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International Journal of Transgenderism

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Ethical, Legal, and Psychosocial Issues in Care of

Transgender Adolescents

Catherine White Holman & Joshua M. Goldberg

To cite this article: Catherine White Holman & Joshua M. Goldberg (2006) Ethical, Legal, and
Psychosocial Issues in Care of Transgender Adolescents, International Journal of Transgenderism,
9:3-4, 95-110, DOI: 10.1300/J485v09n03_05

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Ethical, Legal, and Psychosocial Issues
in Care of Transgender Adolescents
Catherine White Holman
Joshua M. Goldberg

SUMMARY. Complete care for transgender adolescents must be considered in the context of a
holistic approach that includes comprehensive primary care as well as cultural, economic,
psychosocial, sexual, and spiritual influences on health. Not all transgender adolescents have gen-
der dysphoria or wish to undergo sex reassignment. In this article we focus on general care of
transgender adolescents by the non-specialist working in primary care, family services, schools,
child welfare, mental health, and other community settings. doi:10.1300/J485v09n03_05 [Article cop-
ies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address:
<> Website: <> © 2007 by The Haworth
Press, Inc. All rights reserved.]

KEYWORDS. Transgender, transsexual, crossdressing, gender variance, adolescent, adolescence

This article is a companion piece to Clinical the non-specialist working in primary care,
Management of Gender Dysphoria in Adoles- family services, schools, child welfare, mental
cents (de Vries, Cohen-Kettenis, & Delemarre- health, and other community settings.
van de Waal, 2006). That article, written by ad- Complete care for transgender adolescents
vanced practitioners, offers important advice must be considered in the context of a holistic
for gender specialists working with adolescents approach that includes comprehensive primary
who need specialty care relating to gender care as well as cultural, economic, psycho-
dysphoria. However, not all transgender ado- social, sexual, and spiritual influences on
lescents have gender dysphoria or wish to un- health. The non-specialist can facilitate peer
dergo sex reassignment. In this article we focus and family interactions that help the trans-
on general care of transgender adolescents by gender adolescent learn emotional and rela-

Catherine White Holman is Community Counselor at Three Bridges Community Health Centre and Joshua
Goldberg is Education Consultant at the Transgender Health Program, Vancouver, BC, Canada.
Address correspondence to: Catherine White Holman, Three Bridges Community Health Centre, 1292 Hornby
Street, Vancouver, BC, Canada V6Z 1W2 (E-mail:
This manuscript was created for the Trans Care Project, a joint initiative of Transcend Transgender Support &
Education Society and Vancouver Coastal Health’s Transgender Health Program, with funding from the Canadian
Rainbow Health Coalition. The authors thank Sheila Kelton, Roey Malleson, Gerald P. Mallon, Edgardo J.
Menvielle, Daniel L. Metzger, Jorge L. Pinzon, and Wallace Wong for comments on an earlier draft, and Donna
Lindenberg, Olivia Ashbee, A. J. Simpson, and Rodney Hunt for research assistance.
[Haworth co-indexing entry note]: “Ethical, Legal, and Psychosocial Issues in Care of Transgender Adolescents.” Holman, Catherine White,
and Joshua M. Goldberg. Co-published simultaneously in International Journal of Transgenderism (The Haworth Medical Press, an imprint of
The Haworth Press, Inc.) Vol. 9, No. 3/4, 2006, pp. 95-110; and: Guidelines for Transgender Care (ed: Walter O. Bockting, and Joshua M.
Goldberg) The Haworth Medical Press, an imprint of The Haworth Press, Inc., 2006, pp. 95-110. Single or multiple copies of this article are
available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address:].

Available online at

© 2006 by The Haworth Press, Inc. All rights reserved.
doi:10.1300/J485v09n03_05 95

tional skills, including tools to recognize, ex- tal males who identify as young women and na-
press, and manage emotion; resolve conflicts tal females who identify as young men). Many
constructively; and work cooperatively with of our transgender adolescent clients–includ-
others (American Psychological Association, ing those who have sought sex reassignment–
2002). A positive youth development approach have identified outside a gender binary of male/
that focuses on building the adolescent’s com- female, using terms such as gender-fluid, gen-
petence, confidence, and social connectedness der-bending, genderqueer, and pangender to
can help promote resilience and healthy describe their sense of self. A similar trend was
development (Lerner, 2002; Tonkin, 2002). noted by clinicians at the Dimensions youth
Adolescent health is an interdisciplinary clinic in San Francisco (Dimensions, 2000a;
field, and our recommendations are accord- Dimensions, 2000b), as well as by clinicians at
ingly broad. Many of the discipline-specific other North American health centres who were
protocols and recommendations discussed in interviewed as part of the Trans Care Project. It
other articles (e.g., Bockting, Knudson, & may be that this is a population trend specific to
Goldberg, 2006; Feldman & Goldberg, 2006) North America; it is also possible that trans-
are also applicable to clinicians who work with gender youth who are not transsexual tend to
older adolescents. We encourage adaptation of engage with the health and social service
our recommendations to fit the specifics of system in ways that are different than transsex-
clinical practice. ual youth.

Initial Presentation
In a gender clinic or other trans-specialty ser-
To date, most demographic information vice, clients are obviously transgender and
about transgender adolescents is derived from have been referred for help to deal with gender
research performed by specialized clinics for concerns. This is not necessarily the case in a
gender dysphoric children and adolescents in general community service setting, where the
Canada, England, and The Netherlands (Bradley client base and the reasons for seeking service
& Zucker, 1990; Cohen, de Ruiter, Ringelberg, are far more diverse. As professionals provid-
& Cohen-Kettenis, 1997; Di Ceglie, Freedman, ing advocacy, crisis intervention, and counsel-
McPherson, & Richardson, 2002; Zucker, 2004). ing for people of all ages in urban commu-
There is no systematic documentation of nity-based service settings, it is not surprising
transgender adolescents who are not gender that the types of services sought by out
dysphoric, or who pursue sex reassignment transgender clients are different than the pa-
outside the gender clinicsystem (e.g., obtaining tients entering the Amsterdam team’s special-
hormones through Internet purchase, friends, ized hospital clinic for gender dysphoric
or street trade). In the absence of information children and adolescents.
about the broader spectrum of transgender ado- Few of our transgender adolescent clients
lescents, we can only comment on trends within have sought our help specifically to deal with
the population we have worked with, noting in gender identity concerns. Most have presented
particular differences between our client base seeking assistance for the same range of con-
and the clinical picture described by de Vries cerns as non-transgender adolescents–abuse,
and colleagues (2006). Further work is needed anxiety, depression, difficulty at school, disor-
to document trends among the diverse range of dered eating, drug and alcohol use, family
transgender adolescents, both locally and in stress, financial worries, homelessness, loneli-
other regions. ness, peer or relationship violence, questions
about sexual orientation, relationship difficul-
Fluidity of Gender Identity ties, and suicidal ideation. In some situations
transgender identity has had no bearing on our
The Amsterdam team (de Vries et al., 2006) client’s concern, while in others there have
works primarily with adolescents who are been trans-specific components requiring eval-
strongly cross-identified transsexuals (i.e., na- uation and incorporation into the care plan.
Catherine White Holman and Joshua M. Goldberg 97

