Clinical Practice in Pediatric Psychology © 2014 American Psychological Association

2014, Vol. 2, No. 4, 400 – 411 2169-4826/14/$12.00 http://dx.doi.org/10.1037/cpp0000077

An Emerging Opportunity for Pediatric Psychologists: Our Role in a

Multidisciplinary Clinic for Youth With Gender Dysphoria

Melissa K. Cousino Ajuah Davis, Henry Ng,

Case Western Reserve University and Boston and Terry Stancin
Children’s Hospital and Harvard Medical School MetroHealth Medical Center, Cleveland, Ohio, and
Case Western Reserve University
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

An increasing number of youth are identifying themselves as gender variant (e.g.,

This document is copyrighted by the American Psychological Association or one of its allied publishers.

transgender) or nonconforming with culturally defined biological sex-based norms.

Children with persistent gender dysphoria (GD) are at risk for psychological distress;
subsequently, there has been a rise in the number of families, schools, and health-care
providers seeking mental health services and advice regarding medical interventions for
youth experiencing significant GD. Pediatric psychologists are well positioned to fulfill
this need given their expertise in child development and child emotional and behavioral
functioning in addition to their experiences working alongside medical teams and with
patients undergoing medical treatments. This article describes the development and
implementation of a hospital-based multidisciplinary clinic for gender-variant youth.
Particular emphasis is paid to the role of the pediatric psychologist within the clinic. A
case example is illustrated. Obstacles and future directions for pediatric psychologists
working in this area are highlighted.

Keywords: gender dysphoria, gender variance, transgender, multidisciplinary clinic, program

development

The American Psychological Association Statistical Manual of Mental Disorders, Fourth

Task Force on Gender Identity and Gender
Variance (APA, 2009) reported that psycholo-
gists are in increasingly greater demand as
awareness and support for persons identifying
as gender variant increase. The terms gender
variant, gender noncomforming, or transgender
are used to describe those whose self-identity or
self-expression does not conform to culturally
defined norms for one’s biological sex (APA,
2009). For the past decade, the Diagnostic and
This article was published Online First October 27, 2014.
Melissa K. Cousino, Department of Psychological Sci-
ences, Case Western Reserve University, and Division of
Psychiatry, Boston Children’s Hospital and Harvard Medi-
cal School; Ajuah Davis and Henry Ng, Department of
Pediatrics, MetroHealth Medical Center, Cleveland, Ohio,
and Department of Pediatrics, Case Western Reserve Uni-
versity; Terry Stancin, Departments of Pediatrics and Psy-
chiatry, MetroHealth Medical Center, and Department of
Pediatrics, Case Western Reserve University.
Correspondence concerning this article should be ad-
dressed to Terry Stancin, Division of Child and Adolescent
Psychiatry and Psychology, MetroHealth Medical Center,
2500 MetroHealth Drive, Cleveland, OH 44109. E-mail:
tstancin@metrohealth.org
400
Edition (DSM–IV; American Psychiatric Asso-
ciation, 2000) described children and adults
who experience “strong and persistent cross-
gender identification” and “persistent discom-
fort with his or her sex or a sense of inappro-
priateness in the gender role of that sex” (p.
581) as having gender identity disorder (GID).
However, the Diagnostic and Statistical Man-
ual of Mental Disorders, Fifth Edition (DSM-5;
American Psychiatric Association, 2013) re-
cently replaced GID with “gender dysphoria
(GD),” which places focus on the clinically
significant distress associated with the condition
rather than on the behavioral manifestations. To
be diagnosed with GD, there must be a marked,
persistent, and verbalized discrepancy between
the child’s expressed gender and the gender
assigned to him or her by others that causes
clinically significant distress or impairment in
functioning. Children and adolescents with GD
express strong desires to be treated as the other
gender and to be rid of their biologic sex char-
acteristics. They often describe having feelings
and reactions typical of a different gender
(American Psychiatric Association, 2013).
 PEDIATRIC PSYCHOLOGY AND YOUTH GENDER DYSPHORIA
Youth with GD and transgender adults may be
identified by their preferred (or reassigned) gen-
der as “male-to-female” (MTF) or “female-to-
male” (FTM).
The prevalence of childhood GD is very dif-
ficult to determine, and no epidemiologic stud-
ies have been performed to date (Institute of
Medicine, 2011; Zucker & Lawrence, 2009);
however, it has been established that more fam-
ilies are seeking services to address the psycho-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
social and medical needs of children, adoles-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
cents, and young adults who are increasingly
more likely to indentify themselves as gender
variant (APA, 2009). For example, a Canadian
gender clinic reported a near tripling in number
of referrals since 1976 (Zucker, Bradley, Owen-
Anderson, Kibblewhite, & Cantor, 2008). Like-
wise, the first U.S.-based multidisciplinary gen-
der clinic has experienced a 4-fold increase in
the number of patients seen annually since 1998
(4.5 patients/year; Spack et al., 2012). This may
be attributed to growing media attention and
public awareness about gender variance in
childhood and adolescence (APA, 2009; Zucker
et al., 2008) and the increasing availability of
care options (Olson, Forbes, & Belzer, 2011),
such as medical interventions to suppress pu-
berty. With this increased awareness and inter-
est in the experiences of gender-variant youth,
health-care providers must carefully consider
and reexamine how care is to be delivered. As
Edwards-Leeper and Spack (2012) recently
noted, we are amid a time of transition and
development with regards to the treatment of
gender-variant youth.
