Gender-Diverse Youth: Is There Regional Variation in Care?

In a recently released article in Pediatrics, Ms. Tara Weixel and Dr. Beth Wildman examine state-to-state barriers to care for transgender and gender-diverse (TGD) youth in the US (10.1542/peds.2022-057054). Although many physicians are comfortable with the terms, “transgender” and “gender diverse,” I am leading with medical definitions as a quick reminder that youth who self-identify as TGD need healthcare from providers who are respectful and inclusive and use inclusive language; this can be all of us. The United Nations Office of the High Commissioner on Human Rights defines “…the term "gender-diverse"… as persons whose gender identity, including their gender expression, is at odds with what is perceived as being the gender norm in a particular context at a particular point in time, including those who do not place themselves in the male/female binary; the more specific term "trans" is used to describe persons who identify with a different sex than the one assigned to them at birth…”¹ Gender identity refers to how one feels about one’s gender, which may differ from one’s assigned sex at birth.

Now getting back to this excellent article! The authors assessed care for TGD youth by state with respect to:

1. Laws pertaining to gender identity
2. The number of pediatric gender-affirming clinics in each state and per capita
3. The number of mental health providers serving TGD youth in each state and per capita

With respect to laws and policies, the authors used the Movement Advancement Project (MAP), an independent nonprofit aiming to increase equality and opportunity through collaborations with multiple organizations, for a state-by-state assessment of gender identity laws² and created a point-based summary score for each state by counting relevant policies and laws and then subtracting points for harmful or discriminatory policies while adding points for those that are gender affirming. To identify clinical care programs serving TGD youth, the authors aggregated data from the interactive map of the Human Rights Campaign (a nonprofit whose mission is to end discrimination against those who are lesbian, gay, bisexual, transgender and queer or questioning and others (LGBTQ+).³ Finally, I was surprised to learn that there is no universal mental health directory available, so to find mental health providers, the authors identified the best resource as Psychology Today’s “Therapist Finder” feature by state, in which providers must pay to list themselves and self-report qualifications. Data and results are summarized by state and by region (South, West, Midwest and Northeast) in both table format and graphically with maps.

Regions varied, but overall, the data indicate “a pervasive lack of medical and mental health resources for TGD youth in the US.” This discouraging conclusion does not even address additional barriers for persons of color, of lower income, or living in rural (less populated) areas. Research shows higher rates of suicidality, anxiety, and depression among TGD than cis-gender youth,⁴ adding to concern about a paucity of mental health providers trained in care for TGD youth. The South followed by the Midwest had the most barriers in all 3 categories; the Northeast followed by the West had the least barriers. These findings are unfortunately not surprising given current and pending discriminatory legislation in several southern states. As the authors note, pediatricians have an opportunity to make a difference by educating themselves on best practices and local resources for TGD youth and their families. The World Professional Association for Transgender Health is just a click away, and is a reliable, recognized, and available resource whose mission is “to promote evidence-based care, education, research, public policy, and respect in transgender health.” All providers can access this site to increase their knowledge, understanding, and to find resources. Finally, “think globally and act locally” by making sure your practice welcomes all youth. Offering younger and older adolescents the opportunity to confidentially share their gender identification and questions, and providing support to them, is well recognized as good medical care. I attended an awesome presentation at the AAP National Conference & Exhibition meeting by Stephanie Wagner, BSN, RN, IBCLC, a female cis-gender gay lactation consultant, who encouraged all of us to “simply ask” (don’t assume anything about anyone), “remember your tone” (intention is critical), and to “listen when “folx” on the spectrum speak” (and use their language). For those unfamiliar, “folx” is a gender-neutral word and a way of writing “folks” that emphasizes the intention to include marginalized communities including those who identify as LGBTQ+.⁵ Excellent advice, and steps all of us can take towards lowering barriers for TGD youth and families. Thanks to authors Tara Weixel and Beth Wildman for their thought-provoking article, which I hope you will want to link to and learn more about removing any barriers to care for your TGD patients.

 References

1. United Nations. Office of the High Commissioner on Human Rights. The Struggle of Trans and Gender Diverse Persons. https://www.ohchr.org/en/special-procedures/ie-sexual-orientation-and-gender-identity/struggle-trans-and-gender-diverse-persons Accessed 11/16/22.
2. Equality Maps: Snapshot: LGBTQ Equality By State. Movement Advancement Project | 21 Snapshot. https://www.lgbtmap.org/equality-maps. Published 2021. Accessed 11/16/22
3. Interactive Map: Clinical Care Programs for Gender-Expansive Children and Adolescents. 45 Human Rights Campaign. https://www.hrc.org/resources/interactive-map-clinical-care-programs-for-gender-nonconforming-childr Published 2021.  Accessed 11/16/22.
4. Becerra-Culqui TA, Liu Y, Nash R, et al. Mental health of transgender and gender 31 nonconforming youth compared with their peers. Pediatrics. 2018;141(5). 32 Doi:10.1542/peds.2017-3845
5. Cambridge Dictionary online. https://dictionary.cambridge.org/us/dictionary/english/folx Accessed 11/17/22.