How Do I Provide Good Health Care to a Gender-diverse Patient?

Uncategorized

Patient Presentation
A pediatrician stopped her adolescent medicine colleague in the hallway for a quick consultation. “I have a young adult coming to see me who is a trans male. In their notes from the last visit, I saw that they had asked about a breast binder but I don’t know if that was done and if not, where I can send them or get more information for them,” she asked. “We can work with them in the adolescent clinic to get them measured and fitted. A couple of our nurses are trained to do that, and then they usually give them the resources to have them ordered, or sometimes some of the local non-profit agencies have them for low cost or free. I don’t know if any of the agencies do now, but the nurses will know. What time is the patient coming? I can have one of the nurses come over to your clinic if they want us to do the fitting,” the specialist offered. “They are coming late afternoon and I’ll ask them. They are also using oral contraceptives for pregnancy prevention and menstrual suppression and I’m very comfortable with that,” she said. “You know you can always ask me about any gender-related health issues you might not know about or don’t feel comfortable with. All of us working in the adolescent clinic can help, or we can refer the patient to other services, ” the specialist stated. “That’s why I stopped you. I knew I could ask and learn something. Helps me take better care of patients,” she said.

Discussion
Transgender and gender-diverse (TGD) youth in the US are estimated to be 300,000 or 1.4-2% of youth in the US. These numbers are for youth who identify as transgender or a gender identity that is different from their assigned sex at birth (ASAB). “However, the number of gender-diverse youth or youth whose gender expression does not confirm to societal expectations is estimated to be as high as 10% among U.S. high school students.” Among US adults, 1.4 million (0.6%) adults identify as transgender in a nationwide telephone survey.

TGD youth are or can be at increased risk for a variety of health problems including:

  • Bone health – low dietary calcium, risk for bone loss
  • Lifestyle – obesity, decreased activity
  • Mental health – self-harm, suicidal ideation or attempts, depression, anxiety, eating disorders, substance use
  • Sexual health – future fertility loss, pregnancy, sexually transmitted infections
  • Social – bullying/harassment, discrimination, violence including sexual assault or dating violence, socioeconomic disparity including homelessness

Gender affirming care (GAC) is a broad term that is not synonymous with gender transition care. In GAC, “”…the goal (…) is to partner with TGD people to holistically address their social, mental and medical health needs and well-being while being respectfully affirming their gender identity.” GAC may include transition-related care such as puberty blockers, gender-affirming hormones (…), mental health support, and /or a range of therapies, including surgery.” GAC is not unlike the care pediatricians and other professionals provide to all patients in their practices, which would be compassionate, inclusive, holistic, and effective care. For any professional, there are limits to one’s knowledge and experience, so when this occurs professionals seek answers themselves or consult specialists who can manage and treat the patient, or partner with the professional to manage the patient.

Gender identity begins as early as 2 years and continues throughout childhood, adolescence and into young adulthood. The trajectory of gender identity is impossible to predict, and children and youth commonly explore their gender identity. Some people experience gender dysphoria but others may not. Some research “…suggests that the majority of prepubertal youth with gender dysphoria will ultimately identify as cisgender adolescents and adults, whereas postpubertal youth with gender dysphoria are more likely to continue experiencing gender dysphoria through adolescent and adulthood.” Late adolescence and adulthood can also be times where TGD identities also emerge.

Some terminology

  • Gender identity – a person’s own felt sense of their gender (female, male, both, neither)
  • Transgender/cisgender/nonbinary
    • Transgender – a person whose gender does not align with their ASAB
    • Cisgender – a person whose gender does align with their ASAB
    • Nonbinary – a person whose gender is neither strictly female or male, and exists along or outside of the spectrum of gender identity
  • Gender expression – the way a person presents their gender to others
  • Sexual orientation – the gender(s) to whom a person is sexually attracted such as gay, straight, bisexual, lesbian. This is distinct from gender identity
  • Gender dysphoria – the distress a person experiences when their gender identity is not in alignment with their experience of their body or other’s perception of them
  • Transition – “the process whereby an individual makes changes to their gender expression, physical body, name or pronouns for their lived gender role to align more closely with their gender identity”

