Gayathri Chelvakumar, MD

Going to the movies is something I have always enjoyed. What I don’t always enjoy is waiting in line to use the bathroom after the movie is over and invariably picking a stall that has run out of toilet paper or that is in need of cleaning. These minor inconveniences in no way compare to the experiences some of my transgender patients have shared with me. Many of my patients tell me that they avoid using bathrooms in public places because of the anxiety they feel at having to pick a bathroom. Do they use the one that matches their sex assigned at birth or the one that matches their gender identity? Will they be safe and free from harassment in either bathroom? Some of my patients tell me they avoid drinking water at school just so they do not have to deal with going to the bathroom there.

Recently there have been bills introduced in several states that seek to deny transgender youth access to sex-segregated spaces including restrooms and locker rooms. These bills stigmatize an already vulnerable population, potentially increasing their risk of negative health outcomes. In a survey of transgender people in Massachusetts, 65% of respondents reported being discriminated against in public accommodations, and this discrimination was associated with poorer mental and physical health outcomes.¹

In February of 2016, the American Academy of Pediatrics and several other organizations dedicated to the health and welfare of children came out with a letter to state governors in opposition to these bills.² It states: “Transgender kids are already at heightened risk for violence, bullying, and harassment, and these bills exacerbate those risks by creating a hostile environment. … In addition, students who would be affected by these bills are among our most vulnerable to experiencing depression and engaging in self-harm, including suicide.”

On May 13, 2016, the U.S. Department of Justice and the U.S. Department of Education jointly issued a letter directing public schools to allow transgender students to use bathrooms that correspond with their gender identity.³ The letter was accompanied by a 25-page document with examples of policies and emerging practices to support transgender students.⁴

Proponents of these bills state that their purpose is to increase public safety and protect privacy. There are concerns that individuals may take advantage of these policies to sexually harass people in sex-segregated spaces. To date, there are no data to support these claims. In interviews conducted with heads of state police departments in 12 states that have nondiscrimination laws to protect transgender people in public settings, not one of the participants indicated any increase in sexual harassment or abuse in connection with these laws.¹ In addition, should any type of harassment occur, it would not be protected under antidiscrimination laws, and perpetrators would be subject to criminal penalties.

What can we do as health care providers to support our patients?

•  Educate ourselves. Keep up to date with best practice guidelines and evidence on how to promote the health and well-being of all children. The National LGBT Health Education Center has many educational resources to help health care providers provide quality care to LGBT patients and families. It is important to be aware of resources to help patients and families be aware of their rights and advocate for themselves in other settings such as school and work. Two organizations that provide this support and information are Trans Youth Family Allies and Lambda Legal.

•  Create safe spaces. Create spaces in our practice settings where children and youth can safely explore their gender identity and gender expression. This can be done by providing access to gender-neutral bathrooms, prominently displaying nondiscrimination policies that are inclusive of gender identity, and modeling recognition of the variety of ways gender can be experienced by asking and using patients’ preferred names and pronouns.

•  Advocate. Advocate for gender-inclusive environments within local youth-serving organizations including schools, medical facilities, and child welfare agencies. Share available information about the potential negative health effects of stigmatization and discrimination in transgender youth.

Together we can work to promote the well-being of all children.

Resources

•  The National LGBT Health Education Center (www.lgbthealtheducation.org/).

•  Trans Youth Family Allies (www.imatyfa.org/).

•  Lambda Legal (www.lambdalegal.org/know-your-rights/youth).

References

1. Policy Brief: State Anti-transgender Bathroom Bills Threaten Transgender People’s Health and Participation in Public Life. Fenway Institute and Center for American Progress, 2016.

2. American Academy of Pediatrics letter on sex-segregated spaces (www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/AAP_HRCLetter.pdf).

3. Department of Justice and Department of Education Dear Colleague Letter on Transgender Students (www.justice.gov/opa/file/850996/download).

4. Department of Education Examples of Policies and Emerging Practices for Supporting Transgender Students (www2.ed.gov/about/offices/list/oese/oshs/emergingpractices.pdf).

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Going to the movies is something I have always enjoyed. What I don’t always enjoy is waiting in line to use the bathroom after the movie is over and invariably picking a stall that has run out of toilet paper or that is in need of cleaning. These minor inconveniences in no way compare to the experiences some of my transgender patients have shared with me. Many of my patients tell me that they avoid using bathrooms in public places because of the anxiety they feel at having to pick a bathroom. Do they use the one that matches their sex assigned at birth or the one that matches their gender identity? Will they be safe and free from harassment in either bathroom? Some of my patients tell me they avoid drinking water at school just so they do not have to deal with going to the bathroom there.

Recently there have been bills introduced in several states that seek to deny transgender youth access to sex-segregated spaces including restrooms and locker rooms. These bills stigmatize an already vulnerable population, potentially increasing their risk of negative health outcomes. In a survey of transgender people in Massachusetts, 65% of respondents reported being discriminated against in public accommodations, and this discrimination was associated with poorer mental and physical health outcomes.¹

In February of 2016, the American Academy of Pediatrics and several other organizations dedicated to the health and welfare of children came out with a letter to state governors in opposition to these bills.² It states: “Transgender kids are already at heightened risk for violence, bullying, and harassment, and these bills exacerbate those risks by creating a hostile environment. … In addition, students who would be affected by these bills are among our most vulnerable to experiencing depression and engaging in self-harm, including suicide.”

On May 13, 2016, the U.S. Department of Justice and the U.S. Department of Education jointly issued a letter directing public schools to allow transgender students to use bathrooms that correspond with their gender identity.³ The letter was accompanied by a 25-page document with examples of policies and emerging practices to support transgender students.⁴

Proponents of these bills state that their purpose is to increase public safety and protect privacy. There are concerns that individuals may take advantage of these policies to sexually harass people in sex-segregated spaces. To date, there are no data to support these claims. In interviews conducted with heads of state police departments in 12 states that have nondiscrimination laws to protect transgender people in public settings, not one of the participants indicated any increase in sexual harassment or abuse in connection with these laws.¹ In addition, should any type of harassment occur, it would not be protected under antidiscrimination laws, and perpetrators would be subject to criminal penalties.

What can we do as health care providers to support our patients?

•  Educate ourselves. Keep up to date with best practice guidelines and evidence on how to promote the health and well-being of all children. The National LGBT Health Education Center has many educational resources to help health care providers provide quality care to LGBT patients and families. It is important to be aware of resources to help patients and families be aware of their rights and advocate for themselves in other settings such as school and work. Two organizations that provide this support and information are Trans Youth Family Allies and Lambda Legal.

•  Create safe spaces. Create spaces in our practice settings where children and youth can safely explore their gender identity and gender expression. This can be done by providing access to gender-neutral bathrooms, prominently displaying nondiscrimination policies that are inclusive of gender identity, and modeling recognition of the variety of ways gender can be experienced by asking and using patients’ preferred names and pronouns.

•  Advocate. Advocate for gender-inclusive environments within local youth-serving organizations including schools, medical facilities, and child welfare agencies. Share available information about the potential negative health effects of stigmatization and discrimination in transgender youth.

Together we can work to promote the well-being of all children.

Resources

•  The National LGBT Health Education Center (www.lgbthealtheducation.org/).

•  Trans Youth Family Allies (www.imatyfa.org/).

•  Lambda Legal (www.lambdalegal.org/know-your-rights/youth).

References

1. Policy Brief: State Anti-transgender Bathroom Bills Threaten Transgender People’s Health and Participation in Public Life. Fenway Institute and Center for American Progress, 2016.

2. American Academy of Pediatrics letter on sex-segregated spaces (www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/AAP_HRCLetter.pdf).

3. Department of Justice and Department of Education Dear Colleague Letter on Transgender Students (www.justice.gov/opa/file/850996/download).

4. Department of Education Examples of Policies and Emerging Practices for Supporting Transgender Students (www2.ed.gov/about/offices/list/oese/oshs/emergingpractices.pdf).

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Going to the movies is something I have always enjoyed. What I don’t always enjoy is waiting in line to use the bathroom after the movie is over and invariably picking a stall that has run out of toilet paper or that is in need of cleaning. These minor inconveniences in no way compare to the experiences some of my transgender patients have shared with me. Many of my patients tell me that they avoid using bathrooms in public places because of the anxiety they feel at having to pick a bathroom. Do they use the one that matches their sex assigned at birth or the one that matches their gender identity? Will they be safe and free from harassment in either bathroom? Some of my patients tell me they avoid drinking water at school just so they do not have to deal with going to the bathroom there.

