Abstract
The issues of transgender youth have taken center stage in 2025. School nurses are essential in providing support and facts when questions arise from school administrators, school boards, families, and students.
Interest in the topic of gender identity has increased significantly since 1952 when Christine Jorgensen went public with her change (Women & The American Story, n.d.). While most public discussion during the late 20th century focused on those who considered themselves gay, lesbian, and bisexual, the topic of transgender identities continued to stimulate confusion and questions, especially in politics and in schools. The initials LGBT became popular to refer to this larger cohort of those who considered their identities to be lesbian, gay, bisexual, and transgender. However, there was a problem with this acronym, as it combined both gender identity and sexual orientation, two very different concepts.
In the 1980s, the American Psychiatric Association recognized the diagnosis of “gender identity disorder,” specifically for those who were transgender. The purpose was to have an official diagnosis that would justify gender-affirming care for insurance companies, rather than an attempt to identify those who are transgender as mentally ill. More recently, this medical and social issue has become a polarizing political issue, leaving transgender youth, their families, and the schools to navigate the pathway to student well-being. The school nurse, as the liaison between the school and the community, may be asked to explain and address the issues faced by these youth. This article series attempts to assist in that endeavor.
Are There Really Only Two Genders?
While some assert that there are only two genders that are declared at the moment of birth (male and female), others note that the concept of gender is on a spectrum. It is well known that from 0.018% to 1.7% of babies are born with intersex traits, including those born with ambiguous genitalia, with both male and female genitals (previously known as hermaphrodites), as genetic chimeras and with other sexual anomalies, making it difficult to declare a gender at birth (Blackless et al., 2000; Enviroliteracy Team, 2025; Sax, 2002). Those born with both male and female external genitalia have been immortalized in statues and stories for thousands of years. Ambiguous genitalia is defined as atypical genital development that does not appear to be clearly male or female, often with internal reproductive organs that do not match the outer appearance. A chimera is the term used to describe an individual who has some cells that contain XX and others that contain XY, the chromosomes that determine one’s gender. All of these are examples of intersex, or somewhere along the continuum between the typical male and typical female phenotype. Because gender determination is often made in the delivery room, newer terms have emerged, including assigned male at birth (AMAB) and assigned female at birth (AFAB). For some children, their assigned sex may be changed following further genetic, endocrine, and electronic testing.
What Is the Meaning Behind All Those Letters?
The letters LGBTQQIAAP2S+ stand for Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersex, Asexual, Ally, Pansexual, Two-Spirit, and others. This acronym includes a combination of both gender identity and sexual orientation.
Gender identity involves how one feels internally about who or what gender they are; it is not a choice (American Psychological Association [APA], 2023). Identity can fall along a continuum. If one’s biologic sex matches one’s gender identity, they are referred to as cisgender. When there is not a match, there is an array of possible descriptors an individual may use, such as gender nonbinary, gender diverse, gender nonconforming, gender creative, and gender variant. Transgender is one form of gender identity that includes those individuals who feel their identity does not match their physical body parts for that gender. Gender expression is how one chooses to present their gender to society and includes clothing, jewelry, make-up, and behavioral characteristics.
Sexual orientation is different from gender identity; it has to do with who or what sexually attracts someone. Sexual orientation is not determined by choice. Examples of sexual orientation include those who are sexually attracted to individuals of the opposite sex (heterosexual), individuals of the same sex (lesbian, gay, homosexual) or both sexes (bisexual).
Transgender identity does not mean one is of a particular sexual orientation. Transgender individuals are no more sexually attracted to the same or different genders than the general population. The word “transgender” is an adjective; one is either a transgender male (a person AFAB and who now identifies as male), a transgender female (a person AMAB and who now identifies as female), or somewhere else on the continuum.
What Is the Prevalence of Transgender Individuals?
According to the United States Census Bureau, approximately 1% of adults consider themselves to be transgender (USA Facts Team, 2025); this translates into approximately 1.6 million adults (Herman et al., 2022). The Centers for Disease Control and Prevention (CDC) estimates that 3.3% of high school students identify as transgender, with another 2.2% who indicate they are not sure (Marino et al., 2024). Another study indicated that 1.4% of teens identified as transgender (Herman et al., 2022). The prevalence of transgender individuals occurs in all cultural, ethnic, and racial groups across the world, with Germany and Sweden having the highest percentages (World Population Review, 2025). In the United States, Washington, DC, Delaware, and North Carolina have the highest prevalence of transgender individuals (Herman et al., 2022).
These numbers are much smaller than the number of individuals who describe themselves as having a different sexual orientation. Between 2012 and 2023, the number of adults who described themselves as being lesbian, gay, or bisexual doubled from 3.5% to 7.6% (Statistica, 2025). These numbers increase by the ages of those surveyed, with 17% of Millennials (born 1980–1996) and 23% of Gen Z (born 1997–2004) identifying as nonheterosexual (Cox et al., 2023). The 2024 Youth Risk Behavior Survey noted that 25.7% of 9th to 12th graders identified as nonheterosexual, an increase from 8.3% in 2015 (Centers for Disease Control and Prevention [CDC], 2024).
