How Clinicians and Providers Can Support Gender-Affirming Care
March 31, 2023
According to the American Academy of Pediatrics (AAP) in its policy statement Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents, more gender-diverse youth and their families are presenting to pediatric providers for education, care, and referrals as a traditionally underserved population that faces numerous health disparities. The AAP acknowledges that providers often feel ill-equipped to support and care for gender-diverse patients and their families and there is a critical need for more formal training, standardized treatment, and research on safety and medical outcomes. Here are three ways to improve your care of gender-diverse youth and their families.
1. Familiarize yourself with best practices and modern models of care.
There’s no shortage of guidance on how to support gender-diverse youth and improve health outcomes. There are a lot of myths and misconceptions about what constitutes gender-affirming care, and we agree with the AAP that the decision of whether and when to initiate gender-affirmative treatment is personal and involves careful consideration of risks, benefits, and other factors unique to each family. It’s important to know and promote truths about gender-affirming care, for example, how puberty blockers are among safe, effective, and reversible methods to support gender-diverse youth. New research published in The Lancet has shown that regret rates for receiving gender-affirming care are extremely low, less than regret rates for other common procedures and inverse to what is being described by those supporting anti-LGBTQ legislation.
In a gender-affirmative care model (GACM) endorsed by the AAP, pediatric providers offer care that is developmentally appropriate and oriented toward appreciating and understanding the youth’s experience of gender. Exploration of complicated emotions and gender-diverse expressions can be facilitated by a strong, nonjudgmental partnership with youth and their families, all while allowing questions and concerns to surface in a supportive environment.
The GACM works best when resources are integrated – medical, mental health, and social services, including specific supports for parents and families. Working together, providers help destigmatize gender variance, promote the child’s self-worth, facilitate access to care, educate families, and advocate for safer community spaces where children are free to develop and explore their gender.
In a GACM, providers work to convey the following messages:
- transgender identities and diverse gender expressions do not constitute a mental disorder
- variations in gender identity and expression are normal aspects of human diversity, and binary definitions of gender do not always reflect emerging gender identities
- gender identity evolves as an interplay of biology, development, socialization, and culture
- if a mental health issue exists, it most often stems from stigma and negative experiences rather than being intrinsic to the child.
Models for gender-affirming care suggest that clinical assessment be conducted on an ongoing basis in the setting of a collaborative, multidisciplinary approach, including the pediatric provider, a mental health provider ideally with experience caring for gender-diverse youth, a pediatric endocrinologist or adolescent-medicine gender specialist as available, and social and legal supports. Every gender-diverse youth’s experience is different, and there is no prescribed path.
2. Improve your data collection and reporting.
Pediatricians and other health professionals are in a unique position to routinely inquire about gender development in children and adolescents as part of recommended well-child visits and to be a reliable source of validation and support – sometimes they are the first to know there is some distress related to a gender-diverse identity. Care providers are also in an incredibly powerful position to ask information and collect data in a way that demonstrates an understanding of sexual orientation and gender identity. A policy brief from the Fenway Institute details some best practices for clinical settings – it primarily comes down to establishing trust through demonstration of understanding concepts of sexual orientation and gender identity, and creating opportunities for disclosure, as well as being clear about how medical information will be used.
3. Join families and other health professionals in creating inclusive environments.
We know from the Healthy People 2030 goals that social determinants affecting the health of LGBTQI+ people largely relate to oppression and discrimination, including legal discrimination in access to health insurance, employment, housing, marriage, adoption, and retirement benefits; lack of laws protecting against bullying in schools; lack of social programs targeted to and/or appropriate for LGBT youth, adults, and elders; and a shortage of healthcare providers who are knowledgeable and culturally competent in LGBTQI+ health.
The physical environment we need to co-create with and for LGBTQI+ youth includes safe schools, neighborhoods, and housing; access to recreational facilities and activities; availability of safe meeting places; and access to health services where they will be treated respectfully.
The social environment we need to co-create is one where everyone’s experience of their gender identity and gender expression is affirmed, supported, and celebrated. Adolescents who identify as transgender and have at least one supportive person in their life report significantly less distress than those who only experience rejection. In communities with high levels of support, it was found that nonsupportive families tended to increase their support over time, leading to dramatic improvement in mental health outcomes among their children who identified as transgender.