Recently there have been bills introduced in several states that seek to deny transgender youth access to sex-segregated spaces including restrooms and locker rooms. These bills stigmatize an already vulnerable population, potentially increasing their risk of negative health outcomes. In a survey of transgender people in Massachusetts, 65% of respondents reported being discriminated against in public accommodations, and this discrimination was associated with poorer mental and physical health outcomes.¹

In February of 2016, the American Academy of Pediatrics and several other organizations dedicated to the health and welfare of children came out with a letter to state governors in opposition to these bills.² It states: “Transgender kids are already at heightened risk for violence, bullying, and harassment, and these bills exacerbate those risks by creating a hostile environment. … In addition, students who would be affected by these bills are among our most vulnerable to experiencing depression and engaging in self-harm, including suicide.”

On May 13, 2016, the U.S. Department of Justice and the U.S. Department of Education jointly issued a letter directing public schools to allow transgender students to use bathrooms that correspond with their gender identity.³ The letter was accompanied by a 25-page document with examples of policies and emerging practices to support transgender students.⁴

Proponents of these bills state that their purpose is to increase public safety and protect privacy. There are concerns that individuals may take advantage of these policies to sexually harass people in sex-segregated spaces. To date, there are no data to support these claims. In interviews conducted with heads of state police departments in 12 states that have nondiscrimination laws to protect transgender people in public settings, not one of the participants indicated any increase in sexual harassment or abuse in connection with these laws.¹ In addition, should any type of harassment occur, it would not be protected under antidiscrimination laws, and perpetrators would be subject to criminal penalties.

What can we do as health care providers to support our patients?

•  Educate ourselves. Keep up to date with best practice guidelines and evidence on how to promote the health and well-being of all children. The National LGBT Health Education Center has many educational resources to help health care providers provide quality care to LGBT patients and families. It is important to be aware of resources to help patients and families be aware of their rights and advocate for themselves in other settings such as school and work. Two organizations that provide this support and information are Trans Youth Family Allies and Lambda Legal.

•  Create safe spaces. Create spaces in our practice settings where children and youth can safely explore their gender identity and gender expression. This can be done by providing access to gender-neutral bathrooms, prominently displaying nondiscrimination policies that are inclusive of gender identity, and modeling recognition of the variety of ways gender can be experienced by asking and using patients’ preferred names and pronouns.

•  Advocate. Advocate for gender-inclusive environments within local youth-serving organizations including schools, medical facilities, and child welfare agencies. Share available information about the potential negative health effects of stigmatization and discrimination in transgender youth.

Together we can work to promote the well-being of all children.

Resources

•  The National LGBT Health Education Center (www.lgbthealtheducation.org/).

•  Trans Youth Family Allies (www.imatyfa.org/).

•  Lambda Legal (www.lambdalegal.org/know-your-rights/youth).

References

1. Policy Brief: State Anti-transgender Bathroom Bills Threaten Transgender People’s Health and Participation in Public Life. Fenway Institute and Center for American Progress, 2016.

2. American Academy of Pediatrics letter on sex-segregated spaces (www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/AAP_HRCLetter.pdf).

3. Department of Justice and Department of Education Dear Colleague Letter on Transgender Students (www.justice.gov/opa/file/850996/download).

4. Department of Education Examples of Policies and Emerging Practices for Supporting Transgender Students (www2.ed.gov/about/offices/list/oese/oshs/emergingpractices.pdf).

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Ryan is a 15-year-old transmale patient (natal sex female who identifies as male and prefers male pronouns, he/him/his) who presents to the emergency department (ED) with suicidal thoughts that have increased with his period this month. His father explains to the registration staff that Ryan is transgender and while his legal name is still Rachel, he prefers to be addressed as Ryan and uses male pronouns. The registration person passes this on to the nurse who will be caring for Ryan. While in the ED, Ryan is frequently referred to by his birth name, Rachel, and female pronouns by various staff members. Dad corrects them, and staff are responsive to his feedback, but the continued misgendering increases Ryan’s suicidality to the point that dad considers leaving the ED.

Nakeia is a 2-month-old infant female brought to the clinic by her parents Shayla and Marie, who are a married lesbian couple. When the doctor walks in, she introduces herself to Shayla and when she sees Marie, she says, “It’s so nice that your mother came with you to the appointment today.” Marie is taken aback and wonders if they should search for another pediatrician who has experience working with LGB couples.

The two cases above are fictional cases created from a collection of experiences shared by patients and families that have presented to our clinics. While unintentional, the assumptions of staff and providers resulted in distress for the patient and families being cared for. What could have been done differently?

Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth are less likely to access health care than are their non-LGBTQ peers for a variety of reasons. Perceived discrimination within the health care system, and health care providers’ lack of awareness and knowledge of LGBTQ specific health issues are factors that lead to decreased use of health care services.¹ In a 2009 survey of LGBT adults, 56% of LGB respondents and 70% of transgender and gender nonconforming respondents reported experiencing at least one incident of discrimination in the health care setting.² The Institute of Medicine (IOM), the Association of American Medical Colleges (AAMC), and the Joint Commission recommend specific training of health care providers on issues of LGBTQ health as one way of addressing these barriers.^2,3,4 Despite these recommendations, many providers report that they are not adequately trained to provide care for LGBT patients.¹

A number of resources are available to help health care providers and staff increase their competency in caring for LGBTQ patients and families. The National LGBT Health Education Center is one easy-to-use resource that has information on disparities in the LGBT community and strategies that can be implemented in practice to address these disparities. These strategies are not expensive to implement, but do require time, effort, and dedication from staff and providers to provide best quality care to all patients. Below are a few suggestions to create an inclusive health care environment adapted from the center’s guide on creating inclusive health care environments for LGBT people⁵:

All staff receive training on culturally affirming care for LGBT people.

• Training on terminology, health disparities, and how to avoid assumptions and stereotypes is important for all staff members. A positive or negative encounter with one staff member can set the tone for the whole visit.

• Respectful, nonjudgmental communication can help patients and families feel safe and comfortable and increases the likelihood that they remain engaged in care.

Processes and forms reflect the diversity of LGBT people and their relationships.

• Preferred names/pronouns. Many transgender patients have insurance cards and legal documents that do not reflect their current identity. Having a process where preferred names and pronouns can be recorded in the chart and easily communicated to other staff members is important. It is equally important that staff members are trained to recognize and use this information.

• Relationship questions. All staff members should ask the relationship of people accompanying patients to visits and not assume relationships.

• Sexual history questions. When asking or collecting information about sexual history, do not assume heterosexuality.

All patients receive routine sexual health histories.

• A confidential sexual health history should be part of the comprehensive history for all adolescent patients.

• Discussions should be broad, not only focusing on sexual behaviors and risks, but also addressing attraction, readiness for sex, health of relationships, sexual satisfaction, and history of trauma or abuse.

• Ask open-ended and inclusive questions, such as “Are you in a relationship?” “Are you attracted to men, women, both, neither?”

• Ask patients and parents if they have any concerns about gender identity. This offers an opportunity for patients and parents to discuss these issues.

•  Avoid assumptions by asking these questions of all patients.

Clinical care and services incorporate LGBT health care needs.

LGBTQ youth in general have the same health and wellness needs as those of all patients. There are, however, health disparities that exist in this community related to stigma and minority stress. Clinicians should be aware of these disparities so they can provide targeted, individualized care.

• Gay men, bisexual men, and transgender women face higher rates of HIV and STIs. Culturally responsive prevention and testing is important, including availability of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) therapy for HIV as appropriate.

• Smoking and substance use rates are higher in LGBTQ youth; assessing for this and providing appropriate support is important.

• LGBTQ youth are at higher risk of depression, anxiety, suicidality, and bullying. Assessing for family and social support is important as these can be protective. Connecting parents and youth to support groups can be helpful.

• Transgender youth may require specialized services including counseling, psychiatric services, pubertal suppression, and cross-sex hormone therapy. Knowledge of where patients can be appropriately referred is important.

The physical environment welcomes and includes LGBT people.

Studies have shown that many LGBTQ youth and parents look for signs or clues that a clinic or facility is welcoming or safe. Below are some easy ways to communicate openness through the physical space.

• Signs and brochures. Prominently display clinic or institutional nondiscrimination policies. LGBT-friendly symbols such as the rainbow flag or safe zone signs can be displayed on placards, bulletin boards, or staff badges.

• Reading materials. Brochures, magazines and décor that contain images of couples and families should include same-sex couples and LGBT families. Reading materials should include topics relevant to the LGBTQ patients. Information about local LGBTQ resources should be available.

