Pediatric Annals

Special Issue Article 

Affirming Pediatric Care for Transgender and Gender Expansive Youth

Ilana Sherer, MD; Madeleine Hanks, MD

Abstract

Transgender and gender diverse children and youth experience significant health disparities and adverse health outcomes. Pediatricians have an opportunity to improve those outcomes by practicing gender-affirming care. This includes creating a welcoming environment through changes in office settings, intake forms, communication skills, language used, and support for families. Clinicians should be comfortable discussing social transition, puberty blockers, and gender-affirming hormone therapy with patients as needed. For clinicians caring for teenagers, adaptations in sexual health counseling and fertility counseling are necessary. Clinicians should also be aware of the trauma that has been historically inflicted by the medical and mental health system against people who identify as transgender/nonbinary, and that significant disparities exist even within this group along racial and gender lines. These aspects of caring for gender diverse youth are part of primary care pediatrics, and further education in these areas will improve access to care and health outcomes for these youth. [Pediatr Ann. 2021;50(2):e65–e71.]

Abstract

Transgender and gender diverse children and youth experience significant health disparities and adverse health outcomes. Pediatricians have an opportunity to improve those outcomes by practicing gender-affirming care. This includes creating a welcoming environment through changes in office settings, intake forms, communication skills, language used, and support for families. Clinicians should be comfortable discussing social transition, puberty blockers, and gender-affirming hormone therapy with patients as needed. For clinicians caring for teenagers, adaptations in sexual health counseling and fertility counseling are necessary. Clinicians should also be aware of the trauma that has been historically inflicted by the medical and mental health system against people who identify as transgender/nonbinary, and that significant disparities exist even within this group along racial and gender lines. These aspects of caring for gender diverse youth are part of primary care pediatrics, and further education in these areas will improve access to care and health outcomes for these youth. [Pediatr Ann. 2021;50(2):e65–e71.]

As pediatricians, we are dedicated to improving care and health outcomes for all children. Over the past several decades, as awareness of and media attention to gender diversity has grown, increasing numbers of transgender and gender diverse children have been presenting to their pediatricians. These encounters provide an opportunity to affirm youth as they explore their identity and connect deeply with the families who need support navigating this process. Unfortunately, few clinicians receive training regarding gender, and many feel unprepared to address it in clinical practice.1 Limited knowledge of transgender care has also contributed to discrimination within the health care system, resulting in many youth avoiding care or being denied care. A list of commonly used terms relating to gender and their definitions can be found in Table 1.

Commonly Used Gender Terms and Definitions

Table 1.

Commonly Used Gender Terms and Definitions

Surveys of gender diverse groups in the United States demonstrate pervasive disparities across many facets of daily life. According to the report of the US Transgender Survey released in 2016, among the 28,000 respondents, 13% had been sexually assaulted, 40% had attempted suicide, and 33% had experienced a negative interaction with a health care provider related to being transgender.2 For transgender and non-binary people of color, the statistics are even worse. Given these experiences, it is not surprising that many of these youth do not feel safe in health care settings. Although many of these disparities are due to systemic issues, even brief positive experiences with a supportive clinician can improve outcomes.3

Affirming Office Visits

Your patients' experience with a clinician starts the moment they visit your website or call to make an appointment. Do your posters, photos, and promotional materials depict patients who look like them—gender-diverse youth, youth from diverse racial and ethnic backgrounds, and family units of varied structures? Do your forms have gender-selection options other than male or female? Does your staff reflect diversity of gender, racial, and ethnic identities? Do the bathrooms have clear signage that indicates that people of all genders are welcome? Does your front desk staff ask for the name and pronoun(s) that a patient uses and then use it consistently? If not, then the visit may end before your patient even meets you.