Regardless of the presenting concern, we crisis line or resource guide service listings lets
have found it important to evaluate the impact adolescents know that you have an active
of trans-specific issues on the adolescent’s interest in transgender issues.
overall health and well-being. This can be chal- Asking a question about transgender identity
lenging in the community setting when gender on an intake form is a simple way to encourage
concerns are suspected but the adolescent has disclosure of transgender identity. Some clini-
not disclosed transgender identity. cians use “Choose as many as apply: M/F/MTF
(male-to-female)/FTM (female-to-male)/other
(please specify),” or give the options “M/F/
FACILITATING DISCUSSION Transgender.” This not only demonstrates un-
OF TRANSGENDER ISSUES derstanding of transgender issues, but also
raises adolescents’ consciousness that there are
While some transgender adolescents are options beyond a binary gender system.
open about being transgender and may talk
about this on the first visit, others are more wary Routinely Screening for Gender Concerns
initially, or unsure how to discuss it. We have
found the following strategies useful in creat- Internal conflict related to gender identity is
ing an environment conducive to discussion of not always immediately apparent. To date, no
transgender issues with adolescents. screening tools have been developed to facili-
tate detection of gender identity concerns in the
Promoting Adolescent Awareness general community setting. Gender dysphoria
of Transgender Issues measurement instruments (Cohen-Kettenis &
Van Goozen, 1997; Lindgren & Pauly, 1975;
Although public awareness of transgender- Zucker et al., 2005) are designed for use by the
ism has greatly increased in the last decade, gender specialist where there is already suspi-
many individuals with transgender feelings do cion of distress about gender identity. In the ab-
not know how to articulate their concerns. sence of formal screening tools, we recommend
Trans-specific posters, magazines that include incorporating a brief question about gender into
articles about transgender youth, and consumer the intake process with all clients, not just those
information that describes terms relating to the who look gender-variant. We recommend mak-
diversity of transgender identity and experi- ing a short normalizing statement followed by a
ence can help adolescents name and express simple question that can be answered without
their feelings. Inclusion of transgender bro- directly declaring transgender identity. For ex-
chures and posters in public education materi- ample: “Many people struggle with gender. Is
als also demonstrates a trans-positive and this an issue for you?” Asking in this indirect
trans-inclusive approach. It is important that way creates an opening for adolescents who are
materials be reflective of the diversity within unsure of their identity or are embarrassed or
the transgender community (e.g., ethnicity, dis- ashamed of transgender feelings, and would be
ability). intimidated by a direct question. It also avoids a
negative response by non-transgender adoles-
Active Demonstration of Transgender cents who would be confused or angry if asked a
Awareness and Sensitivity direct question about transgender identity. A
positive answer should be followed by a more
Adolescents may fear a negative reaction detailed evaluation, as outlined in Table 1.
upon disclosure of transgender identity, or may For the adolescent who is confused, ques-
assume that the clinician will not be able to re- tioning, or unsure about gender issues, counsel-
late to their concerns. Emphasis on non-judg- ing by the non-specialist and referral to age-
mental attitude, reassurance about confidenti- appropriate community resources are often
ality, and active demonstration of transgender sufficient. As with lesbian, gay, bisexual or
awareness and sensitivity helps convey safety questioning adolescents, this level of support
and approachability. Inclusion of a statement typically focuses on normalization of feelings,
such as “Transgender people are welcome” in discussion of options for identification and ex-

TABLE 1. Evaluating Gender Concerns in Adolescents

Topic Areas to Explore

Nature of gender • What is the adolescent concerned about (e.g., discrepancy between body and
concerns identity, social perceptions, social roles, sexual arousal from crossdressing)?
• When did these feelings start?
• Are the feelings constant, or do they come and go? Does anything make them
better or worse?
• How intense are the feelings?

Impact on the • How are the gender concerns impacting on the adolescent’s overall well-being
adolescent’s life (including mental health and developmental progress)?
• What is the impact on peer and family relationships?
• What is the impact on school and work?
• What are the adolescent’s coping strategies? Are there any concerns about
escalating substance use, self-harm, binge eating, compulsive exercise, or other
potentially harmful coping mechanisms?
• How aware is the adolescent of community resources and options for support?

Feelings about • What is the adolescent’s belief structure about transgenderism?

transgenderism • How does the adolescent feel about the possibility that they may be transgender?
• What is the adolescent’s information about transgenderism based on (e.g., talk
shows, peer opinion, cultural or religious beliefs, Internet, movies)?

Related or • Are there any other physical or psychosocial concerns that are contributing to the
co-existing adolescent’s distress?
factors • Do these seem related to the gender concerns? If so, how?

pression, exploration of fears and anxiety, and Psychiatric Association, 2000) defines two
discussion of non-destructive ways to cope conditions relating to gender concerns: Gender
with societal stigma (Fontaine & Hammond, Identity Disorder (GID) and Transvestic Fe-
1996). To alleviate the isolation commonly ex- tishism (TF). GID is divided into two age
perienced by gender conflicted adolescents, groupings–GID of Childhood (302.6) and GID
community peer support groups, internet re- of Adolescence and Adulthood (302.85)–with
sources, and other options for social connection both referring to a discrepancy between felt
should be identified. Evaluation by a mental sense of gender and the gender assigned at birth.
health clinician specializing in gender identity GID Not Otherwise Specified is used when the
concerns is recommended if the adolescent client is felt to have GID but does not meet crite-
(a) is so distressed about gender issues that ria for GID of Adolescence. Transvestic Fetish-
health and well-being, relationships, school, or ism (302.3) refers to erotically motivated cross-
work are negatively affected; (b) expresses dressing that has become so obsessive or
feelings of gender dysphoria, an aversion to as- compulsive as to cause problems in other as-
pects of their body associated with sex or gen- pects of life.
der, discomfort with gender identity, or a wish There is controversy about these diagnoses
to live as the opposite sex; (c) is compulsively (Bartlett, Vasey, & Bukowski, 2000; Bockting
crossdressing or pursuing validation of gender & Ehrbar, 2005; Burgess, 1999; Hill, Rozanski,
identity–for example, through compulsive sex- Carfagnini, & Willoughby, 2005; Langer &
ual or online encounters; or (d) has a co-existing Martin, 2004; Menvielle, 1998; Minter, 1999;
or pre-existing condition that complicates eval- Moore, 2002; Newman, 2002; Wilson, Griffin,
uation of gender concerns–for example, schizo- & Wren, 2002). Some clinicians feel that a di-
phrenia, personality disorder, or cognitive dis- agnosis of GID or TF is fundamentally impor-
ability. tant in guiding clinical consideration of options
Dilemmas in diagnosis of gender concerns for treatment in adolescents, and that a formal
in adolescence. The DSM-IV-TR (American diagnosis enables understanding and accep-
Catherine White Holman and Joshua M. Goldberg 99