• Restrooms. Transgender and gender nonconforming youth often experience anxiety using public restrooms in part due to fear of harassment. Health care spaces should have policies that allow patients to use restrooms based on their gender identity rather than birth sex. If possible, it is helpful to provide access to single occupancy unisex restrooms.

Creating a space that is safe, welcoming, and respectful of LGBTQ patients and families is one way to begin addressing the health disparities that exist in this community. Below are resources to help your clinic or institution become one of these spaces.

1. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (National Academies Press: Washington, 2011).

2. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV (New York: Lambda Legal, 2010).

3. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who are LGBT, Gender Non-Conforming, or born with DSD: A Resource for Medical Educators. (AAMC: Washington, 2014).

4. The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient and Family Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. (The Joint Commission: Oak Brook, Ill. 2011)

5. Ten Things: Creating Inclusive Health Care Environments for LGBT People. National LGBT Health Education Center (www.lgbthealtheducation.org).

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Ryan is a 15-year-old transmale patient (natal sex female who identifies as male and prefers male pronouns, he/him/his) who presents to the emergency department (ED) with suicidal thoughts that have increased with his period this month. His father explains to the registration staff that Ryan is transgender and while his legal name is still Rachel, he prefers to be addressed as Ryan and uses male pronouns. The registration person passes this on to the nurse who will be caring for Ryan. While in the ED, Ryan is frequently referred to by his birth name, Rachel, and female pronouns by various staff members. Dad corrects them, and staff are responsive to his feedback, but the continued misgendering increases Ryan’s suicidality to the point that dad considers leaving the ED.

Nakeia is a 2-month-old infant female brought to the clinic by her parents Shayla and Marie, who are a married lesbian couple. When the doctor walks in, she introduces herself to Shayla and when she sees Marie, she says, “It’s so nice that your mother came with you to the appointment today.” Marie is taken aback and wonders if they should search for another pediatrician who has experience working with LGB couples.

The two cases above are fictional cases created from a collection of experiences shared by patients and families that have presented to our clinics. While unintentional, the assumptions of staff and providers resulted in distress for the patient and families being cared for. What could have been done differently?

Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth are less likely to access health care than are their non-LGBTQ peers for a variety of reasons. Perceived discrimination within the health care system, and health care providers’ lack of awareness and knowledge of LGBTQ specific health issues are factors that lead to decreased use of health care services.¹ In a 2009 survey of LGBT adults, 56% of LGB respondents and 70% of transgender and gender nonconforming respondents reported experiencing at least one incident of discrimination in the health care setting.² The Institute of Medicine (IOM), the Association of American Medical Colleges (AAMC), and the Joint Commission recommend specific training of health care providers on issues of LGBTQ health as one way of addressing these barriers.^2,3,4 Despite these recommendations, many providers report that they are not adequately trained to provide care for LGBT patients.¹

A number of resources are available to help health care providers and staff increase their competency in caring for LGBTQ patients and families. The National LGBT Health Education Center is one easy-to-use resource that has information on disparities in the LGBT community and strategies that can be implemented in practice to address these disparities. These strategies are not expensive to implement, but do require time, effort, and dedication from staff and providers to provide best quality care to all patients. Below are a few suggestions to create an inclusive health care environment adapted from the center’s guide on creating inclusive health care environments for LGBT people⁵:

All staff receive training on culturally affirming care for LGBT people.

• Training on terminology, health disparities, and how to avoid assumptions and stereotypes is important for all staff members. A positive or negative encounter with one staff member can set the tone for the whole visit.

• Respectful, nonjudgmental communication can help patients and families feel safe and comfortable and increases the likelihood that they remain engaged in care.

Processes and forms reflect the diversity of LGBT people and their relationships.

• Preferred names/pronouns. Many transgender patients have insurance cards and legal documents that do not reflect their current identity. Having a process where preferred names and pronouns can be recorded in the chart and easily communicated to other staff members is important. It is equally important that staff members are trained to recognize and use this information.

• Relationship questions. All staff members should ask the relationship of people accompanying patients to visits and not assume relationships.

• Sexual history questions. When asking or collecting information about sexual history, do not assume heterosexuality.

All patients receive routine sexual health histories.

• A confidential sexual health history should be part of the comprehensive history for all adolescent patients.

• Discussions should be broad, not only focusing on sexual behaviors and risks, but also addressing attraction, readiness for sex, health of relationships, sexual satisfaction, and history of trauma or abuse.

• Ask open-ended and inclusive questions, such as “Are you in a relationship?” “Are you attracted to men, women, both, neither?”

• Ask patients and parents if they have any concerns about gender identity. This offers an opportunity for patients and parents to discuss these issues.

•  Avoid assumptions by asking these questions of all patients.

Clinical care and services incorporate LGBT health care needs.

LGBTQ youth in general have the same health and wellness needs as those of all patients. There are, however, health disparities that exist in this community related to stigma and minority stress. Clinicians should be aware of these disparities so they can provide targeted, individualized care.

• Gay men, bisexual men, and transgender women face higher rates of HIV and STIs. Culturally responsive prevention and testing is important, including availability of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) therapy for HIV as appropriate.

• Smoking and substance use rates are higher in LGBTQ youth; assessing for this and providing appropriate support is important.

• LGBTQ youth are at higher risk of depression, anxiety, suicidality, and bullying. Assessing for family and social support is important as these can be protective. Connecting parents and youth to support groups can be helpful.

• Transgender youth may require specialized services including counseling, psychiatric services, pubertal suppression, and cross-sex hormone therapy. Knowledge of where patients can be appropriately referred is important.

The physical environment welcomes and includes LGBT people.

Studies have shown that many LGBTQ youth and parents look for signs or clues that a clinic or facility is welcoming or safe. Below are some easy ways to communicate openness through the physical space.

• Signs and brochures. Prominently display clinic or institutional nondiscrimination policies. LGBT-friendly symbols such as the rainbow flag or safe zone signs can be displayed on placards, bulletin boards, or staff badges.

• Reading materials. Brochures, magazines and décor that contain images of couples and families should include same-sex couples and LGBT families. Reading materials should include topics relevant to the LGBTQ patients. Information about local LGBTQ resources should be available.

• Restrooms. Transgender and gender nonconforming youth often experience anxiety using public restrooms in part due to fear of harassment. Health care spaces should have policies that allow patients to use restrooms based on their gender identity rather than birth sex. If possible, it is helpful to provide access to single occupancy unisex restrooms.

Creating a space that is safe, welcoming, and respectful of LGBTQ patients and families is one way to begin addressing the health disparities that exist in this community. Below are resources to help your clinic or institution become one of these spaces.

1. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (National Academies Press: Washington, 2011).

2. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV (New York: Lambda Legal, 2010).

3. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who are LGBT, Gender Non-Conforming, or born with DSD: A Resource for Medical Educators. (AAMC: Washington, 2014).

4. The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient and Family Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. (The Joint Commission: Oak Brook, Ill. 2011)

5. Ten Things: Creating Inclusive Health Care Environments for LGBT People. National LGBT Health Education Center (www.lgbthealtheducation.org).

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Ryan is a 15-year-old transmale patient (natal sex female who identifies as male and prefers male pronouns, he/him/his) who presents to the emergency department (ED) with suicidal thoughts that have increased with his period this month. His father explains to the registration staff that Ryan is transgender and while his legal name is still Rachel, he prefers to be addressed as Ryan and uses male pronouns. The registration person passes this on to the nurse who will be caring for Ryan. While in the ED, Ryan is frequently referred to by his birth name, Rachel, and female pronouns by various staff members. Dad corrects them, and staff are responsive to his feedback, but the continued misgendering increases Ryan’s suicidality to the point that dad considers leaving the ED.

Nakeia is a 2-month-old infant female brought to the clinic by her parents Shayla and Marie, who are a married lesbian couple. When the doctor walks in, she introduces herself to Shayla and when she sees Marie, she says, “It’s so nice that your mother came with you to the appointment today.” Marie is taken aback and wonders if they should search for another pediatrician who has experience working with LGB couples.

The two cases above are fictional cases created from a collection of experiences shared by patients and families that have presented to our clinics. While unintentional, the assumptions of staff and providers resulted in distress for the patient and families being cared for. What could have been done differently?

Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth are less likely to access health care than are their non-LGBTQ peers for a variety of reasons. Perceived discrimination within the health care system, and health care providers’ lack of awareness and knowledge of LGBTQ specific health issues are factors that lead to decreased use of health care services.¹ In a 2009 survey of LGBT adults, 56% of LGB respondents and 70% of transgender and gender nonconforming respondents reported experiencing at least one incident of discrimination in the health care setting.² The Institute of Medicine (IOM), the Association of American Medical Colleges (AAMC), and the Joint Commission recommend specific training of health care providers on issues of LGBTQ health as one way of addressing these barriers.^2,3,4 Despite these recommendations, many providers report that they are not adequately trained to provide care for LGBT patients.¹

A number of resources are available to help health care providers and staff increase their competency in caring for LGBTQ patients and families. The National LGBT Health Education Center is one easy-to-use resource that has information on disparities in the LGBT community and strategies that can be implemented in practice to address these disparities. These strategies are not expensive to implement, but do require time, effort, and dedication from staff and providers to provide best quality care to all patients. Below are a few suggestions to create an inclusive health care environment adapted from the center’s guide on creating inclusive health care environments for LGBT people⁵:

All staff receive training on culturally affirming care for LGBT people.

• Training on terminology, health disparities, and how to avoid assumptions and stereotypes is important for all staff members. A positive or negative encounter with one staff member can set the tone for the whole visit.

• Respectful, nonjudgmental communication can help patients and families feel safe and comfortable and increases the likelihood that they remain engaged in care.

Processes and forms reflect the diversity of LGBT people and their relationships.

• Preferred names/pronouns. Many transgender patients have insurance cards and legal documents that do not reflect their current identity. Having a process where preferred names and pronouns can be recorded in the chart and easily communicated to other staff members is important. It is equally important that staff members are trained to recognize and use this information.

• Relationship questions. All staff members should ask the relationship of people accompanying patients to visits and not assume relationships.

• Sexual history questions. When asking or collecting information about sexual history, do not assume heterosexuality.

All patients receive routine sexual health histories.

• A confidential sexual health history should be part of the comprehensive history for all adolescent patients.

• Discussions should be broad, not only focusing on sexual behaviors and risks, but also addressing attraction, readiness for sex, health of relationships, sexual satisfaction, and history of trauma or abuse.

• Ask open-ended and inclusive questions, such as “Are you in a relationship?” “Are you attracted to men, women, both, neither?”

• Ask patients and parents if they have any concerns about gender identity. This offers an opportunity for patients and parents to discuss these issues.

•  Avoid assumptions by asking these questions of all patients.

Clinical care and services incorporate LGBT health care needs.

LGBTQ youth in general have the same health and wellness needs as those of all patients. There are, however, health disparities that exist in this community related to stigma and minority stress. Clinicians should be aware of these disparities so they can provide targeted, individualized care.

• Gay men, bisexual men, and transgender women face higher rates of HIV and STIs. Culturally responsive prevention and testing is important, including availability of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) therapy for HIV as appropriate.

• Smoking and substance use rates are higher in LGBTQ youth; assessing for this and providing appropriate support is important.

• LGBTQ youth are at higher risk of depression, anxiety, suicidality, and bullying. Assessing for family and social support is important as these can be protective. Connecting parents and youth to support groups can be helpful.

• Transgender youth may require specialized services including counseling, psychiatric services, pubertal suppression, and cross-sex hormone therapy. Knowledge of where patients can be appropriately referred is important.

The physical environment welcomes and includes LGBT people.

Studies have shown that many LGBTQ youth and parents look for signs or clues that a clinic or facility is welcoming or safe. Below are some easy ways to communicate openness through the physical space.

• Signs and brochures. Prominently display clinic or institutional nondiscrimination policies. LGBT-friendly symbols such as the rainbow flag or safe zone signs can be displayed on placards, bulletin boards, or staff badges.

• Reading materials. Brochures, magazines and décor that contain images of couples and families should include same-sex couples and LGBT families. Reading materials should include topics relevant to the LGBTQ patients. Information about local LGBTQ resources should be available.

• Restrooms. Transgender and gender nonconforming youth often experience anxiety using public restrooms in part due to fear of harassment. Health care spaces should have policies that allow patients to use restrooms based on their gender identity rather than birth sex. If possible, it is helpful to provide access to single occupancy unisex restrooms.

Creating a space that is safe, welcoming, and respectful of LGBTQ patients and families is one way to begin addressing the health disparities that exist in this community. Below are resources to help your clinic or institution become one of these spaces.

1. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (National Academies Press: Washington, 2011).

2. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV (New York: Lambda Legal, 2010).

3. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who are LGBT, Gender Non-Conforming, or born with DSD: A Resource for Medical Educators. (AAMC: Washington, 2014).

4. The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient and Family Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. (The Joint Commission: Oak Brook, Ill. 2011)

5. Ten Things: Creating Inclusive Health Care Environments for LGBT People. National LGBT Health Education Center (www.lgbthealtheducation.org).

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Gender identity typically develops in early childhood, and by age 4 years, most children consistently refer to themselves as a girl or a boy.¹ For the majority of children, natal sex or sex assigned at birth, aligns with gender identity (a person’s innate sense of feeling male, female, or somewhere in between). However, this is not always the case. Gender identity can be understood as a spectrum with youth identifying as a gender that aligns with their natal sex (cisgender), is opposite of their natal sex (transgender), no gender (agender), or somewhere in between (genderqueer). The distress that can result from an incongruence between natal sex and gender identity is called gender dysphoria. Youth with gender dysphoria are at increased risk for a number of conditions, including suicide and self-harm. Early identification and appropriate care of these youth can reduce these risks. This month’s column will briefly review assessment of these youth in the pediatric setting.

Many youth who have a gender-nonconforming identity in childhood will not go on to have one in adulthood.^2,3 Those who have a consistent, insistent, and persistent nonconforming identity are more likely to have this identity persist into adulthood. Youth who experience increased gender dysphoria with the onset of puberty rarely have this subside.

As it can be difficult to predict the trajectory of gender identity from childhood to adolescence, the approach to the prepubertal and pubertal gender nonconforming patient is different. It is important to note that research suggests that gender identity is innate and cannot be changed with interventions. The goals of care for gender-nonconforming (GN) youth include providing a safe environment where youth can explore their identities, and individualizing treatment to meet the needs of each patient and family.

Care for prepubertal GN youth

For parents:

Have you noticed, or are you concerned about your child’s:

• Preference or rejection of particular toys/games?

• Hair and clothing preferences or rejections?

• Preferred (if any) gender of playmates?

Has your child ever expressed:

• A desire to be or insistence that they are the other gender?

• A dislike of their sexual anatomy?

• A desire for primary (penis, vagina) or secondary (periods, facial hair) sex characteristics of the other gender?

Are you concerned about bullying ?

Do you have any concerns about your child’s mood or concerns for self-harm?

For children:

• Do you feel more like a girl, boy, neither, both?

• How would you like to play, cut your hair, dress?

• What name or pronoun (she for girl, he for boy) fits you?⁴

The goal for prepubertal youth with nonconforming identities is to ensure that they are safe at home, school, and at play. Some youth may express a desire to “transition” or live as their identified gender by changing their name and dressing as their identified gender. Some youth and families may choose to transition only in certain settings (at home, but not at school). Some youth and families may want a safe space where the child can grow, develop, and continue to explore their identity without transitioning. Mental health providers trained in the care of GN youth can help patients and families decide if transition is appropriate for them and support them with the process and timing of transitioning. For youth who experience depression, anxiety, bullying, or thoughts of self-harm related to their gender identity, care by an experienced mental health provider is essential. It is important to recognize that each patient and family will need an individualized approach based on their needs.

Care for pubertal GN youth

©Olga Ekaterincheva/Thinkstock

The development of secondary sex characteristics can be particularly distressing for GN youth. Some youth may first experience gender dysphoria at this time. This distress combined with the psychosocial stressors of adolescent development can lead to depression, anxiety, suicidal ideation, self-harm, and other risk taking behaviors. Visits with pubertal GN youth, as with any adolescent, should include confidential time alone with the medical provider to discuss any concerns. Youth should be informed that information will be kept confidential, but parents will need to be notified of any safety concerns (such as suicidality or self-harm). As with prepubertal youth, a history related to hair and clothing preferences; distress related to genital anatomy; and the desire to be the other gender should be obtained. A pubertal history and any related symptoms of distress also should be obtained.

DO

• Ask preferred name and pronoun.

• Perform confidential strength and risk assessment.

• Assess for family and social support.

• Refer to appropriate mental health and transgender providers.

DON’T

• Assume names and pronouns.

• Interview patient only with parent in the room.

• Disclose identity without patient consent.

• Dismiss parents as sources of support.

