Transgender And Gender Nonbinary Research Articles

What does gender affirmation mean to you? An exploratory study.

Gender affirmation lessens mental health disparities among transgender and gender nonbinary (TGNB) persons. However, the concept of what it means to be affirmed in one's gender has not been fully explored, nor has the impact of gender affirmation on other health indicators been determined. The purpose of this study was to explore the meaning of gender affirmation among a sample of TGNB persons. This qualitative, narrative inquiry study consisted of individual, in-depth, semi-structured interviews with a convenience sample of 20 TGNB persons. Descriptive content analysis was conducted to discover themes. This study identified salient themes regarding the multiple levels of affirmation (including internal, external and societal) needed to achieve the overall goal of living an optimal life described as "being seen, heard and even celebrated" as TGNB. Results of this study have clinical, educational, research, and policy implications. Future research should explore the impact of gender affirmation on important health indicators in the TGNB community, differences in the experiences and needs among subgroups of TGNB persons, and the potential impact of nurses on the health experience of TGNB persons across the spectrum of transition.

Buffering against Depressive Symptoms: Associations between Self-Compassion, Perceived Family Support and Age for Transgender and Nonbinary Individuals.

Transgender and gender nonbinary (TGNB) individuals often report higher levels of depression compared to cisgender individuals. Higher levels of depression in TGNB populations may be partially attributed to a lack of family support, which may be particularly salient for younger individuals. However, two possible protective factors that may mitigate depressive symptoms are self-compassion, defined as an attitude of kindness and understanding towards one’s own imperfections, and perceived support, especially from family. The present study aimed to explore whether self-compassion was negatively associated with self-reported depressive symptoms, and whether perceived family support moderated this association, especially for younger individuals. Participants who were (1) at least 18 years of age, (2) identified as TGNB, and (3) experienced gender dysphoria were eligible for this study. Cross-sectional data from 148 individuals were collected online during May 2020. In support of the hypotheses, self-compassion was negatively associated with depressive symptoms, and perceived family support furthered this association. Additionally, results showed that younger participants (ages 18–24) with lower family support reported the highest levels of depressive symptoms. Taken together, these results suggest that self-compassion and perceived family support may be significant protective factors against depressive symptoms for TGNB individuals, although longitudinal research is needed. Taking a strengths-based perspective, mental health clinicians working with TGNB individuals may consider interventions geared toward increasing self-compassion in daily life and working with clients’ families to increase support.

Pride Camp: Pilot study of an intervention to develop resilience and self-esteem among LGBTQ youth

BackgroundMany LGBTQ youth experience rejection and discrimination in their families and schools, and the range of interventions for improving their resilience and well-being is limited. We developed and piloted an LGBTQ-youth-focused intervention to build resilience and promote health equity, called Pride Camp, in an urban environment in the Midwest.MethodsUsing a mixed-method approach we examined the impact of Pride Camp on resilience and other measures of well-being among LGBTQ high school students who attended camp on a college campus in 2015, 2016, and 2017. Camp attendees and the research sample included a majority proportion of transgender and gender nonbinary (TGN) youth.ResultsPre- and post-test data from our quantitative surveys (n = 28), indicated significant increases in resilience, self-esteem, and quality of life in LGBTQ youth who attended camp. Similar results were found among the TGN participants (n = 19). Qualitative data from focus groups indicated that specifically for TGN youth, the affirming environment at the camp provided social opportunities that they had not found elsewhere.ConclusionsFindings suggest that the Pride Camp intervention provides a platform for LGBTQ youth to meet peers and engage in LGBTQ communities, improving their resilience and outlook on the future. A larger controlled study of the Pride Camp intervention including measurement of additional specific health outcomes over a longer follow-up period is warranted to examine the impact of this program on health equity.

Nipple-areola complex reconstruction in transgender patients undergoing mastectomy with free nipple grafts: a systematic review of techniques and outcomes.