tance that the distress is clinically serious and et al., 2001) and co-existing mental illness
that treatment may be required. Others have ex- should be screened for and appropriately treated
pressed concern that these diagnoses pathol- as part of the care plan. Behaviours that may
ogize transgender identity and erotic cross- have been adopted as mechanisms to cope with
dressing, fail to differentiate between distress gender dysphoria (e.g., cutting, burning, binge
caused by gender dysphoria and distress caused eating, substance use) should be addressed and
by societal pressures (internalized stigma, soci- monitored as the dysphoria is treated.
etal marginalization, etc.), and are not scientifi-
cally valid or reliable as psychiatric diagnoses. Conducting a Detailed Trans-Inclusive
The characterization of gender dysphoria as a Psychosocial Evaluation
disorder of identity may lead parents of young There are various tools that can be used to
gender-variant adolescents to seek “normaliz- evaluate psychosocial concerns in adolescents.
ing, “conversion,” or “reparative” therapies HEEADSSS is a way of organizing the evalua-
that reinforce stigma and shame by attempting tion of the adolescent to assess psychosocial
to change the adolescent’s identity or behaviour concerns in eight areas: Home, Education/em-
(Raj, 2002; Rosenberg, 2002). ployment, Eating, Activities, Drugs, Sexuality,
Regardless of clinical or political position on Suicide/depression, and Safety (Goldenring &
GID and TF diagnoses, it is important to thor- Rosen, 2004). While none of the HEEADSSS
oughly assess the gender-conflicted client’s questions include trans-specific content, many
history and current concerns as the basis for an of the questions are conducive to disclosure of
informed opinion relating to care, and to record transgender concerns for the closeted adoles-
this in a way that facilitates understanding by cent.
other clinicians (to promote continuity of care). For the adolescent who has already disclosed
This includes formal charting of the nature, se- transgender identity, the HEEADSSS inter-
verity, and persistence of gender concerns over view can be modified to include trans-specific
the duration of a client’s care. content, as in Table 2. As in the original
By definition, the clinical threshold for GID HEEADSSS protocol, the wording, pacing,
requires not only cross-gender behaviour but and number of questions used should be
also “clinically significant distress or impair- adapted in consideration of the needs of each
ment in social, occupational, or other important client.
areas of functioning.” This is a subjective judg-
ment that has been applied to include youth who
are unhappy when forced to conform to prevail- COMMON PSYCHOSOCIAL CONCERNS
ing gender norms. We do not believe it is help-
ful to apply the distress criterion to parents’ Many non-dysphoric transgender adoles-
cents struggle with the same psychosocial is-
distress that their child is atypical, or to an ado-
sues as those described by de Vries and col-
lescent’s distress about other people’s trans-
leagues (2006), such as concerns about body
phobic reactions. These are societally-caused
image, relationships, or sexuality. Both dys-
situations that can be addressed by supportive phoric and non-dysphoric transgender adoles-
intervention with the parents focused on build- cents share psychosocial struggles related to
ing acceptance for gender diversity (Menvielle societal marginalization, including identity
& Tuerk, 2002), along with intervention for the confusion, internalized stigma, shame, guilt,
youth to build resilience and address stigma is- isolation, discrimination, harassment, and vio-
sues. lence. In the following section we briefly iden-
While untreated gender dysphoria can result tify psychosocial concerns commonly ex-
in anxiety, depression, and other mental health pressed by the transgender adolescents we have
problems, not all mental health concerns stem worked with.
from gender dysphoria. Overall, adolescents
with gender dysphoria do not show more Safety
psychopathology than other adolescents (Cohen
et al., 1997; Cohen-Kettenis & Van Goozen, Visibly gender-variant people and those
1997), but there is variation individually(Smith who have disclosed their transgender identity

TABLE 2. Sample Trans-Specific Modification of HEEADSSS Psychosocial Interview (adapted from

Goldenring & Rosen, 2004)

Topic Sample questions

Home • Do the people who live with you know that you are transgender? (Who?) How did they
find out, and how did they react?
• How much do you feel you can be yourself at home?

Education/ • Do people at school or work know that you are transgender? (Who?) How did they find
employment out, and how did they react?
• Are there people at school or work you feel you could talk to if you needed to talk
about transgender issues? (Who?)
• Do you skip or miss classes? How often? What do you do instead?
• Have you ever been harassed or attacked at school or work?
• Do you ever worry about your academic or work future as a transgender person?
• Has anyone ever offered you money, clothes, alcohol, or drugs in exchange for sex?
Has anyone ever tried to get you involved in the sex trade?

Eating • What do you like and not like about the way you look? Do you wish you looked
different? (How?)
• Do you ever daydream about your body being different than it is now? What is your
ideal image?
• Do you eat more (less) when you are under stress?

Activities • Do any of your friends know that you are transgender? How did they find out, and how
did they react?
• Do you know any other transgender people? How did you meet them?
• How much time do you spend on the Internet in a week?

Drugs • Do you ever use drugs or alcohol to cope with stress?

• What do you think is a safe limit for drug and alcohol use? Have you ever crossed that
limit? (How often?)
• Have you ever done things when you were drunk or high that you regretted

Sexuality • Have any of the people you’ve dated known that you are transgender? How did they
find out, and how did they react?
• Is being transgender part of your sex life? (How?)
• Are you attracted to boys, girls, other transgender people?
• Are there parts of your body that are off-limits sexually?

Suicide/ • Do you worry about people finding out you are transgender?
depression • Do you ever wish you weren’t transgender?
• Does thinking about transgender issues ever make you feel stressed, sad, or lonely?
• Do you ever feel that your situation is hopeless?

Safety • Has anyone ever threatened to “out” you as transgender? Do you worry about this
• Have you ever been threatened or attacked because you are transgender, or for other
reasons? Do you worry about this happening?
• How safe do you feel in your neighbourhood or the places where you hang out?

to others are vulnerable to hate-motivated ha- not formally tracked in most jurisdictions in
rassment and violence by dates, acquaintances, North America, but newspaper and anecdotal
family members, school-age peers, co-workers, reports collected by community organizations
and strangers (Kenagy, 2005; Kosciw & Cul- suggest that transgender people of colour in the
len, 2001; Lombardi, Wilchins, Priesing, & male-to-female (MTF) spectrum are particu-
Malouf, 2001; Odo & Hawelu, 2001; Wyss, larly vulnerable to violence as a result of the tri-
2004). Violence against transgender people is ple burden of transphobia, sexism, and racism
Catherine White Holman and Joshua M. Goldberg 101

(Currah & Minter, 2000; Goldberg & White, ness to accept the adolescent back into the
2004). We have also observed heightened risk home). Adolescents whose family members
of interpersonal violence among transgender were unaware of transgender identity prior to
people who are financially dependent on an- leaving home and who wish to reconnect with
other person, cognitively impaired, physically family members may need support around
disabled, homeless, or involved in the sex trade. management of disclosure. Trans-specific ad-
Adolescents are particularly vulnerable to vio- vocacy relating to foster care and emergency
lence due to their limited options for economic shelter is discussed elsewhere (White Holman
independence, the prevalence of age-peer vio- & Goldberg, 2006).
lence in schools, and power differentials be-
tween adults and youth. Sex Work
De Vries and colleagues (2006) note the
need to discuss safety relating to disclosure of For both MTF and FTM adolescents without
transgender identity in sexual relationships. financial support from family, the sex trade
We also routinely assess transgender adoles- may offer a means of financial survival (Klein,
cents’ potential risks for violence and their per- 1999; Pazos, 1999). A study of North American
ception of safety at school, home, the work- adolescents in the sex trade concluded that the
place, and general public settings (e.g., public financial costs of sex reassignment and the low
transit) and, where necessary, create safety earning power of adolescents left transsexual
plans (e.g., a safe place to go, trans-positive youth without family economic support few
emergency services, and group safety). choices other than the sex trade (Estes &
Weiner, 2001). In addition, the sex trade can ap-
Poverty and Homelessness peal to young transgender women as a way to
find community, validate identity as a woman,
and feel desirable (Worth, 2000). In British Co-
Within the published literature there is rec- lumbia, the combined impacts of colonization,
ognition that gender-variant adolescents are poverty, racism, and violence as well as a lack
vulnerable to abuse, neglect, and parental rejec- of accessible and relevant supports have led to
tion, with resulting poverty and homelessness high numbers of Aboriginal youth among ado-
(de Castell & Jenson, 2002; Estes & Weiner, lescents involved in the sex trade (Social Ser-
2001; Klein, 1999; Leichtentritt& Arad, 2004). vices and Community Safety Division–Justice
Cross-gender behaviour may be met with Institute of British Columbia, 2002).
scorn, ridicule, abuse, or violence, and the ado- In Canada, provincial governments typically
lescent may have to choose between living in a define exchange of sex for drugs, money, food,
way that is not congruent with identity or leav- shelter, or other goods as commercial sexual
ing home. The adolescent may attempt to sup- exploitation (CSE) if a youth 18 years or youn-
press transgender feelings as a way of coping, ger is involved (Assistant Deputy Ministers’
or may leave home or be forced to leave. Gender Committee on Prostitution and the Sexual Ex-
dysphoric adolescents without family support ploitation of Youth, 2000). While in British Co-
face numerous psychological and socioeco- lumbia the term “sexual exploitation” is used
nomic challenges and it may be impractical to by some former sex workers who are now advo-
begin sex reassignment until stability has been cates (Tubman & Bramly, 1998), transgender
regained. In other instances the clinician and adolescents involved in the sex trade typically
client may feel that sex reassignment should do not use the term “sexual exploitation” to de-
proceed along with interventions focused on scribe their situation (Klein, 1999), and many
psychosocial stability. of the adolescents we have worked with reject
Transgender adolescents who have left home the term as patronizing. Like Klein, we have
voluntarily or involuntarily may struggle to found adolescents are most receptive to dis-
find safe and affordable housing. While some cussing involvement in the sex trade when they
homeless transgender adolescents may wish to are confident that the clinician is non-judgmen-
reunite with their families of origin, for others tal about their involvement in sex work. For this
reunification is not appropriate (e.g., high risk reason we use the term “sex trade” here rather
of familial abuse) or feasible (e.g., no willing- than CSE.

