (bathroom/locker rooms), participate on affirmed gender teams, and above all else have access to a safe environment conducive to learning. Psychological intervention can function as an initial liaison between the family and school, increasing effective communication and reducing stress.

Addressing Health and Wellness Behaviors

Lastly, patient and family negative health behaviors should be addressed. For example, transgender youth are at higher risk for substance use (Day, Fish, Perez-Brumer, Hatzenbuehler, & Russell, 2017) and STIs (highest rates of HIV are observed in the transgender female population; Kellogg, Clements-Nolle, Dilley, Katz, & McFarland, 2001). Psychological interventions should promote positive health behaviors to reduce rates of substance use and STIs. Moreover, providers may have unique opportunities if a patient is seeking gender-affirming hormone therapy. In addition to writing letters of support to medical providers on behalf of their patients, providers can also address smoking and weight management. Patients seeking estrogen therapy will be at increased risk for stroke; those risks are increased with smoking. Similarly, patients seeking testosterone will be at increased risk for high cholesterol; being a healthy weight and maintaining a balanced diet can decrease this risk.

Diverting Families from Controversial Approaches

With transgender youth, the approach commonly known as conversion therapy should be avoided due to its harmful effects. This highly questionable approach, sometimes referred to as reparative therapy, aims to change an individual’s sexual orientation or gender identity to conform to societal norms (i.e., heterosexual and cisgender). A recent retrospective study exploring long-term outcomes of adults who were referred for conversion therapy in adolescence revealed higher rates of depression, suicidal thoughts, suicide attempts, lower educational attainment, and lower weekly income (Ryan, Toomey, Diaz, & Russell, 2018). The APA, American Academy of Child and Adolescent Psychiatry, and the American Academy of Pediatrics have all deemed this therapy unethical. Numerous states have outlawed the therapy (14 states and the District of Columbia when this chapter was written) and more have pending bills awaiting approval. Families interested in seeking this form of therapy should be given the above information and should be cautioned from participating in such an approach.

DSD

Given the complexity of DSD, care consensus statements and clinical guidelines advise that affected individuals and their families receive care within the context of a multidisciplinary team, including the presence of a behavioral health specialist (Cools et al., 2018; Lee et al., 2006). Thus, working with teams to routinely consult psychology when DSD is known or suspected is recommended. While DSD-specific psychological interventions have not been developed or tested, evidence-based treatments from other chronic conditions may be of use (Eccleston, Palermo, Fisher, & Law, 2012). Therapeutic tasks are largely dependent on time of diagnosis, developmental level of the patient, specific DSD condition, and setting (Sandberg, Gardner, & Cohen-Kettenis, 2012). With neonatal diagnosis, psychologists consulting on inpatient units or at outpatient medical visits can target parental postpartum depression or anxiety, coping with differences in infant’s physical appearance, receiving unexpected and unwelcomed news, and dealing with uncertainty (particularly if gender assignment is delayed). In addition, caregivers may have been given inaccurate information from medical providers who do not have expertise in the condition; thus, it is essential that behavioral health providers optimize family knowledge to enhance both coping and decision-making. In addition, consulting psychologists can facilitate effective and supportive physician-family communication, including emphasizing the healthy aspects of the infant (Liao & Simmonds, 2013). Coaching caregivers in self-care and using cognitive-behavioral strategies to enhance coping may be helpful, as has been demonstrated in studies of caregivers in the NICU (not specific to DSD; Mendelson, Cluxton-Keller, Vullo, Tandon, & Noazin, 2017). Problem-solving interventions (Sahler et al., 2005) may also be of use, particularly in working with families on information-sharing strategies related to their family, friends, and other people involved in the infant’s care, with the goal of enhancing social support and decreasing shame-inducing secrecy. In addition, it is within the role of the psychologist consultant to insist that families are receiving a robust shared decision-making process related to all important decisions such as gender assignment and medical and surgical interventions (Tamar-Mattis, Baratz, Baratz Dalke, & Karkazis, 2014).

As children age, ongoing education for parents on gender identity is important, for example, that their child can be content with their gender assignment even as they display gender atypical behaviors and the risk of compromised child adjustment when a child perceives parental pressure to conform to gender stereotypes. Educating parents on the harms associated with withholding developmentally appropriate information from children about their anatomical differences, medical condition, or future fertility is essential, as is supporting hesitant parents in the act of information sharing with their child in a developmentally appropriate manner (Liao & Simmonds, 2013).

Providing psychological support to patients with a DSD depends on developmental stage and presenting concerns. With younger children, body acceptance and highlighting child strengths are a general good strategy, as is education related to gender identity/roles/behaviors (“You can be a boy who likes to dance!”)—a number of children’s books are available that celebrate differences (https://www.dsdfamilies.org/parents/childrens-books). As children age, assessing for gender concerns or stigma/shame related to karyotype or body image is important to facilitate positive self-image and adjustment; if these concerns are noted, psychoeducation and cognitive-behavioral strategies may be implemented (perhaps specifically targeting differences; Clarke, Thompson, Jenkinson, Rumsey, & Newell, 2013). In adolescence and young adulthood, providing support and problem-solving around interpersonal/sexual intimacy or experimentation, interpersonal communication with significant others, and fertility concerns may be targets of intervention. Behavioral health providers may also assist with the treatment burden associated with DSD, such as increasing adherence to hormone therapy, coping with medical exams (Tishelman, Shumer, & Nahata, 2017), or decreasing anxiety related to vaginal dilation.

Conclusion

Pediatric psychologists’ systems orientation and competence in assessment, enhancing emotion/behavior regulation, and communication dovetail with the needs of youth with DSD and/or gender variance and their families. The current dynamic sociocultural zeitgeist of gender identity creates opportunities for consulting psychologists to positively influence the experience of individuals and families by facilitating comprehensive health care that is up-to-date, person-centered, and informed by scientific evidence.