Some of these interventions reflect small changes, whereas others may require larger shifts in clinic culture. All office staff and providers should receive training in cultural competency, and your practice should have a clear nondiscrimination policy that addresses gender and sexual orientation. Electronic medical records should be configured to keep track of both assigned sex and affirmed gender, as well as a patient's chosen name and pronouns. Provider continuity should be emphasized as much as possible, but in the event your patient needs to see another clinician in your office, the relevant information of chosen name and pronouns should be easily visible on the medical record. Confidentiality should be assured. More information regarding affirmative office settings can be found in Table 2.

Online Resources for Gender Diverse Youth

Table 2.

Online Resources for Gender Diverse Youth

Gender identity can present in your office in different ways. Some patients will come into your office with an affirmed identity that is different from their assigned sex at birth. Their families and schools may be aware, and they may have already socially transitioned. Others may be questioning their identity or how to tell their parents. Some may indicate it on visit questionnaires, and still others may show no cues or only nonverbal cues such as dress and appearance. We recommend asking all patients as part of their routine intake and/or health maintenance examinations, confidentially when appropriate. Some ways to ask this are included in Figure 1.

A questionnaire for asking about gender identity.

Figure 1.

A questionnaire for asking about gender identity.

Once a patient discloses their gender, the next step is to determine what level of support is needed. Asking a question like “who else knows?” can quickly give you a sense of how open they are about their gender. A patient might laugh and say, “Well, just about everyone,” in which case you could move on to discussing their specific health care and support needs. For patients who respond saying “no one else knows,” the next step might be exploring ways they could share this information or live authentically even if they are not yet ready to come out to family and friends. They may need to be reassured that you will keep this information confidential, including in their medical records. Some patients may still be figuring out which terms best describe their identity and how to express gender to professionals and friends, so modeling unconditional support for their journey may be the most useful next step.

Communicating with Parents

Family support is the single most powerful tool in improving outcomes for gender diverse youth. Transgender youth from accepting families are 8 times less likely to attempt suicide and nearly 6 times less likely to report high levels of depression than those from families displaying high levels of rejection.4 The clinician's role is to facilitate communication and understanding and to model support and affirmation for the patient. Each family brings their own unique circumstances, cultures, and communication styles. Sometimes parents who initially seem unsupportive may just need to slow the conversation down to understand and adjust. With the exception of cases when a patient's safety and welfare are directly at risk, alienating a parent often delays the process and can ultimately have more negative impacts on the youth's mental health. In addition, it is never appropriate to discuss a patient's identity with caregivers without the explicit consent of the patient. In other words, it is never okay to “out” a patient unless they have asked for help coming out to their family.

Most parents have their child's best interests at heart but may struggle to accept their identity. For young adolescents who have already talked to their parents or specifically request support in talking to their parents, we have found the most effective first step involves an in-person visit with the parent(s) and their child. Ask the child to explain their feelings and identity to you as the clinician, as if it is your first conversation. This gives you an opportunity to model affirmative language and listening for parents. Often observing their child with an affirming professional is enough to shift perspective of parents. This is also an opportunity for you to provide more information; peer, professional, or religious support; reading materials; and other resources. If parental concerns stem from religious ideologies, you can connect them to affirming faith-based organizations. Parents who are concerned about their child's safety and future may benefit from connecting with an adult member of the trans community who can talk about their experience and ways they were supported, or with a school administrator. Resources to support families can be found in Table 2.

Mental Health and Safety

Medical institutions have a long history of pathologizing gender diversity rather than treating it as a normal and natural part of human development. This not only perpetuates stigma but also limits access to affirming care. Although a specific diagnosis is often required for insurance purposes, even the existence of a diagnosis such as “gender identity disorder” or more current “gender dysphoria” feels limited compared to the actual diversity of people's experiences, and this pathologization may make young people distrustful of accessing care. Furthermore, guidelines for care of gender diverse youth require evaluation by a mental health provider prior to starting puberty blockers or cross sex hormones,5 but many people are unable to access these providers. We believe that children embracing and living their true identity is cause for celebration, not pathologization. The details of this history and the profound ways the field of medicine perpetuates stigma toward the transgender community are beyond the scope of this article, but it is important to consider whenever working with gender diverse youth.