In our experience there is great diversity of cians working with transgender adolescents
gender identity among adolescents who work should be aware of the possibility of sex trade
in the sex trade. We have worked with three dif- involvement, and ensure that services for
ferent populations of transgender adolescents transgender adolescents are both relevant and
in the sex trade: accessible to youth who are involved in the sex
trade. Klein (1999) suggests services for
1. Adolescent MTFs who strongly identify transgender youth in the sex trade should in-
as women: Some work as women, while clude assistance with education, employment,
others feel it is too dangerous to do so and life skill development; psychotherapeutic
prior to genital surgery and work in the interventions aimed at exploring transgender
sex trade as men (but present in other set- identity and building resilience to deal with
tings as women). A small number have conflict, relationships, shame, stigma, depres-
been able to work openly as transgender sion, safer sex, and peer pressure; and facilita-
women in escort agencies or on the street tion of connections with peer support. It is also
“tranny track.” In our experience the important that involvement in the sex trade not
trans-specific concerns of this group pri- be considered an exclusionary criterion for
marily relate to validation of female iden- youth who are seeking sex reassignment, as this
tity and obtaining sex reassignment. leaves adolescents who are economically de-
2. Adolescent males who do not identify as pendent on the sex trade unable to access care
women, but work crossdressed: This (Raj, 2002).
group crossdresses only for work pur-
poses, and outside of work identifies as Sexual Health
male. Many of our clients in this circum-
stance did not identify as transgender but De Vries and colleagues (2006) identified
wanted support relating to transphobic the need to discuss sexuality with adolescents
violence or harassment they experienced undergoing sex reassignment. In our experi-
while working. Some also sought coun- ence this is also a key issue for transgender ado-
seling relating to confusion about gender lescents who are not undergoing reassignment.
identity or sexual orientation. Sexual health education with transgender
3. Adolescent FTMs working as women: adolescents should involve frank, explicit, and
We have worked with a few FTMs who, sex-positive discussion about the actual prac-
while personally identifying strongly as tices an adolescent is engaged in, with no as-
masculine or male and living as male in sumptions about the gender of partner(s) or
their personal and social life, worked in sexual activities. While some transgender adol-
the sex trade as women. FTMs in the sex escents are strongly dysphoric about their geni-
trade have been a more hidden population
tals, others are not. Both MTFs and FTMs may
and it may well be that some FTM adoles-
cents are able to work as men, despite not engage in receptive or insertive oral, vaginal,
having access to genital surgery. The and anal intercourse, as well as sexual activities
number of FTM sex workers in our client that do not involve penetration. The same sex-
base is too small to identify service themes. ual health topics that are routinely discussed
with non-transgender adolescents (e.g., sexually
Clinicians working with transgender adoles- transmitted infections, contraception) should
cents have the opportunity to engage in positive also be discussed with transgender adolescents,
interventions that make it possible for youth to using language that corresponds to the adoles-
get sufficient social and economic supports to cent’s identity (i.e., ask the adolescent what
have alternatives to the sex trade, and also pro- words they use for their genitals). While cross-
vide support for transgender adolescents al- sex hormones decrease fertility and may cause
ready involved in the sex trade (Social Services permanent sterility, hormones taken as part of
and Community Safety Division–Justice Insti- sex reassignment are not failsafe contracep-
tute of British Columbia, 2002). A detailed dis- tives (Feldman & Goldberg, 2006). MTF ado-
cussion of prevention and support strategies is lescents who are taking feminizing hormones
outside the realm of this document, but clini- and engage in penile penetration should be
Catherine White Holman and Joshua M. Goldberg 103

aware that the hormones typically reduce erec- son–a challenging task in a society that has a
tile firmness, and condoms may therefore be binary and polarized gender schema.
more likely to slip or leak. The distinction of transgender emergence
Body image. As noted by de Vries and col- from typical gender identity development is a
leagues (2006), body image problems are com- culturally-derived phenomenon, stemming from
mon in adolescents with gender dysphoria. It the societal assumption that there are two gen-
has been our experience that non-dysphoric ders (corresponding to two sexes) and that there
transgender adolescents who have had few pos- are norms of appearance and behaviour for
itive transgender role models also tend to have a each. While in our experience transgender
distorted self-image, compounded by media adolescents have not typically struggled with
stereotypes of MTFs and the invisibility of denial, avoidance, or repression for the same
FTMs in popular culture. Generalsocietalnorms length of time or to the same degree as trans-
and standards for non-transgender women and gender adults (Lev, 2004), youth who do not fit
men also affect transgender people. In particu- the dominant gender norms must still find a way
lar we have noticed a struggle with North to consciously articulate their difference and
American values of thinness and standards of find language to express their identity.
attractiveness among adolescent MTFs, with Transgender emergence is often considered
high value placed on ability to “pass” as a analogous to the process of “coming out” as les-
non-transgender woman and conformity to bian, gay, or bisexual. While both processes in-
beauty norms for non-transgender women. Ex- volve disclosure of a personal secret that may
ploration of transgender identity may be impor- evoke a negative response by others, trans-
tant as part of intervention. Transgender com- gender emergence is not just a matter of declar-
munity involvement and peer support may also ing membership in a stigmatized group. The
be useful in exploring myths and stereotypes existence of homosexuality and bisexuality is
about transgender “attractiveness” and worth. generally recognized; in contrast, transgender-
For adolescents with intense frustration or ism is not widely recognized or understood, and
distress about body image, in addition to a gen- challenges societal beliefs about sex, gender,
eral screening tool for eating disorders such as and sexuality in a way that can be disorienting
the SCOFF questionnaire or the Eating Disor- to the transgender individual and the people
der Screen for Primary Care (Kagan & around them (Brown & Rounsley, 1996). For
Melrose, 2003) it may be appropriate to inquire most transgender individuals, a search for
about excessively tight breast binding (FTM) language is a key element in the emergence
or tucking of the penis and testicles (MTF). If process.
binding or tucking is causing pain or skin rash, The following discussion of interventions
peer support or information resources may be to support transgender emergence in adoles-
helpful in discussing less physically harmful cence is adapted from Lev (2004)’s model of
techniques that can be used. six stages of transgender emergence in adults
undergoing gender transition. The levels of
intervention described below are not intended
SUPPORTING TRANSGENDER as a model for transgender adolescent devel-
EMERGENCE IN ADOLESCENCE opment, but rather to help the non-specialist
consider appropriate strategies for clinical
Even in the absence of gender dysphoria, assistance. A “stages of change” approach
transgender youth may struggle with identity (Prochaska, DiClemente, & Norcross, 1992)
development. Lev (2004) characterizes trans- may also be useful in guiding clinical interven-
gender emergence as a developmental process tions.
of realizing, discovering, identifying, or nam-
ing one’s gender identity. This does not neces- Awareness of Diversity of Gender Identity
sarily mean a transition from male-to-female or and Expression
female-to-male; for some adolescents (and
adults) transition involves emergence as a Some adolescents have only been exposed to
bi-gender, pan-gender, or androgynous per- information about transsexuality and are not