• Refer for reparative therapy.⁴

Youth who are suspected to have a diagnosis of gender dysphoria should be referred to mental health and medical providers with experience caring for transgender youth. These specialists can work with patients and families, and determine when and if youth are eligible for puberty blocking therapy with GnRH analogues and/or hormone therapy. GnRH analogues, if appropriate, can be prescribed after patients have reached sexual maturity rating stage 2. The rationale for this treatment is to prevent the development of unwanted secondary sex characteristics while giving the youth a chance to continue with psychotherapy and explore their gender identity.⁵ Hormone therapy, if appropriate, can be prescribed a few years later under the care of a transgender specialist and mental health provider.

Summary

It is normal to experiment with gender roles and expression in childhood. Providing a safe space to do this is important.

Individuals who have a persistent, consistent, and insistent gender-nonconforming identification and who have increased distress with puberty are unlikely to have this subside.

Pediatricians can assess for gender dysphoria and screen for related mood disorders and behaviors in the primary care setting. Appropriate referral to trained professionals is important.

Care should be individualized and focused on the health and safety of the patient.

Resources

For health care professionals

• World Professional Association for Transgender Health: Standards of care on care of transgender patients and provider directory. www.wpath.org• Physicians for Reproductive Health’s adolescent reproductive and sexual health education program (ARSHEP): Best practices for adolescent and reproductive health: Module on caring for transgender adolescent patients. prh.org/teen-reproductive-health/arshep-downloads/

For patients and families

• Family Acceptance Project: familyproject.sfsu.edu/

• Healthychildren.org: Parenting website supported by the American Academy of Pediatrics. Links to articles on gender nonconforming and transgender children; gender identity development in children. www.healthychildren.org

References

1. Caring for Your School Age Child: Ages 5-12 by the American Academy of Pediatrics (New York: Bantam Books, 1995).

2. Dev Psychol. 2008 Jan;44(1):34-45.

3. J Am Acad Child and Adolesc Psychiatry. 2008;47(12):1413-23

4. Caring for Transgender Adolescent Patients. Physicians for Reproductive Health’s Adolescent Reproductive and Sexual Health Education Program (ARSHEP): Best practices for adolescent and reproductive health: prh.org/teen-reproductive-health/arshep-downloads/

5. World Professional Association of Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, 7th Edition (International Journal of Transgenderism. 2011;13:165-232)

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Gender identity typically develops in early childhood, and by age 4 years, most children consistently refer to themselves as a girl or a boy.¹ For the majority of children, natal sex or sex assigned at birth, aligns with gender identity (a person’s innate sense of feeling male, female, or somewhere in between). However, this is not always the case. Gender identity can be understood as a spectrum with youth identifying as a gender that aligns with their natal sex (cisgender), is opposite of their natal sex (transgender), no gender (agender), or somewhere in between (genderqueer). The distress that can result from an incongruence between natal sex and gender identity is called gender dysphoria. Youth with gender dysphoria are at increased risk for a number of conditions, including suicide and self-harm. Early identification and appropriate care of these youth can reduce these risks. This month’s column will briefly review assessment of these youth in the pediatric setting.

Many youth who have a gender-nonconforming identity in childhood will not go on to have one in adulthood.^2,3 Those who have a consistent, insistent, and persistent nonconforming identity are more likely to have this identity persist into adulthood. Youth who experience increased gender dysphoria with the onset of puberty rarely have this subside.

As it can be difficult to predict the trajectory of gender identity from childhood to adolescence, the approach to the prepubertal and pubertal gender nonconforming patient is different. It is important to note that research suggests that gender identity is innate and cannot be changed with interventions. The goals of care for gender-nonconforming (GN) youth include providing a safe environment where youth can explore their identities, and individualizing treatment to meet the needs of each patient and family.

Care for prepubertal GN youth

For parents:

Have you noticed, or are you concerned about your child’s:

• Preference or rejection of particular toys/games?

• Hair and clothing preferences or rejections?

• Preferred (if any) gender of playmates?

Has your child ever expressed:

• A desire to be or insistence that they are the other gender?

• A dislike of their sexual anatomy?

• A desire for primary (penis, vagina) or secondary (periods, facial hair) sex characteristics of the other gender?

Are you concerned about bullying ?

Do you have any concerns about your child’s mood or concerns for self-harm?

For children:

• Do you feel more like a girl, boy, neither, both?

• How would you like to play, cut your hair, dress?

• What name or pronoun (she for girl, he for boy) fits you?⁴

The goal for prepubertal youth with nonconforming identities is to ensure that they are safe at home, school, and at play. Some youth may express a desire to “transition” or live as their identified gender by changing their name and dressing as their identified gender. Some youth and families may choose to transition only in certain settings (at home, but not at school). Some youth and families may want a safe space where the child can grow, develop, and continue to explore their identity without transitioning. Mental health providers trained in the care of GN youth can help patients and families decide if transition is appropriate for them and support them with the process and timing of transitioning. For youth who experience depression, anxiety, bullying, or thoughts of self-harm related to their gender identity, care by an experienced mental health provider is essential. It is important to recognize that each patient and family will need an individualized approach based on their needs.

Care for pubertal GN youth

©Olga Ekaterincheva/Thinkstock

The development of secondary sex characteristics can be particularly distressing for GN youth. Some youth may first experience gender dysphoria at this time. This distress combined with the psychosocial stressors of adolescent development can lead to depression, anxiety, suicidal ideation, self-harm, and other risk taking behaviors. Visits with pubertal GN youth, as with any adolescent, should include confidential time alone with the medical provider to discuss any concerns. Youth should be informed that information will be kept confidential, but parents will need to be notified of any safety concerns (such as suicidality or self-harm). As with prepubertal youth, a history related to hair and clothing preferences; distress related to genital anatomy; and the desire to be the other gender should be obtained. A pubertal history and any related symptoms of distress also should be obtained.

DO

• Ask preferred name and pronoun.

• Perform confidential strength and risk assessment.

• Assess for family and social support.

• Refer to appropriate mental health and transgender providers.

DON’T

• Assume names and pronouns.

• Interview patient only with parent in the room.

• Disclose identity without patient consent.

• Dismiss parents as sources of support.

• Refer for reparative therapy.⁴

Youth who are suspected to have a diagnosis of gender dysphoria should be referred to mental health and medical providers with experience caring for transgender youth. These specialists can work with patients and families, and determine when and if youth are eligible for puberty blocking therapy with GnRH analogues and/or hormone therapy. GnRH analogues, if appropriate, can be prescribed after patients have reached sexual maturity rating stage 2. The rationale for this treatment is to prevent the development of unwanted secondary sex characteristics while giving the youth a chance to continue with psychotherapy and explore their gender identity.⁵ Hormone therapy, if appropriate, can be prescribed a few years later under the care of a transgender specialist and mental health provider.

Summary

It is normal to experiment with gender roles and expression in childhood. Providing a safe space to do this is important.

Individuals who have a persistent, consistent, and insistent gender-nonconforming identification and who have increased distress with puberty are unlikely to have this subside.

Pediatricians can assess for gender dysphoria and screen for related mood disorders and behaviors in the primary care setting. Appropriate referral to trained professionals is important.

Care should be individualized and focused on the health and safety of the patient.

Resources

For health care professionals

• World Professional Association for Transgender Health: Standards of care on care of transgender patients and provider directory. www.wpath.org• Physicians for Reproductive Health’s adolescent reproductive and sexual health education program (ARSHEP): Best practices for adolescent and reproductive health: Module on caring for transgender adolescent patients. prh.org/teen-reproductive-health/arshep-downloads/

For patients and families

• Family Acceptance Project: familyproject.sfsu.edu/

• Healthychildren.org: Parenting website supported by the American Academy of Pediatrics. Links to articles on gender nonconforming and transgender children; gender identity development in children. www.healthychildren.org

References

1. Caring for Your School Age Child: Ages 5-12 by the American Academy of Pediatrics (New York: Bantam Books, 1995).

2. Dev Psychol. 2008 Jan;44(1):34-45.

3. J Am Acad Child and Adolesc Psychiatry. 2008;47(12):1413-23

4. Caring for Transgender Adolescent Patients. Physicians for Reproductive Health’s Adolescent Reproductive and Sexual Health Education Program (ARSHEP): Best practices for adolescent and reproductive health: prh.org/teen-reproductive-health/arshep-downloads/

5. World Professional Association of Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, 7th Edition (International Journal of Transgenderism. 2011;13:165-232)

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Gender identity typically develops in early childhood, and by age 4 years, most children consistently refer to themselves as a girl or a boy.¹ For the majority of children, natal sex or sex assigned at birth, aligns with gender identity (a person’s innate sense of feeling male, female, or somewhere in between). However, this is not always the case. Gender identity can be understood as a spectrum with youth identifying as a gender that aligns with their natal sex (cisgender), is opposite of their natal sex (transgender), no gender (agender), or somewhere in between (genderqueer). The distress that can result from an incongruence between natal sex and gender identity is called gender dysphoria. Youth with gender dysphoria are at increased risk for a number of conditions, including suicide and self-harm. Early identification and appropriate care of these youth can reduce these risks. This month’s column will briefly review assessment of these youth in the pediatric setting.