Learning Point
Most care provided to TGD is the same care providers give to all of their patients. There may be some legal restrictions on specific types of care for TGD. Some specific care that TGD patients may need includes:

  • Welcoming environment for all children, youth and young adults
    • Use of preferred name and pronouns has been shown to decrease depression, suicidal ideation and suicidal behaviors. Include this information in electronic medical record if the youth agrees, ASAB also needs to be recorded as some health risks are based on this
    • Inclusive physical space including signage and gender neutral bathrooms if possible
  • History and physical examination
    • History taking using non gendered language
    • Appropriate confidentiality
    • Standard history for all youth including social, mental and sexual health histories
    • History includes youths’ experience with their gender identity such as social transitioning, gender dysphoria, family and community support
    • Trauma informed care sensitivity
    • Standard physical examination including monitoring for pubertal changes
  • Body contours
    • Breast binding
      • To flatten the chest using breast binders, tight sports bras, or ace wraps
    • Male genital contouring
      • Tucking
        • To move the testicles and penis posteriorly or into the inguinal canals
      • Packing
        • To use devices to create the appearance of a penis such as socks, clothing, pouches, packers, etc.
      • Reversible, recommended to be used only for intervals of time
  • Body hair
    • Referrals for body hair removal through lasers/electrolysis, depilatory, threading, waxing, etc.
    • Reversible or permanent
  • Speech therapy/Voice training
    • Assistance in utilizing their voice that is more consistent with their gender identity
    • Reversible
  • Hormonal therapy
    • Pregnancy prevention and menstrual suppression
      • Usually provided as part of general adolescent care
      • Reversible
    • Pubertal suppression – gonadotropin-releasing hormone analogues
      • May need referral to specialist or multidisciplinary clinic
      • Reversible
    • Exogenous gender affirming hormones – testosterone or estrogen
      • May need referral to specialist or multidisciplinary clinic
      • Most effects are considered irreversible, but some may be reversible
    • Fertility preservation
      • May need referral to specialist or multidisciplinary clinic
  • Surgical intervention
    • These procedures may be performed at the age of majority, and need referral to a surgeon
    • Creation of desired anatomy
    • Removal or undesired organs
    • Modification of anatomy
  • Sexual health
    • Routine sexual health screening and treatment
    • Pregnancy prevention and menstrual suppression
  • Mental health
    • Therapy referrals for mental health or other social problems, including facilitating discussions of gender identity and exploration
  • Social support
    • Health care providers are good supports for youth
    • Help assist identity disclosure to family or others
    • Provide support, education and mental health referrals for family members who may face challenges in accepting their child’s gender identity. As with all people, parental support has significant positive effects on TGD
    • Referral for legal services

Questions for Further Discussion
1. What resources do you have in your community for TGD?
2. What if any legal restrictions on treatment exist for TGD in your location?
3. How do you screen for substance abuse and what resources are available in your location?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Teen Health, Teen Development and Teen Sexual Health.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Voss, RV, Simons S. Supporting the Health of Transgender and Gender-Diverse Youth in Primary Care Settings. Prim Care Clin Office Pract. 2021:48;259-270.

Hodax JK, Crouch JM. Sethness JL. et. al. Strategies for Providing Gender-Affirming Care for Adolescents in the Primary Care Setting. Pediatr Ann. 2023;52(12);e442-e449.

Salvetti B, Gallagher M, Schapiro NA, Daley AM. Prioritizing Gender-Affirming Care for Youth: The Role of Pediatric-Focused Clinicians. Journal of Pediatric Health Care. 2024;38(2):253-259. doi:10.1016/j.pedhc.2023.12.006

Ho T, Ricklefs C. Healthcare for Sexual and Gender Minority Adolescents. Primary Care: Clinics in Office Practice. 2024;51(4):675-688. doi:10.1016/j.pop.2024.05.007

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Published