LGBTQ discussed until 10 to 15 years ago. Now, thanks in part to celebrities like Caitlyn Jenner who have made their gender identification and transition public, the transgender topic is no longer a closeted issue. “Today’s more relaxed attitudes make it easier for transgender people to come out and seek the assistance and support they need,” says Ian Marshall, MD, associate professor of pediatrics. In his practice in the Robert Wood Johnson Medical Group, Dr. Marshall cares for transgender adolescents at different stages of gender affirmation treatment. is a broad umbrella, cover- ing a diverse community of people including those who are transgender. Unfortunately, acceptance and understanding for individual gender preferences have been slow to come. Among the wider population, transgenderism was barely wrong clothes. To them, even their given names may seem wrong. Peers perceive that transgender children at any age feel—and sometimes look—nonconforming: transgender girls may prefer short-cropped hair or more traditional boys’ activities. Transgender boys who prefer feminine clothing, as well as games and interests traditionally associated with girls, may have an even more difficult time. Both groups are the frequent victims of bullies. O rientations associated with LGBTQ individuals may overlap, says Dr. Marshall, but gender identification is distinct from sexual orientation. “Gender defineshowwe see ourselves—as women or men—and is not necessarily the same as the biological sex we were first assigned, whereas sexual orientation defines the sex, male or female, we are attracted to.” For many reasons, some transgender individuals may never transition—either through hormone replacement treatment or, far less commonly, surgically—to the gender they identify with, continuing to live in a body that they often feel does not belong to them. From earliest child- Transgender Defined professor of pediatrics, cares for transgender adolescents at different stages of gender affirmation treatment. Ian Marshall, MD, associate A Empathy and Expertise hood, this can create a state of mind known as gender dysphoria—distress and doubt caused by the sense of mismatch between one’s sex and gender. Gender dysphoria is a disturbing but common condition for transgender children. They often describe themselves as living inside someone else’s skin. They feel that they are referred to by the wrong pronouns (“he” or “she,” “his” or “hers”), given the wrong toys, and expected by their families to dress in the t home, transgender children’s relations with parents and other family members can be strained, but in Dr. Marshall’s practice and through his referrals, his patients and their families find empathy and care. Initially, his patients come to him for medical care in their transition—whether male-to-female (MtF) or female-to-male (FtM). For those who embark on the transition journey, Dr. Marshall prescribes hormonal affirmation treatment and provides additional referrals for services such as sociopsychological counseling. To ensure that transgender adolescents receive the extra emotional support they need, he works closely with the family to determine the level of parental acceptance. He also discourages the par- 18 Robert Wood Johnson I MEDICINE