However, the lack of longitudinal and treat-
ment outcome studies in this area brings about
several challenges for treatment providers
(Olson et al., 2011). Although data are limited,
GD may not persist into adolescence for many
children. For example, of the 77 children ages
5–12 years with GD followed prospectively by
Dutch researchers, 43% denied persistent dys-
phoria as an adolescent. Among this group, all
of the natal girls reported a heterosexual orien-
tation and half of the natal boys reported a
heterosexual orientation. Greater intensity of
GD at baseline as measured by various parent-
and child-reported questionnaires and semi-
structured interviews was found to be associated
with persisting GD in adolescence. Of the 77
participants, 27% reported persisting GD and
nearly this entire group self-identified as homo-
401
sexual or bisexual at follow-up, with sexual
orientation classified in accord with natal sex
(Wallien & Cohen-Kettenis, 2008). Of note,
30% of participants could not be reached at
follow-up; thus, they were not included in fol-
low-up analyses. Similar to these recent find-
ings, other studies suggest that approximately
12–27% of early childhood cases of GD persist
into adolescence and beyond (Drummond,
Bradley, Peterson-Badali, & Zucker, 2008;
Zucker & Bradley, 1995). Thus, although the
most likely outcome of childhood-onset GD is
homosexuality or bisexuality (Wallien & Co-
hen-Kettenis, 2008) in adolescence and adult-
hood, there is no clear way to predict which
children will have persisting GD in later years.
Emerging research from a study of 127 adoles-
cents with childhood GD suggests that greater
intensity of GD in childhood is correlated with
higher likelihood of GD persistence (Steensma,
McGuire, Kreukels, Beekman, & Cohen-
Kettenis, 2013).
For children with GD, the mental health-care
needs are often great. Psychosocial distress may
also intensify with the onset of puberty and the
emergence of secondary sex characteristics
(e.g., American Academy of Pediatrics, 2013).
Youth who are distressed by their biological sex
and/or assigned gender role are at increased risk
for depression and anxiety. Suicidal ideation
and self-injurious behaviors are also higher
among children and adolescents with GD
(Spack et al., 2012; Wallien, Swaab, & Cohen-
Kettenis, 2007). For example, among a sample
of children and adolescents with GD, 44% had
received a previous psychiatric diagnosis, 35%
were prescribed psychiatric medications, 20%
reported a history of self-injurious behaviors,
and 9% reported a past suicide attempt(s) and
psychiatric hospitalization. Of those with a pre-
vious psychiatric diagnosis, depression (25%),
generalized anxiety disorder (7%), and bipolar
disorder (7%) were most common among the
sample (Spack et al., 2012). Externalizing prob-
lems are also more common among youth with
GD as compared with children without GD
(Saewyc et al., 2006). Many children and ado-
lescents with GD experience teasing, bullying,
and peer rejection. Furthermore, physical and
sexual abuse is often greater among this popu-
lation (Saewyc et al., 2006).
Given the psychosocial risks, medical inter-
vention that facilitates an adolescent’s transition
 402 COUSINO, DAVIS, NG, AND STANCIN
to a more desired gender appearance may be
considered. The first multidisciplinary pediatric
gender specialty clinic in North America was
the Gender Management Service (GeMS) at
Boston Children’s Hospital. The GeMS pro-
gram, which includes representatives from pe-
diatric endocrinology, urology, psychology,
psychiatry, and social work, was founded in
2007; however, the hospital has provided med-
ical-based services to transgender youth since
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1998 (Spack et al., 2012). On the basis of their
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work at GeMS, Edwards-Leeper and Spack
(2012) reported the following psychological
benefits of reversible pubertal suppression: pre-
venting and/or reducing psychological sequelae,
having extended time to meet with a mental
health professional for assessment and self-
exploration of gender identity, and allowing for
an easier full transition in adulthood if desired.
Emerging research from other centers supports
these clinical findings. Moreover, of 70 adoles-
cents diagnosed with GD following a compre-
hensive psychological intervention to determine
appropriateness for medical intervention who
were subsequently treated with puberty-
suppressing hormones, all continued with their
transition to the desired sex by pursuing addi-
tional treatment options (i.e., cross-gender hor-
mone therapy) (de Vries, Steensma, Doreleijers,
& Cohen-Kettenis, 2010). Although research is
beginning to suggest that medical intervention
can promote improvements in psychological
functioning of youth with GD, the treatment
options are complicated with considerable eth-
ical and developmental considerations.
On the one hand, there is significant dis-
tress and risk for psychological morbidities
that may be reduced with medical interven-
tions (e.g., Edwards-Leeper & Spack, 2012).
