A significant number of youth are the victims of systemic and interpersonal discrimination as a result of claiming identities that are minoritized in the United States. Researchers in prevalence studies estimate that in the United States, 14% of high school youth identify as Black, 25% as Hispanic, and 1.8% as transgender.1,2 Black and Hispanic children are more likely to live in poverty and to be uninsured compared with their white peers.2–4 Transgender individuals face significantly higher risk of poverty, homelessness, and victimization compared with their cisgender peers; race and ethnicity only compound these outcomes.5 Current literature likely underestimates the prevalence and racial diversity of gender diverse (GD) individuals in the United States. Data from the Williams Institute at UCLA School of Law, a leading research center on sexual orientation, gender identity law, and public policy, reveal that there is overrepresentation of white respondents in some of the largest transgender surveys to date.5–8 Previous experience with rejection, victimization, and transmisogyny may cause GD persons not to self-identify. Limited sexual orientation–gender identity (SOGI) data options further exclude GD individuals who do not identify as cisgender or transgender or whose gender identity falls outside a binary (female or male) model of gender.
In this issue of Pediatrics, the study “Prevalence of Gender Diverse Youth in an Urban School District” by Kidd et al9 contributes a unique and more accurate reflection of the distribution of GD youth and also reflects the growing appreciation of the complexity of adolescent identity formation: a major developmental task that paves the way to a healthy adulthood. Authors of this study also offer more nuanced opportunities to consider the intersection of race and gender in adolescent identity formation. They found that 9.2% of those in the urban high school cohort self-reported being GD, a prevalence that is strikingly higher than other studies. Acknowledging, as the authors of this study have, that gender identity is more complex than simply using binary descriptors offers greater opportunity to include those youth who do not identify as transgender but who are exploring gender and may feel misaligned with the sex they were assigned at birth. The use of a two-step questionnaire better delineates a more nuanced description of gender identities, proving that collecting accurate and more representative SOGI data is not an arduous or impossible task. More granular SOGI data offer better insights into the complexity of adolescent gender identity formation and reflect the contemporary changes and fluidity in language, definitions, and paradigms. In so doing, inclusive SOGI data offer a more sophisticated reflection of subpopulation differences and can be better used to assess for disparities.
Kidd et al9 add to the growing body of literature corroborating and highlighting the lack of diversity among GD youth receiving gender-affirming care. The majority of GD youth in the authors’ study reported being multiracial (68%) and feminine (38%) compared with GD youth seeking care at the only pediatric gender clinic in the same region where 88% and 65% of patients receiving care identified as white and masculine, respectively.10 As the authors note, pediatric gender research continues to overrepresent groups of patients who are overwhelmingly white, with higher socioeconomic status and masculine identities.11,12 The differences between these data are striking and make visible the disparities in race related to access to local gender services. Where are and what is happening with our GD youth of color?
The intersection of minoritized identities continues to unfold with this study’s larger representation of gender identity. Most GD youth identified as feminine, or nonbinary compared with previous studies. The authors’ inclusion of a nonbinary option further emphasizes potential racial differences in adolescent identity formation: fewer Black and Hispanic youth identified as nonbinary compared with other racial groups. Is their path to identify formation inherently more difficult and restricted than their white peers? Furthermore, if these youth and the stories are not made visible and if their stories are not heard, then how can health providers begin to understand their intersectional experience of identity and tailor care to address their unique needs?
GD youth are more likely to struggle with depression, anxiety, and suicidal ideation, to face discrimination in schools, to use substances, and to have engagement in the juvenile justice system and/or sex trafficking than their cisgender peers.13–20 Information on the experiences of GD youth of color is limited. The few studies available highlight even greater disparities in mental health and HIV risk for GD youth of color, particularly those who are feminine identified.21,22 Research has also consistently revealed the protective factors of both parental support and early access to gender-affirming care.23,24 In this article, researchers provide initial data that suggest GD feminine youth of color are not presenting to pediatric gender clinics at the same rates as their white masculine peers.10 If GD youth of color are not seen and counted in these gender clinics, then where and how can they receive life-saving gender-affirming care? How can parents and families receive the education and resources they need to best support their child? Although we can speculate on the causes of this gap in care, we sadly do not need to look far to understand the outcomes of this disparity. Transgender women of color disproportionately face disparities in the experience of depression, suicidal ideation, homelessness, unemployment, and poverty.5,25,26 They are more likely to report engagement in sex work and with law enforcement, be the victim of violence, and use self-prescribed hormones.5,25,26 Kidd et al9 highlight a painful reality: by allowing systems to continue to minoritize both women and persons of color, we are failing our youngest and most vulnerable GD children, feminine persons of color, right from the start.
As medicine and society slowly gain a deeper understanding of the value of diversity and the impact social determinants have on health outcomes, the field of pediatrics requires research that continues to examine the intersections of various marginalized identities and how these impact child and adolescent development. Without these data, how can we deliver inclusive, patient-centered care for all children? Although this study provides excellent representation of an urban northeastern high school cohort, a significant number of youth (27%, n = 1282) could not be counted because they did not report race and ethnicity and/or gender data. What might this indicate? How might answers of youth who decline to pick a race or gender identity be counted in the future? How do we better elucidate the needs of these hidden youth who, when faced with options that do not reflect their lived experience, are yet again marginalized?
This study is a call to recognize and to end passive acceptance of historical racist and transphobic treatment of patients, which has a long history in US medicine and culture. By highlighting the diversity found within GD youth, the authors emphasize the importance of re-evaluating the systems and structures that contribute to race-based and gender inequities. Pediatric providers should take this call to action and begin using their skills in providing routine anticipatory guidance, by having regular and more nuanced conversations with all youth about gender development and gender diversity. Pediatricians have vital roles in providing counseling to parents on the growing medical evidence demonstrating the critical importance of parental support and early intervention, thus creating safe pathways for young people to access gender-affirming care. Likewise, knowing the stress that experiencing multiple marginalized identities may have on our young patients calls pediatric providers to work harder and more intentionally to seek ways to make access and resources more equitable for all children.
For too long, medical research and clinical programs have avoided uncomfortable discussions about race and gender. Routinely discussing gender diversity in primary care, across the various ages and stages of development, models our understanding that diversity in child identity development is expected and should be celebrated. Pediatricians should acknowledge their unique role as advocates by forming antiracist alliances with our patients, families, and communities, affirming that all children are loved and should be valued as their unique, authentic selves. It feels intuitive and right for pediatricians to listen carefully and respectfully to our children as they explore multiple aspects of development and identity formation. It is equitable and just that all children have the resources and opportunities to grow in safe and healthy ways into their best and fullest selves.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2021-049823.
sexual orientation–gender identity
POTENTIAL CONFLICT OF INTEREST: Dr Forcier works as a clinical consultant for Planned Parenthood and Open Door Health and receives royalties for authorship with Up to Date and Springer; and Ms Wagner and Dr Holland 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.