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Pediatricians are key in supporting transgender, gender-diverse youths :

September 17, 2018

In recent years, “gender identity” has increasingly been recognized as a complex concept that goes beyond traditional definitions of masculinity and femininity. Society struggles to adapt to and appreciate the diverse experiences of transgender and gender-diverse (TGD) individuals, which contributes to intolerance, discrimination and stigma. In this context, TGD youths and their families increasingly present to pediatric providers for advocacy, care and referrals.

The Academy stands against stigmatization and marginalization of TGD youths, and emphasizes the need for their acceptance as members of our families, communities and workforce. A new policy statement, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents,uses strengths-based concepts to outline the role of pediatricians in addressing the needs, challenges and resilience of TGD youths and their families.

The policy, from the Committee on the Psychosocial Aspects of Child and Family Health, the Committee on Adolescence, and Section on Lesbian, Gay, Bisexual and Transgender Health and Wellness, is available at https://doi.org/10.1542/peds.2018-2162 and will be published in the October issue of Pediatrics.

Provide gender-affirmative care

TGD individuals have high rates of depression, anxiety, substance use, self-harm and suicidality. Some youths experience gender dysphoria when the incongruence between assigned sex at birth and asserted gender identity becomes so distressing that it impairs the youth in school, relationships and overall functioning. When people feel they must suppress their genuine self or emotions around their identity, it often leads to shame and adverse mental health outcomes.

However, there is no evidence that risk for mental illness is inherently due to a gender-diverse identity.

TGD youths, like all children, flourish when they feel supported. Therefore, the policy emphasizes a gender-affirmative model of developmentally appropriate care oriented toward understanding and appreciating the gender experience of all youths.

This approach accepts that gender identity and expression are normal aspects of human diversity, and that binary definitions of male and female do not always reflect emerging identities. Research shows that regardless of developmental stage, prepubertal children who assert a TGD identity know their gender as clearly and consistently as their developmentally equivalent peers and benefit from the same level of validation and social acceptance.

Instead of attempting to predict, prevent or pathologize who a child may become, or withholding critical support, a gender-affirmative model is aimed at valuing every child for who they are in the present, even at a young age.

Such care is most effective when it can be delivered within collaborative systems that ensure access to gender-competent and -affirming primary and specialty medical care, mental health and social services, including specific resources for parents and families.

Through strong, nonjudgmental partnerships with TGD youths and their families, providers can facilitate a safe environment for exploration of complicated emotions and gender-diverse expressions. Providers can ensure that questions and concerns are addressed, while offering evidence-based information.

As pediatric providers know, caring for children necessitates attending to the family. In addition to validating the feelings of the patient, it is important to appreciate how challenging, and at times scary, it can be for family members to realize their child’s experience and feelings. Research increasingly shows that family efforts at acceptance or rejection ultimately have little influence on the youth’s gender identity, but they may profoundly affect the child’s ability to openly discuss concerns about identity.

The gender-affirmation process involves reflection, acceptance and, for some, intervention. These interventions might include social adaptations (change of name, pronouns, dress, etc.), changes to legal documents, pubertal suppression, hormones or medications, and when appropriate, surgical interventions. The decision of whether or when to pursue various interventions is very personal, and interventions vary depending on pubertal and developmental progression.

Promoting protections

Pediatric providers can help build safer communities through public education and advocacy regarding transgender rights. Less than half of states have laws prohibiting discrimination based on gender identity or expression in terms of employment, housing, public accommodations and insurance benefits. Legal obstacles interfere with changing one’s name or gender marker. Many TGD youths do not feel safe at school as they face alarmingly high rates of harassment, victimization and bullying. While explicit anti-bullying policies, accessible supports and inclusion of lessons on tolerance and acceptance into the curriculum improve the school environment for TGD youths, such programs are far from universal.

Overall, pediatric providers can play an important, if not life-saving, role in promoting the health and development of TGD youths. While every family’s experience is distinct, the need for nonjudgmental affirmation and empathy is universal. In addition to ensuring access to comprehensive, gender-affirming and developmentally appropriate care for TGD youths and their families, the policy also recommends:

  • development of electronic health records and billing systems that respect the asserted gender identity of each patient;
  • insurance plans that offer health care coverage specific to the needs of TGD youths;
  • increased provider education and clinical research on the emotional and physical health needs and best practices for the care of TGD youths and their families; and
  • advocacy with school districts, communities and policymakers to promote acceptance, inclusion and legal protection for all children without fear of harassment, exclusion or bullying because of gender expression.

Dr. Rafferty is the lead author of the policy statement and a member of the AAP Section on Lesbian, Gay, Bisexual and Transgender Health and Wellness. 

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