Transgender youth have much higher rates of mental health disorders, but these disparities are multifactorial and stem from environmental stressors rather than their identity itself. Their housing, food, and safety are at the mercy of adults who may not be supportive of their gender identity. They may also be juggling multiple identities simultaneously and struggling to integrate them. Pervasive social stigma, real threats to safety, and bullying can generate toxic levels of stress. Given these risks, clinicians must thoroughly screen for mental health concerns and safety.6 Although many youths will benefit from mental health support, it is important to remember that gender diversity in and of itself does not require mental health support. There are plenty of gender diverse youth who are thriving with supportive families and communities.

Transgender youth also have significantly higher rates of eating disorders when compared with their cisgender peers.7 Multiple studies have indicated that this is in part due to a desire to make changes to the body that reflect their gender identity. A recurring theme suggests that adolescents may use food restriction as a way to control or delay pubertal development. Several of these same studies showed improvement in eating disorder symptoms once patients accessed gender-affirming care.8 We recommend an interdisciplinary approach that emphasizes gender affirmation to treat these youth. Standard eating disorder treatment alone may not be sufficient in transgender teens, and inpatient or specialized eating disorder care is often less accessible to gender diverse/transgender youth.8,9

Bullying in school and outside of school affects a large proportion of youth who are perceived to be gender diverse, and this has significant mental health and safety implications. The 2015 US Transgender Survey found that 54% of people who were “out” or perceived as transgender experienced verbal harassment in school, and 24% had been physically attacked at some point.2 Approximately 17% had such severe experiences that they left school as a result.2 It is important not only to screen for this at visits but also become familiar with regional legal protections for students and requirements for schools, which are noted in Table 2.

Patients who do not have family support are at risk of experiencing homelessness. In the 2015 US Transgender Survey, 20% of transgender people reported experiencing homelessness, frequently as a result of family rejection.2 Many of these same people also experienced high rates of harassment and rejection from homeless shelters based on their gender.2 Homeless transgender youth are also more likely to engage in “survival sex” (ie, exchange of sexual acts for basic needs such as food or shelter or even hormones).10 Due to the criminalization of sex work, many of these people also have negative experiences with law enforcement and end up in prisons where they experience further violence. Similarly, youth who identify as LGBTQ+ (lesbian, gay, bisexual, transgender, queer/questioning) are significantly overrepresented in foster care and much more likely to face harassment, physical abuse, substance abuse, and suicidality than their peers.11 Unfortunately, only 16 states have laws to protect youth in foster care from discrimination based on sexual orientation and gender identity.12 There are a growing number of organizations and support networks for gender diverse youth in foster care or unstable housing, and pediatricians should be aware of and ready to refer to these resources, some of which are noted in Table 2.

Gender diverse youth have higher rates of sexually transmitted infections (STI), survival sex, and intimate partner violence.13 Clinicians should always take a thorough sexual history based on the patient's identity and anatomy. Gender identity does not determine sexuality, and it is important not to make assumptions about your patient's sexual orientation. Patients should be screened and counseled based on the anatomy they currently have and use for sex. The language used in these conversations requires particular sensitivity, as many people are triggered by words commonly used to describe their genitals. Whenever possible, it is best to ask what words your patient prefers. Any physical examinations should be particularly sensitive to the possibility of previous negative health care experiences, dysphoria, and abuse. Your approach should focus on giving the patient a sense of control and trust.