aware of other options for transgender identity clothing, wigs, shoes, or makeup to our ap-
or of ways other than physical change to ex- pointments to try interacting with another
press or affirm a transgender identity. With ad- person as their imaginedself. We do not suggest
olescents who have already made a decision to that adolescents try a form of gender expression
pursue sex reassignment, we do not try to dis- they are uncomfortable with, but rather encour-
suade them but do try to focus on keeping op- age them to try experimenting as a way of de-
tions open and promoting awareness of diverse ciding who they are and what feels right. We
possibilities for gender identity and expression. find that adolescents usually relate easily to the
Books and movies that include transsexual and concept of experimentation and are excited by
non-transsexual transgender individuals can be the possibility of trying out ways of expressing
useful in demonstrating a breadth of identity themselves that are in keeping with their (possi-
and expression. Contact with a diverse range of bly shifting) sense of self.
transgender individuals (appropriately screened For both questioning adolescents and those
age peers as well as older role models) can also who already have a strong sense of self, the em-
help demonstrate options for gender identity phasis is on self-understanding rather than
and expression that include but are not limited reaching towards a preset goal. If there are con-
to sex reassignment. This includes discussion cerns about fragmentation of identity or if the
of challenges, risks, and societal limits if the ad- process of experimentation seems to be in-
olescent expresses increasing interest in mov- creasing distress, we suggest involvement of an
ing beyond private exploration to integrate advanced mental health clinician with experi-
transgender identity or expression into life at ence in treatment of co-existing gender concerns
home, school, or work. and mental illness.
With adolescents who are in early stages of
questioning or exploring their gender, we en- Increasing Congruence Between Gender
courage ways of exploring identity and experi- Identity and Daily Life
menting that do not involve disclosing trans-
gender identity to others or making decisions For the adolescent who has a clear and con-
about transition or sex reassignment (Lev, sistent sense of self, the next step is the identifi-
2004). If asked we provide information about cation of strategies to reconcile discrepancies
transition options, but the focus is exploration between identity and daily life. The hormonal
rather than decision-making. This may include and surgical interventions discussed by de
journaling, collage or other creative expres- Vries and colleagues (2006) are, for many gen-
sions; trying out a new name or pronoun in the der dysphoric adolescents, a necessary treat-
clinical setting to see how it feels; reading or ment to alleviate the dysphoria. However, not
watching movies that portray various kinds of all transgender adolescents are dysphoric, and
gender expression; or attending trans-themed sex reassignment is not the only course of ac-
community events (e.g., drag performances). It tion a transgender adolescent may take to bring
has been our experience that many youth who daily life into closer congruence with felt sense
are early in exploration or questioning find peer of self.s
contact overwhelming and need time to explore The World Professional Association for
on their own; others are more social and want Transgender Health’s (WPATH) Standards of
peer contact earlier in the process. Care (Meyer et al., 2001) identify a range of
With transgender adolescents who have a non-medical possibilities transgender individ-
generally stable core sense of self (i.e., no uals may explore, spontaneously or with pro-
evidence of dissociation, thought disorder, or fessional support: (a) learning about trans-
personality disorder) we actively encourage genderism fromtheInternet,layandprofessional
experimentation with fluidity of gender identi- literature,or peers; (b) participatingin peer sup-
fication and expression as part of the explora- port or self-help groups, or in the transgender
tion process. This may include experimentation community; (c) counseling to explore gender
with gender pronouns, name, and aspects of identity and to deal with psychosocial pres-
appearance. Some adolescents who are consid- sures; (d) disclosing transgender identity to
ering gender transition bring cross-gender family, friends, and other loved ones (“coming
Catherine White Holman and Joshua M. Goldberg 105

out”); (e) integrating of transgender awareness likely reactions of the people they are telling,
into daily living; (f) changing gender pronoun and potential resources to help facilitate under-
or name; (g) episodic crossdressing or cross- standing and adjustment. Loved ones often go
living; and (h) undertaking temporary and po- through stages of adjustment involving feel-
tentially reversible changes to gender expres- ings of shock, disbelief, denial, fear, anger, and
sion, such as changing hairstyle, makeup, or betrayal, followed by sadness and possibly
clothing; removing facial and body hair, or ap- eventual acceptance (Ellis & Eriksen, 2002;
plying facial hair; wearing prosthetic breasts or Emerson & Rosenfeld, 1996). This is important
penile prosthesis; binding the chest or tucking for transgender people of all ages to be aware of
the genitals; and changing speech and voice. but is particularly important to discuss with ad-
This list is not meant to be exhaustive, but sim- olescents, as there is often dependence on
ply to illustrate that there are multiple options others for financial and emotional support.
that may be considered by transgender adoles- In our experience adolescents are often
cents. Some options require a high level of cog- aware of potential risks of disclosure and are
nitive and social sophistication and will likely willing to engage in discussion about possible
not be spontaneously pursued by young adoles- negative reactions. When there are concerns
cents. Whatever options are considered, there about possible violence or eviction from the
should be thought as to how changes will realis- home we include a crisis and safety plan as part
tically be integrated into daily life, and what re- of the preparation for disclosure. In some cir-
actions there might be by others. cumstances a safety plan includes discussion of
Disclosing transgender identity to others. the possible consequences of involuntary dis-
For some transgender adolescents, increased covery of transgender status. For example, we
congruence between identity and daily life in- have worked with several adolescents who
volves disclosing transgender identity to oth- transitioned early in life and whose teachers
ers. “Coming out” as transgender may be and age peers were not aware of transsexual his-
prompted by a desire to make feelings or iden- tory; as genital surgery is not recommended
tity known to others, or by planned changes in prior to age 18, there is a risk for any cross-liv-
social role or appearance. Disclosure is not only ing adolescent that their transgender status will
an issue early in transgender emergence: be discovered. In these types of situations the
throughout life, transgender adolescents need benefits of controlled disclosure are important
to consider how much to disclose. Clarity about to discuss.
what the adolescent wants to convey is an im- With the adolescent’s consent, the clinician
portant part of decision-making regarding may be involved in the disclosure process. For
disclosure. example, the clinician may offer to meet with
In “coming out” literature there is often an family members or other professionals in the
emphasis on disclosure as a necessary stage in adolescent’s life to provide information about
self-acceptance, and adolescents may feel they transgender issues or referral to peer or profes-
have to come out to be a “real” transgender per- sional resources. Family therapy can be useful
son. In our experience it is viable for some in helping both the transgender adolescent and
transgender individuals to live comfortably and their family members reach a deeper under-
in a congruent way without disclosing their standing of each other’s perspectives and
identity to others. The decision not to disclose is concerns.
not necessarily evidence of shame or embar- Ethical and legal issues relating to parental
rassment; it may be based on concern about the consent to treatment. Transgender adolescents
likely response of others, or may be a reflection who are questioning or exploring their gender
of the adolescent’s feeling that this aspect of identity are often fearful that the clinician will
their identity is private. We encourage adoles- disclose information to family members, teach-
cents to consider disclosure as only one of many ers, social workers, or others involved in care.
possible paths in transgender emergence,and to As with any other sensitive area of care (e.g.,
focus on self-acceptance as the primary goal. substance use, sexual health) the adolescent
The adolescent who is considering disclo- should be reassured that clinical professions
sure should be supported to think about the have strict rules governing confidentiality and

