LGBT Youth Consult

I recently was on a panel of experts discussing how to prevent HIV among transgender youth. Preventing HIV among transgender youth, especially transgender youth of color, remains a challenge for multiple reasons – racism, poverty, stigma, marginalization, and discrimination play a role in the HIV epidemic. A barrier to preventing HIV infections among transgender youth is a lack of knowledge on how to provide them with comprehensive sexual and reproductive health care. Here are some tips and resources that can help you ensure that transgender youth are safe and healthy.

sturti/E+

One of the challenges of obtaining a sexual history is asking the right questions to illicit the appropriate history: Focus on organs and activities instead of gender. For example, if you have a transgender male assigned female at birth, ask whether their partners produce sperm instead of asking about the sex of their partners. A transgender male’s partner may identify as female but is assigned male at birth and uses her penis during sex. Furthermore, a transgender male may be on testosterone, but he still can get pregnant. Asking how they use their organs is just as important. A transgender male who has condomless penile-vaginal sex with multiple partners is at a higher risk for HIV infection than is a transgender male who shares sex toys with his only partner.

Normalizing that you ask a comprehensive sexual history to all your patients regardless of gender identity may put the patient at ease. Many transgender people are reluctant to disclose their gender identity to their provider because they are afraid that the provider may fixate on their sexuality once they do. Stating that you ask sexual health questions to all your patients may prevent the transgender patient from feeling singled out.

Finally, you don’t have to ask a sexual history with every transgender patient, just as you wouldn’t for your cisgender patients. If a patient is complaining of a sprained ankle, a sexual history may not be helpful, compared with obtaining one when a patient comes in with pelvic pain. Many transgender patients avoid care because they are frequently asked about their sexual history or gender identity when these are not relevant to their chief complaint.

Here are some helpful questions to ask when taking a sexual history, according to the University of California, San Francisco, Transgender Care & Treatment Guidelines.¹

• Are you having sex? How many sex partners have you had in the past year?
• Who are you having sex with? What types of sex are you having? What parts of your anatomy do you use for sex?
• How do you protect yourself from STIs?
• What STIs have you had in the past, if any? When were you last tested for STIs?
• Has your partner(s) ever been diagnosed with any STIs?
• Do you use alcohol or any drugs when you have sex?
• Do you exchange sex for money, drugs, or a place to stay?

Also, use a trauma-informed approach when working with transgender patients. Many have been victims of sexual trauma. Always have a chaperone accompany you during the exam, explain to the patient what you plan to do and why it is necessary, and allow them to decline (and document their declining the physical exam). Also consider having your patient self-swab for STI screening if appropriate.¹

Like obtaining a sexual history, routine screenings for certain types of cancers will be based on the organs the patient has. For example, a transgender woman assigned male at birth will not need a cervical cancer screening, but a transgender man assigned female at birth may need one – if the patient still has a cervix. Cervical cancer screening guidelines are similar for transgender men as it is for nontransgender women, and one should use the same guidelines endorsed by the American Cancer Society, American Society of Colposcopy and Cervical Pathology, American Society of Clinical Pathologists, U.S. Preventive Services Task Force, and the World Health Organization.^2-4

Cervical screenings should never be a requirement for testosterone therapy, and no transgender male under the age of 21 years will need cervical screening. The University of California guidelines offers tips on how to make transgender men more comfortable during cervical cancer screening.⁵

Contraception and menstrual management also are important for transgender patients. Testosterone can induce amenorrhea for transgender men, but it is not good birth control. If a transgender male patient has sex with partners that produce sperm, then the physician should discuss effective birth control options. There is no ideal birth control option for transgender men. One must consider multiple factors including the patient’s desire for pregnancy, desire to cease periods, ease of administration, and risk for thrombosis.