Nipple-areola complex (NAC) reconstruction in transgender and gender non-binary (TGNB) individuals undergoing chest wall masculinization surgery is critical for adequate satisfaction and aesthetic results. Here, we conducted a systematic review to find the various techniques and outcomes of NAC reconstruction in double-incision mastectomy and free nipple grafts (DIM-FNG). A comprehensive search of several databases was conducted based on PRISMA guidelines. We included studies that described the NAC reconstruction technique after DIM-FNG, and evaluated the surgical outcomes, or satisfaction, or aesthetic results after a minimum duration of follow-up of 6 months. Studies were assessed for risk of bias. A qualitative synthesis was performed. A total of 19 studies, comprising 1,587 patients (3,174 breasts), were included. There was a total of 14 studies using the conventional FNG technique, 4 describing new approaches for NAC reconstruction in FNG and 1 study comparing the conventional FNG technique to another alternative technique. A total of 1,347 patients underwent DIM-FNG with conventional FNG and 240 underwent alternative techniques for NAC reconstruction after DIM-FNG. Postoperative complications were low, and satisfaction was high for conventional and alternative techniques. Newer techniques aim to reshape the new NACs in an oval shape, reduce nipple size and place the NACs using the pectoralis major lateral and inferior borders as reference. In addition, a horizontal oval incision at the recipient site may avoid an undesired vertical NAC.

Transgender and Gender Non-Binary Healthcare Coverage in State Medicaid Programs: Recommendations for More Equitable Approaches

Transgender and gender non-binary (TGNB) individuals face discrimination in healthcare settings and barriers to healthcare access, resulting in health disparities. These inequities are compounded by the intersection of lower socioeconomic status and geography. To understand the differences in how states provide healthcare to TGNB individuals in poverty, we ask: What are state Medicaid programs offering TGNB residents, and how can coverage be more equitable across jurisdictions? To answer these questions, we examine medical services covered by 15 diverse Medicaid programs and compare them to the services recommended by the World Professional Association for Transgender Health (WPATH). Unsurprisingly, the analysis reveals inconsistent TGNB health coverage across states. While some states include coverage for TGNB-related care, some do not, and others place access to services in the hands of medical providers. These coverage disparities leave many TGNB Medicaid recipients across the U.S. without coverage for medically necessary services, prompting equity questions for both research and practice.

Understanding the Impact of the COVID-19 Pandemic on the Mental Health of Transgender and Gender Nonbinary Individuals Engaged in a Longitudinal Cohort Study

ABSTRACT While the COVID-19 pandemic in the United States disproportionately impacts marginalized communities, no empiric US-based research has focused specifically on transgender and gender nonbinary (TGNB) people. We examined the pandemic’s impact on an established longitudinal cohort of TGNB individuals (N = 208) by administering an online survey between March-June 2020. We used multivariable linear regression to examine reduced LGBTQ/TGNB community support and disruptions in gender-affirming health care as predictors of psychological distress during the pandemic. We found that the pandemic exacerbated ongoing mental health disparities for TGNB individuals. Furthermore, reduced LGBTQ/TGNB support was associated with increased psychological distress during the pandemic. Interruption and/or delay in gender-affirming health care was not associated with increased psychological distress during the pandemic. Special attention is needed to address the unique ways in which TGNB individuals were affected by the COVID-19 pandemic. This includes increasing access to LGBTQ/TGNB community support and addressing long-standing health disparities.

No Venous Thromboembolism Increase Among Transgender Female Patients Remaining on Estrogen for Gender-Affirming Surgery.

Both surgery and exogenous estrogen use are associated with increased risk of venous thromboembolism (VTE). However, it is not known whether estrogen hormone therapy (HT) exacerbates the surgery-associated risk among transgender and gender nonbinary (TGNB) individuals. The lack of published data has contributed to heterogeneity in perioperative protocols regarding estrogen HT administration for TGNB patients undergoing gender-affirming surgery. A single-center retrospective chart review was performed on all TGNB patients who underwent gender-affirming surgery between November 2015 and August 2019. Surgery type, preoperative HT regimen, perioperative HT regimen, VTE prophylaxis management, outcomes, and demographic data were recorded. A total of 919 TGNB patients underwent 1858 surgical procedures representing 1396 unique cases, of which 407 cases were transfeminine patients undergoing primary vaginoplasty. Of the latter, 190 cases were performed with estrogen suspended for 1 week prior to surgery, and 212 cases were performed with HT continued throughout. Of all cases, 1 patient presented with VTE, from the cohort of transfeminine patients whose estrogen HT was suspended prior to surgery. No VTE events were noted among those who continued HT. Mean postoperative follow-up was 285 days. Perioperative VTE was not a significant risk in a large, homogenously treated cohort of TGNB patients independent of whether HT was suspended or not prior to surgery.

Electronic Consultations as an Educational Tool to Improve the Care of Transgender Patients in Primary Care.