However, as research shows, it is difficult to
determine for whom GD will persist (Wallien
& Cohen-Kettenis, 2008). Therefore, given the
psychological risks present among this popula-
tion, developmental considerations, limited ev-
idence-based guidelines, and complicated med-
ical treatment options, pediatric psychologists
are well positioned to work as leaders and mem-
bers of multidisciplinary specialty teams for
gender-variant youth. In addition to having ex-
pertise in child development, family systems,
and the treatment of childhood psychological
disorders, pediatric psychologists have special-
ized training in serving children and families
undergoing medical treatments and procedures.
Moreover, pediatric psychologists are skilled in
helping children and families navigate challeng-
ing medical decisions. These skills are particu-
larly important within the context of pediatric
gender clinics. In addition, pediatric psycholo-
gists are well versed in working alongside pe-
diatricians and as members of medical teams.
As the need for multidisciplinary pediatric gen-
der clinics increases, the services of pediatric
psychologists will be in greater demand. Given
its novelty, especially in the realm of pediatric
psychology, the purpose of this article is to
describe a multidisciplinary specialty clinic for
gender-variant youth with particular emphasis
given to the important role of pediatric psychol-
ogists in this area of clinical practice. Guide-
lines for clinical practice are highlighted and a
case example is provided.
The KIDz PRIDE Clinic at MetroHealth
Medical Center
Who We Are
MetroHealth Medical Center is an urban,
public, academic medical system affiliated with
Case Western Reserve University in Cleveland,
Ohio. Most pediatric patients served at Metro-
Health Medical Center qualify for Medicaid
health insurance coverage. Initiated in 2008, the
KIDz PRIDE Clinic at MetroHealth Medical
Center is dedicated to the care and support of
gender-variant and transgender children, ado-
lescents, and their families. The KIDz PRIDE
Clinic was developed in response to the needs
of gender-variant children who presented for
initial consultation through the adult LGBT
PRIDE Clinic at MetroHealth Medical Center,
which was established in 2007 as the region’s
first specialty clinic devoted to the health-care
needs of the lesbian, gay, bisexual, and trans-
gender (LGBT) communities. The clinic model
was developed in accordance with the guide-
lines set forth by the World Professional Asso-
ciation for Transgender Health (WPATH) and
the Endocrine Society (Coleman et al., 2012;
Hembree et al., 2009; Meyer, Bockting, Cohen-
Kettenis, & Harry Benjamin International Gen-
der Dysphoria Association, 2011). Emerging
research from GeMS at Boston Children’s Hos-
pital and the VU Medical Center in Amsterdam,
the Netherlands provides additional guidance
 PEDIATRIC PSYCHOLOGY AND YOUTH GENDER DYSPHORIA
for the medical and psychological services pro-
vided in our clinic; however, albeit similar, our
clinic is not a direct replication of these previ-
ously established clinics. Our program was de-
veloped in response to a need in a varied setting
from those previously established given the
largely under-resourced population serviced by
our hospital.
The KIDz PRIDE Clinic is serviced by a
multidisciplinary team that includes specialists
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and trainees from the areas of pediatric psychol-
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ogy, pediatric endocrinology, internal medicine/
pediatrics, and social work. To date, the KIDz
PRIDE Clinic has provided care for 20 youth
and their families ranging in age from 7 to 19
years seeking gender-related medical and men-
tal health-care services. The mean age of cur-
rent patients is 14.5 years (⫾3.0), with 50%
identified as FTM and 50% as MTF. Families
most commonly learn of our services via social
media, Internet searches, and by word of mouth.
We have not formally advertised or marketed
our clinic, which may explain the small patient
population, in addition to the unknown inci-
dence rate of GD in children. Because there are
so few similar programs in the country, and
none to our knowledge that serve a predomi-
nantly Medicaid population, patients and fami-
lies travel from all over the state to receive the
multidisciplinary, specialized care offered by
the KIDz PRIDE Clinic.
Summary of Medical Services, Clinical
Guidelines, and Competencies
The pediatrician is often the initial point of
contact for families with gender-variant chil-
dren who seek gender-related services. The pe-
diatrician conducts the initial biopsychosocial
interview with parent(s) and child and a physi-
cal exam. The pediatrician introduces the family
to our clinic, educates the family about their
options, explains the roles of all team members,
and provides resources (e.g., local community-
based support groups for transgender people,
web-based references on gender and sexuality).
It is recommended that all patients and families
are seen by the team’s pediatric psychologist
before beginning medical intervention for a
thorough assessment, which is detailed below.
For those considering medical intervention, a
referral is made to the team’s pediatric endocri-
nologist who has expertise in the management
403
of children with early or late pubertal develop-
ment and disorders of sexual differentiation.
Graduate-level trainees in psychology and med-
icine also participate in the provision of clinic
services. Although each specialist sees patients
and families during separate visits, attempts are
made to coordinate for same-day appointments
when possible. The team meets monthly to dis-
cuss cases and treatment plans. The team con-
tinuously works together to assess and monitor
each child’s psychological and physical appro-
priateness and readiness for medical interven-
tion.