Most transgender men may balk at the idea of taking estrogen-containing contraception, but it is more effective than oral progestin-only pills. Intrauterine devices are highly effective in pregnancy prevention and can achieve amenorrhea in 50% of users within 1 year,but some transmen may become dysphoric with the procedure. ⁶ The etonogestrel implants also are highly effective birth control, but irregular periods are common, leading to discontinuation. Depot medroxyprogesterone is highly effective in preventing pregnancy and can induce amenorrhea in 70% of users within 1 year and 80% of users in 2 years, but also is associated with weight gain in one-third of users.⁷ Finally, pubertal blockers can rapidly stop periods for transmen who are severely dysphoric from their menses; however, before achieving amenorrhea, a flare bleed can occur 4-6 weeks after administration.⁸ Support from a mental health therapist during this time is critical. Pubertal blockers, nevertheless, are not suitable birth control.

When providing affirming sexual and reproductive health care for transgender patients, key principles include focusing on organs and activities over identity. Additionally, screening for certain types of cancers also is dependent on organs. Finally, do not neglect the importance of contraception among transgender men. Taking these principles in consideration will help you provide excellent care for transgender youth.

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at the Children’s Hospital of Pittsburgh. He said he had no relevant financial disclosures. Email him at [email protected].

References

1. Transgender people and sexually transmitted infections (https://transcare.ucsf.edu/guidelines/stis).

2. CA Cancer J Clin. 2012 May-Jun;62(3):147-72.

3. Ann Intern Med. 2012;156(12):880-91.

4. Cervical cancer screening in developing countries: Report of a WHO consultation. 2002. World Health Organization, Geneva.

5. Screening for cervical cancer for transgender men (https://transcare.ucsf.edu/guidelines/cervical-cancer).

6. Contraception. 2002 Feb;65(2):129-32.

7. Rev Endocr Metab Disord. 2011 Jun;12(2):93-106.

8. Int J Womens Health. 2014 Jun 23;6:631-7.

Resources

Breast cancer screening in transgender men. (https://transcare.ucsf.edu/guidelines/breast-cancer-men).

Screening for breast cancer in transgender women. (https://transcare.ucsf.edu/guidelines/breast-cancer-women).

Transgender health and HIV (https://transcare.ucsf.edu/guidelines/hiv).

Centers for Disease Control and Prevention: HIV and Transgender People (https://www.cdc.gov/hiv/group/gender/transgender/index.html).

I recently was on a panel of experts discussing how to prevent HIV among transgender youth. Preventing HIV among transgender youth, especially transgender youth of color, remains a challenge for multiple reasons – racism, poverty, stigma, marginalization, and discrimination play a role in the HIV epidemic. A barrier to preventing HIV infections among transgender youth is a lack of knowledge on how to provide them with comprehensive sexual and reproductive health care. Here are some tips and resources that can help you ensure that transgender youth are safe and healthy.

sturti/E+

One of the challenges of obtaining a sexual history is asking the right questions to illicit the appropriate history: Focus on organs and activities instead of gender. For example, if you have a transgender male assigned female at birth, ask whether their partners produce sperm instead of asking about the sex of their partners. A transgender male’s partner may identify as female but is assigned male at birth and uses her penis during sex. Furthermore, a transgender male may be on testosterone, but he still can get pregnant. Asking how they use their organs is just as important. A transgender male who has condomless penile-vaginal sex with multiple partners is at a higher risk for HIV infection than is a transgender male who shares sex toys with his only partner.

Normalizing that you ask a comprehensive sexual history to all your patients regardless of gender identity may put the patient at ease. Many transgender people are reluctant to disclose their gender identity to their provider because they are afraid that the provider may fixate on their sexuality once they do. Stating that you ask sexual health questions to all your patients may prevent the transgender patient from feeling singled out.

Finally, you don’t have to ask a sexual history with every transgender patient, just as you wouldn’t for your cisgender patients. If a patient is complaining of a sprained ankle, a sexual history may not be helpful, compared with obtaining one when a patient comes in with pelvic pain. Many transgender patients avoid care because they are frequently asked about their sexual history or gender identity when these are not relevant to their chief complaint.