Many youth who have a gender-nonconforming identity in childhood will not go on to have one in adulthood.^2,3 Those who have a consistent, insistent, and persistent nonconforming identity are more likely to have this identity persist into adulthood. Youth who experience increased gender dysphoria with the onset of puberty rarely have this subside.

As it can be difficult to predict the trajectory of gender identity from childhood to adolescence, the approach to the prepubertal and pubertal gender nonconforming patient is different. It is important to note that research suggests that gender identity is innate and cannot be changed with interventions. The goals of care for gender-nonconforming (GN) youth include providing a safe environment where youth can explore their identities, and individualizing treatment to meet the needs of each patient and family.

Care for prepubertal GN youth

For parents:

Have you noticed, or are you concerned about your child’s:

• Preference or rejection of particular toys/games?

• Hair and clothing preferences or rejections?

• Preferred (if any) gender of playmates?

Has your child ever expressed:

• A desire to be or insistence that they are the other gender?

• A dislike of their sexual anatomy?

• A desire for primary (penis, vagina) or secondary (periods, facial hair) sex characteristics of the other gender?

Are you concerned about bullying ?

Do you have any concerns about your child’s mood or concerns for self-harm?

For children:

• Do you feel more like a girl, boy, neither, both?

• How would you like to play, cut your hair, dress?

• What name or pronoun (she for girl, he for boy) fits you?⁴

The goal for prepubertal youth with nonconforming identities is to ensure that they are safe at home, school, and at play. Some youth may express a desire to “transition” or live as their identified gender by changing their name and dressing as their identified gender. Some youth and families may choose to transition only in certain settings (at home, but not at school). Some youth and families may want a safe space where the child can grow, develop, and continue to explore their identity without transitioning. Mental health providers trained in the care of GN youth can help patients and families decide if transition is appropriate for them and support them with the process and timing of transitioning. For youth who experience depression, anxiety, bullying, or thoughts of self-harm related to their gender identity, care by an experienced mental health provider is essential. It is important to recognize that each patient and family will need an individualized approach based on their needs.

Care for pubertal GN youth

©Olga Ekaterincheva/Thinkstock

The development of secondary sex characteristics can be particularly distressing for GN youth. Some youth may first experience gender dysphoria at this time. This distress combined with the psychosocial stressors of adolescent development can lead to depression, anxiety, suicidal ideation, self-harm, and other risk taking behaviors. Visits with pubertal GN youth, as with any adolescent, should include confidential time alone with the medical provider to discuss any concerns. Youth should be informed that information will be kept confidential, but parents will need to be notified of any safety concerns (such as suicidality or self-harm). As with prepubertal youth, a history related to hair and clothing preferences; distress related to genital anatomy; and the desire to be the other gender should be obtained. A pubertal history and any related symptoms of distress also should be obtained.

DO

• Ask preferred name and pronoun.

• Perform confidential strength and risk assessment.

• Assess for family and social support.

• Refer to appropriate mental health and transgender providers.

DON’T

• Assume names and pronouns.

• Interview patient only with parent in the room.

• Disclose identity without patient consent.

• Dismiss parents as sources of support.

• Refer for reparative therapy.⁴

Youth who are suspected to have a diagnosis of gender dysphoria should be referred to mental health and medical providers with experience caring for transgender youth. These specialists can work with patients and families, and determine when and if youth are eligible for puberty blocking therapy with GnRH analogues and/or hormone therapy. GnRH analogues, if appropriate, can be prescribed after patients have reached sexual maturity rating stage 2. The rationale for this treatment is to prevent the development of unwanted secondary sex characteristics while giving the youth a chance to continue with psychotherapy and explore their gender identity.⁵ Hormone therapy, if appropriate, can be prescribed a few years later under the care of a transgender specialist and mental health provider.

Summary

It is normal to experiment with gender roles and expression in childhood. Providing a safe space to do this is important.

Individuals who have a persistent, consistent, and insistent gender-nonconforming identification and who have increased distress with puberty are unlikely to have this subside.

Pediatricians can assess for gender dysphoria and screen for related mood disorders and behaviors in the primary care setting. Appropriate referral to trained professionals is important.

Care should be individualized and focused on the health and safety of the patient.

Resources

For health care professionals

• World Professional Association for Transgender Health: Standards of care on care of transgender patients and provider directory. www.wpath.org• Physicians for Reproductive Health’s adolescent reproductive and sexual health education program (ARSHEP): Best practices for adolescent and reproductive health: Module on caring for transgender adolescent patients. prh.org/teen-reproductive-health/arshep-downloads/

For patients and families

• Family Acceptance Project: familyproject.sfsu.edu/

• Healthychildren.org: Parenting website supported by the American Academy of Pediatrics. Links to articles on gender nonconforming and transgender children; gender identity development in children. www.healthychildren.org

References

1. Caring for Your School Age Child: Ages 5-12 by the American Academy of Pediatrics (New York: Bantam Books, 1995).

2. Dev Psychol. 2008 Jan;44(1):34-45.

3. J Am Acad Child and Adolesc Psychiatry. 2008;47(12):1413-23

4. Caring for Transgender Adolescent Patients. Physicians for Reproductive Health’s Adolescent Reproductive and Sexual Health Education Program (ARSHEP): Best practices for adolescent and reproductive health: prh.org/teen-reproductive-health/arshep-downloads/

5. World Professional Association of Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, 7th Edition (International Journal of Transgenderism. 2011;13:165-232)

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

As a member of a multidisciplinary clinic that cares for gender-nonconforming (GN) youth, I frequently field questions from providers about how to handle gender identity concerns in the primary care setting. The specific health care needs of these youth matter as GN youth are at increased risk of self-harm, suicide attempts, mood disorders, eating disorders, substance use, and low school performance.^{1, 2} These increased risks appear to be related to the rejection and stigma associated with gender nonconformity that can extend to the health care setting.

More than 50% of transgender adults report experiences of discrimination in health care.³ The literature suggests that creating a supportive and affirming environment for GN youth may decrease these risks. If we can do just that during their health care visits, we can make a positive impact on our patients.

Terminology

A review of terminology and clarification of the difference between biologic sex, gender identity, gender expression, and sexual orientation are necessary before discussing the care of GN youth. Biologic sex is typically assigned at birth and is determined by a person’s chromosomes, hormones, and anatomy. Sex most commonly is female or male. For a minority of the population, there may be disorders or differences of sex development in which the development of chromosomal, gonadal, or anatomic sex is atypical. Examples of these conditions are congenital adrenal hyperplasia and androgen insensitivity syndrome. Gender includes the behavioral, cultural, and psychological characteristics associated with femaleness or maleness.² Gender identity is a person’s innate sense of feeling male, female, or somewhere in between. Individuals who have a gender identity that is congruent with their assigned sex are referred to as cisgender; those who have a gender identity that does not align with their birth sex are often referred to as transgender. Gender expression is how people choose to present themselves to the world. A person’s gender may or may not be consistent with his/her internal gender identity. For example, an individual may be female biologically (XX chromosomes, with a uterus, ovaries, and vagina) and self-identify as female, but express herself in a masculine way by having her hair cut short and wearing more masculine clothing.

Gender dysphoria occurs when an individual experiences psychological distress caused by the incongruence between his/her biologic sex and his/her internal gender identity, and this mismatch leads to clinically significant distress or impairment in daily functioning. Gender dysphoria is a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It has replaced the earlier diagnosis of gender identity disorder in the DSM-IV. The new diagnosis focuses on the distress related to an incongruence between gender identity and biologic sex and does not label it as pathologic. Gender-nonconforming individuals do not follow other people’s ideas or stereotypes about how they should look or act based on the sex they were assigned at birth. It is important to note that an individual’s gender identity is separate from sexual orientation. Sexual orientation describes an individual’s pattern of sexual and physical attraction. An individual may be attracted to members of the same sex (homosexual, lesbian, gay), opposite sex (heterosexual), or both sexes (bisexual). Increasingly youth are using a variety of terms to describe their gender (for example, genderqueer, asexual, gender fluid) and sexual orientation (for example, pansexual, asexual). These terms may have different meanings for different youth, and it is important to respectfully ask and clarify what these terms mean to each individual patient.

