As the political targeting of transgender youth and families continues to play out on the national stage, it is more important than ever for pediatricians and other primary care providers to support this vulnerable population by defending the recommendations and guidelines of reputable medical organizations based in science and to show grace and humility in caring for their patients.
Guidelines and resources
All leading medical groups in the United States with statements or policies related to gender-affirming care (including the American Medical Association, the American Academy of Pediatrics, the Society for Adolescent Health and Medicine, the Pediatric Endocrine Society, the American Academy of Child and Adolescent Psychiatry, and many more) recognize that this care is medically necessary and that exclusions for gender-related services are harmful to patients and their families. As pediatricians, families and youth rely on our expertise and guidance related to childhood and adolescent development, including the development of gender identity and ways to create safe and supportive environments needed for youth to reach their full potential.1
Dr. Jonathan Warus
While pediatricians are experts in youth development, some may have had limited access to training specific to LGBTQ+ identity development and interventions related to gender-affirming care. There are, however, readily accessible resources to help guide pediatricians in providing support and recommendations to families with concerns around gender or sexuality (See Resources). The American Academy of Pediatrics and Bright Futures recommend discussing the differences between assigned sex at birth and gender identity development with parents of those younger than 12 months of age as well as beginning to discuss and explore gender identity with all youth beginning at 4-5 years of age. Beginning at 8 years of age, pediatricians are also recommended to assess for a patient’s understanding and feelings toward emerging puberty to identify any potential concerns for gender dysphoria.2 If concerns or questions emerge from screening, the family can then be referred to a gender-affirming care specialist for more support.
Gender dysphoria and gender-affirming care
Gender dysphoria may present in different ways and at different times for each patient. Some patients may present early in childhood with gender-diverse behaviors or the assertion of a gender identity different than their assigned sex at birth. However, the most commonly seen presentation is just prior to or during puberty, when one’s physical body starts to change in ways that are not consistent with their gender identity. Many patients report distress around gender before this time, but the distress that comes with the physical changes of puberty often prompts patients to reach out to parents, friends, and/or medical providers for help. Other than youth specifically disclosing their gender identity, as with any life stressors, gender dysphoria may initially present with a decline in school or social functioning, increased mood irritability, depression, or anxiety.3
The goal of support prior to puberty is for youth to grow and thrive as any other child and to not have gender dysphoria get in the way of normal development and social functioning.4 Some families will pursue social transition, the process of making changes within different areas of social interaction (such as name, pronouns, clothing, hairstyle, etc.) to decrease distress around gender. The decision of whether to pursue social transition is unique to each patient and family. The goal of this process is to allow youth to explore these changes in an effort to decrease the distress they experience in social interactions. Youth should be centered in this process and be the leader of any potential changes with parents and schools providing safe and supportive environments.5 Social transition has been shown to decrease rates of depression in gender-diverse youth to the same level as that of their cisgender peers.6
It is important to note that there are no recommended medical interventions for gender-affirming care before the time of puberty and, once a patient reaches Sexual Maturity Rating II (early puberty), the first potential treatment option is the reversible suppression of puberty using gonadotropin-releasing hormone (GnRH) analogues. The goal of this type of medication is to allow youth more time to explore their gender and avoid the permanent physical changes that occur during their endogenous puberty that can have a significant negative impact on their gender dysphoria and psychosocial functioning. Youth and their families can then later decide to discontinue the medication and go through their endogenous puberty or to proceed with gender-affirming hormone treatment.7
With the growing number of states who have or are attempting to ban gender-affirming care for youth, more patients and families will be left with no options for accessing this potentially life-saving care and support within their home state. Some families have already been forced to relocate to more supportive environments or to travel significant distances to receive medically necessary care.8 This summer, the American Academy of Pediatrics reaffirmed their current policy stating, “The AAP opposes any laws or regulations that discriminate against transgender and gender-diverse individuals, or that interfere in the doctor-patient relationship,” and they “support giving transgender adolescents access to the health care they need.”9
Pediatricians should continue to utilize existing resources for recommended routine screening and subsequent referral for patients or families with concerns around gender identity. When possible, connect patients and families in need of more supportive services around gender-affirming care to appropriate specialty providers. If providers are uncertain about the current legal climate in their state, it is recommended to consult with legal counsel if needed. As pediatricians, we must strive to uphold the tenets of medicine, follow expert recommendations and guidelines based on the best available evidence to provide comprehensive care to all patients, and continue to advocate for our patients and families.
Dr. Warus is an adolescent medicine physician who specializes in care for transgender and gender-nonconforming youth, and LGBTQ health for youth at Children’s Hospital of Los Angeles. He is assistant professor of pediatrics at University of Southern California, Los Angeles.
Resources
Bright Futures – Promoting healthy development of sexuality and gender identity (Implementation tip sheet).
Rafferty J. AAP Committee on Psychosocial Aspects of Child and Family Health, AAP Committee on Adolescence, AAP Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents.
References
1. Rafferty J. AAP Committee on Psychosocial Aspects of Child and Family Health, AAP Committee on Adolescence, AAP Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents.
2. Bright Futures – Promoting healthy development of sexuality and gender identity (Implementation tip sheet).
3. Shumer DE et al. Advances in the care of transgender children and adolescents.
4. Vance SR et al. Psychological and medical care of gender nonconforming youth.
5. Ehrensaft D et al. Prepubertal social gender transitions: What we know; what we can learn – A view from a gender affirmative lens.
6. Olson KR et al. Mental health of transgender children who are supported in their identities.
7. Olson J et al. Management of the transgender adolescent.
8. Rodgers A and Goldberg M. New State laws force families with trans kids to seek gender-affirming care elsewhere.
9. Wyckoff AS, ed. AAP reaffirms gender-affirming care policy, authorizes systematic review of evidence to guide update.