Given that many cases of childhood GD do
not persist into adulthood (Wallien & Cohen-
Kettenis, 2008), medical care for children ne-
cessitates a different approach from that of
adults (Coleman et al., 2012). The Endocrine
Society’s Transgender Task Force (Hembree et
al., 2009) recommends that a diagnosis of GID
be made by a mental health professional before
considering medical intervention, albeit this
will likely be updated given the recent DSM-5
changes. Specifically, for children and adoles-
cents, the task force notes that this diagnosis
should be made by a trained mental health pro-
fessional with expertise in developmental psy-
chopathology (Hembree, 2011; Hembree et al.,
2009). The diagnosing mental health profes-
sional refers the child to medical providers for
the consideration of medical interventions, such
as pubertal suppression, only after thorough as-
sessment has been performed. In addition to a
diagnosis of GD, other eligibility criteria for
pubertal suppression include increases in GD at
the onset of puberty, available psychosocial
support, absence of serious psychiatric comor-
bidities, and awareness and understanding of
pubertal suppression treatment outcomes
(WPATH Guidelines; Meyer et al., 2011).
Reversible pubertal suppression starting at
the onset of puberty (i.e., Tanner stage II), in
combination with a societal role change to the
desired gender, is recommended as the first
form of medical intervention (Hembree et al.,
2009). It is recommended that pubertal suppres-
sion begins at the first sign of puberty (Tanner
stage II sexual development), which is typically
indicated by breast development (age range
8.25–12.1 years) in girls and testicular enlarge-
ment (ages 9 –13.5 years) in boys (Hembree et
al., 2009; Hughes, 2008; Rosenfield, Cooke, &
Radovick, 2008). These changes are detected by
 404 COUSINO, DAVIS, NG, AND STANCIN
physical examination and confirmed by labora-
tory and X-ray studies. This intervention allows
an individual time to more fully experience their
desired gender role before the initiation of
cross-gender hormone treatment or the develop-
ment of irreversible physical changes (Coleman
et al., 2012; Hembree et al., 2009). The task
force recommends that gonadotropin releasing
hormone (GnRH) therapy be used to suppress
the pituitary-gonadal axis before the onset of
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full biological puberty (Hembree et al., 2009).
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Leuprolide acetate (i.e., Lupron), given as a
once-monthly or once every 3 months intramus-
cular injection, is the most widely used GnRH
agent in the United States. A subcutaneous his-
trelin acetate implant, which provides continu-
ous hormonal suppression for 12 months, is also
available. As a result of these treatments, sec-
ondary sex characteristics regress or are halted
in their progression (Lee, 1994; Rosenfield et
al., 2008; Wheeler & Styne, 1991). For these
reasons, in addition to the emerging research
highlighting the psychological benefits of this
approach (de Vries, Doreleijers, Steensma, &
Cohen-Kettenis, 2011; Spack et al., 2012), pu-
bertal suppression is the most common medical
intervention currently utilized in our clinic. Of
our 20 patients, 6 are being treated with GnRH
to suppress puberty.
Throughout this intervention course, the
team’s pediatric endocrinologist provides close
monitoring of the hormonal regimen so that the
desired outcomes are reached based upon an
adapted treatment protocol for central preco-
cious puberty (Coleman et al., 2012; Hembree
et al., 2009; Rosenfield et al., 2008). Endocrine
follow-up is recommended quarterly for the first
year and 1–2 times annually in following years
to monitor for adequate pubertal suppression
and any negative side effects.
Once an adolescent is past the age for which
puberty is expected, questions about partially
reversible cross-gender hormone therapy may
arise, although this is not true for all youth with
GD. Given research suggesting that GD may
not persist for some adolescents beyond child-
hood, WPATH and the Endocrine Society ad-
vise that cross-gender hormone treatment not be
introduced until approximately 16 years of age
(Coleman et al., 2012; Hembree et al., 2009;
Meyer et al., 2011). We interpret this guideline
as allowing for some flexibility when making
decisions regarding initiation of cross-gender
hormones earlier than age 16 for adolescents
with appropriate screening that includes mental
health and social supports. Ongoing psycholog-
ical assessment should confirm that the individ-
ual continues to meet criteria for GD and that
confounding psychosocial and medical prob-
lems have been addressed. The adolescent
should ultimately be able to make an informed
decision about their medical treatment and ac-
tively engage in therapy. Individual responses
to cross-gender hormone treatment may vary
and require adjustment until the desired effects
are achieved (Hembree et al., 2009). Clear ex-
pectations about the extent and timing of phys-
ical changes are important because there is in-
dividual variability. To date, 5 of our 20 patients
have been treated with cross-gender hormone
therapy, but many others are beginning to make
such requests as they get older.
Some, but not all, transgender individuals
desire surgical interventions. It is important to
note that the WPATH and Endocrine Society’s
guidelines recommend that surgical interven-
tion be deferred until the adolescent has reached
legal adulthood (18 years or older). In addition,
the individual must feel completely satisfied
with their societal role change to the desired
gender and the cross-gender hormone effects
(Hembree et al., 2009; Meyer et al., 2011).
Although surgical intervention is not provided
in our clinic, we do make referrals to surgeons
if a patient requests. For example, we have
supported efforts by one of our FTM patients
(age 19) to obtain breast reduction (a.k.a. “top”)
surgery.