Electronic consultations (eConsults) have demonstrated benefits in many areas of clinical care including educational value for primary care clinicians (PCCs). It has been shown that few PCCs have knowledge and confidence to manage transgender and gender non-binary (TGNB) patients. In this report, we explored the impact of eConsults submitted to a TGNB specialist panel on PCC experience and on their education on TGNB-related topics. We conducted a retrospective review of de-identified data from the RubiconMD electronic consultation platform used by PCCs in 36 U.S. states for eConsults submitted to the TGNB specialty. We found that 90% of eConsults were from federally qualified health centers, other community clinics, and rural areas. Primary care clinicians reported outcomes as "educational" for 50% and "improved care plan" for 88% of eConsults. These results suggest that eConsults play an important role in educating PCCs on TGNB care and may also lead to improved PCC and patient experiences.

Project Uplift: A Behavioral Health Intervention for Transgender and Non-Binary Young Adults

Transgender and gender non-binary (TNB) individuals are disproportionately impacted by mental health disorders, substance use, and suicidal ideation and attempts than the general population.1–4 In addition, TNB individuals are more likely to experience stress due to trauma, stigma, discrimination, victimization, under/unemployment, housing instability, and lack of access to gender affirming behavioral healthcare, all of which contribute to poor behavioral health outcomes.1,5–8 In the southern region of the US, where the largest number and proportion of TNB individuals reside, cultural conditions that contribute to significant LGBTQ+ stigma and discrimination, racism, fewer educational and employment opportunities, and greater overall poverty further compound the risks of behavioral health disparities.9–12

Prevalence and minority-stress correlates of past 12-month prescription drug misuse in a national sample of transgender and gender nonbinary adults: Results from the U.S. Transgender Survey

BackgroundPrescription drug (PD) misuse, particularly opioid misuse, is a major US public health concern. While transgender and gender nonbinary (TGNB) individuals experience numerous health disparities, including substance use disparities, little research has focused on PD misuse in this population. MethodsData for this secondary analysis come from the US Transgender Survey (N = 26,689). First, we examined bivariate differences in past 12-month PD misuse among binary transgender women, binary transgender men, nonbinary individuals assigned-female-at-birth (AFAB), and nonbinary individuals assigned-male-at-birth (AMAB). We then used multivariable logistic regression (separately based on sex-assigned-at-birth) to examine the relationship between gender-identity related discrimination and PD misuse. ResultsPD misuse was significantly more common among binary transgender men (17.3 %), nonbinary AFAB individuals (18.7 %), and nonbinary AMAB individuals (18.0 %); compared to binary transgender women (13.5 %). In multivariable analyses, nonbinary identity was associated with higher odds of PD misuse among TGNB AFAB individuals (OR = 1.121; 95 %CI 1.021−1.232) and AMAB individuals (OR = 1.315; 95 % CI 1.133−1.527). Controlling for overall health status and psychological distress, public accommodations discrimination was associated with PD misuse among TGNB AMAB individuals (OR = 1.578, 95 %CI 1.354−1.839). Among both groups, healthcare discrimination was associated with PD misuse (AFAB OR = 1.388, 95 %CI 1.255−1.534; AMAB OR = 1.227, 95 %CI 1.073−1.404). ConclusionIn this national sample of TGNB individuals, nonbinary individuals were at greater risk for PD misuse than binary individuals, possibly due to less societal affirmation. Similar to other TGNB health disparities, discrimination based on gender identity/expression was associated with PD misuse. This highlights the importance of interventions to reduce discrimination against TGNB individuals.

Telemedicine and Inequities in Health Care Access: The Example of Transgender Health.

Due to concerns about the risk of infectious exposures during the coronavirus disease 2019 (COVID-19) pandemic, the uptake of telemedicine has increased rapidly, aided by increased acceptance by clinicians and patients and a reduction in regulatory and reimbursement hurdles. The increased access to telemedicine may have benefits beyond the reduction in contagious risk, especially for vulnerable populations. By breaking down some of the common barriers to care for vulnerable populations, the broad implementation of telemedicine may help reduce some inequities in health care access, but telemedicine does raise other challenges that need to be considered and addressed. One vulnerable group that can benefit from telemedicine is transgender and gender nonbinary (TGNB) individuals, who have less access to both gender-affirming and general medical care due to the consequences of stigma, discrimination, and marginalization. Telemedicine allows TGNB individuals to access clinical expertise even if it is not available locally, and without the expense of travel and without the concern for exposure to discrimination and mistreatment. However, lack of access to or expertise in navigating the required technology, lack of a safe and confidential space to access care, and an unpredictable regulatory and reimbursement environment remain hurdles for harvesting the full benefits of telemedicine.