privacy. We have found it helpful to candidly development of secondary sex characteristics,

review the legal limits of confidentiality (e.g., a noticeable transition will not be an issue. For
duty to report child abuse), and the process that adolescents who were not cross-living prior to
we use when there is information that must be starting high school, the transition from male-
disclosed to a third party. to-female or female-to-male is more complex.
Legislation relating to consent by parents or Advocacy with teachers and school administra-
guardians in medical treatment of adolescents tors is often necessary during this stage of the
varies greatly across jurisdictions. In British transition process, particularly if the adolescent
Columbia, as with any other type of non-emer- wants to remain at the same school throughout
gency medical treatment, sex reassignment of transition or has no alternative (e.g., in rural ar-
adolescents is governed by the Infants Act. eas). Discussion topics with school staff may
Medical treatment for mature minors (defined include decisions relating to disclosure (to staff
in provincial legislation as a person under the and students); the need for accommodation re-
age of 19) can be provided in the absence of pa- lating to washrooms, change rooms, and gen-
rental consent if (a) the health provider has ex- der-specific activities; change of name on
plained the treatment options to the adolescent school records and in verbal interactions; use of
and is satisfied that the adolescent “understands preferred pronoun; and, if there are concerns
the nature and consequences and the reason- about peer violence, anti-harassmentand safety
ably foreseeable benefits and risks”; (b) the planning measures (White Holman & Goldberg,
health provider has made “reasonable efforts to 2006).
determine and has concluded that the health We have worked with several adolescents
care is in the infant’s best interests,” and (c) the whose schools were sufficiently supportive to
patient has provided consent. make it possible to stay during the process of
With sex reassignment, decisions about the change. In other situations, the harassment ex-
risk and benefits of proceeding without paren- perienced at early stages of transition was so in-
tal consent must be carefully considered, as tense that our clients have decided to drop out of
there is the potential for negative psychologi- school and start fresh at a new school where
cal, social, and economic consequences in ad- peers are not aware they are transgender. Some
dition to the normal health risks of any medical clients have waited until hormonal changes had
procedure. De Vries and colleagues (2006) reduced their visibility as a gender-variant per-
“strongly recommend” that adolescents under- son before starting at a new school.
going sex reassignment have adequate familial In some circumstances adolescents have al-
support and stability. For adolescents who are ready left school by the time they seek treat-
already living independently when treatment ment, and may be living independently outside
starts, it may be appropriate to assess social sup- the parental home. While human rights legisla-
ports independent of family, particularly if the tion in some jurisdictions offers protection
adolescent is estranged from the family-of-ori- against termination of employment on the basis
gin. of sex, gender, and disability, even when these
Managing the “real life experience” (RLE) grounds are held to extend to transgender indi-
at school and work. Adolescents who are not al- viduals (or there is explicit protection against
ready cross-living prior to sex reassignment discrimination on the basis of gender identity or
will undergo “real life experience” (RLE)–liv- expression) it is not uncommon for transgender
ing as the desired gender in every aspect of life– people (of all ages) to experience employment
as part of the reassignment process (de Vries et discrimination, including termination of em-
al., 2006; Meyer et al., 2001). For adolescents ployment and difficulty finding work (findlay,
this often involves transition at school and work Laframboise, Brady, Burnham, & Skolney-
settings. Elverson, 1996; Lombardi et al., 2001; Nemoto,
Some transgender youth undergo role transi- Operario, Keatley, & Villegas, 2004; Odo &
tion prior to puberty and enter high school al- Hawelu, 2001). This possibility should be dis-
ready cross-living full-time. For adolescents cussed with the adolescent and thought given to
whose puberty has been suppressed, while possible strategies that could be used to prepare
there may be teasing or gossip about the lack of an employer, disclose identity to co-workers,
Catherine White Holman and Joshua M. Goldberg 107

and otherwise manage the workplace transi- perspective about the temporary wait that is
tion. With adolescents who are new to the typically involved while the hormone assess-
workforce we may provide information relat- ment is completed. Expedited referrals to clini-
ing to employees’ rights and responsibilities, cians who can provide medical monitoring
and discuss trans-specific issues (such as ask- should be considered for the adolescent who
ing an employer for time off for sex reassign- has disclosed use of hormones without medical
ment procedures). assistance.
Some of our older adolescent clients have Feminizing or masculinizing surgery. While
been strongly dysphoric, committed to transi- sex reassignment surgery is typically not indi-
tion, and yet unable to cross-live in their current cated prior to age 18 (de Vries et al., 2006), it is
employment or school. In difficult situations important to begin discussion about surgery
such as these the clinician must consider early on if the adolescent has expressed a clear
whether the inability to live full-time in the de- intention to transition. Treatment options, im-
sired role is simply a mature and reasonable ac- pacts, and limitations should be clearly ex-
commodation of difficult circumstances, or plained, as some adolescents believe that sur-
ambivalenceabout full-timecross-living. Plan- gery is a simple process that will magically
ning around RLE must include consideration of resolve all of their problems. Consumer educa-
the adolescent’s safety and the relative risks tion materials appropriate for older adolescents
and benefits of undergoing RLE. have recently been developed as part of the
Feminizing or masculinizing hormones. There Trans Care Project (Simpson & Goldberg,
are documented reports of transgender individ- 2006a; Simpson & Goldberg, 2006b).
uals obtaining hormones without medical ap- Discussion about surgery should include in-
proval (Dean et al., 2000; Hope-Mason, Conners, formation about costs and options for payment.
& Kammerer, 1995), and the WPATH Stan- In jurisdictions where private or public health
dards of Care (Meyer et al., 2001) also recog- insurance is an option, the eligibility criteria
nize this risk. Estrogen and testosterone can be and process for application should be dis-
purchased illicitly or through the internet, or cussed. In many jurisdictions insurance explic-
shared among friends. The risks associated itly excludes coverage for sex reassignment
with cross-sex hormones are exponentially in- surgery, and adolescents should be made aware
creased when there is no screening for health of this so they understand that they may not be
conditions that may be made worse by hormone able to obtain surgery at age 18. For adolescents
use, or regular medical monitoring of adverse in this situation, appropriately screened experi-
effects after hormones are started (Dahl, enced peer mentors may be helpful in sharing
Feldman, Goldberg, & Jaberi, 2006). Non-pre- information about ways to cope with not having
scription-grade hormones may be poor quality access to needed surgery.
and may be diluted with toxic substances. For
those taking hormones by injection, improper Integration of Transgender Identity
injection technique or needle sharing poses ad- into Core Identity
ditional health hazards such as abscess and
transmission of HIV and Hepatitis C. Integration relates to awareness of the self as
It has been our experience that transgender a whole person, of which transgender identity is
individuals who take hormones without medi- a part rather than the consuming focus (Lev,
cal assistance often do so because they don’t 2004). Transgender issues are not necessarily
know who to approach for help, cannot access completely resolved or static, but the adoles-
hormones in any other way, or believe that the cent feels relatively settled and content in terms
process for hormone assessment is so lengthy of gender issues. Some clients describe this as
that their transition will be greatly delayed. Ad- being “able to imagine a future.”
olescents who are considering hormone ther- Integration does not necessarily mean devel-
apy should be informed of local service options. opment of a fixed gender identity. Some indi-
Appropriately screened peer mentors may be viduals retain a fluid identity throughout life, or
helpful in explaining what to expect from the have periods of ambivalenceabout identity.For
hormone assessment process, and in providing some adolescents integration includes accep-