Trajectory of gender identity

Experimenting with gender expression and gender roles is a normal part of childhood. The majority of young children with nonconforming gender identification will not persist with this identification through adolescence. Some of these children will go on to have a nonheterosexual sexual orientation when they are older. While it can be difficult to predict the trajectory of cross-gender identification in early childhood, those with a persistent, insistent, and consistent cross-gender identification in childhood are more likely to experience gender dysphoria and continue with a transgender identity into adulthood. Adolescence is a particularly difficult time for GN youth. The development of secondary sex characteristics that are not consistent with an individual’s identified gender, in addition to the psychosocial challenges of adolescent development, can lead to increased suicidal thoughts, self-harm behaviors, anxiety, isolation, and risk-taking behaviors. Gender dysphoria that increases with the onset of puberty rarely subsides with time.

Approach to GN patients in practice

Research is ongoing related to best practices for the care of GN youth. Clinical guidelines and standards of care have been published and endorsed by organizations including the Endocrine Society, Pediatric Endocrine Society, World Professional Association for Transgender Health, and the American Academy of Pediatrics. My recommendations for the care of GN youth are based on these guidelines.

Primary care providers are often the first place families turn when a child experiences gender identity concerns. Primary care providers can play an important role in providing a safe nonjudgmental environment for patients and families to discuss their concerns, and connecting patients and families to appropriate resources. Providers should first work to educate themselves and their staff about issues affecting GN youth and learn to provide culturally competent care to these youth. Asking youth their preferred names and preferred pronouns (for example, “he/him/his,” “she/her/hers,” “they/them/their,” or something else), documenting this in the medical record, and training clinic staff to use preferred names and pronouns creates an environment that validates, supports, and respects these youth.

It is important to ask all adolescents if they have questions or concerns about their gender identity, in addition to asking questions about sexual identity. It is important when asking these questions to avoid assumptions about an individual’s gender identity based on his or her gender expression. Providers also should familiarize themselves with local referral resources for these youth. As mentioned earlier, GN youth are at high risk for mental health complications including suicide, self-harm, and mood disorders. When referring patients for mental health services, you should be familiar with providers who have expertise in issues of gender identity. A recent report by the Substance Abuse and Mental Health Services Administration states that variations in gender identity are normal, and conversion therapies or other efforts to change gender identity are not effective, are harmful, and are not appropriate therapeutic practices.⁴

As increasing numbers of youth are identifying as transgender or gender nonconforming, the number of clinics that can coordinate with local providers to provide multidisciplinary care for GN patients is growing.

Resources for health care professionals

• National LGBT Health Education Center, the Fenway Institute. At its website, learning modules, webinars, and other educational resources are available for health care organizations.

• World Professional Association of Transgender Health. This website provides standards of care for transgender patients and a provider directory.

• The Genderbread Person. This website has a helpful infographic illustrating differences between biologic sex, gender identity, gender expression, and sexual orientation, which can be useful for education with patients, families, and trainees.

• Center of Excellence for Transgender Health. This organization works to increase access to comprehensive, effective, and affirming health care services for trans communities.

Resources for patients and families

• The Trevor Project. This website provides crisis intervention and suicide prevention services.

• National Center for Transgender Equality. This advocacy organization works to promote policy change to advance transgender equality.

• Family Acceptance Project. This research, intervention, education, and policy initiative works to prevent health and mental health risks for lesbian, gay, bisexual, and transgender children and youth, including suicide, homelessness, and HIV – in the context of their families, cultures, and faith communities.

References

1. Pediatrics. 2012 Mar;129(3):418-25.

2. Pediatrics. 2014 Dec;134(6):1184-92.

3. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV, Lambda Legal, 2010. Available at www.lambdalegal.org/health-care-report.

4. Substance Abuse and Mental Health Services Administration. Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth. HHS Publication No. (SMA) 15-4928. October 2015. Available at http://store.samhsa.gov/shin/content//SMA15-4928/SMA15-4928.pdf.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

As a member of a multidisciplinary clinic that cares for gender-nonconforming (GN) youth, I frequently field questions from providers about how to handle gender identity concerns in the primary care setting. The specific health care needs of these youth matter as GN youth are at increased risk of self-harm, suicide attempts, mood disorders, eating disorders, substance use, and low school performance.^{1, 2} These increased risks appear to be related to the rejection and stigma associated with gender nonconformity that can extend to the health care setting.

More than 50% of transgender adults report experiences of discrimination in health care.³ The literature suggests that creating a supportive and affirming environment for GN youth may decrease these risks. If we can do just that during their health care visits, we can make a positive impact on our patients.

Terminology

A review of terminology and clarification of the difference between biologic sex, gender identity, gender expression, and sexual orientation are necessary before discussing the care of GN youth. Biologic sex is typically assigned at birth and is determined by a person’s chromosomes, hormones, and anatomy. Sex most commonly is female or male. For a minority of the population, there may be disorders or differences of sex development in which the development of chromosomal, gonadal, or anatomic sex is atypical. Examples of these conditions are congenital adrenal hyperplasia and androgen insensitivity syndrome. Gender includes the behavioral, cultural, and psychological characteristics associated with femaleness or maleness.² Gender identity is a person’s innate sense of feeling male, female, or somewhere in between. Individuals who have a gender identity that is congruent with their assigned sex are referred to as cisgender; those who have a gender identity that does not align with their birth sex are often referred to as transgender. Gender expression is how people choose to present themselves to the world. A person’s gender may or may not be consistent with his/her internal gender identity. For example, an individual may be female biologically (XX chromosomes, with a uterus, ovaries, and vagina) and self-identify as female, but express herself in a masculine way by having her hair cut short and wearing more masculine clothing.

Gender dysphoria occurs when an individual experiences psychological distress caused by the incongruence between his/her biologic sex and his/her internal gender identity, and this mismatch leads to clinically significant distress or impairment in daily functioning. Gender dysphoria is a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It has replaced the earlier diagnosis of gender identity disorder in the DSM-IV. The new diagnosis focuses on the distress related to an incongruence between gender identity and biologic sex and does not label it as pathologic. Gender-nonconforming individuals do not follow other people’s ideas or stereotypes about how they should look or act based on the sex they were assigned at birth. It is important to note that an individual’s gender identity is separate from sexual orientation. Sexual orientation describes an individual’s pattern of sexual and physical attraction. An individual may be attracted to members of the same sex (homosexual, lesbian, gay), opposite sex (heterosexual), or both sexes (bisexual). Increasingly youth are using a variety of terms to describe their gender (for example, genderqueer, asexual, gender fluid) and sexual orientation (for example, pansexual, asexual). These terms may have different meanings for different youth, and it is important to respectfully ask and clarify what these terms mean to each individual patient.

Trajectory of gender identity

Experimenting with gender expression and gender roles is a normal part of childhood. The majority of young children with nonconforming gender identification will not persist with this identification through adolescence. Some of these children will go on to have a nonheterosexual sexual orientation when they are older. While it can be difficult to predict the trajectory of cross-gender identification in early childhood, those with a persistent, insistent, and consistent cross-gender identification in childhood are more likely to experience gender dysphoria and continue with a transgender identity into adulthood. Adolescence is a particularly difficult time for GN youth. The development of secondary sex characteristics that are not consistent with an individual’s identified gender, in addition to the psychosocial challenges of adolescent development, can lead to increased suicidal thoughts, self-harm behaviors, anxiety, isolation, and risk-taking behaviors. Gender dysphoria that increases with the onset of puberty rarely subsides with time.

Approach to GN patients in practice

Research is ongoing related to best practices for the care of GN youth. Clinical guidelines and standards of care have been published and endorsed by organizations including the Endocrine Society, Pediatric Endocrine Society, World Professional Association for Transgender Health, and the American Academy of Pediatrics. My recommendations for the care of GN youth are based on these guidelines.

Primary care providers are often the first place families turn when a child experiences gender identity concerns. Primary care providers can play an important role in providing a safe nonjudgmental environment for patients and families to discuss their concerns, and connecting patients and families to appropriate resources. Providers should first work to educate themselves and their staff about issues affecting GN youth and learn to provide culturally competent care to these youth. Asking youth their preferred names and preferred pronouns (for example, “he/him/his,” “she/her/hers,” “they/them/their,” or something else), documenting this in the medical record, and training clinic staff to use preferred names and pronouns creates an environment that validates, supports, and respects these youth.

