There have been increasing calls to integrate counseling into multidisciplinary care for students with differences in sex development, the literature on mental health needs of this population remains scarce and there is no empirical consensus regarding mental health outcomes or appropriate intervention for these youth (Schwiezer, Brunner, Schuzmann, Schonbucher, and Richter-Appelt, 2009). The inconsistency present in the literature has not been fully explained, but multiple causes are possible, including low study participant numbers and poorly powered studies, variability within and across samples in terms of specific diagnoses, severity of condition, treatment history and premorbid psychological risk, and cohort effects due to rapidly changing models and techniques (Johannsen, Ripa, Mortensen, and Main, 2006; Kasiannan, 2012; Kleinemeier, Jürgensen, Lux, Widenka, and Thyen, 2010). Neverless, some important issues have been identified. In this article, the authors review the issues, which include: (1) family and individual stressors; (2) gender identity; (3) creating affirming and inclusive school communities; and (4) support for families, youth, and systems.