An Environmental Scan of Sex and Gender in Electronic Health Records: Analysis of Public Information Sources.

BackgroundHistorically, the terms sex and gender have been used interchangeably as a binary attribute to describe a person as male or female, even though there is growing recognition that sex and gender are distinct concepts. The lack of sex and gender delineation in electronic health records (EHRs) may be perpetuating the inequities experienced by the transgender and gender nonbinary (TGNB) populations.ObjectiveThis study aims to conduct an environmental scan to understand how sex and gender are defined and implemented in existing Canadian EHRs and current international health information standards.MethodsWe examined public information sources on sex and gender definitions in existing Canadian EHRs and international standards communities. Definitions refer to data element names, code systems, and value sets in the descriptions of EHRs and standards. The study was built on an earlier environment scan by Canada Health Infoway, supplemented with sex and gender definitions from international standards communities. For the analysis, we examined the definitions for clarity, consistency, and accuracy. We also received feedback from a virtual community interested in sex-gender EHR issues.ResultsThe information sources consisted of public website descriptions of 52 databases and 55 data standards from 12 Canadian entities and 10 standards communities. There are variations in the definition and implementation of sex and gender in Canadian EHRs and international health information standards. There is a lack of clarity in some sex and gender concepts. There is inconsistency in the data element names, code systems, and value sets used to represent sex and gender concepts across EHRs. The appropriateness and adequacy of some value options are questioned as our societal understanding of sexual health evolves. Outdated value options raise concerns about current EHRs supporting the provision of culturally competent, safe, and affirmative health care. The limited options also perpetuate the inequities faced by the TGNB populations. The expanded sex and gender definitions from leading Canadian organizations and international standards communities have brought challenges in how to migrate these definitions into existing EHRs. We proposed 6 high-level actions, which are to articulate the need for this work, reach consensus on sex and gender concepts, reach consensus on expanded sex and gender definitions in EHRs, develop a coordinated action plan, embrace EHR change from socio-organizational and technical aspects to ensure success, and demonstrate the benefits in tangible terms.ConclusionsThere are variations in sex and gender concepts across Canadian EHRs and the health information standards that support them. Although there are efforts to modernize sex and gender concept definitions, we need decisive and coordinated actions to ensure clarity, consistency, and competency in the definition and implementation of sex and gender concepts in EHRs. This work has implications for addressing the inequities of TGNB populations in Canada.

Algorithm to identify transgender and gender nonbinary individuals among people living with HIV performs differently by age and ethnicity

PurposeHIV research among transgender and gender nonbinary (TGNB) people is limited by lack of gender identity data collection. We designed an EHR-based algorithm to identify TGNB people among people living with HIV (PLWH) when gender identity was not systematically collected. MethodsWe applied EHR-based search criteria to all PLWH receiving care at a large urban health system between 1997 and 2017, then confirmed gender identity by chart review. We compared patient characteristics by gender identity and screening criteria, then calculated positive predictive values for each criterion. ResultsAmong 18,086 PLWH, 213 (1.2%) met criteria as potential TGNB patients and 178/213 were confirmed. Positive predictive values were highest for free-text keywords (91.7%) and diagnosis codes (77.4%). Confirmed TGNB patients were younger (median 32.5 vs. 42.5 years, P < .001) and less likely to be Hispanic (37.1% vs. 62.9%, P = .03) than unconfirmed patients. Among confirmed patients, 15% met criteria only for prospective gender identity data collection and were significantly older. ConclusionEHR-based criteria can identify TGNB PLWH, but success may differ by ethnicity and age. Retrospective versus intentional, prospective gender identity data collection may capture different patients. To reduce misclassification in epidemiologic studies, gender identity data collection should address these potential differences and be systematic and prospective.

Survey of Experiences of Transgender and Gender Nonbinary Patients During Imaging Encounters and Opportunities for Improvement.