tance of ambiguity and the shifting nature of cess to clinical and peer resources, particularly
their feelings. When these shifts occur without in rural regions. While specialists should coor-
distress, integration has been achieved. dinate care of youth who are gender dysphoric
For the adolescent undergoing sex reassign- or highly distressed about gender identity is-
ment, integration does not always depend on sues, the non-specialist should expect to be in-
completion of surgical changes. As Lev (2004) volved in care of transgender adolescents at
states, some point in their practice. Both the specialist
and the non-specialist can have a significant
In the beginning of this journey some
transsexuals focused exclusively on “get- positive influence in promoting healthy devel-
ting the surgery,” as if surgery validated opment of transgender adolescents. We hope
their gender transition . . . In the integra- this article helps non-specialists to feel more
tion stage, most transsexuals, including confident in working with this underserved
those who are postsurgical, accept that population.
“the surgery” is neither the end all or be all
of their identity. Although they may
choose surgery, their gender identity does REFERENCES
not depend on their genitalia, but on who
they know themselves to be. (p. 268) American Psychiatric Association (2000). Diagnostic
and statistical manual of mental disorders (DSM-
IV-TR) (4th Ed., Text Revision ed.). Washington,
The clinician’s role in this stage depends on DC: Author.
the adolescent’s overall development. In some American Psychological Association (2002). Develop-
circumstances regular appointments stop be- ing adolescents: A reference for professionals. Wash-
cause the adolescent no longer needs clinical ington, DC: Author.
assistance. For other adolescents, resolution of Assistant Deputy Ministers’ Committee on Prostitution
gender issues reveals areas of development that and the Sexual Exploitation of Youth (2000). Sexual
have been hampered by concerns about gender exploitation of youth in British Columbia (Rep. No.
identity (e.g., development of social skills) or C00-960303-4). Victoria, BC, Canada: BC Ministry
of Health.
the existence of psychosocial concerns unre-
Bartlett, N. H., Vasey, P. L., & Bukowski, W. M. (2000).
lated to transgender concerns. As discussed in Is Gender Identity Disorder in children a mental dis-
the preceding chapter, psychotherapy may order? Sex Roles, 43, 753-785.
continue after surgery. Bockting, W.O., & Ehrbar, R. (2005). Commentary:
In our experience integration is a long-term Gender variance, dissonance, or identity disorder.
process that is rarely achieved during adoles- Journal of Psychology and Human Sexuality, 17(3/
cence. We are encouraged by outcome data 4), 125-134.
from the Amsterdam clinic (Cohen-Kettenis & Bockting, W. O., Knudson, G., & Goldberg, J. M. (2006).
Van Goozen, 1997; Smith, Cohen, & Cohen- Counseling and mental health care for transgender
adults and loved ones. International Journal of Trans-
Kettenis, 2002), where supportive treatment of
genderism, 9(3/4), 35-82.
gender-variant adolescents is more easily ac- Bradley, S. J., & Zucker, K. J. (1990). Gender identity
cessed at an earlier age. These studies suggest disorder and psychosexual problems in children and
that with appropriate treatment and supports, adolescents. Canadian Journal of Psychiatry, 35,
even highly dysphoric transgender adolescents 477-486.
can reach an integrated state. Brown, M. L., & Rounsley, C. A. (1996). True selves:
Understanding transsexualism–For families, friends,
coworkers, and helping professionals. San Francisco,
Burgess, C. (1999). Internal and external stress factors
associated with the identity development of trans-
Synchronized care for transgender adoles- gendered youth. In G. P. Mallon (Ed.), Social ser-
cents is a challenge for clinicians working in vices with transgendered youth (pp. 35-47). Bingham-
community settings. Careful communication is ton, NY: Harrington Park Press.
needed to ensure that transgender and gen- Cohen, L., de Ruiter, C., Ringelberg, H., & Cohen-
der-questioning adolescents have adequate ac- Kettenis, P. T. (1997). Psychological functioning of
Catherine White Holman and Joshua M. Goldberg 109

adolescent transsexuals: Personality and psychopath- Fontaine, J. H., & Hammond, N. L. (1996). Counseling
ology. Journal of Clinical Psychology, 53, 187-196. issues with gay and lesbian adolescents. Adolescence,
Cohen-Kettenis, P. T., & Van Goozen, S. H. M. (1997). 31, 817-830.
Sex reassignment of adolescent transsexuals: a fol- Goldberg, J. M., & White, C. (2004). Expanding our un-
low-up study. Journal of the American Academy of derstanding of gendered violence: Violence against
Child and Adolescent Psychiatry, 36, 263-271. trans people and loved ones. Aware: The Newsletter
Currah, P., & Minter, S. (2000). Transgender equality: of the BC Institute Against Family Violence, 11,
A handbook for activists and policymakers. New 21-25.
York, NY: National Gay and Lesbian Task Force and Goldenring, J. M., & Rosen, D. S. (2004). Getting into
The National Center for Lesbian Rights. adolescent heads: An essential update. Contempo-
Dahl, M., Feldman, J., Goldberg, J. M., & Jaberi, A. rary Pediatrics, 21, 64-90.
(2006). Physical aspects of transgender endocrine Hill, D. B., Rozanski, C., Carfagnini, J., & Willoughby,
therapy. International Journal of Transgenderism, B. (2005). Gender identity disorders in childhood
9(3/4), 111-134. and adolescence: A critical inquiry. Journal of Psy-
de Castell, S. & Jenson, J. (2002). No place like home: chology & Human Sexuality, 17(3/4), 7-34.
Final research report on the Pridehouse Project. Hope-Mason, T., Conners, M. M., & Kammerer, C. A.
Burnaby, BC, Canada: Simon Fraser University. (1995). Transgender and HIV risks: Needs assess-
de Vries, A. L. C., Cohen-Kettenis, P. T., & Delemarre- ment. Boston, MA: Department of Public Health,
van de Waal, H. (2006). Clinical management of HIV/AIDS Bureau.
gender dysphoria in adolescents. International Jour- Kagan, S., & Melrose, C. (2003). The SCOFF question-
nal of Transgenderism, 9(3/4), 83-94. naire was less sensitive but more specific than the
Dean, L., Meyer, I. H., Robinson, K., Sell, R. L., Sember, ESP for detecting eating disorders. Evidence-Based
R., Silenzio, V. M. B., Bowen, D. J., Bradford, J., Nursing, 6, 118.
Rothblum, E., White, J., Dunn, P., Lawrence, A., Kenagy, G. P. (2005). Transgender health: Findings
Wolfe, D., & Xavier, J. (2000). Lesbian, gay, bisex- from two needs assessment studies in Philadelphia.
ual, and transgender health: Findings and concerns. Health & Social Work, 30, 19-26.
Journal of the Gay and Lesbian Medical Association, Klein, R. (1999). Group work practice with transgend-
4, 102-151. ered male to female sex workers. In G. P. Mallon
Di Ceglie, D., Freedman, D., McPherson, S., & Richard- (Ed.), Social services with transgendered youth
son, P. (2002). Children and adolescents referred to a (pp. 95-109). Binghamton, NY: The Haworth Press,
specialist gender identity development service: Clin-
ical features and demographic characteristics. Inter-
Kosciw, J. G., & Cullen, M. K. (2001). The GLSEN
national Journal of Transgenderism, 6. Retrieved
2001 National School Climate Survey: The school-
January 1, 2005, from
related experiences of our nation’s lesbian, gay, bi-
sexual and transgender youth. New York, NY: Gay,
Dimensions (2000a). Dimensions treatment guidelines
for FTM Transition. Retrieved January 1, 2005, from Lesbian and Straight Education Network. Langer, S. J., & Martin, J. I. (2004). How dresses can
Dimensions (2000b). Dimensions treatment guidelines make you mentally ill: Examining Gender Identity
for MTF transition. Retrieved January 1, 2005, from Disorder in children. Child and Adolescent Social Work Journal, 21, 5-23.
Ellis, K. M., & Eriksen, K. (2002). Transsexual and Leichtentritt, R. D., & Arad, B. D. (2004). Adolescent
transgenderist experiences and treatment options. The and young adult male-to-female transsexuals: Path-
Family Journal: Counseling and Therapy for Couples ways to prostitution. British Journal of Social Work,
& Families, 10, 289-299. 34, 349-374.
Emerson, S., & Rosenfeld, C. (1996). Stages of adjust- Lerner, R. M. (2002). Adolescence: Development, di-
ment in family members of transgender individuals. versity, context, and application. Upper Saddle River,
Journal of Family Psychotherapy, 7, 1-12. NJ: Prentice-Hall.
Estes, R. J., & Weiner, N. A. (2001). The commercial Lev, A. I. (2004). Transgender emergence: Therapeutic
sexual exploitation of children in the U.S., Canada, guidelines for working with gender-variant people
and Mexico. Philadelphia, PA: University of Penn- and their families. Binghamton, NY: The Haworth
sylvania. Clinical Practice Press.
Feldman, J., & Goldberg, J. M. (2006). Transgender pri- Lindgren, T. W., & Pauly, I. B. (1975). A body image
mary medical care. International Journal of Trans- scale for evaluating transsexuals. Archives of Sexual
genderism, 9(3/4), 3-34. Behavior, 4, 639-656.
findlay, b., Laframboise, S., Brady, D., Burnham, C. W. Lombardi, E. L., Wilchins, R. A., Priesing, D., & Malouf,
G., & Skolney-Elverson, S. R. (1996). Finding our D. (2001). Gender violence: Transgender experiences
place: The transgendered law reform project. Van- with violence and discrimination. Journal of Homo-
couver, BC, Canada: High Risk Project Society. sexuality, 42, 89-101.