Of note, each of these medical interventions
involves active and ongoing management deci-
sions. Side effects are possible. For example,
GnRH agonists used for pubertal suppression
may cause drug sensitivity reactions and abnor-
mal weight gain. Moreover, because of a lack of
insurance coverage, these interventions are
costly. For example, Lupron, which is com-
monly used in our clinic to suppress puberty,
would cost most of our families $2,100 –$2,500
monthly without insurance coverage. This sig-
nificant expense, in addition to the expectations,
limitations, and side effects of treatment, should
be thoroughly discussed with each individual
and family. To date, no controlled clinical trials
exist evaluating the safety or efficacy of cross-
gender hormones, and long-term adverse effects
are unknown (Gooren, Giltay, & Bunck, 2008).
 PEDIATRIC PSYCHOLOGY AND YOUTH GENDER DYSPHORIA
The Role of Pediatric Psychology
Therefore, in addition to assessing for and
managing psychological comorbidities and de-
velopmental level, pediatric psychologists are
critically important for helping youth and fam-
ilies understand and navigate difficult decisions
regarding the complex medical interventions
available for youth with GD. The role of pedi-
atric psychology in our multidisciplinary clinic
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varies from case to case. Several factors, such as
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child age, degree of familial support, level of
child distress, and stage of medical treatment,
influence the ways in which pediatric psychol-
ogy is involved. All children and families seek-
ing gender-related services in our clinic are seen
by the pediatric psychologist for an initial men-
tal health assessment and psychoeducation. The
assessment phase ranges from two to four ses-
sions. The pediatric psychologist first meets
with parents/guardians to complete a clinical
interview to obtain in-depth child and family
history. Level of familial support around the
child’s expressed gender preferences is as-
sessed. Consistent with psychological practice
in the founding pediatric gender clinics in North
America and the Netherlands, parents/guardians
complete a battery of measures to assess the
child’s level of GD and psychosocial function-
ing. Parents and teachers are asked to complete
broad-based child emotional/behavioral rating
scales. If psychiatric comorbidites, such as at-
tention-deficit/hyperactivity disorder, are sus-
pected, then additional measures are given.
At the second session, the pediatric psychol-
ogist typically meets with the child for further
clinical interviewing and assessment, including
administration of the 12-item Gender Identity
Interview Schedule (Zucker et al., 1993). Chil-
dren at least 11 years of age complete broad-
based child emotional/behavioral self-rating
scales. Some initial psychoeducation about GD
is usually provided for children. If a child has
been seen for mental health services elsewhere,
then records are obtained and reviewed, and
collateral is made.
Subsequent assessment sessions may be con-
ducted, and then the family is brought together
to review assessment results. Feedback on the
mental health status of the child is discussed,
and education is provided to the family includ-
ing information about the unknown develop-
mental trajectory of GD. At this time, a psy-
405
chology treatment plan is discussed. Currently,
the pediatric psychologist provides three levels
of service depending on the needs of the child/
family: (a) ongoing (biweekly to monthly) in-
dividual child psychological treatment related
to GD, comorbid psychiatric problems, and/or
other identified needs; (b) ongoing (biweekly to
monthly) family psychological treatment to pro-
mote family support around gender-related is-
sues; and (c) gender-specific consultation (2– 4
sessions annually) to supplement outside psy-
chological/psychiatric services. The level of
psychological intervention needed is discussed
by all team members and in collaboration with
patients and caregivers. Those with comorbid
psychiatric problems and/or greater family con-
flict around gender-related issues are most often
recommended for ongoing psychological treat-
ment. Treatment goals can include those fo-
cused on gender-related issues in addition to
other common psychiatric presentations, such
as depression and anxiety.
Overall, the treatment approach utilized in
our clinic for psychological services is one that
is supportive and affirming in nature; however,
as discussed below, no cross-comparison treat-
ment studies or randomized controlled trials
have been conducted to support which treat-
ment approach is most beneficial. Especially
with the youngest children (in which the even-
tual outcome is most ambiguous), the pediatric
psychologist works closely with parents who
may be struggling with making decisions about
how to respond to the child’s request to present
as the opposite gender. Should they permit the
child to wear gender-variant clothes and engage
in activities only at home? Do they allow the
child to display gender-variant appearances and
activities in public? Should they support the
child in “going stealth”—presenting in all set-
tings as the desired gender? Questions regarding
school responsibilities and sibling issues are
frequently explored. Most often, the psycholo-
gist works with the child and family to recog-
nize the struggle, tolerate and understand the
range of outcomes for the child, and to support/
affirm all possible outcomes (Perrin & Stancin,
2013). As the child approaches adolescence, the
psychologist provides support for emerging
challenges, especially with peers and pubertal
development.
All clinic patients meet with the pediatric
psychologist before beginning medical inter-
 406 COUSINO, DAVIS, NG, AND STANCIN
vention, such as pubertal suppression or cross-
gender hormone therapy. Follow-up sessions
are conducted throughout the course of medical
treatment to assess the need for additional ser-
vices. For example, referrals to child and ado-
lescent psychiatrists are made when the child
and family are likely to benefit from a psycho-
pharmacological consult. The pediatric psychol-
ogist works closely with psychiatry in these
instances to provide the combination psycho-
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therapy services. In addition, parents are regu-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
larly referred to a parent/family support group
facilitated by a collaborating social worker. To
date, 6 clinic patients are followed regularly by
pediatric psychology for ongoing treatment and
14 patients have been seen on a consultative-
only basis by the psychologist. To illustrate the
various roles of pediatric psychology in the
multidisciplinary KIDz Pride Clinic, a case vi-
gnette is presented.