OBJECTIVE. The purpose of this study was to assess the inclusivity of imaging centers for transgender and gender nonbinary (TGNB) patients and those patients' level of comfort during imaging center visits. MATERIALS AND METHODS. A survey of TGNB persons was developed to explore their experiences during imaging encounters. The survey was distributed via purposive snowball sampling with link sharing on social media and listservs as well as at TGNB community events and conferences during the period from January to December 2018. RESULTS. Of the 555 respondents who initiated the survey, 363 (65.4%) completed it and satisfied inclusion criteria. Of the 363, 257 (70.8%) reported having had at least one negative imaging encounter. Nearly one-third (32.4%, 116/358) had to instruct imaging facility staff about TGNB persons to receive appropriate care. Ultrasound examinations and image-guided procedures contributed to the highest rates of unexpected emotional discomfort (49.1% [109/222] and 38.1% [16/42], respectively). Noninvasive modalities also contributed to unexpected emotional discomfort, with the highest percentage of patients (23.5%) reporting emotional discomfort during MRI. Many imaging environments were considered unwelcoming toward TGNB patients, with 45.2% (164/363) of respondents noting no visible reading materials or other postings that could be considered to be affirming to lesbian, gay, bisexual, transgender, or queer patients and 39.1% (142/363) noting a lack of all-gender or gender-neutral restrooms. CONCLUSION. To our knowledge, our data provide the largest documentation and first quantification of the experiences of TGNB patients during imaging encounters. The data show several aspects of imaging encounters that may contribute toward negative experiences for TGNB patients, which may be improved through education of imaging personnel in TGNB cultural competency, redesign of facilities with sensitivity toward TGNB persons, and incorporation of TGNB patient feedback in the adoption of departmental policies.

Assessing Registered Dietitian Nutritionists' Knowledge Regarding Nutrition and Health Care for Transgender and Gender Non-Binary (TGGNB) Individuals

Assessing Registered Dietitian Nutritionists' Knowledge Regarding Nutrition and Health Care for Transgender and Gender Non-Binary (TGGNB) Individuals

Stigmatization, Resilience, and Mental Health Among a Diverse Community Sample of Transgender and Gender Nonbinary Individuals in the U.S.

Transgender and gender nonbinary (TGNB) individuals were recently designated a health disparity population by the U.S. National Institutes of Health. We examined the effect of gender-related discrimination and resilience factors on the mental health of a community sample diverse in gender identity, age, and race/ethnicity. We report on the baseline data of a longitudinal study of transgender identity development across the lifespan with 330 TGNB individuals recruited through venue-based recruitment in three major metropolitan areas in the U.S. Mean age of participants was 34.4years (SD= 13.7). Structured interviews collected self-report data on sociodemographics, gender-related discrimination, mental health, and resilience. We used hierarchical regression to examine the association between gender-related discrimination and psychological distress (BSI-18) and tested the moderating effect of family support, transgender community connectedness, gender literacy, and transgender activism on this relationship. In adjusted analyses, gender-related discrimination was positively associated with psychological distress. Family support was negatively associated with psychological distress. Contrary to our expectations, gender literacy and transgender activism were positively associated with psychological distress, while no significant relationship was found for transgender community connectedness. Family support, transgender community connectedness, gender literacy, and transgender activism did not moderate the effect of gender-related discrimination on psychological distress. Future mental health interventions should consider leveraging family support among TGNB individuals. Longitudinal studies are needed to better understand the role of gender literacy and activism with respect to mental health and development of identity and resilience among TGNB people.

Three Populations Knowledge Regarding Nutrition and Health Care for Transgender and Gender Non-Binary (TGGNB) Individuals

Abstract Objectives The transgender and gender non-binary (TGGNB) community makes up about 0.6% of the United States population. A 2011 survey showed that 50% of TGGNB individuals report having to teach medical providers about TGGNB care. This research asked how knowledgeable the nutrition and healthcare community and related others are in interacting with the TGGNB population. The first aim compared Registered Dietitian Nutritionists (RDN) with a university community and members of the general public with regard to current health and nutrition knowledge related to the TGGNB community. The second aim assessed responses from the general public before and after viewing an educational model. Methods De-identified cross-sectional surveys were conducted in the three communities through REDcap, a secure web application. Participants were directed to REDcap through social media sites and list serves. Questions on the pre/post survey tested the effectiveness of a brief educational module on TGGNB terminology, health monitoring, and health disparities. Results Responses to the surveys included 305 RDNs (experience range 0–10 + years), 73 from general population (20% working in healthcare), and 77 from Bastyr University (provides education for healthcare providers currently undergoing diversity, equity, and inclusion (DEI) training). A question concerning the effects of testosterone hormone therapy (HRT) on a lipid panel was asked to collect baseline knowledge among the three communities. Outcomes showed 13.0% correct responses from the Bastyr community, 24.7% from the general population, and 27.3% from RDNs. The pre/post survey found an increase in confidence and knowledge after viewing the module. A question on using correct terminology indicated a 10.0% increase in confidence. A question about lipid panel changes in response to testosterone HRT resulted in a 66.2% increase in knowledge. A question on disordered eating health disparities of TGGNB youth showed a 16.5% increase in knowledge. Conclusions This research highlights limitations in RDNs knowledge in interacting with TGGNB individuals and indicates the benefits of a brief educational module on increasing knowledge and confidence on a target population such as the TGGNB community. Funding Sources N/A.