As physicians, public health professionals, and other healthcare providers, we have an obligation to support these youth with unique healthcare needs who are at higher risk for negative health outcomes from discrimination, bullying, physical assault, and suicide. Join us by engaging in meaningful dialogue about best practices for gender-diverse kids to improve quality of life, reduce mental health disparities, and through an intersectional lens, help the most historically marginalized kids achieve their optimal health.
Quick Resources for Clinicians
Glossary of Identity-Related Terms
Sex: An assignment that is made at birth, usually male or female, typically based on external genital anatomy but sometimes based on internal gonads, chromosomes, or hormone levels
Assigned male at birth: Children believed to be male when born and initially raised as boys
Assigned female at birth: Children believed to be female when born and initially raised as girls
Birthing person: Someone who gives birth, regardless of their gender identity, which may be female, male, nonbinary, or other
Gender identity: A person’s deep internal sense of being female, male, a combination of both, somewhere in between, or neither, resulting from a multifaceted interaction of biological traits, environmental factors, self-understanding, and cultural expectations
Sexual orientation: A person’s sexual identity in relation to the gender(s) to which they are attracted; sexual orientation and gender identity develop separately.
Gender expression: The external way a person expresses their gender, such as with clothing, hair, mannerisms, activities, or social roles
Gender perception: The way others interpret a person’s gender expression
Affirmed gender: When a person’s true gender identity, or concern about their gender identity, is communicated to and validated from others as authentic
Gender diverse: A term that is used to describe people with gender behaviors, appearances, or identities that are incongruent with those culturally assigned to their birth sex; gender-diverse individuals may refer to themselves with many different terms, such as transgender, nonbinary, genderqueer,7 gender fluid, gender creative, gender independent, or noncisgender. “Gender diverse” is used to acknowledge and include the vast diversity of gender identities that exists. It replaces the former term, “gender nonconforming,” which has a negative and exclusionary connotation.
Gender dysphoria: A clinical symptom that is characterized by a sense of alienation to some or all of the physical characteristics or social roles of one’s assigned gender; also, gender dysphoria is the psychiatric diagnosis in the DSM-5, which has focus on the distress that stems from the incongruence between one’s expressed or experienced (affirmed) gender and the gender assigned at birth.
Gender identity disorder: A psychiatric diagnosis defined previously in the DSM-IV (changed to “gender dysphoria” in the DSM-5); the primary criteria include a strong, persistent cross-sex identification and significant distress and social impairment. This diagnosis is no longer appropriate for use and may lead to stigma, but the term may be found in older research.
Agender: A term that is used to describe a person who does not identify as having a particular gender
Cisgender: A term that is used to describe a person who identifies and expresses a gender that is consistent with the culturally defined norms of the sex they were assigned at birth
FTM; affirmed male; trans male: Terms that are used to describe individuals who were assigned female sex at birth but who have a gender identity and/or expression that is asserted to be more masculine
Intersex: Children whose anatomy develops differently than usual for either males or females. Most transgender children do not have intersex traits.
MTF; affirmed female; trans female: Terms that are used to describe individuals who were assigned male sex at birth but who have a gender identity and/or expression that is asserted to be more feminine
Nonbinary: Children and adults who don’t identify as male or female
Transgender: A subset of gender-diverse youth whose gender identity does not match their assigned sex and generally remains persistent, consistent, and insistent over time; the term “transgender” also encompasses many other labels individuals may use to refer to themselves.
Definitions derived from Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents
Gender-Affirming Healthcare Consistently Shown to Reduce Health Disparities for Youth
A February report from the American Medical Association confirmed that lack of access to puberty blockers or hormone therapy was strongly correlated with poor mental health and suicidal ideation among trans youth. Conversely, and powerfully, research released on March 29 shows that transgender and nonbinary young people who came out about their gender identity and had high family support reported lower rates of considering and attempting suicide in the past year.
Children and Their Families Have a Right to Gender-Affirming Healthcare
As physicians, public health professionals, and care providers, we have an obligation to support youth with unique healthcare needs who are at higher risk for negative health outcomes from discrimination, including bullying, physical assault, and suicide. Join us by engaging in meaningful dialogue about best practices for gender diverse kids to improve quality of life, reduce mental health disparities, and most importantly, help the most historically marginalized kids achieve their optimal health.
Racially Motivated Violence is a Children’s Health Issue
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