For many in the general public transgender issues and even transgender people seems to have come out of nowhere! Suddenly bathroom bills, and the very public transition of Bruce Jenner to Katelyn Jenner, have made this a hot button issue. However, transgender individuals and issues have always existed, and have been slowly being more openly addressed by many communities over the past several decades. Camps have been some of these communities, often accommodating and adapting to serve their customers in ways they never envisioned. As transgender visibility increases, these individuals will need to be accommodated by the camp industry, and camp nurses in increasing numbers.
Welcoming and appropriately handling campers who are transgender or gender queer requires a significant amount of education and introspection for staff, campers, and parents. It will require a lot of change in thinking and belief for everyone. The nurse and health center are actually a very small, but vital component in the process. This article will assist in educating nurses about the social, medical, and emotional issues around accommodating and welcoming transgender campers.
It is estimated that between 2-5 percent of the population fits under the broader transgender identity in which they experience some gender dysphoria. In general, little data exists on the lives of transgender people. The reports that do exist typically focus on the transgender population as a whole and do not distinguish between the experiences of young and older individuals.. However, an analysis of the Youth Risk Behavior Survey administered to San Francisco students found that 1.3 percent of middle school students in that system identified as transgender. Although nationwide data is not available, if these numbers are extrapolated to your camp population, they are absolutely statistically significant, if you have a large enough camp community, it is only a matter of time until you run into a camper who is identifying as transgender, or gender queer. Especially as trans visibility increases and persons with gender dysphoria are given the words and options to express their inner feelings.
That was the first day (age 3) I ever heard the word “transgender.” I remember feeling this overwhelming sense of relief that there was finally a word that described me—a girl who had accidentally been born into a boy’s body. - Jazz Jennings
Gender identity is the gender a person feels and explains their lived experience – who they are. When one’s gender identity does not match their assigned sex they may experience dysphoria, which is a feeling of disconnectedness from their body. An individual can experience gender dysphoria, and come to the realization that they are transgender, at any point in their life. Very young children, adolescents, and adults can all experience gender dysphoria. Signs are not always evident throughout a person’s life, and others may be surprised when a young person discloses that they are transgender. The age at which children begin to articulate their experience of gender dysphoria or assert a gender identity that is distinct from their assigned sex at birth is highly variable, however most experts agree that children are aware of gender and gender differences around age two, and by age four gender identity is solidified. . Most transgender or gender queer youth feel an intense pressure to “play it straight” and may not be able to articulate or feel comfortable disclosing their authentic gender identity. Some continue to publicly identify as their biological gender, while having a more gender fluid existence at home and around trusted individuals  Gender dysphoria often leads to symptoms of depression, anxiety, social isolation, behavioral problems, school struggles, and suicidal ideation at shockingly young ages 
Gender dysphoria is a very serious issue, and a scientific conciseness on the proper treatment of it is lacking. However, studies on the transgender adult and youth population confirm the dismal psychological outcomes in this population when gender dysphoria is not addressed. Although there is presently no published evidence to support mental health providers in suggesting social transition as a beneficial intervention, many families, and individuals, make the decision to socially transition based on observational evidence in response to seeing how suffering can be alleviated by allowing the child to express their own sense of gender. 
Social transition, however, is where the transgender individual begins to experience external conflict with society, and where the camp and camp health community needs to begin it's journey to acceptance of the transgender persons true, rather then biological gender. This begins with realizing that transition is generally not a matter of simply “wanting” or “feeling” it is often a needed treatment to prevent psychological trauma. In some cases, it may even be lifesaving. Studies show that socially transitioned children have depression rates identical to their cisgendered peers, and anxiety rates dramatically lower than their non-socially transitioned peers .
It should be noted that much like gender itself, a social transition is not always a binary process. Individuals may keep their biological gender assignment, but have dress or behavior that favors the opposite gender. These individuals are considered gender non-conforming, or sometimes by the term gender queer.
Social transitioning is becoming more common and has recently been granted strong legal protection in the area of public education, under title IX. Transgender students have the right and expectation be treated according to the gender they identify with. Schools cannot require them to provide legal or medical evidence in order to have their true gender respected. They are to be called by the name and pronouns consistent with their gender identity. They must be free of harassment due to being transgender or gender non-conforming. If school administrators become aware of bullying or harassment they must take action to end it. They may not be excluded from school activities or events because of transgender or gender non-conforming status. They have the right to dress and present in a way that is consistent with their gender identity. Most controversially transgender students have the right to use restrooms, locker rooms, and other facilities that are consistent with their gender identity, and they can’t be forced to use separate facilities. 
