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Evidence-Based Strategies for Common Clinical Questions

June 2021

Coming Out and Flourishing: Caring for Transgender Youth

 

Author: Jordan Marquess, MD | Pediatrics Resident

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Column Editor: Kathleen Berg, MD | Co-Director, Office of Evidence-Based Practice | Pediatric Hospitalist, Division of Pediatric Hospital Medicine | Clinical Assistant Professor of Pediatrics, UMKC School of Medicine 

 

While transgender youth constitute a minority of the pediatric population, they continue to be grossly under-supported by the medical community, even though the number of individuals identifying as transgender continues to grow every year.1 This population is presented with a unique set of barriers, but their story is one of empowerment and hope. Providers must be committed to maintaining a safe environment for these patients, which can be achieved with education, advocacy, destigmatization and promotion of self-worth. 

To care for transgender youth, we must use accurate and consistent terminology. “Sex” is a label that is usually male or female and is assigned at birth based on anatomical or chromosomal features. In a policy statement regarding transgender care released by the American Academy of Pediatrics (AAP), “gender identity” is defined as “one’s internal sense of who one is, which results from a multifaceted interaction of biological traits, developmental influences, and environmental conditions.”1 A transgender person is one whose gender identity is incongruent with their sex assigned at birth. A cisgender person is one whose gender identity is congruent with their sex assigned at birth. Sexual orientation refers to the gender that an individual is physically or sexually attracted to and develops independent of gender identity.

A retrospective cohort study found that of those seeking care for gender dysphoria, the average age at which they recognized their gender as “different” from the birth-assigned sex was 8.5 years of age.2 Therefore, pediatricians must be equipped to provide quality care for a gender-diverse population. Unfortunately, large-scale studies to direct care for transgender youth are lacking. The AAP recommends providing care through a gender-affirmative care model (GACM). Pillars of this model include reinforcing that diverse gender expression is not a mental illness and that variations from typical expressions of gender are normal. It emphasizes the complex role that “biology, developmental, socialization, and culture all have on formation of gender identity.” It emphasizes the importance of a team-based medical approach, requiring the expertise of medical, mental health and social work professionals.1

One of the most vital components of a GACM is the therapeutic relationship between the patient and the health care team. A recent study showed: “One in four adults who identified as transgender avoided a necessary doctor’s visit because of fear of being mistreated.”2 Providers should feel comfortable supporting patients through their gender affirmation, which focuses on the individual and their personal goals. Patients’ goals vary widely and may change over time. Social affirmation is the outward expression of one’s gender identity, and may influence choice of clothing, name, pronouns or restrooms. One may also seek legal affirmation including changing a name or gender on legal documentation. Some elect to use puberty blockers, which are gonadotrophin-releasing hormones (such as leuprolide or histrelin) which temporarily delay puberty. Others may choose to explore the possibility of cross-sex hormone therapy (testosterone or estrogen + androgen inhibitor) and/or gender-affirming surgeries to address gender dysphoria.

Care for transgender youth is best accomplished by a multidisciplinary team. This team includes patients’ families, as more supportive home environments have been linked to better mental and physical outcomes.4 One source for education for families is healthychildren.org. Review the section on “Gender Diverse and Transgender Children.”5 Another resource for families and providers is the Children’s Mercy Gender Pathways Services.6 It is important for providers to be aware of the unique health care needs of a gender-diverse population and to develop therapeutic relationships with transgender patients and their families.

 

References:

  1. Rafferty J. Committee on Psychosocial Aspects of Child and Family Health; Committee on Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring comprehensive care and support for transgender and gender diverse children and adolescents. Pediatrics. 2018;142(4): e20182162. doi: 10.1542/peds.2018-2162.
  2. Olson J, Schrager SM, Belzer M, Simons LK, Clark LF. Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria. J Adolesc Health. 2015;57(4):374–380. doi: 10.1016/j.jadohealth.2015.04.027.
  3. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S. Transgender Survey. Washington, D.C.: National Center for Transgender Equality; 2016.
  4. Simons L, Schrager SM, Clark LF, Belzer M, Olson J. Parental support and mental health among transgender adolescents. J Adolesc Health. 2013 Dec;53(6):791-3. doi: 10.1016/j.jadohealth.2013.07.019.  
  5. Rafferty J. HealthyChildren. https://www.healthychildren.org/English/ages-stages/gradeschool/Pages/Gender-Diverse-Transgender-Children.aspx. Accessed June 2, 2021.
  6. Children’s Mercy Kansas City. Gender Pathway Services. https://www.childrensmercy.org/departments-and-clinics/endocrinology/gender-pathway-services/. Accessed June 2, 2021.