School Nurse Primer on Gender Identity and Transgender Youth: Part II

What Is Meant by Gender-Affirming Care?

Gender-affirming care is defined by the Endocrine Society as medically necessary, evidence-based, individualized care that uses a multidisciplinary approach to help a person transition from their assigned gender (designated at birth) to their affirmed gender—the gender by which they want to be known (Hembree et al., 2024). It also relates to procedures that align a person’s physical gender expression with their gender identity. This type of care may also include cisgender males who suffer from gynecomastia (Dai et al., 2024). The goal of gender-affirming care is primarily to provide the most appropriate care to people who are transgender and gender-diverse and it is supported by the American Medical Association, the American Academy of Pediatrics, the American Psychiatric Association, and the American Association of Child and Adolescent Psychiatry (2024; American Medical Association, 2024; American Psychological Association Council of Representatives, 2024; Sulaski, 2023). Gender-affirming care includes medical, surgical, social, and legal domains, with the social domain including names, pronouns, hairstyles, and clothing.

Denial of gender-affirming care for transgender youth is increasing. In 2022, four states had laws that restricted gender-affirming care to youth; by June 2025, that number had increased to 27 (Dawson & Kates, 2025). These laws threaten penalties against parents who seek gender-affirming care for their children on the grounds of child abuse. In some states, school personnel are not permitted to counsel youth to access gender-affirming care, as it is considered “aiding and abetting.” An Executive Order of January 28, 2025, reinforced these positions (Trump, 2025). However, repeated research findings support that gender-affirming care is viewed by transgender individuals as essential and lifesaving by decreasing rates of depression and lowering the risk of suicide (Human Rights Campaign, 2023).

Gender transitioning is individualized to each child and family. The primary focus of gender-affirming care is treating individuals according to their gender identity. All generally start with psychosocial transitioning, where one lives and presents themselves as the gender to which they identify. This includes using names and pronouns of their choice, wearing clothing and hairstyles that approximate their gender identity, and disclosing their gender identity to others. For many, no medical interventions are needed, other than being treated with respect and dignity by healthcare professionals (Human Rights Campaign, 2023).

The World Professional Association for Transgender Health (WPATH), an interdisciplinary professional and educational organization, used international findings to develop updated standards of care for youth and adults who identify as transgender. They recommended that healthcare providers take into account the emotional, cognitive, and psychosocial maturity of the youth requesting any partially reversible medication (Coleman et al., 2022).

From a medical standpoint, the next step in gender-affirming care may be starting the use of hormones. There are two general categories of hormones: those that block puberty (primarily gonadotropin-releasing hormone agonists) and those considered cross-sex hormone therapy (primarily estrogen and testosterone) that promote the development of desired secondary sex characteristics. It must be emphasized that not all transgender people seek a medical diagnosis or treatments related to their identity. One study found that of 18,000 transgender individuals with private insurance, less than 1,000 youth accessed puberty blockers and less than 200 accessed hormones (Hughes et al., 2025).

Puberty blockers have been used for decades to suppress precocious puberty, and estrogen and testosterone are given routinely for conditions such as dysmenorrhea and breast and testicular cancer, as well as for birth control. Sex hormones do have side effects. Estrogen can cause venous thromboembolism, gallstones, increased weight, and decreased bone density. Testosterone can result in polycythemia, acne, and male-pattern baldness (Coleman et al., 2022). While the puberty blockers are completely reversible once the medication is stopped (Human Rights Campaign, 2023), some physiologic changes that result from gender-affirming hormone therapy (breast development, voice deepening, facial hair) may not fully return to baseline (Hedian, n.d.).

Perhaps the most controversial component of gender-affirming care is the issue of surgical sexual reassignment. A study of all ages of individuals who had surgery related to sex between 2016 and 2020 found that over half (56.6%) of the 48,000 surgeries were of the breasts and chest, 35% were genital reconstruction, and 14% were facial/cosmetic. Of these surgeries, 52.3% were in those 19 to 30 and 7.7% were in those 12 to 18 (Wright et al., 2023). A similar study in 2023 found that the average age was 29 and that less than 1% had any regrets (Bruce et al., 2023).

A 2024 study of 13- to 17-year-old youth found that the prevalence of sexually related surgery for youth 15 to 17 years of age was 2.1/100,000 youth, and for 13- to 14-year-olds, it was 0.1/100,000. There were no reports of sexual reassignment surgery in those 12 and younger (Dai et al., 2024). Of the surgeries performed, 96.4% were chest-related. Of the 151 breast reductions among minors, 97% were actually performed on cisgender males related to gynecomastia and were not related to transgender youth. This supports that gender-affirming care is for everyone.

What Is the Degree of Satisfaction or Regret Related to Medical Gender-Affirming Care Interventions?

The Princeton University Transgender Youth Project found that 5 years after the social transition of 317 children 3 to 12, only 2.5% (8) identified as cisgender; 94% identified as transgender and 3.5% identified as nonbinary. Most of those who stopped the transitioning process did so by age 10 (Olson et al., 2022). Similar findings in the Netherlands found that only 16 of 720 adults who started hormone treatment during their adolescence stopped using the gender-affirming hormones (Van der Loos et al., 2022). A study of 92,000 youth and young adults over age 16 found that 94% were more satisfied after their transition and that 98% were more satisfied if they were receiving hormones. Only 3% were less satisfied (James et al., 2024).

Thornton et al. (2024) performed a systematic review and found that while regret following gender-affirming surgery for transgender adults was less than 1%, regret following various other elective plastic surgeries by the general public was significantly higher. For example, regret by the cisgender general population ranged from 0% to 47% with breast reconstruction and 5% to 9% for breast augmentation. Regret following a new tattoo was 16%.

