The assessment of the adolescent with a history of gender identity issues is complex and requires considerable expertise and skill. Intervention typically begins with a complete, comprehensive assessment by qualified health and mental health professionals. Specialized training is needed in this clinical area, which is not typically found or adequate in most graduate programs for medical or mental health professionals. Assessment involves careful consideration of the individual adolescent, his/her family, social environment, and life circumstances. Confusion about gender identity by the adolescent can be related to a range of issues, such as interpersonal and family conflict, poor school performance, substance use, depression, suicidal thoughts and attempts, etc. Often the underlying sexual identity issues remain unexplored or unaddressed leading to inappropriate treatment, school failure, and poor social and psychological adjustment. Special Issues for Adolescents with HIV: Gender Identity Issues 1. Sex: Refers to anatomy and biology. 2. Intersex: Refers to persons born with genitals or sexual anatomy that are ambiguous or with genitals of both sexes. 3. Sexual Orientation: Involves one’s feeling of sexual attraction (revealed through fantasies, erotic, or romantic feelings) and is distinguishable from behavior. 4. Gender: Is a complex phenomenon that some believe to be independent of sex and some believe is interchangeable with sex. It is generally assigned at birth based on genitalia and in the context of cultural norms. 5. Gender Identity: Refers to a person’s inner experience of gender; what a person feels she or he is. 6. Gender role: Involves public behavior; the role taken on in the world with others, often reflecting cultural expectations. 7. Transgender: An umbrella term that designates someone who does not fit neatly into the socially-accepted “male” or “female” and who intentionally rejects the gender assigned to her or him at birth. 8. Transsexual: Refers to an individual whose internally felt gender identity does not match the biological body he or she was born with and/or the gender he or she was assigned at birth. 9. Cross-dressing: Refers to the act of dressing in the clothing worn by the other gender and may be used with reference to both transsexuals and cross-dressers (formerly transvestite). The term cross-dresser is reserved for individuals who like to cross-dress, but who do not experience a dissonance between their biologic body and their gender identity and who do not wish to permanently change their sex or gender. 10. Passing: Term used to assert that a transperson is successful at presenting self in public as the other gender. 11. Transitioning: Refers to the process of moving from one sex/gender to the opposite one. Given the need for information on specific terms related to gender identity issues, the following list of definitions (Kirk, 2006) may be useful to clinicians in their work with adolescents with gender identity issues.

Clinical Resource Guide Background Criteria Associated FeaturesApproach Counseling and individual psychotherapy to cope with the psychological, social, and familial issues Family counseling Educational conferences are essential to address social issues in order to avoid interpersonal issues, school failure and drop-out Psychoeducational approaches are central to working with all involved since many teachers, parents and health professionals have limited knowledge of gender identity issues and related topics Effort should be made to provide the adolescent with counseling as well as antidepressants, antianxiety agents for the treatment of associated depression and anxiety if needed Referral for substance use treatment may be indicated if the adolescent is engaged in self-medication as a means of dealing with stress, anxiety, depression, or peer pressure Issue Social isolation which contributes to low self esteem School failure, aversion, or drop out due to discomfort or ostracism Preoccupation with appearance Impairment of relationships with parents, teachers, others in authority Self treatment with hormones Engage in sex work for pay, clothes, hormones, drugs, etc. Anxiety and depression may be present Suicidality, attempts Adolescents experience similar gender identity issues as adults Strong or persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex) Persistent discomfort with his or her own sex or sense of inappropriateness in the gender role of that sex Disturbance is not concurrent with a physical intersex condition Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning Adolescent Gender Identity Issues By late adolescence or adulthood, 3/4 of males who had a childhood history of gender identity disorder report homosexual or bisexual orientation. The is no data on females. Some adolescents may develop a clearer cross-gender identification and request sexual reassignment or may continue a chronic course of gender confusion or dysphoria.

References 1.Adams, Gerald, (2005) Adolescent Development. In T. Gullotta and G. Adams (Eds). Handbook of Adolescent Behavioral Problems, pp 3-26, New York: Springer Science and Business Media, Inc. 2.Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, American Psychiatric Association, Kazdin, A (2004). Psychotherapy for Children and Adolescents. In M Lambert (Eds), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (5th ed., pp ) New York: John Wiley. 4. Kirk, S. Frank, L., Clinical Transgender Risk Assessment: A Quick Reference Guide, University of Pittsburgh, Graduate School of Public Health Pennsylvania/MidAtlantic AETC, Kirk, S. The Whole Person: A Paradigm for Integrating the Mental and Physical Health of Trans Clients. In Shankle, M. (Ed). Handbook of Lesbian, Gay, Bisexual and Transgender Public Health: A Practitioner’s Guide to Service, This tool was developed by the Mental Health subset (Chair: Linda Frank, PhD, MSN, ACRN, PA/MA AETC) of the AIDS Education and Training Centers (AETC) National Resource Center, Adolescent HIV/AIDS Workgroup (Chair: Marion Donohoe, RN, MSN, CPNP, St. Jude Children’s Research Hospital, ANAC and Ronald Wilcox, MD, FAAP, Delta Region AETC). Collaborating members include Elizabeth Cabrera, MEd (TX/OK AETC), Verita Ingram, MBA (TX/OK AETC), Elise Johnson, MSW (Bickerstaff Pediatric Family Center), Jennifer Scanlon, FNP (The Children's Hospital, Denver), and Ronald Wilcox. The workgroup efforts were coordinated by the AETC National Resource Center (Managing Editor: Megan Vanneman, MPH). Credits