Case Vignette
“Alex”
Although cases vary considerably in presen-
tation, consider the following child1 who serves
as an example of the patients and services pro-
vided in KIDz Pride Clinic. “Alex” is a biologic
female (i.e., FTM) who was described by par-
ents as showing distress at an early age when in
a dress. As a very young child, Alex preferred to
play with cars, balls, and male action hero toys,
showing no interest in dolls or anything “pink.”
Alex verbalized by age 3 “I am a boy” and
persistently sought male friends and sports ac-
tivities. Alex refused to wear dresses or girl’s
bathing suits and became anxious or angry
when placed in groups or told to “line up” with
girls. In addition, Alex refused to use the girls’
bathroom in public, leading to enuresis. Before
the parents seeking gender-related treatment for
Alex, he endorsed intermittent suicidal ideation.
At age 10 years, Alex presented to the KIDz
Pride Clinic for evaluation and was first seen by
the team pediatrician who obtained a thorough
medical and social history, conducted a physical
exam of Alex, and provided education about the
program and treatment options. The parents and
child followed up on three subsequent appoint-
ments with the pediatric psychologist, who con-
ducted diagnostic interviews with parents and
child (separately and together); administered
broad-based and gender-specific assessment
measures with parents, the child, and teachers;
and provided feedback and education.
Alex presented with mild anxiety and a mild
reading disorder. Alex and his parents reported
that he was well liked at school by other stu-
dents and adults. Alex was male appearing in
dress, grooming, and mannerisms. Initially ret-
icent to talk about gender issues, Alex had little
difficulty talking about family, friends, and
school. During the interview, Alex said “I want
to be a boy” and added “I feel like I am a boy,
not a girl and I always have.” Later, Alex added
“I don’t like the way I am growing” and rated
how badly he felt about having breasts devel-
oping as a “10” on a 1–10 scale. Alex expressed
interest in “getting the shots so they stop grow-
ing.”
Alex was then evaluated by the team endo-
crinologist, who reviewed the medical history,
conducted a physical exam, and obtained a bone
age X ray and baseline hormone laboratory lev-
els. Alex was assessed to be in Tanner II stage
of development and considered to be a candi-
date for pubertal suppression. After team com-
munication, Alex was diagnosed with GD by
the pediatric psychologist and a follow-up
meeting was arranged with Alex’ parents and
the team. Information about known outcomes of
gender-variant children was shared with his par-
ents including the very real possibility that Alex
would not persist with a desire to alter physical
gender. Treatment options including pubertal
suppression and later cross-gender hormone
treatments were discussed, along with recom-
mendation for ongoing mental health support
for Alex and the family. Although both parents
were supportive of Alex’s male gender expres-
sion, initially the mother was reluctant to agree
to puberty-suppressing hormone treatments, and
decisions about treatment were delayed for sev-
eral months. However, at a return visit, both
parents had agreed to puberty suppression,
prompted by concern that Alex was so dis-
tressed about developing breast buds that he
began expressing suicidal ideation.
Alex began pubertal suppression at age 11.
The family struggled with insurance companies
who refused to pay for the expensive GnRH
1
Cases are composites or have been altered so that the
individual patient or family cannot be identified.
 PEDIATRIC PSYCHOLOGY AND YOUTH GENDER DYSPHORIA
treatment. Now at age 13, Alex is pleased with
the results, but he describes his discomfort with
the painful injections. Mild anxiety has sub-
sided, and Alex’ performance in school has
improved. He is involved in extracurricular ac-
tivities, including basketball and soccer, and his
middle school permits him to use male rest-
rooms. Alex has persisted in his identification as
male and in his interest in continuing the pro-
cess of altering his body to match his gender
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
identity as male. Alex and family have fol-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
low-up appointments with the pediatric psy-
chologist every 4 – 6 months for support. The
family receives additional support from their
involvement in local and nationwide Internet-
based support groups for families of children
indentifying as transgender or gender variant.
Pubertal suppression is likely to continue until
Alex turns 16, when the next difficult set of
decisions will be made regarding the initiation
of cross-gender hormones. He and his parents
have expressed concerns that other boys his age
are beginning to display signs of pubertal
changes and that without cross-gender hor-
mones Alex may begin to lag behind, especially
with sports.
Challenges Faced by the Pediatric
Psychologist in Clinic
Even in the case of Alex, in which his family
was generally supportive of his desire to be
male and no significant psychiatric comorbidi-
ties were present, obstacles and challenges have
presented for the pediatric psychologist. Given
the nature of childhood GD and the guiding
eligibility criteria, which states that a diagnosis
of GD be made by a mental health professional
before initiating medical intervention (Hembree
et al., 2009; Hembree, 2011), the decision to
treat often weighs heavily on the initial assess-
ment of the team’s pediatric psychologist. Thus,
it has been our experience that the pediatric
psychologist may be seen by patients and fam-
ilies as the “gatekeeper” to access puberty sup-
pression or cross-gender hormone treatment.