As with their cisgender peers, transgender youth are at risk of unintended pregnancy, but those youth who are taking gender-affirming hormone therapy (GAHT) may be unaware of this risk. Transmasculine youth may falsely believe that testosterone prevents pregnancy but, although it makes it less likely, it is still possible and may be harder for the patient to detect. In addition, testosterone is a known teratogen. To mitigate this risk, pediatricians should provide clear information and access to protection and contraceptives for all sexually active youth.14

In addition to general safe sex practices and STI risk, HIV is of particular concern in the LGBTQ+ community. According to the Centers for Disease Control and Prevention, among the 3 million reported tests in 2017, the percentage of transgender people who received a new HIV diagnosis was 3 times higher than the national average.15 Of particular concern, in a systematic review of studies from 2006 to 2017, an estimated 44% of Black transgender women and 26% of Latinx transgender women were HIV positive.16 For patients who are at high risk of HIV, clinicians should counsel about pre-exposure prophylaxis, which is approved for use in adolescents.

In all of these conversations, it is easy to focus primarily on risk factors and victimization, but the emphasis should always be focused on resilience. Questions should start with an exploration of the patient's strengths and protective factors. In addition to providing reproductive care and referrals to local resources and social services when necessary, clinicians can play a key supportive role by taking a collaborative and affirmative approach to patient care.

Elements of Transition

Professional guidelines published by both the World Professional Association of Transgender Health5 and the Endocrine Society17 provide a framework for social, medical, legal, and surgical transition. Protocols should be adapted to each patient's individual needs and goals. Some patients who identify as nonbinary may desire features associated with both sexes and prefer a combination of interventions. Patients who are transgender men might not be interested in removal of their uterus given their desire for future pregnancy. Timing also plays a role as some patients present after puberty, when puberty blockers are less helpful. Overall, these guidelines should be seen as a starting point for discussions rather than strict protocols.

Social Transition and Puberty Blockers

The literature often describes social transition as a complex decision that families make to change things like a child's name, pronouns, and clothes. In our experience, children usually make this decision organically, and after persistently identifying as a different gender the family starts to shift their perspective, sometimes with the consultation of an affirming mental health provider. We know that starting at young ages, gender diverse children understand their identity just as much as cisgender peers.18 In addition, children who have been allowed to socially transition report similar rates of depression to their cisegender peers instead of the much higher rates generally seen in this population.6

For children who identify with a gender other than their assigned sex, the onset of puberty can be traumatic. Puberty blockers, or gonadotropin-releasing hormone agonists, are a treatment approved by the US Food and Drug Administration for central precocious puberty but are also used off-label to suppress the development of secondary sexual characteristics in a fully reversible way. These medications can be a lifeline for young people who are questioning their gender and need time and relief from the worsening of dysphoria caused by onset of puberty prior to making any irreversible decisions. More details on administration, adverse effects, and monitoring of puberty blockers can be found at the University of California, San Francisco Transgender Center of Excellence Primary Care Protocols,19 as well as the clinical practice guidelines authored by the World Professional Association for Transgender Health 5 and Pediatric Endocrine Society.17

Unwanted uterine bleeding can cause distress for many transmasculine people. Although testosterone itself can cause cessation of menses, hormonal contraception is also an effective and reversible option. We find that the progestin-only pill is well tolerated, less likely to increase dysphoria, and generally effective in suppressing menstruation. There are multiple additional options for hormonal contraception summarized in the literature.20

Gender-Affirming Hormone Therapy

Young adults who present later in development or have been on blockers and are entering a pubertal age can consider GAHT. Cross-sex hormones (ie, estrogen and testosterone), referred to as GAHT, can be started in mid-adolescence and are considered partially reversible. Reversible effects of both hormones include skin texture and muscle mass changes, as well as fat deposition changes. Irreversible changes include Adam's apple protrusion, voice deepening, male pattern baldness from testosterone, and breast development from estrogen.21 Some guidelines recommend starting GAHT at age 16 years, but many providers are now starting hormones earlier based on development. In youths who are able to participate in an informed consent process, the goal is to initiate GAHT at an age congruent with puberty in their cis-gender peers.22 Detailed descriptions of physical changes, dosing protocols, and laboratory monitoring can be found in clinical practice guidelines.5,17,19