What Are the Concerns Regarding Bathroom and Locker Room Use?

Most concerns about what happens in bathrooms and locker rooms are related to sexual orientation rather than gender identity, although many public and school officials do not understand the differences in these terms. Concerns regarding bathroom use by those who are transgender has resulted in increased risk of retaining urine, urinary tract infections, dehydration, or leaving school (59% avoided using the bathroom at school/work; Herman et al., 2022).

Adults are concerned that cisgender youth will see breasts or genitals, especially as it relates to trans-females. However, in women’s public bathrooms, including in schools, all activities take place privately behind closed stalls. Public men’s bathrooms also have private stalls. Locker rooms do not always offer this privacy. In many schools with transgender children and youth, the health office bathroom may offer both a respite and safety for both urination and defecation needs as well as for changing clothes, although this option may not always be the most beneficial. Other options should be considered first. The school nurse must be an ally to advocate for safe spaces throughout the building.

Another concern that is often brought up is that of sexual assault by a transgender female in a female bathroom or locker room; however, gender identity has nothing to do with sexual orientation. There have been no reports in the United States to validate any of these concerns. Ybarra (2022) found that transgender youth were twice as likely to experience sexual violence compared to their cisgender peers, but less likely to attempt rape or commit sexual assault.

In 2016, President Obama directed the US Departments of Education and Justice Civil Rights Divisions to allow transgender youth to use the bathroom and locker room that aligned with their gender identity (Tucker, 2016). This directive was rescinded by President Trump during his first term (Vitali et al., 2017) and further substantiated with a 2025 executive order to prohibit federal employees from using their preferred bathroom (Newhouse, 2025). State and district regulations and laws around this topic must be followed, requiring school nurses and school officials to stay up-to-date on changes while balancing the health and safety needs of all students.

What Are the Concerns Related to Transgender Youth Participation in Sports?

Sports participation is associated with positive physical, emotional, and mental health outcomes. It is also associated with a sense of inclusion and team support. Lee et al. (2024) found that states with laws that ban sports participation for transgender youth also saw significant increases (ranging from 7% to 72%) in the rates of suicide among transgender youth 13 to 17 compared to states that did not. While concerning, it must be emphasized that correlation does not imply cause and effect. The impact of the exclusion of transgender individuals from sports needs further examination.

Even when it is not prohibited, transgender youth often have lower rates of sports participation. One reason may be that participation could result in their transgender status inadvertently being revealed. For instance, binders and other restrictive devices used by transgender youth may show through uniforms or restrict movement.

Most concerns around transgender persons’ sports participation generally revolve around the use of locker rooms and shower facilities, and physical advantages in female sports for transgender female athletes. Consideration for the length of time a student has been medically transitioning to their gender identity could help determine whether they should be allowed to participate in sports. For example, the Ladies Professional Golf Association (2025) policy allows participation of trans females if transitioning began prior to Tanner Stage 2 or age 12, whichever comes first; this includes Girls Golf for youth. For those receiving hormone treatment, they must have continuously maintained the concentration of testosterone in their serum below 2.5 nmol/L. To date, school administrators, parents, and athletes struggle to find a solution to the questions around participation in sports. However, a solution that supports the health and safety of all children and youth is needed.

What Other Issues Must Schools Consider Related to Transgender Youth?

There are multiple matters that must be considered when addressing the needs of transgender youth in the schools. School supports for both the parent/guardian and the transgender or questioning/fluid student should be universal and discussed among the school staff. State and district regulations must also be considered. In particular, guidelines are needed for how to handle student requests to be called a name other than the one they were registered with or to be addressed by pronouns that differ from the ones that correspond to their sex assigned at birth. This includes what should be written in electronic and paper files.

Support groups for transgender and questioning students and their families may be helpful. Groups can be offered at school (if allowed) or within the community. Local hospital systems may also provide educational sessions or support groups.

Additional areas where schools should establish gender-supporting guidelines include school dances, Valentine’s Day activities, sex education classes, overnight class trips, homecoming, theater activities, dress codes, and any activities that divide students by gender. State and federal laws as well as local policies must be followed, but the school nurse can be part of the solution by assuring that evidence-informed policies and practices, such as bullying policies and dress codes, are nondiscriminatory, culturally sensitive, and safe for transgender youth. It may help to consult the school’s legal team.

How Can School Nurses Best Support Transgender Youth?

When a student shares with the school nurse their questions about gender identity, it is essential to respond to those queries with compassion and facts. While the school may have policies that prevent what can and cannot be taught, providing appropriate health care and guidance is an essential role of the school nurse (National Association of School Nurses, 2024). Having a handout of trusted websites and resources is helpful for both the youth and their families.

No one pathway will fit all situations; care must be individualized. Assure safety and let them know you care and hear them; let them know that they are not alone. Be their ally and advocate for their needs. Help them feel connected to the school. Ask them what you should say if you have to call their home. The Human Rights Campaign Foundation has multiple resources that might be helpful to the school community regarding how to respond to different questions.

Conclusion

Regardless of their gender identity or their sexual orientation, it is essential to identify and focus on the strengths of all youth. All students should be given the message that it is OK to be true to themselves and recognized for who they are. All youth need to feel safe. They need to feel that someone cares and hears them. They need to feel that they are not alone. These messages can be given whenever discussion of diversity, tolerance and civil rights are discussed. Our goal is to help them be as healthy and successful as possible. One single compassionate and sensitive teacher or school nurse can make a difference.

Resources for Transgender Individuals and Their Families