Youth sometimes present as guarded and un-
willing to discussing underlying ambivalence
about gender-related issues and concerns. De-
spite attempts to develop strong rapport with
youth and their families, assuring them that the
role of the psychologist is to assess, support,
consult, and treat based on their personal needs,
407
our experiences support the notion that many
youth view the psychologist as the “one to get
past.” For example, a 14-year-old MTF patient
presented to her appointment and said, “I am
here to convince you that I am ready for cross-
gender hormones.”
Moreover, there is a lack of evidence-based
research to guide and inform treatment deci-
sions. To date, treatment literature in this area
has many gaps and is lacking in conclusiveness
(APA, 2009; Byne et al., 2012). For example,
some behavioral-based interventions, also re-
ferred to as reparative or conversion therapies,
have been used to reinforce behaviors typical of
the child’s biological sex (Zucker & Bradley,
1995). Others argue that this form of interven-
tion could be detrimental and advocate for an
approach that is supportive and strength-based
in nature and encourages family acceptance and
affirmation of the child’s gender identity
(Burnes et al., 2010; Meyer et al., 2011).
In addition, as in the case of Alex and nearly
all youth seen in our clinic, reimbursement is-
sues are commonly present. Medical treatment
for GD is currently not covered under most
insurance policies and/or Medicaid. Moreover,
a diagnosis of GD made by a pediatric psychol-
ogist may be payable by mental health benefits,
but it could exclude a child from receiving
coverage for medical treatments. Some families
have been successful at convincing employers
to include medical coverage for GD medical
and psychological services on health benefit
plans, but this remains the exception rather than
the rule in our experience. Thus, health-care
coverage for families and reimbursement for
providers treating children with GD continues
to be an area of concern. It is interesting to note
that psychological services for children with
GD in our clinic have been covered more read-
ily than have some medical services. The ability
to pay out of pocket for GD services varies
considerably among families. Some of the fam-
ilies seeking our services do find resources to
cover medical expenses, but many cannot. We
have encouraged parents to take steps to con-
vince employers to add transgender medical
care to insurance plans as a covered service, and
some have done so successfully.
Practice in this area is also fraught with eth-
ical issues. The initiation of medical treatment
acknowledges the acceptance of informed con-
sent on the part of a child who is unlikely to
 408 COUSINO, DAVIS, NG, AND STANCIN
fully comprehend all implications. For example,
GnRH agonists reverse and delay progression in
pubertal development. The child is ideally tran-
sitioned from gonadal suppression to cross-
gender hormonal therapy without a break in
treatment. This means that full gonadal maturity
will not occur, and the possibility of future
fertility is compromised. Hormonal suppression
also means that the child has an artificially
delayed onset of puberty, which is typically a
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
source of stress for teens who are anxious to fit
This document is copyrighted by the American Psychological Association or one of its allied publishers.
in with their peers. Furthermore, in our clinic,
some patients under the age of 16 years have
presented having already been started on cross-
hormone therapies by other providers and re-
quest that we take over managing their care. In
some instances, diagnosis of GD was uncertain,
and there was no evidence of ongoing involve-
ment with a qualified mental health profes-
sional. Some patients had unrealistic expecta-
tions for treatments or did not understand the
extent of medical follow-up and ongoing treat-
ments required. When families have become
emotionally invested in their child’s treatment,
a change in plan, even if based on safety and
drug interactions, may be unwelcome. In other
cases, children stopped or had less frequent
mental health services and medical follow-up
than recommended, but they continued with
their hormone suppression. In these cases, the
team was faced with deciding whether or not to
withhold medical care until psychological sup-
port was resumed, which could result in further
psychological trauma if puberty progressed. If
the child and family did not see a need for
psychological services, could the medical team
ethically withhold treatment?
Other ethical challenges include parental ob-
jectives versus child welfare. In one instance,
the team worried that a parent, who appeared
distraught by the child’s biological sex, was
seeking medical treatment for their child with-
out the child expressing genuine GD. In these
cases, it can be difficult to discern the child’s
actual gender-based feelings and experiences.
Other ethical issues include working with
school systems because many are reluctant to
support a youth’s full immersion into the de-
sired gender (i.e., using a female bathroom as a
biological male). Family conflict can put care
providers in difficult and ethically complex sit-
uations in which one parent is in agreement with
the plan and treatment and the other is ada-
mantly against treatment.
Lessons Learned
When initiating a new service or clinic, les-
sons are learned along the way. In our case,
youth and their families began presenting to the
PRIDE clinic with “nowhere else to go.” The
director of the PRIDE clinic, a general internist
and pediatrician with additional training in
transgender health, sought to meet this need by
bringing together a pediatric multidisciplinary
team. However, at the time, our team psychol-
ogist had little experience working with chil-
dren with GD. Thus, consultation with experts
nationwide was critically important. The pedi-
atric psychologist sought guidance from psy-
chologists and pediatricians with expertise in
treating children and adolescents with gender-
related problems. As pediatric gender clinics
become increasingly popular (e.g., Ann and
Robert H. Lurie Children’s Hospital of Chicago
recently received national attention for their ini-
tiation of the Gender Identity Clinic), pediatric
psychologists will likely be called upon to pro-
vide consultation and treatment-related ser-
vices. Thus, it will be important to seek out
consultation from those working in established
clinics and providing pediatric GD treatment
services. As ethical dilemmas present, consul-
tation with hospital and/or state ethics boards is
also highly recommended.