A transgender person who presents later in puberty or has not used blockers will also have many of the irreversible secondary sex characteristics of their endogenous puberty. Many of these patients are interested in surgical interventions such as “top surgery” for breast removal, facial feminization, tracheal shave to remove the Adam's apple, or other surgeries to achieve an appearance that matches their identity. This underscores the importance of offering blockers when appropriate to avoid the need for later surgeries. Although surgeries are typically reserved for adulthood, they can be performed on adolescents on a case-by-case basis, specifically chest masculinization or “top surgery,” with positive outcomes.23

Some patients also use nonpharmaceutical methods to achieve gender congruence. Examples include the use of binders by transmasculine youth to flatten the existing breast tissue or packers to create the impression of male genitalia through clothing. Transfeminine youth may “tuck” by pulling the penis into the gluteal crease and securing it with tight underwear or tape. These methods are important ways many people reduce their dysphoria, but they should be used safely to avoid side effects like skin break down or lung restriction.24

Given how difficult it is for some young people to access affirmative care secondary to discrimination, insurance issues, and financial hardship, there is also a “street market” for various medical interventions. Some young people rely on these sources for hormones or “fillers” that can be injected into hips, breasts, and/or buttocks to create curves. Use of hormones or fillers without proper monitoring can have dangerous complications and should be discouraged; however, the clinician should be sensitive to systemic and personal challenges that drive people to make these choices.

Prior to starting any kind of medical therapy, it is important to discuss informed consent, which includes a discussion about fertility. The effects of GAHT on future fertility are not yet fully understood, but there are several options for fertility preservation that range greatly in effort, cost, and success rates.25 Furthermore, a child who starts taking hormone blockers and then proceeds to cross-sex hormones will not experience the maturation of their gametes required for fertility. Counseling on fertility options should be offered to every youth who is starting GAHT.5

Legal Transition

Youth may want to change the gender marker and name on their identity documents, such as birth certificates, passports, or school identification cards. Protocols around this differ region to region and state to state. Resources can be found in Table 2.

Conclusion

There are a growing number of gender clinics across the country that provide invaluable support and affirmative care, but these spaces are not always accessible. Furthermore, with increasing patient volumes, many of these clinics have long wait times to establish care. Although there may be times when referral to a specialist is necessary for specialized treatment, most of this care falls under the umbrella of primary care. We hope that through increased awareness and education more pediatric clinicians will feel empowered and excited to work with gender diverse youth. Ultimately, by providing affirmative care in general pediatric clinics we have an opportunity to decrease stigma, improve access to care, and improve health outcomes for gender diverse young people.

References

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  12. Human Rights Campaign. State equality index 2019. Accessed January 15, 2021. https://www.hrc.org/resources/state-equality-index.
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  14. Mehringer J, Dowshen NL. Sexual and reproductive health considerations among transgender and gender-expansive youth. Curr Probl Pediatr Adolesc Health Care. 2019;49(9):100684. doi:10.1016/j.cppeds.2019.100684 [CrossRef] PMID:31735693
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Commonly Used Gender Terms and Definitions

Term Definition
Gender diverse A broad term that is used to describe people with gender expressions or identities that are different from their assigned sex at birth; gender diverse people may refer to themselves with many different terms, such as transgender, nonbinary, gender queer, gender fluid, gender creative, gender independent, gender expansive, or non-cisgender. Gender diverse is used to acknowledge and include the vast diversity of gender identities that exists. It replaces the terms gender nonconforming and gender variant, which have negative and exclusionary connotations
Transgender A subset of gender diverse people whose gender identity does not match their assigned sex. The term “trans” also encompasses many other labels people may use to refer to themselves. Transmasculine or transgender man refers to someone with a gender identity toward or on the masculine end of the spectrum; transfeminine or transgender woman refers to someone toward or on the feminine side of the spectrum. Nonbinary refers to someone whose affirmed gender includes both male and female aspects, whereas agender refers to someone who does not identify with any gender or may see themself as gender-neutral. MTF (male to female) and FTM (female to male) are terms that some people still use but they are becoming less common. Many people are uncomfortable with the implication that they at some point in thepast a gender other than their affirmed gender
Gender affirmation/gender affirmative care The process of receiving social, medical, and psychological support for one's gender identity or gender expression
Sex An assignment that is made prenatally or at birth, based usually on external genital anatomy or chromosomes
Gender identity A person's internal sense of being female, male, a combination of both, or neither
Gender expression The external way a person expresses their gender, such as with clothing, hair, or social roles
Cisgender A person who identifies and expresses a gender identity that is consistent with the culturally defined norms of the sex they were assigned at birth
Gender dysphoria A clinical symptom that is characterized by a sense of alienation to some or all of the physical characteristics or social roles of one's assigned gender
Gender affirming hormone therapy A reference to use of exogenous testosterone to masculinize features or estrogen along with an androgen blocker to feminize features, or to hormone blockers (gonadotropin-releasing hormone agonists) to block puberty; sometimes referred to as hormone replacement therapy

