In our November issue, we shared with you the winning submission to our annual essay contest—this year focusing on access to care—by Dr Michael Mattiucci. We are pleased to publish the other competition finalist, written by Drs Sarah Bernstein and Holly Lewis. Bernstein and Lewis's essay explores another aspect of access to care. They argue that "access" is not just about helping to get patients through the door, but about providing culturally-sensitive and affirming care. The authors conclude by offering up several practical suggestions that can help providers to create office and hospital environments where all patients—particularly those who identify as LGBTQ—feel welcome and supported.

Expelling a heavy breath, Emily discarded the plush towel clinging to her waist and pressed her toes into the icy tile. Inhaling the sterile scent of Lysol, she shifted awkwardly in front of the mirror; staring down at her scrotum, she tried to reconcile what she saw externally with what she knew internally.

“Brian! Hurry up!” her father shouted. Glancing around the bathroom, she noted that everything was intentionally blue and deliberately masculine. Despondent, she conjured the image of Picasso’s Old Guitarist, the disjointed figure, the loneliness, and the despair. It would be several years before she would learn the words “queer” or “transgender” and longer still before she was able to fully claim her identity. During that time, she would struggle with isolation, depression, alcohol addiction, and drug abuse.

Sitting solemnly in clinic, staring at the thick scars of self-harm etched into her forearms, Emily looked up at me and sighed, “Had just 1 doctor or adult asked me how I felt about my changing body as a child, my life might have turned out differently.”

Unfortunately, she is not alone in this sentiment. Accessing culturally sensitive, affirming health care continues to be a challenge for transgender patients. More than 30% of adults who identify as transgender report harassment in medical settings, and 28% postpone medical care when sick or injured to avoid discrimination.1 As pediatricians, we can and should do a better job caring for patients who identify as lesbian, gay, bisexual, transgender, and queer (LGBTQ).

Establishing yourself as an ally begins the moment you enter a room. A typical conversation may look like this: “Hi, I’m Dr Bernstein, are you Brian? No? Okay, what name do you like to be called?” Such an open-ended question creates a safe space for the patient to respond with something like, “Actually, I prefer Emily. I hate the way Brian sounds, and Emily is the name I wish everyone called me.” Clinicians should nonjudgmentally validate such a statement, and a great way to do so is by describing their own gender identity: “It’s great to meet you, Emily. I like to use the pronouns ‘she’ and ‘her’ for myself. What words do you use for yourself?” This exchange can be beneficial for all patients, as a number of studies have revealed that patient satisfaction improves when you call someone by their preferred name, regardless of gender identity.2,3 

Many pediatricians ask patients about their self-image during the home, education/employment, peer group activities, drugs, sexuality, and suicide and/or depression assessment as a screening tool for eating disorders and other behavioral risk factors. Simply expanding this question, by asking patients how they feel about their changing bodies, creates an open space for the patient to talk about masculinizing or feminizing changes with a trusted clinician. This is an ideal screening technique because it provides children the space to talk about their bodies even if they have never heard phrases like “gender dysphoria” before. Transgender individuals of all ages face both implicit and explicit bias in their daily lives, so they may not openly divulge sensitive information if they are not asked for it.

In the LGBTQ community, to transition means to live in accordance with one’s gender identity and is independent of medical and surgical therapies. There is no “all-the-way” or “partway” transition, and not all patients have the same goals regarding available therapy and outcomes. For example, the majority (72%) of transgender men will never seek gender-affirming genital surgery. Physicians do not start any patient’s gender transition but rather provide medical, surgical, or psychological support as well as appropriate anticipatory guidance for each patient along their journey. These practices are reflected in guidelines from the World Professional Association for Transgender Health (WPATH), the most well-established organization for transgender health. The World Professional Association for Transgender Health endorses a shared decision-making model for providing care to transgender patients.4 To facilitate informed decision-making, clinicians can incorporate a discussion of risks, benefits, and alternatives for each of the options being considered.

It is important for the general pediatrician to become familiar not only with practice guidelines for the care of transgender patients but also how to screen for concurrent medical conditions and associated risk factors. For example, transgender patients have been shown to be at increased risk for secondary diseases such as skin and/or soft tissue infections and damage to the urethra, prostate, and bladder from techniques used to minimize the appearance of secondary sexual characteristics such as binding and tucking.5,7 Ensuring that youth are aware of these risks is crucial to minimizing potentially negative outcomes.

In some senses, providing quality primary care for children who identify as transgender can be simple, because they are at risk for many of the same health problems as all children. All pediatric patients should be routinely screened for suicide, substance abuse, and sexually transmitted infections. A number of research studies have shown that LGBTQ youth are at an increased risk for suicide, polysubstance abuse, and sexually transmitted infections, and screening can be complicated by insufficient or insensitive interactions with the health care system.8,11 Asking standard questions about body image and secondary sex characteristics creates a safe space for any child to discuss his or her self-perceptions.

A common misconception is that transgender patients are an isolated population who are seen only in specialized clinics and are beyond the scope of general pediatrics. However, many of us will encounter transgender patients at some point in our practice, regardless of what specialty we pursue. As medical trainees, therefore, we are well-positioned to take the lead by educating ourselves and our colleagues about LGBTQ health. Excellent open-access resources for health care providers can be found online by searching the Center of Excellence for Transgender Health or consulting the American Academy of Pediatrics Section on LGBT Health and Wellness, University of California San Francisco’s National Center of Excellence for Transgender Health, the Fenway Institute, and the Association of American Medical Colleges’ Web site.

Interested residents might consider hosting a lecture on transgender health at morning report or grand rounds, facilitating focused discussions on the wards, or organizing a session to allow house staff to practice culturally sensitive communication skills. It would also be important to review the meanings of key terms like “genderqueer” and “transition,” which are frequently misunderstood and consequently often misused.

Emily recently told me transgender people tend to be big supporters of individuals with disabilities because, “The world was not built for them, just like it was not built for us.” As pediatricians, we can help make the world feel a little safer for all children by cultivating supportive environments in our clinics, hospitals, and broader communities. Although physicians may not personally design access ramps or accessible bathrooms, we have long advocated for patients with mobility and learning needs; similar approaches can be adapted to make our clinical spaces more welcoming for transgender children, as well.

Signage and paperwork in our clinics should reflect people of every race, disability, sexuality, and gender identity. Patients and caregivers should be screened for literacy, and educational resources should always be provided in locally relevant languages, because transgender children can be found in any ethnic and/or linguistic group. Additionally, the use of gender neutral, third person singular pronouns in publications can help to dissipate gendered assumptions, which is a grammatical shift that has recently been supported by several major media outlets.12 The incorporation of LGBTQ-friendly children’s books into our waiting room collections and avoidance of gender-segregated toy areas can also support developing brains and encourage children’s self-expressions. As physicians empowered with LGBTQ health competency, we can break down the cycles of ignorance, shame, and toxic stress that harm children who identify as transgender and improve their chances of leading happy, healthy adult lives.

     
  • LGBTQ

    lesbian, gay, bisexual, transgender, and queer

Drs Bernstein and Lewis conceptualized and drafted the initial manuscript, and reviewed and revised the manuscript. Both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.