Transgender and Gender Nonbinary Persons' Health and Well-Being: Reducing Minority Stress to Improve Well-Being.

This article describes minority stress theory as applied to health disparities and health-care experiences of transgender and gender nonbinary (TGNB) persons. The combination of stigma, social and structural inequalities, and actual discrimination events result in mutually reinforcing dynamics that drive persistent and stubborn disparities in physical and mental health for TGNB persons (Halkitis, Kapadia, Ompad, & Perez-Figueroa, 2015). Together with distrust of the medical system and discomfort of health-care providers in caring for TGNB persons (Smith & Turell, 2017), minority stress contributes to poorer health outcomes and reduced quality of care for sexual and gender minority populations. Ways to reduce health-care-related minority stress for TGNB persons are proposed, with the goal of improving TGNB health and well-being.

Gender Dysphoria, Mental Health, and Poor Sleep Health Among Transgender and Gender Nonbinary Individuals: A Qualitative Study in New York City.

Background: A vast amount of research has demonstrated the numerous adverse health risks of short sleep duration and poor sleep health among the general population, and increasing studies have been conducted among lesbian, gay, and bisexual individuals. However, although poor sleep health is disproportionately experienced by sexual and gender minority populations, little research has examined sleep quality and associated factors among transgender and gender nonbinary (TGNB) individuals. This study qualitatively explored the relationship that factors such as gender identity, mental health, and substance use have with sleep health among a sample of TGNB individuals in New York City.Methods: Forty in-depth interviews were conducted among an ethnically diverse sample who identified as transgender male, transgender female, and gender nonbinary from July to August 2017. All interviews were transcribed, coded, and thematically analyzed for domains affecting overall sleep, including mental health, gender identity, and various coping mechanisms to improve overall sleep.Results: TGNB interview participants frequently described one or more problems with sleeping. Some (15%) participants suggested that mental health issues caused them to have difficulty falling asleep, but that psychiatric medication was effective in reducing mental health issues and allowing them to sleep. An even larger number (35%) told us that their gender identity negatively impacted their sleep. Specifically, participants described that the presence of breasts, breast binding, stress and anxiety about their identity, and concerns about hormonal therapy and gender-affirming surgery were all reported as contributing to sleep problems. Given these sleep challenges, it is not surprising that most (60%) participants used various strategies to cope with and manage their sleep problems, including prescription and over-the-counter sleep medications (33%) and marijuana (18%).Conclusions: Our findings document that sleep health is frequently an issue for TGNB individuals, and they also offer insight into the various ways that TGNB individuals attempt to cope with these sleep problems. Sleep health promotion interventions should be developed for TGNB people, which would promote positive mental health, reduce the risk of pharmaceutical adverse events, and help alleviate psychosocial stress in this target population.

Beyond circles and squares: A commentary on updating pedigree nomenclature to better represent patient diversity.

With changes in our understanding of gender identity and disorders of sex differentiation (DSDs), as well as a need to promote medical care that appropriately reflects the intersectional personal identities of patients with respect to sex and gender, we explored possible modifications of pedigree nomenclature to better represent such patient diversity. There are currently no widely accepted standard symbols to simultaneously represent both gender identity and assigned sex at birth within a pedigree. Previous studies assessing perspectives from members of the transgender and gender non-binary (TGNB) community have highlighted the need for a unique symbol to represent non-binary individuals and better ways to represent core gender identities for gender minorities such as transgender individuals. In our experience we have encountered similar dilemmas with documentation for individuals with DSDs in terms of a lack of unequivocal symbolic representation within the pedigree. Here we propose three distinct symbols for gender identity combined with superscript symbols to represent sex assigned at birth, which we think may unequivocally represent TGNB individuals and patients with DSDs. It is clear that further research is needed to ensure that any proposed changes are acceptable by and respectful of all patients regardless of their gender identity and assigned sex at birth. We hope that further research will include focus groups and surveys to get broader input from gender minority stakeholders so that new standards can be developed and modified as we strive to meet the needs of our increasingly diverse patient population.