Transgender and gender-diverse children & adolescents

When permitted, all children and adolescents will experiment with gender expressions and roles; however, some children may assert a gender identity different from the sex they were assigned at birth.

These children will consistently:

• Insist on being a different gender.
• Express dysphoria regarding their gender or body.
• Have a desire to be a different gender (Focier, n.d.).

OTPs can promote inclusive and safe environments, encourage self-advocacy, and support TGD children and adolescents in their gender exploration.

• Chest binding, also referred to as binding, is the practice of using a commercial binder, tight sports bras, undershirts, or other materials to provide a flat, more masculinized chest contour.
• Typically, adolescents learn binding techniques from online sources or peers so OTPs should verify that the adolescent is using appropriate materials and is binding safely.
• Good hygiene for both the user’s skin and the garment is important, as well as monitoring wear schedules. While TGD adolescents may want to bind tightly to achieve a more masculine appearance, OTPs should educate proper safety and hygiene and on the risks of tight binding.
• Common negative side effects of chest binding include skin irritation, back pain, rib pain, shortness of breath, and overheating.
• Adolescents who chest bind have reported increased comfort, increased safety, and decreased rates of being misgendered (Coleman et al., 2022).
• A binder is considered an undergarment and falls under the activity of daily living (ADL) of dressing and due to its benefits can be used to decrease overall stress and anxiety for TGD students.

Social transitioning includes the steps the individual, family, and community take to affirm a child’s gender identity. Social transitioning includes:

• Getting a gender-affirming hairstyle or haircut.
• Wearing gender-affirming clothes.
• Using a chosen name and pronouns.
• Participating in gender-affirming activities.
• Using restrooms that match their identity.

Things to remember about social transitioning

• Social transitioning is reversible at any time if the child no longer feels comfortable (Human Rights Campaign Foundation [HRFC], 2016).
• Some states have recently passed laws or policies against gender-affirming healthcare (e.g. puberty blockers, hormone replacement therapy, or gender-affirming surgery) for transgender youth.
• Despite these laws or policies being in place, social transitioning is not the same as medical transitioning.
• In states where there are policies against medical transitioning, OTPs may still support TGD in social transitioning.
• Social transitioning is linked to improved mental health and behavioral functioning (HRCF, 2016). Community connectedness, familial support, and acceptance are linked to more positive mental health outcomes for transgender children and teens (Olson et al., 2016; Ryan, Russell, Huebner, Diaz, & Sanchez, 2010; Simons et al., 2013).
• Social transitioning includes multiple ADLs and IADLs. OTPs can advocate for clients who wish to social transition and assist parents or guardians in understanding the benefits of allowing their child to transition socially (AOTA; OTPF-4, 2022).

The use of a chosen name and correct pronouns has been shown to decrease:

• rates of gender dysphoria,
• depression,
• anxiety,
• self-harm ideation,
• self-harm behavior,
• suicidal ideation, and
• suicidal behaviors (Russell et al., 2018)

Clinics and schools should work to use the appropriate name and pronouns in paperwork and reports. An individual may use one name and set of pronouns at school or in private but not use the same name and set of pronouns around parents or guardians. The OTP should work to ensure their client is not placed in a situation where they are outed before they are ready.

• Genital tucking is the practice of tucking the testicles into the inguinal canals and securing the phallus backward between the legs to create a flatter genital region.
• The genitals are then held in place using an undergarment such as a gaff or special tape.
• There are limited studies on the risks or benefits of tucking for youths; however, the Oregon Health and Science University (OHSU) has listed some risks as UTIs, problems with urine flow, and twisting and inflammation of the testes.
• As tucking involves increased skin friction, side effects may also include skin irritation and redness (Coleman et al., 2022; OHSU Doernbecher Children’s Hospital, 2020).
• OHSU Doernbecher Children’s Hospital has created a handout to explain how to tuck safety, what materials can be used, and side effects.
• Tucking can be considered an ADL for adolescents who may desire to perform this occupation and OTPs can provide support by teaching safe techniques and providing education.

• This is the process where an adolescent is prescribed a gonadotropin-releasing hormone (GnRH) agonist that halts the puberty process.
• Providers can prescribe the medication after a child shows initial signs of puberty.
• This intervention can assist with the emotional distress a TGD adolescent may experience when going through puberty with the sex they were assigned at birth (SAAB), but do not identify with (i.e. if assigned female at birth, the puberty blockers may prevent breast from growing which means they would not require gender-affirming top surgery later if they wanted it).
• The use of puberty blockers for TGD adolescents has helped reduce anxiety, depression, and substance abuse (Edwards-Leeper & Spack, 2012; J. Olson et al., 2015; Steensma et al., 2013). Puberty blockers are considered a reversible gender-affirming treatment for early adolescents (HRCF, 2016).

