An increasing number of transgender and gender diverse (TGD) youth are seeking health care services today, and pediatric urologists are likely to care for these patients even outside specialized multidisciplinary programs focused on gender affirmation.¹ This article focuses on points to consider when caring for TGD youth, including creating an inclusive office environment, urological care considerations and current legislation that may affect the ability of TGD youth to seek gender-affirming care.

Trans-Competent Care

As approximately 1 in 4 transgender adults may avoid a necessary doctor’s visit because of fear of being mistreated, trans-competent care is essential.² The patient’s interactions with the physical environment and every member of the workforce are equally important in providing an inclusive, safe environment (Fig. 1). Our patients have unique gender identities and preferences for how they would like to be addressed, which may change over time as their gender identity is explored. A familiarity with basic gender identity terminology and understanding the differences between gender identity, gender expression and sexual orientation are imperative to communicate with patients. Inclusive intake forms can provide space for patients to express their pronouns and gender identity, and are ideally reflected in the electronic medical record (EMR). Most TGD youth desire opportunities for EMR-wide preferred name and pronoun documentation, regardless of legal name.³ Introductions that include your pronouns can signal to patients that your office is a safe space. All office staff have a role in affirming a patient’s gender identity. Cultural competency trainings include content such as education about TGD youth, health disparities, gender-affirming communication and data entry into the EMR. Examples of online educational modules are available at The Fenway Institute.⁴ Finally, the physical environment in which you provide care matters. Gender-neutral bathrooms, “safe space” signage, and inclusive waiting room artwork and magazines all reveal awareness and inclusivity.⁵

Figure 1. Practical tips to make your clinic space affirming.

Urological Care

To provide comprehensive urological care for TGD youth, it is helpful to understand the typical gender-affirming treatments available at different ages, including gonadotropin-releasing hormone agonists around the typical time of puberty (reversible pubertal suppression), exogenous hormones in early adolescence and gender-affirming bottom surgery, which in most cases is restricted to patients 18 years or older.

Table 1. Fertility preservation options for TGD patients

Genital exams

TGD patients, whose genitals are often a significant source of their gender dysphoria, may be particularly anxious about genital exams. Demonstrate that it is a safe environment and discuss why there is a need for the exam—spending the extra time and effort is important. In addition, careful attention to the child’s medical history and examination occasionally reveals an underlying intersex or differences of sex development condition.

Voiding dysfunction

Voiding dysfunction occurs in TGD patients as in all youth, though the rates in this population are unknown. Common coexistent mental health issues for TGD youth include anxiety, depression and eating disorders, all known to also be associated with voiding dysfunction. Additionally, TGD patients often feel uncomfortable using public restrooms and may hold their urine for long periods of time. Hormone initiation can trigger lower urinary tract symptoms that may require working with the patient’s hormone provider to adjust dosing. Feminizing hormones typically include estrogen with an antiandrogen such as spironolactone, which will cause a diuretic effect and may compound underlying voiding dysfunction. Tucking is a practice used by trans women to conceal the testicles and penis, pushing the testicles up into the inguinal canal and the penis down. Understanding this practice is important in the context of clinical concerns such as testicular pain, epididymo-orchitis, urinary tract infections and genital skin irritation, although no robust literature exists.

Table 2. Examples of transgender legislation types

Figure 2. Transgender-related health care bills in the United States. A, expansive bills. B, restrictive bills.

Sexual health and fertility

Opening the door to talk about sexual health is important, and TGD individuals who are on testosterone and estrogen should be aware that being on hormones is not sufficient contraception. In particular, amenorrhea does not equate to pregnancy prevention among transmasculine individuals taking testosterone, and unintended pregnancies have been reported.⁶ However, TGD individuals who choose gender-affirming treatments are at risk for future infertility. Pubertal suppression and gender-affirming hormones suppress gonadal function to varying degrees, and gonadectomy results in permanent sterilization. Therefore, individuals who receive gender-affirming treatments should receive counseling regarding the potential for future infertility and subfertility.

Established and experimental fertility preservation options both apply to TGD individuals, with eligibility dependent on pubertal status and gonadal type (Table 1). Uptake of the nonexperimental options has been limited due to considerations including exacerbation of gender dysphoria from procedures necessary to complete fertility preservation (ie masturbation, hormones for ovarian stimulation/egg retrieval).^7,8

Legislation

There has been a significant increase in transgender-focused legislation at the state level over the last 4–5 years in the United States. The types of legislation can be divided into “expansive” and “restrictive” categories, with restrictive-type legislation predominating and potentially limiting the care pediatric urologists can provide to TGD patients (Table 2). During the 2022 legislative session, there have been 5 active expansive-type health care bills in 5 states and 25 active restrictive-type health care bills in 19 states. Most of these bills have intersex “carve-outs,” meaning the proposed restrictions do not apply to individuals with verified disorders/differences of sex development conditions. Figure 2 summarizes recent transgender-related health care bills in the United States. Though access to health care is highly variable and dependent on state-level policies and politics, the Affordable Care Act prohibits health care discrimination at federally funded health care facilities based on gender identity.

Transition to Adult Care

Transition of care to adult services (also known as “transitional care”) ideally provides uninterrupted care for the patient. With the growth of specialized pediatric clinics for TGD health care services, an emphasis should be placed on creating partnerships with adult programs of equal standards of care. Already a vulnerable population, transgender and nonbinary youth may face unique obstacles in this paradigm change, and thus our goal should be to create a safe, competent and gender-affirming medical home for emerging adults.