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Caring for transgender pediatric patients

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Child holding rainbow colored puzzle pieces


How pediatricians can support transgender youth

From Caitlyn Jenner being named Glamour Magazine’s Woman of the Year in 2015 to the recent barrage of lawsuits over transgender athletes, trans identity is gaining widespread recognition. As awareness of gender nonconformity increases, pediatricians will more often find themselves in a position to provide care and support for transgender youth.

Transgender childGender basics and gender dysphoria

Starting as young as age 2, children start to express gender, which can fall anywhere along a spectrum that includes both masculinity and femininity. Some children will identify as a gender that differs from the one they were assigned at birth. Ways of expressing gender variations include:

  • Gender diversity, expansiveness, creativity or nonconformity. These may include appearing or behaving in a way that does not match traditional ideas and stereotypes about gender.
  • Transgender, or consistently identifying with a gender other than the one assigned at birth.
  • Gender neutral, genderqueer (not following binary gender norms), gender fluid (changes over time in gender expression or gender identity) and agender (lack of a gender), which cover other types of gender variations.

A recent CDC survey of high-school students found that about 1.8% of respondents identify as transgender. Children are typically considered transgender or nonbinary if they are consistent, insistent and persistent about their transgender identity. Children who are nonbinary may feel that they are neither male nor female, or are possibly a combination of both.

Health risks

Transgender children face unique health risks compared with their cisgender peers. They have a higher risk of suicide, self-harm, depression, eating disorders, substance use, homelessness and anxiety.

Every 45 seconds, at least one LGBTQ youth between 13 and 24 year old attempts suicide in the US. They are four times likelier to seriously consider suicide, to create a plan and to attempt suicide. In part because of higher risks of suicide, substance abuse, violence and homelessness, a transgender person’s life expectancy is just 30 to 35 years of age.

Support and care

Pediatricians have an important opportunity to help support transgender children and guide parents in providing gender-affirming behavior at home. Health care professionals must also ensure they provide gender-affirming care in their practice. This includes social, psychological, behavioral and medical interventions that support and affirm a person’s gender identity when it is different from the gender they were assigned at birth.

Any attempt to change a child’s gender identity can permanently harm their mental health, and such actions have been condemned by the American Psychological Association, the American Medical Association, the American Psychiatric Association and other groups. As trusted members of their communities, pediatricians have influence and can support youth by publicly backing the queer, trans and nonbinary community — including use of accurate pronouns and preferred names — and speaking out against conversion therapies.

Physicians can also help parents of transgender patients by advising them on how to talk to their child about gender identity, and sharing information, resources and informative documents that families can give to schools and other organizations. Doctors should also make sure transgender children receive regular health care including vaccines, routine screenings and birth control, as well as gender transition care.

Options for transitioning

The diagnosis typically used when a person’s assigned birth gender is different from how they identify is gender dysphoria. This diagnosis is often necessary to receive insurance coverage for gender-affirming care. Pediatric and adolescent patients have a variety of options to affirm their gender identity, including:

  •  Changing their clothing and behavior
  • Changing their name and using preferred pronouns
  • Taking medication such as puberty blockers and hormone treatments
  • Learning about the options for surgery when they are old enough.

Pediatricians can help affirm patients’ gender identity by being supportive of clothing and behavior changes, as well as using preferred names and pronouns. They may also discuss or administer available medical interventions. Puberty blockers, given as a shot or as an implant, delay the changes typically seen during puberty, including menstrual periods, growth of breasts, growth of facial hair and a deepening of the voice. Most of the effects of these treatments are reversible; however, they can also affect height and decrease bone density, making bones more brittle in the future.

Pediatric patients may also be interested in hormonal or surgical transition, which require permission from a parent or guardian prior to age 18 in most of the US. Patients will also need to get a letter of support from a mental health professional before beginning treatment.

Hormone treatment, given as a shot, pill, patch, implant or gel/cream, can deepen the voice, promote growth of facial hair, promote development of breasts and change body shape. Most of these changes are permanent. Hormone blockers do carry some risks, such as blood clots, liver inflammation, high blood pressure and trouble conceiving. Patients taking hormones will need to regularly visit a qualified health care professional.

Surgical options are usually only available to patients older than 18; however, teens may be able to get a mastectomy. Pediatricians can also inform patients of surgical options they can consider when they are old enough.

Leading on policy

One way pediatricians can support transgender children outside their practice is by speaking out against bills that target the rights of transgender youths, including those that:

  • Ban transgender youths from participating on athletic teams that align with their gender identity.
  • Restrict access to school restrooms that align with their gender identity.
  • Ban changes to birth certificates.
  • Block health care professionals from providing or referring patients for gender-affirming care.
  • Allow providers to refuse care to transgender patients.

The American Academy of Pediatrics and other groups have filed amicus briefs to various challenges to these types of legislation. AAP members are also raising concerns about these bills with state lawmakers, as they could leave transgender teens without health care and criminalize pediatricians who treat them.

By providing gender-affirming care and advocating for transgender children, pediatricians can help some of their most vulnerable patients live their healthiest, happiest lives.

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April Hollis is a health care editor at SmartBrief. Connect with her on LinkedIn.