The elements that make up an individual’s psychosexual identity include, but are not limited to, assigned sex at birth, gender identity, gender expression, and sexual attraction. Assigned sex at birth is generally determined by genital anatomy at the time of birth, and is recorded on the birth certificate accordingly. In many states across the US, this can be changed if someone identifies later as a different gender. There are still some states that do not allow this change. Gender identity is an individual’s internal sense and experience of “maleness” or “femaleness.” For transgender adolescents and young adults (AYAs), this is incongruent with their assigned sex at birth. Gender expression includes how an individual presents his or her gender with clothing, hair, name, pronouns, and mannerisms, as well as gender performance; how an individual acts with respect to the cultural constructs and expectations around gender. Sexual attraction refers to who an individual finds romantically and sexually attractive. Sexual attraction is often mistakenly conflated with gender identity. Transgender AYAs have a range of sexual attraction identity labels, and should not be assumed to have any particular sexual orientation labels based on their assigned sex at birth. For example, an individual assigned a male gender at birth, who has a transfeminine identity, might be sexually and romantically attracted to men, women, both, neither, or anygendered people. From a health care perspective, risk for sexually transmitted infections (STIs) and necessary screening should rely on assessment of specific sexual behavior and presence of specific body parts. Gender identity, gender expression, and sexual attraction are not binary. There are an infinite number of places along the spectrum of male → female or masculine → feminine that all people might identify. Additionally, they may fluctuate over time, particularly gender expression. Transgender AYAs may make socioculturally strategic decisions about gender expression in different environments. For younger adolescents, realization that there is a spectrum of identities that are not limited to the male/female binary is important information for them to have in their gender exploration process.

While professionals, academics, families, and allies adopt language to define the gender identities of others, it is critical to recognize that individuals should, and do, self-identify their own gender. Mental and medical health providers should be cognizant that the lexicon is dynamic, particularly among transgender AYAs, and best approached by asking each individual how he or she identifies himself or herself before assigning a label. Some AYAs may prefer not to identify themselves as transgender in any way, and identify simply as “boy/man” or “girl/woman.”

Increasingly common is the emergence of AYAs who identify as “nonbinary.” These young people reject the traditional gender binary categories of male and female, and instead consider themselves both, neither, or something else entirely. The approach to non-binary-identified AYAs requires attention to each individual’s needs. Gender nonconforming or transgender AYAs should be asked about their preferred name and pronoun at each office visit. Inquiring about each young person’s identity, name, and pronoun preference can help to foster trust and develop rapport between provider and patient.

There continues to be a lack of information accurately or consistently describing the prevalence of transgender individuals, and studies from around the world report a broad range from 1:200
to 1:100,000.⁴,⁵,⁶ While specific prevalence rates are unknown, it is the case that increasing numbers of transgender youth are seeking care in clinics around the world.¹,² In the most recent data from the American College Health Association’s National College Health Assessment, 0.2% of respondents reported their gender as transgender.⁷

Transgender AYAs experience initial awareness about their gender incongruence in many ways. Many recognize from very early childhood that their gender is different than the one they were assigned at birth. Some are able to articulate their experience to parents, family members, or others in early childhood, and some are not. Many AYAs describe a history of feeling “different” but not necessarily ascribing that difference to gender incongruence until later in adolescence. It is common for young people to acquire language around the transgender phenomenon from the popular media or the Internet. Limited data and clinical experience seem to indicate a bimodal distribution of transgender awareness in transgender boys/young men with one peak in early childhood and a second around or shortly after the experience of puberty. Among transgender girls/young women, there is more commonly awareness of gender incongruence during early childhood, although later discovery is also not uncommon. This may be due to the societal inability to tolerate “boys in girls’ clothing,” which might subsequently drive parents/caregivers to seek professional care earlier. For youth who discover their transgender identity in adolescence, disclosure often occurs first among close friends, followed by parents and extended family. Parent/caregiver response to the disclosure of transgender identity is critical to the well-being and future of these youth. Parents who are accepting, open, and supportive help mitigate the multitude of psychosocial challenges faced by transgender youth.¹⁰