At What Age Do Children Develop a Gender Identity?
Children are around 3 years of age when they learn that there are different genders and that they are labeled as a boy or a girl. Therefore, gender identity begins around ages 3 to 5. This is the earliest some children may become aware that they are “in the wrong body” (Zaliznyak et al., 2020). Sexual orientation, on the other hand, may begin around the onset of puberty or whenever sexual interest and activity begins. A meta-analysis determined that, on average, youth question their sexual orientation at age 13 (Hall et al., 2021).
The question of “How Do They Know?” is often asked. While not a proven approach, one might respond as follows: How do you know whether you are right or left-handed? This trait development occurs at about the same time as gender identity development. You pick up a crayon or a spoon in one hand over the other because it “feels more comfortable.” When you try using the other hand, your movements are not as smooth, not as comfortable, and not as coordinated. You don’t think about it all the time, but any time you need to use your hands, one hand takes dominance. The same is true for gender identity.
Is It a Mental Disorder?
The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (APA, 2023) describes gender dysphoria as significant distress that may accompany the incongruence between one’s assigned gender and the way they feel about themselves (referred to as their “experienced gender”). To be diagnosed with gender dysphoria, the individual must experience this incongruence for at least 6 months. It includes a strong and persistent physiological and psychological discomfort and distress with one’s gender, anatomy, and sex assigned at birth. The individual expresses the desire to be the other gender. This state may also be labeled as gender incongruence (World Health Organization, 2024). The diagnosis of gender dysphoria helps many to access medically necessary treatment. These diagnoses do not imply mental illness, but rather mental distress (Yarbrough et al., 2017).
Not all transgender individuals experience gender dysphoria; some are comfortable being who they are (Yarbrough et al., 2017). This comfort with who they are is enhanced by using names, pronouns, and clothing that align with their gender identity, as well as support from the family and the school. A report by the Human Rights Campaign (2023) noted that 45% of individuals who identify as transgender were never or only occasionally able to dress in a way that expressed their gender identity; 35% were not allowed to use their chosen name, 60% had difficulty using the pronouns they preferred, and 70% were restricted in their use of bathrooms that match their gender identify. These data are concerning for the health and well-being of the transgender child or youth. “When parents accept and affirm their child’s gender identity, the positive mental health impact can be substantial—and the harm in its absence could be life-threatening” (Human Rights Campaign, 2023, Outness to Family).
What Is the Impact on the Youth Who Is Transgender?
Imagine being told you can’t be who you are. The vast majority (92%) of transgender individuals have heard negative messages and have had their identity denied (The Trevor Project, 2023). Depression occurs in 58% to 72% of transgender youth (compared to 26% in those who are cisgender), and there is an increased risk of attempting suicide (50% considered it and 10.3% attempted it) compared to 2% among those who are cisgender. Data from the Youth Risk Behavior Survey of high school students found that 53.8% of transgender students seriously considered suicide in 2023, compared to 20.4% for cisgender students (CDC, 2024). The percentages were higher for transgender 9th graders (>61%). In addition, 71% of transgender high school students felt sad or hopeless compared to 39.7% of cisgender students.
At least half of transgender individuals have been physically threatened or harmed, and the majority experienced discrimination, according to the Trevor Project (2023). Physical violence and bullying are persistent fears. Twenty-seven percent of transgender youth feel unsafe going to and from school, and 40% reported being bullied at school as compared to 16% of cisgender youth (CDC, 2024). Over 14% of transgender high school students reported being threatened or injured with a weapon on school property compared to 9% for cisgender students; 9th graders who identify as transgender reported a higher incidence (23.6%; CDC, 2024).
Being transgender is not generally considered to be a mental health disorder; however, the bullying, rejection, and discrimination commonly experienced by those who are transgender can result in altered mental health. When a transgender identity is not accepted by peers, family, or school staff, their sense of belonging is diminished, and they can feel disrespected and outcast. The first provision from the Code of Ethics for Nurses is that “the nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (American Nurses Association, 2025). Like all students, transgender students must be supported.
School nurses with their knowledge that bridges health and education are well-positioned to increase understanding of what gender identity means and interpret how to best support the well-being of all students (National Association of School Nurses, 2025). The second article in this series will explore additional topics related to gender identity and transgender children and youth, including gender-affirming care, concerns about bathroom and locker room use, and sports participation. The article will also discuss the role of the school nurse and identify other matters schools should consider to promote an inclusive environment.
Resources for Transgender Individuals and Their Families
Footnotes
Ethics Approval Statement
This article adheres to NASN’s established ethical standards. Ethical approval was not required as the work did not involve human participants, animal subjects, or sensitive data.
Dr. Selekman is the developer and author of School nursing: A comprehensive text for the first three editions. She is also the author of the School Nursing Certification Review. She is a national speaker on multiple topics involving children and youth and school nurses.