Bruce Jenner's recent transition to Caitlyn has placed transgender healthcare into a new spotlight and has elevated the issue of gender nonconformity in children and adolescents to a hot topic in pediatrics. In 2011, it was estimated that 0.3% or 1 million adults in the United States identify as transgender (Gates, 2011); however, with recent media attention and ensuing acceptance, it is likely that this estimate is low. What should the pediatric nurse say to the parents of a boy who wants to go to school as a girl? What advice do you have for the parent who asks "should my child be in therapy to try to change what she is saying about wanting to be a boy? Or should I support her in her identified gender?" Recently, more and more physicians and mental healthcare professionals are expressing skepticism with how gender identity is assessed and treated, with increasing numbers supporting the approach to let transgender children and adolescents live as their identified gender.

Gender nonconformity is defined as "a desire to express gender in ways that differ from gender-cultural norms linked to sex at birth, and was until very recently considered a mental pathology by the psychiatric community" (Reicherzer, 2008). In one of the most extensive articles published on the topic of transgender healthcare, Stroumsa (2014) reviewed the issue of gender nonconformity from its historical perspective to current thinking. Gender identity disorder was identified in the early 1920s and first appeared as a psychiatric diagnosis in the third edition of the American Psychiatric Association (2013)Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980 until the fifth edition that was published in 2013. In the DSM-5, the diagnosis was changed to gender dysphoria that is less controversial but still carries a stigma of pathology. Nevertheless, the new terminology does support appropriate treatment for gender reassignment. Increasingly psychiatrists and other healthcare providers have realized that gender nonconformity is not an illness to be overcome or cured.

Problems in accessing medical care by this population has been well documented and includes lack of insurance coverage, prejudice, and lack of knowledge among providers that leads to untimely, disrespectful, culturally insensitive, and inadequate care. These factors can result in poorer health outcomes including increased risk for sexually transmitted disease, violence, and suicide (Stroumsa, 2014). Lack of research on transgender healthcare needs is another issue, including those related to transitioning, safety, mental health, and routine primary care. For example, where can an adolescent girl who identifies as a boy go for care where he will be respected for who he is and will receive adequate gynecological care?

New science is emerging pointing to a complex set of factors for gender nonconformity. Olson, Key, and Eaton (2015) studied 32 transgender children aged 5 to 12 and concluded that there are many biological factors that contribute to how we psychologically feel about our gender. They found that early in development, transgender children youth are virtually indistinguishable in a number of measures from children who are not transgender but of the same gender identity. In 2 years of research, with a small sample of children, who with the support of their families transitioned from their birth gender to their expressed gender, none have reverted. Olson concluded that transgender children are not confused, delayed, or showing gender-atypical responding (Olson et al., 2015). Albeit a small sample, this should give us pause. While we wait for more definitive research, we need to examine our biases, learn all that we can about transgender healthcare, and share what we have gleaned with parents and families. It seems to make sense to "let kids be kids" ...as the gender with which they identify.

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