Specifically, the following competencies are
recommended by WPATH (Meyer et al., 2011):
(a) a Masters- or doctoral-level degree and li-
cense to practice in the mental health field; (b)
expertise in child and adolescent developmental
psychopathology; (c) proficiency in the assess-
ment, diagnosis, and treatment of common
childhood psychological disorders; (d) knowl-
edge about gender-related presenting problems
in children, adolescents, and adults; (e) experi-
ence in the assessment and treatment of GD;
and (f) continuing education to continuously
build expertise in working with individuals with
GD. On the basis of our experiences, it is also
strongly recommended that the pediatric psy-
chologist (or mental health professional) be
knowledgeable of the various medical interven-
tions, treatment courses, and side effects. Expe-
rience in helping youth and families navigate
difficult medical decisions is desirable. Compe-
 PEDIATRIC PSYCHOLOGY AND YOUTH GENDER DYSPHORIA
tency in working as a member of multidisci-
plinary teams is also very important because
team meetings and frequent communication
have been critically helpful for us as providers
and for our patients.
Our team meets in person once monthly (at a
minimum). Trainees may also be present in
meetings. All active cases are discussed, and
each team member provides updates regarding
recent patient appointments. Concerns are dis-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
cussed among the team. For example, the psy-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
chologist may raise concerns with the team
about parents differing in level of support for
initiating medical treatments and request that
the endocrinologist and psychologist meet to-
gether with parents before any medical deci-
sions are made. Together, treatment plans are
collaboratively developed and reformulated as
needed. Recent articles and guidelines are
shared among the group. All team members
participate in continuing education related to
working with and treating children with gender-
related concerns. Thus, these experiences are
also discussed during team meetings to ensure
that all team members are aware of the latest
research and clinical guidelines from the vari-
ous disciplines of practice.
Lastly, we have found that local, regional,
and national support groups have been very
beneficial for our families. Beyond the general
support families receive from connecting with
others with similar experiences, the networks
have helped families find an initial provider or
point of entry for care and learn strategies for
advocating for their child. We recently initiated
a parent group in our setting to meet the impor-
tant need for parent support. Our patients have
also enjoyed attending special youth programs
for gender-variant youth, such as Camp
Aranu’tiq, an overnight summer camp for trans-
gender and gender-variant children and adoles-
cents.
Future Directions
With referrals to pediatric gender clinics on
the rise, pediatric psychologists may find their
skills and services in greater demand. This is an
area of emerging opportunity for pediatric psy-
chologists. Our specialized training in working
with children undergoing medical treatments
and procedures, in addition to our experiences
working as members of multidisciplinary med-
409
ical teams, lends itself well to serving the di-
verse and complex needs of youth with GD and
their families.
In addition, there is a critical need for re-
search in this area. Long-term follow-up stud-
ies, treatment satisfaction studies, and quality
improvement studies are needed to improve the
development and delivery of interventions and
treatment for youth with GD. Specifically,
building upon the recent work of Spack and
colleagues (2012), among others, further exam-
ination of long-term psychosocial outcomes of
youth with GD who undergo medical interven-
tions and their families is needed. Given high
rates of bullying and negative psychological
sequelae among youth with GD, further re-
search is needed to identify risk and resilience
factors among this population. We must also
advance our evidence base for understanding
which children are most likely to persist with
GD and which will not. In the 5 years since we
have started evaluating and treating children in
our clinic, every child diagnosed with GD has
persisted in interest to alter physical features to
transition as the opposite gender. This is not
consistent with a literature that predicts a much
lower rate of persistence. This may be because
most of our patients are approaching adoles-
cence when we first meet them. It will also be
critical that resources for parents, families, and
school systems be developed and distributed to
aide in generating support for gender-variant
youth. Furthermore, parental stress and family
conflict associated with youth GD is an addi-
tional area in need of investigation.
Lastly, despite the increased demand for psy-
chologists in this area, the APA (2009) reports
that only 27% of psychologists feel sufficiently
trained in LGBT issues. Of note, LGBT issues
are different than childhood GD-related con-
cerns and treatment. It is likely that even fewer
psychologists have training in this area. Thus, it
is important that psychology graduate school,
internship, and fellowship programs provide
training opportunities in these areas. In our
clinic, psychology trainees have opportunities
to be involved in psychological interviews and
subsequent follow-up sessions as well as to
observe patient’s medical appointments during
which treatment options are discussed and fol-
low-up medical care may be provided. Students
have reported that these experiences have pro-
vided excellent clinical training in multidisci-
 410 COUSINO, DAVIS, NG, AND STANCIN
plinary collaboration, developmental psychol-
ogy, family and community systems, and
clinical practice with LGBT youth.
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Received March 31, 2014
Revision received July 29, 2014
Accepted July 29, 2014 䡲

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