• Hormone replacement therapy (HRT) is the administration of hormones (testosterone or estrogen) and other hormone-modulating medication to produce physical changes in secondary sex characteristics in line with gender identity. HRT is not considered a reversible process.
• HRT is considered part of medical transitioning and not all adolescents may be eligible for HRT depending on previous medical history, stage of puberty, or other factors.
• Eligibility varies and is determined on a case-by-case basis (Coleman et al., 2022).
• OTPs who work with adolescents taking HRT should make sure they are able to manage their medication properly and are obtaining medication from a safe and authorized provider.

• Obtaining surgical treatment for adolescents is a lengthy process that typically occurs closer to adulthood.
• Data regarding gender-affirming surgical treatment for adolescents are limited and requirements to qualify for surgery are thoroughly laid out by the World Professional Association for Transgender Health Standards of Care Version 8.
• These guidelines suggest that some TGD adolescents may benefit from chest masculinization surgery if the surgery is clinically and developmentally appropriate.
• Data regarding post-surgery attitudes for chest masculinization surgery showed minimal regret, satisfaction of results, and good surgical outcomes (Coleman et al., 2022).

• While OTPs do not prescribe or administer medical processes, TGD adolescents may benefit from occupational therapy regarding learning new occupations as well as physical and mental health.
• Teaching safety, medication management, addressing mental health concerns, teaching emotional regulation, and teaching now to manage side effects or symptoms are all under the scope of occupational therapy (AOTA; OTPF-4, 2020).

• There is some evidence to suggest that neurodivergent individuals are more likely to identify as transgender or gender diverse compared to non-neurodivergent individuals (Glidden et al., 2016; Warrier et al., 2020).
• OTPs should maintain a client-centered, gender-affirming approach when working with their neurodiverse clients.
• Current literature advocates for children and adolescents to be involved in their health and lives and OTPs should promote the exploration of occupations that would be gender-affirming (Coleman et al., 2022).
• Not enforcing gender-specific roles, occupations, or play allows children and adolescents to explore their gender identity.
• It's important to acknowledge that neurodiverse clients may have trouble expressing their lived experiences or articulating their discomfort around their current gender identity.
• OTPs should work with their clients to help them navigate their gender exploration, participate in meaningful occupations, and encourage self-advocacy.

• Sports bans — restrict TGD students from participating in sports that align with their gender identity.
• Parental disclosure laws — require schools to disclose to parents if a student is using a different name and/or set of pronouns at school.
• Bathroom bans — restrict TGD individuals from using the bathroom that aligns with their gender identity.
• Curriculum restriction — prohibit discussion or teaching on gender identity, sexual orientation, or sexual materials in the classroom.
• Library bans — the removal of library books that discuss or mention sexuality, sexual orientation, or gender identity.
• Student club screens — require parental consent or notification if a student wants to join clubs

These laws and policies may result in TGD students experiencing:

• occupational injustice,
• occupational marginalization,
• occupational deprivation, and
• occupational apartheid (Durocher et a., 2013)

• OTPs have a place in advocating for TGD students to fully participate in their occupations and to participate with their peers.
• TGD students at a school with a bathroom ban may avoid using the restrooms at school and would be at increased risk of a UTI, dehydration, kidney infection, constipation, and future bladder control issues (Herman, 2013).
• Schools with curriculum restrictions on sexuality and gender identity may not deliver quality sexual education courses that can assist students to avoid HPV, HIV, STIs, or unintended pregnancies (CDC, 2023). Participation in sports activities is linked to increased:
  • mental and physical health,
  • social skills,
  • life skills, and
  • self-efficacy (U.S. Department of Health and Human Services, 2020

• By excluding TGD students from sports, TGD students are blocked from receiving the benefits of sports activities.
• The school environment can contribute to decreased mental well-being and increased victimization for TGD students.
• TGD students are at a higher risk of victimization than their cisgender peers which can lead to increased emotional stress, decreased academic performance, and increased rates of absenteeism (Martín-Castillo et al., 2020).
• By promoting an inclusive environment and advocating for TGD students, OTPs can help decrease the risk of suicidal behaviors, decrease victimization, and increase mental, physical, and academic well-being (Martín-Castillo et al., 2020; Russell et al., 2018).