Although privet schools and institutions such as camps are not required to grant these same rights, it will almost certainly become the expectation of both new and established campers, who are transgender, that their rights will be respected in a similar fashion. As social transition becomes easier, in the public sector. Camps, in the privet sector, should prepare to accept both campers who arrive for their first season presenting with their true rather than biological gender, and also accommodate campers who socially transition from one summer to another, as both scenarios will undoubtedly become increasingly common, although statistically still rare, in the next several years. Even if your camp does not presently identify a transgender/ gender queer camper, the anti-bullying program already in place should expand to include the LGBT umbrella specifically. Attempts should also be made to move forms and activities away from a focus on the gender binary. This may feel uncomfortable given the age of the campers, but explicit expressions of acceptance can be lifelines to children who are conflicted about gender and worry about being ostracized, both in public and at home.
Medical care of transgender youth differs depending on the developmental stage of the child. For transgender, or gender queer children of all ages and stages, care should focus on creating a safe and welcoming environment for the child.  These children can face varying levels of discrimination and hardship in their day to day life in addition to their internal struggle. Camp and the camp health service should do their best not to add to this situation. Cultural sensitivity and awareness begins with office staff, and other staff that are initial points of contact for parents and campers. They should inquire about appropriate pronouns and name, that the child prefers. This is the first, and potentially most important step toward creating a culturally sensitive and welcoming environment. Camp staff can model appropriate use of names and pronouns in the presence of other campers and each other to create an affirming space for the transgender child.  Avoid using the child's former name that does not align with their true gender. This is called “dead naming” and can be quite hurtful to the individual.
Increasing numbers of young people are presenting with non-binary or gender queer identities, preferring gender-neutral pronouns, such as ze and hir in place of him or her, as a more accurate way to be described. It is not uncommon for people to struggle with gender-neutral pronouns, and inadvertently invalidate non-binary identities. Regardless of whether non-binary identities are a stepping stone to a more binary identity, or are landing spots, they are valid and need to be honored. When in doubt of pronouns the transgender/ gender queer individual prefers, you are always safe with the individuals name, or you. Avoid using “it” as a pronoun unless specifically asked as this is generally considered a hurtful slur against trans persons. 
From a camp health perspective interfacing with the campers home mental health professional will be very helpful to you in understanding the child's individual needs. The child's home therapists also can work closely with camp to help them understand what the child is experiencing, and will likely need to be successful in the camp environment. They can also connect your organization with educational resources to help staff understand and interact with the trans camper in a positive way.  The camp should also support and encourage telephonic or online therapy during the camp session, to keep the trans camper connected to their home support system, and to help address any issues or concerns that may arise during the camp session.
Medical intervention in transgender/gender queer youth who are pre-pubertal is generally only focused on mental health, and treating gender dysphoria. As the child approaches puberty medical interventions to arrest puberty may be initiated. Youth with gender dysphoria often experience significant trauma at the onset of the puberty process. Gender dysphoria may also first emerge with the onset of puberty, as the development of secondary sexual characteristics can be the solidification of an undesired physical developmental process for those with a gender identity that is in conflict with their biological sex  Imagine how traumatic puberty would have been for thirteen year old you, if you suddenly started developing the characteristics of the opposite gender!
In order to avoid the development of undesired secondary sexual characteristics, GnRH analogues, such as Leuprolide acetate (Lupron) or Histrelin (Vantas), ideally are initiated at the earliest stages of puberty possible. Arresting puberty is a low-risk intervention that allows the trans youth to assess their desire for further hormone therapy, or to assess their feelings around social transition, without fighting against their natural developmental process. And generally will not need the assistance of the camp health service beyond an intramuscular injection once every three or four months, or occasional labs to assure appropriate dosing. While rare, reported side effects from the use GnRH analogues may include diminished bone mineral density acquisition, weight gain, abscesses at the site of injection (if injectable form is used), irregular vaginal bleeding, and emotional malaise. 
As the transgender camper ages the decision will be made to discontinue GnHR analogs and allow the puberty consistent with their biological sex to progress, or to begin the administration of gender affirming hormones. While the current Endocrine Society guidelines recommend starting gender-affirming hormones at about age 16, some specialty clinics and experts now recommend the decision to initiate gender-affirming hormones be individually determined, based more on state of development rather than a specific chronological age. This may seem very unusual, and may raise ethical concerns regarding making major and permanent physical changes in children who are perceived as to young to understand their decisions however, those concerned should remember awareness of one's gender identity does not require cognitive capacity acquired in adolescence or early adulthood, nor does it require a fully myelinated frontal lobe. Gender studies in non-transgender participants have found that children are aware of their gender by the age of five or six, and often earlier.[1o] available data from the Netherlands indicates that those youth who reach adolescence with gender dysphoria are unlikely to revert to a gender identity that is congruent with their assigned sex at birth.