Online Resources for Gender Diverse Youth

Type of resource Name of organization Description of content
Clinical UCSF Transgender Center of Excellence <ext-link ext-link-type="uri" xlink:href="www.transhealth.ucsf.edu" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">www.transhealth.ucsf.edu</ext-link> Comprehensive resource for transgender health information, including affirming office environments, hormone protocols and monitoring, surgical options
Patient/family support Family Acceptance Project <ext-link ext-link-type="uri" xlink:href="familyproject.sfsu.edu" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">familyproject.sfsu.edu</ext-link> Pamphlets, videos, research papers and resources related to family support of LGBTQ+ youth
Mental health/suicide prevention Trans Lifeline <ext-link ext-link-type="uri" xlink:href="www.translifeline.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">www.translifeline.org</ext-link> The Trevor Project<ext-link ext-link-type="uri" xlink:href="www.thetrevorproject.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">www.thetrevorproject.org</ext-link> Transgender-led organization that has a crisis hotline and connects transgender people to the community and provides support and resources National organization providing crisis support for youth who are LGBTQ+ youth
Faith/religious Welcoming Resources <ext-link ext-link-type="uri" xlink:href="www.welcomingresources.org/" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">www.welcomingresources.org/</ext-link> Transfaith <ext-link ext-link-type="uri" xlink:href="www.transfaithonline.org/engage/" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">www.transfaithonline.org/engage/</ext-link> Provides support/resources for churches and faith communities Transgender-led nonprofit that provides support to faith communities and transgender spiritual leaders
Advocacy/legal Transgender Law Center <ext-link ext-link-type="uri" xlink:href="www.transgenderlawcenter.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">www.transgenderlawcenter.org</ext-link> Human Rights Campaign<ext-link ext-link-type="uri" xlink:href="www.hrc.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">www.hrc.org</ext-link> National Center for Transgender Equality <ext-link ext-link-type="uri" xlink:href="www.transequality.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">www.transequality.org</ext-link> Lambda Legal<ext-link ext-link-type="uri" xlink:href="www.lambdalegal.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">www.lambdalegal.org</ext-link> Legal support and information about identity document changes for transgender people, information on laws impacting transgender people Advocacy organization for LGBTQ+ people and gender diverse children. Advocacy group for transgender people National organization providing legal support and advocacy for the LGBTQ+ (including gender diverse youth) community
Authors

Ilana Sherer, MD, is a Pediatrician, Palo Alto Medical Foundation; the Co-founder, Child and Adolescent Gender Center, University of California, San Francisco (UCSF) Benioff Children's Hospital; and a Volunteer Clinical Faculty member, UCSF School of Medicine. Madeleine Hanks, MD, is a Pediatrician, Tamalpais Pediatrics, and Clinical Faculty, UCSF Benioff Children's Hospital Oakland.

Address correspondence to Ilana Sherer, MD, Palo Alto Medical Foundation, 4050 Dublin Boulevard, Dublin, CA 94568; email: shereri@sutterhealth.org.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/19382359-20210115-01

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