It is important to ask all adolescents if they have questions or concerns about their gender identity, in addition to asking questions about sexual identity. It is important when asking these questions to avoid assumptions about an individual’s gender identity based on his or her gender expression. Providers also should familiarize themselves with local referral resources for these youth. As mentioned earlier, GN youth are at high risk for mental health complications including suicide, self-harm, and mood disorders. When referring patients for mental health services, you should be familiar with providers who have expertise in issues of gender identity. A recent report by the Substance Abuse and Mental Health Services Administration states that variations in gender identity are normal, and conversion therapies or other efforts to change gender identity are not effective, are harmful, and are not appropriate therapeutic practices.⁴

As increasing numbers of youth are identifying as transgender or gender nonconforming, the number of clinics that can coordinate with local providers to provide multidisciplinary care for GN patients is growing.

Resources for health care professionals

• National LGBT Health Education Center, the Fenway Institute. At its website, learning modules, webinars, and other educational resources are available for health care organizations.

• World Professional Association of Transgender Health. This website provides standards of care for transgender patients and a provider directory.

• The Genderbread Person. This website has a helpful infographic illustrating differences between biologic sex, gender identity, gender expression, and sexual orientation, which can be useful for education with patients, families, and trainees.

• Center of Excellence for Transgender Health. This organization works to increase access to comprehensive, effective, and affirming health care services for trans communities.

Resources for patients and families

• The Trevor Project. This website provides crisis intervention and suicide prevention services.

• National Center for Transgender Equality. This advocacy organization works to promote policy change to advance transgender equality.

• Family Acceptance Project. This research, intervention, education, and policy initiative works to prevent health and mental health risks for lesbian, gay, bisexual, and transgender children and youth, including suicide, homelessness, and HIV – in the context of their families, cultures, and faith communities.

References

1. Pediatrics. 2012 Mar;129(3):418-25.

2. Pediatrics. 2014 Dec;134(6):1184-92.

3. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV, Lambda Legal, 2010. Available at www.lambdalegal.org/health-care-report.

4. Substance Abuse and Mental Health Services Administration. Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth. HHS Publication No. (SMA) 15-4928. October 2015. Available at http://store.samhsa.gov/shin/content//SMA15-4928/SMA15-4928.pdf.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

As a member of a multidisciplinary clinic that cares for gender-nonconforming (GN) youth, I frequently field questions from providers about how to handle gender identity concerns in the primary care setting. The specific health care needs of these youth matter as GN youth are at increased risk of self-harm, suicide attempts, mood disorders, eating disorders, substance use, and low school performance.^{1, 2} These increased risks appear to be related to the rejection and stigma associated with gender nonconformity that can extend to the health care setting.

More than 50% of transgender adults report experiences of discrimination in health care.³ The literature suggests that creating a supportive and affirming environment for GN youth may decrease these risks. If we can do just that during their health care visits, we can make a positive impact on our patients.

Terminology

A review of terminology and clarification of the difference between biologic sex, gender identity, gender expression, and sexual orientation are necessary before discussing the care of GN youth. Biologic sex is typically assigned at birth and is determined by a person’s chromosomes, hormones, and anatomy. Sex most commonly is female or male. For a minority of the population, there may be disorders or differences of sex development in which the development of chromosomal, gonadal, or anatomic sex is atypical. Examples of these conditions are congenital adrenal hyperplasia and androgen insensitivity syndrome. Gender includes the behavioral, cultural, and psychological characteristics associated with femaleness or maleness.² Gender identity is a person’s innate sense of feeling male, female, or somewhere in between. Individuals who have a gender identity that is congruent with their assigned sex are referred to as cisgender; those who have a gender identity that does not align with their birth sex are often referred to as transgender. Gender expression is how people choose to present themselves to the world. A person’s gender may or may not be consistent with his/her internal gender identity. For example, an individual may be female biologically (XX chromosomes, with a uterus, ovaries, and vagina) and self-identify as female, but express herself in a masculine way by having her hair cut short and wearing more masculine clothing.

Gender dysphoria occurs when an individual experiences psychological distress caused by the incongruence between his/her biologic sex and his/her internal gender identity, and this mismatch leads to clinically significant distress or impairment in daily functioning. Gender dysphoria is a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It has replaced the earlier diagnosis of gender identity disorder in the DSM-IV. The new diagnosis focuses on the distress related to an incongruence between gender identity and biologic sex and does not label it as pathologic. Gender-nonconforming individuals do not follow other people’s ideas or stereotypes about how they should look or act based on the sex they were assigned at birth. It is important to note that an individual’s gender identity is separate from sexual orientation. Sexual orientation describes an individual’s pattern of sexual and physical attraction. An individual may be attracted to members of the same sex (homosexual, lesbian, gay), opposite sex (heterosexual), or both sexes (bisexual). Increasingly youth are using a variety of terms to describe their gender (for example, genderqueer, asexual, gender fluid) and sexual orientation (for example, pansexual, asexual). These terms may have different meanings for different youth, and it is important to respectfully ask and clarify what these terms mean to each individual patient.

Trajectory of gender identity

Experimenting with gender expression and gender roles is a normal part of childhood. The majority of young children with nonconforming gender identification will not persist with this identification through adolescence. Some of these children will go on to have a nonheterosexual sexual orientation when they are older. While it can be difficult to predict the trajectory of cross-gender identification in early childhood, those with a persistent, insistent, and consistent cross-gender identification in childhood are more likely to experience gender dysphoria and continue with a transgender identity into adulthood. Adolescence is a particularly difficult time for GN youth. The development of secondary sex characteristics that are not consistent with an individual’s identified gender, in addition to the psychosocial challenges of adolescent development, can lead to increased suicidal thoughts, self-harm behaviors, anxiety, isolation, and risk-taking behaviors. Gender dysphoria that increases with the onset of puberty rarely subsides with time.

Approach to GN patients in practice

Research is ongoing related to best practices for the care of GN youth. Clinical guidelines and standards of care have been published and endorsed by organizations including the Endocrine Society, Pediatric Endocrine Society, World Professional Association for Transgender Health, and the American Academy of Pediatrics. My recommendations for the care of GN youth are based on these guidelines.

Primary care providers are often the first place families turn when a child experiences gender identity concerns. Primary care providers can play an important role in providing a safe nonjudgmental environment for patients and families to discuss their concerns, and connecting patients and families to appropriate resources. Providers should first work to educate themselves and their staff about issues affecting GN youth and learn to provide culturally competent care to these youth. Asking youth their preferred names and preferred pronouns (for example, “he/him/his,” “she/her/hers,” “they/them/their,” or something else), documenting this in the medical record, and training clinic staff to use preferred names and pronouns creates an environment that validates, supports, and respects these youth.

It is important to ask all adolescents if they have questions or concerns about their gender identity, in addition to asking questions about sexual identity. It is important when asking these questions to avoid assumptions about an individual’s gender identity based on his or her gender expression. Providers also should familiarize themselves with local referral resources for these youth. As mentioned earlier, GN youth are at high risk for mental health complications including suicide, self-harm, and mood disorders. When referring patients for mental health services, you should be familiar with providers who have expertise in issues of gender identity. A recent report by the Substance Abuse and Mental Health Services Administration states that variations in gender identity are normal, and conversion therapies or other efforts to change gender identity are not effective, are harmful, and are not appropriate therapeutic practices.⁴

As increasing numbers of youth are identifying as transgender or gender nonconforming, the number of clinics that can coordinate with local providers to provide multidisciplinary care for GN patients is growing.

Resources for health care professionals

• National LGBT Health Education Center, the Fenway Institute. At its website, learning modules, webinars, and other educational resources are available for health care organizations.

• World Professional Association of Transgender Health. This website provides standards of care for transgender patients and a provider directory.

• The Genderbread Person. This website has a helpful infographic illustrating differences between biologic sex, gender identity, gender expression, and sexual orientation, which can be useful for education with patients, families, and trainees.

• Center of Excellence for Transgender Health. This organization works to increase access to comprehensive, effective, and affirming health care services for trans communities.

Resources for patients and families

• The Trevor Project. This website provides crisis intervention and suicide prevention services.

• National Center for Transgender Equality. This advocacy organization works to promote policy change to advance transgender equality.

• Family Acceptance Project. This research, intervention, education, and policy initiative works to prevent health and mental health risks for lesbian, gay, bisexual, and transgender children and youth, including suicide, homelessness, and HIV – in the context of their families, cultures, and faith communities.

References

1. Pediatrics. 2012 Mar;129(3):418-25.

2. Pediatrics. 2014 Dec;134(6):1184-92.

3. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV, Lambda Legal, 2010. Available at www.lambdalegal.org/health-care-report.

4. Substance Abuse and Mental Health Services Administration. Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth. HHS Publication No. (SMA) 15-4928. October 2015. Available at http://store.samhsa.gov/shin/content//SMA15-4928/SMA15-4928.pdf.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.