Hormone dosing in youth will vary based on the age, health, and other factors specific to the child's individual situation and desires. Administration of gender affirming hormones is generally accomplished with weekly subcutaneous or intramuscular injection. Transdermal patches may be used and are generally applied every three to four days. Topical application of testosterone therapy is less commonly used and may present difficulty in the camp setting as they require a daily application, and have the risk of cross dosing with individuals in close contact with the patient. Dosage for these hormones is generally accomplished based on clinical response, but labs may be required to monitor therapy.  Generally hormone replacement can be accomplished with minimal interruption of the camp program, and should be carried out with extreme consideration to the privacy and sensitivity of the patient at all times.
Transgender youth may also engage in the practice of binding, packing or tucking to better physically represent their true gender. Binding involves the use of tight fitting sports bras, shirts, ace bandages, or a specially made binder to provide a flat chest contour. In some people with larger breasts, multiple garments may be used, and breathing may be restricted. Prolonged binding may result in breast pain, local skin irritation, or fungal infections. 
Tucking allows a visibly smooth crotch contour. In this practice, the testicles are moved into the inguinal canal, and moving the penis and scrotum posterior in the perineal region. Tight fitting underwear, or a special undergarment known as a gaffe is then worn to maintain this alignment. In some cases, adhesive or even duct tape may be used. In addition to local skin effects, this practice could result in urinary trauma or infections, as well as testicular complaints. Long term binding or tucking should be discouraged as the risk for complication increases the longer these activities are carried out. 
Packing is the placing of a penile prosthesis in one's underwear, giving both an outward appearance as well as reducing gender dysphoria. No health concerns are generally associated with packing, remember although the appliance may seem cosmetic it is a medical intervention and should be treated with the seriousness that is appropriate for any other prosthesis 
Surgical intervention, or transition is not recommended for transgender youth at this time. However Transmasculine youth who have undergone natural puberty commonly experience significant chest dysphoria, after breast development. They may engage in inappropriate methods of chest binding. Binding with duct tape, ace bandages and plastic wrap can all lead to serious medical complications. Even well fitted chest binders are hot, uncomfortable and make exercising difficult. Male chest reconstruction is a medically necessary part of their gender transition. While increasing numbers of insurance companies are covering the cost of male chest reconstruction, the procedure is often being recommended for persons under 18. 
Transgender/ gender queer campers are a rapidly developing issue in the camp industry. A general understanding of transgender issues and health are critical to successfully integrating these children into your camp program. However remember that at the end of the day a transgender child attending isn't about the politics or policy of the world at large, it is about supporting that individual child to grow and achieve, just like every other child at camp. Just because your camp hasn't had to address this issue yet doesn't mean you shouldn't be thinking about it. Campers at your camp right now may be experiencing gender dysphoria, practicing gender non-conformity at home in secret, or be preparing to transition in the coming school year. They are absolutely watching you and your camp wondering if they will experience rejection. Be sure you are sending positive and understanding messages and are ready to meet their needs, and continue to welcome them into your community.
 “Transgender Issues: A Factsheet.” Transgender Law and Policy Institute. Retrieved fromhttp://www.transgenderlaw.org/resources/transfactsheet.pdf
 Shields JP et al. Estimating Population Size and Demographic Characteristics of Lesbian, Gay, Bisexual, and Transgender Youth in Middle School. Journal of Adolescent Health 2013: 52(2) 248-250.
 Coleman, E. et al. (2011). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism. 13, 165-232.
 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People: Health considerations for gender non-conforming children and transgender adolescents http://www.transhealth.ucsf.edu/trans?page=guidelines-youth
 Raising my rainbow: adventures in raising a fabulous, gender creative son Lori Duron - Broadway Books – 2013
 Olson KR, Durwood L, DeMeules M, McLaughlin KA .Mental health of transgender children who are supported in their identities. Pediatrics. 2016;137(3):e20153223
 National Center for Transgender Equality http://www.transequality.org/know-your-rights/schools
 University of Wisconsin-Milwaukee. Retrieved October 05, 2016, from https://uwm.edu/lgbtrc/support/gender-pronouns/
 Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. The Journal of clinical endocrinology and metabolism. 2009;94(9):3132-3154.
 Ruble DN, Taylor LJ, Cyphers L, Greulich FK, Lurye LE, Shrout PE. The role of gender constancy in early gender development. Child Dev. 2007;78(4):1121-1136.
Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. The Journal of clinical endocrinology and metabolism. 2009;94(9):3132-3154.