Menvielle, E. J. (1998). Gender identity disorder. Jour- Simpson, A. J., & Goldberg, J. M. (2006). Surgery: A
nal of the American Academy of Child & Adolescent guide for FTMs. Vancouver, BC, Canada: Vancou-
Psychiatry, 37, 243-244. ver Coastal Health Authority.
Menvielle, E. J. & Tuerk, C. (2002). A support group for Simpson, A. J., & Goldberg, J. M. (2006). Surgery: A
parents of gender-nonconforming boys. Journal of guide for MTFs. Vancouver, BC, Canada: Vancou-
the American Academy of Child & Adolescent Psy- ver Coastal Health Authority.
chiatry, 41, 1010-1013. Smith, Y. L. S., Cohen, L., & Cohen-Kettenis, P. T.
Meyer, W. J., III, Bockting, W. O., Cohen-Kettenis, P. (2002). Postoperative psychological functioning of
T., Coleman, E., Di Ceglie, D., Devor, H., Gooren, adolescent transsexuals: A Rorschach study. Archives
L., Hage, J. J., Kirk, S., Kuiper, B., Laub, D., Lawrence, of Sexual Behavior, 31, 255-261.
A., Menard, Y., Monstrey, S., Patton, J., Schaefer, L., Smith, Y. L. S., Van Goozen, S. H. M., & Cohen-
Webb, A., & Wheeler, C. C. (2001). The standards of Kettenis, P. T. (2001). Adolescents with gender iden-
care for Gender Identity Disorders (6th ed.). Minne- tity disorder who were accepted or rejected for sex
apolis, MN: Harry Benjamin International Gender reassignment surgery: a prospective follow-up study.
Dysphoria Association. Journal of the American Academy of Child and Ado-
Minter, S. (1999). Diagnosis and treatment of gender lescent Psychiatry, 40, 472-481.
identity disorder in children. In M. Rottnek (Ed.), Social Services and Community Safety Division - Jus-
Sissies and tomboys: Gender nonconformity and ho- tice Institute of British Columbia (2002). Commer-
mosexual childhood (pp. 9-33). New York: New York cial sexual exploitation: Innovative ideas for working
University Press. with children and youth. New Westminster, BC, Can-
Moore, S. M. (2002). Diagnosis for a straight planet: A ada: Justice Institute of British Columbia.
critique of gender identity disorder for children and Tonkin, R. S. (2002). Accenting the positive: A develop-
adolescents in the DSM-IV. Dissertation Abstracts mental framework for reducing risk and promoting
International, 63(4B), 2066. (University Microfilms positive outcomes among BC youth. Vancouver, BC,
No. AAI3051898) Canada: McCreary Centre Society.
Nemoto, T., Operario, D., Keatley, J., & Villegas, D. Tubman, M., & Bramly, L. (1998). Out from the Shadows:
(2004). Social context of HIV risk behaviours among International Summit of Sexually Exploited Youth–
male-to-female transgenders of colour. AIDS Care, Final summit report. Ottawa, ONT, Canada: Save
16, 724-735. the Children.
Newman, L. K. (2002). Sex, gender and culture: Issues White Holman, C., & Goldberg, J. (2006). Social and
in the definition, assessment and treatment of gender medical transgender case advocacy. International
identity disorder. Clinical Child Psychology & Psy- Journal of Transgenderism, 9(3/4), 197-217.
chiatry, 7, 352-359. Wilson, I., Griffin, C., & Wren, B. (2002). The validity
Odo, C., & Hawelu, A. (2001). Eo na Mahu o Hawai’i: of the diagnosis of gender identity disorder (child
the extraordinary health needs of Hawai’i’s Mahu. and adolescent criteria). Clinical Child Psychology
Pacific Health Dialog, 8, 327-334. & Psychiatry, 7, 335-351.
Pazos, S. (1999). Practice with female-to-male trans- Worth, H. (2000). Up on K Road on Saturday night:
gendered youth. In G. P. Mallon (Ed.), Social ser- Sex, gender and sex work in Auckland. Venereology:
vices with transgendered youth (pp. 65-82). Bingham- Interdisciplinary, International Journal of Sexual
ton, NY: The Haworth Press, Inc. Health, 13, 15-24.
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. Wyss, S. E. (2004). ‘This was my hell’: The violence ex-
(1992). In search of how people change: Applica- perienced by gender non-conforming youth in US
tions to addictive behaviors. American Psychologist, high schools. International Journal of Qualitative
47, 1102-1114. Studies in Education, 17, 709-730.
Raj, R. (2002). Towards a transpositive therapeutic model: Zucker, K. J. (2004). Gender identity development and
Developing clinical sensitivity and cultural compe- issues. Child and Adolescent Psychiatric Clinics of
tence in the effective support of transsexual and trans- North America, 13, 551-568.
gendered clients. International Journal of Trans- Zucker, K. J., Deogracias, J. J., Johnson, L. L., Meyer-
genderism, 6. Retrieved January 1, 2005, from http:// Bahlburg, H. F., Kessler, S. J., & Schober, J. M. (2005). The Gender Identity Questionnaire for Adults
Rosenberg, M. (2002). Children with gender identity is- and the Recalled Childhood Gender Questionnaire-
sues and their parents in individual and group treat- Revised: Final analyses. Poster presentation, Meet-
ment. Journal of the American Academy of Child and ing of the International Academy of Sex Research,
Adolescent Psychiatry, 41, 619-621. Ottawa, ONT, Canada.