"Transgender" is a broad term that refers to a variety of gender-nonconforming identities and behaviors (Ryan & Futterman, 1997) and includes transsexuals, cross-dressers, and those individuals who purposefully present with ambiguous gender identity (gender-blenders/benders) (Grossman & D'Augelli, 2006). Transgender youths are at higher risk for anxiety, depression, substance abuse, suicide (Olson, Forbes, & Belzer, 2011; Society for Adolescent Health and Medicine, 2013), sexually transmitted disease (STD) including HIV, substance abuse, needle sharing (Stieglitz, 2010), violence, victimization, discrimination, harassment, and physical and sexual abuse (Grossman & D'Augelli) than their peers.

In a study of 24 transgender youths between the ages of 15 and 21, Grossman and D'Augelli (2006) documented four major issues of health-related concerns for the participants including lack of: safe environments, access to healthcare services, resources related to mental health, and continuity of care for themselves and their caregivers. In spite of this early research, and guidelines for gender-affirming healthcare published between 2009 and 2013 by a number of professional organizations including the Endocrine Society, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the World Professions Association for Transgender Health, Gridley et al. (2016) reconfirmed this lack of access to healthcare services. In a study of 65 transgender youths between the ages of 14 and 22 who were living in Seattle, WA, Gridley et al. found six themes focused on barriers to access of gender-affirming healthcare. Participants reported that there were few, if any, providers trained in gender-affirming healthcare for youths and their caregivers who were accessible within a reasonable distance. The lack of this specialized training for providers was evident in inconsistent use of appropriate pronouns, inconsistent use of evidence-based treatment protocols as outlined in national guidelines, uncoordinated care and unacceptable use of gatekeeping, limited and/or delayed access to pubertal blockers and cross-sex hormones, and inappropriate insurance exclusions (Gridley et al.). Patients and their families not only experienced frustrations with the lack of access, but in turn these barriers continue to place transgender youths at significant risk for violence and victimization, physical and sexual abuse, STDs, mental illness, and suicide. Participants suggested several recommendations including: mandatory training on gender-affirming protocols, development of specific protocols directed toward younger patients and their families, cultural humility training, an increase in multidisciplinary gender clinics, increased implementation of well-accepted protocols for age-appropriate cross-sex hormone therapy, and designing clinic-based patient navigation systems for transgender youths and their families (Gridley et al.). Further recommendations include education programs for caregivers about their transgender children and their needs, and self-esteem and resilience promoting group programs for transgender youths (Stieglitz, 2010).

With accurate and up-to-date knowledge, pediatric nurses can take the lead role in advocating for evidence-based culturally competent care for transgender youths in all pediatric settings. As nurses, we are in a unique role as the most trusted of healthcare professionals to be able to support these highly vulnerable teens and their caregivers.

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