Here are some helpful questions to ask when taking a sexual history, according to the University of California, San Francisco, Transgender Care & Treatment Guidelines.¹

• Are you having sex? How many sex partners have you had in the past year?
• Who are you having sex with? What types of sex are you having? What parts of your anatomy do you use for sex?
• How do you protect yourself from STIs?
• What STIs have you had in the past, if any? When were you last tested for STIs?
• Has your partner(s) ever been diagnosed with any STIs?
• Do you use alcohol or any drugs when you have sex?
• Do you exchange sex for money, drugs, or a place to stay?

Also, use a trauma-informed approach when working with transgender patients. Many have been victims of sexual trauma. Always have a chaperone accompany you during the exam, explain to the patient what you plan to do and why it is necessary, and allow them to decline (and document their declining the physical exam). Also consider having your patient self-swab for STI screening if appropriate.¹

Like obtaining a sexual history, routine screenings for certain types of cancers will be based on the organs the patient has. For example, a transgender woman assigned male at birth will not need a cervical cancer screening, but a transgender man assigned female at birth may need one – if the patient still has a cervix. Cervical cancer screening guidelines are similar for transgender men as it is for nontransgender women, and one should use the same guidelines endorsed by the American Cancer Society, American Society of Colposcopy and Cervical Pathology, American Society of Clinical Pathologists, U.S. Preventive Services Task Force, and the World Health Organization.^2-4

Cervical screenings should never be a requirement for testosterone therapy, and no transgender male under the age of 21 years will need cervical screening. The University of California guidelines offers tips on how to make transgender men more comfortable during cervical cancer screening.⁵

Contraception and menstrual management also are important for transgender patients. Testosterone can induce amenorrhea for transgender men, but it is not good birth control. If a transgender male patient has sex with partners that produce sperm, then the physician should discuss effective birth control options. There is no ideal birth control option for transgender men. One must consider multiple factors including the patient’s desire for pregnancy, desire to cease periods, ease of administration, and risk for thrombosis.

Most transgender men may balk at the idea of taking estrogen-containing contraception, but it is more effective than oral progestin-only pills. Intrauterine devices are highly effective in pregnancy prevention and can achieve amenorrhea in 50% of users within 1 year,but some transmen may become dysphoric with the procedure. ⁶ The etonogestrel implants also are highly effective birth control, but irregular periods are common, leading to discontinuation. Depot medroxyprogesterone is highly effective in preventing pregnancy and can induce amenorrhea in 70% of users within 1 year and 80% of users in 2 years, but also is associated with weight gain in one-third of users.⁷ Finally, pubertal blockers can rapidly stop periods for transmen who are severely dysphoric from their menses; however, before achieving amenorrhea, a flare bleed can occur 4-6 weeks after administration.⁸ Support from a mental health therapist during this time is critical. Pubertal blockers, nevertheless, are not suitable birth control.

When providing affirming sexual and reproductive health care for transgender patients, key principles include focusing on organs and activities over identity. Additionally, screening for certain types of cancers also is dependent on organs. Finally, do not neglect the importance of contraception among transgender men. Taking these principles in consideration will help you provide excellent care for transgender youth.

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at the Children’s Hospital of Pittsburgh. He said he had no relevant financial disclosures. Email him at [email protected].

References

1. Transgender people and sexually transmitted infections (https://transcare.ucsf.edu/guidelines/stis).

2. CA Cancer J Clin. 2012 May-Jun;62(3):147-72.

3. Ann Intern Med. 2012;156(12):880-91.

4. Cervical cancer screening in developing countries: Report of a WHO consultation. 2002. World Health Organization, Geneva.

5. Screening for cervical cancer for transgender men (https://transcare.ucsf.edu/guidelines/cervical-cancer).

6. Contraception. 2002 Feb;65(2):129-32.

7. Rev Endocr Metab Disord. 2011 Jun;12(2):93-106.

8. Int J Womens Health. 2014 Jun 23;6:631-7.

Resources

Breast cancer screening in transgender men. (https://transcare.ucsf.edu/guidelines/breast-cancer-men).

Screening for breast cancer in transgender women. (https://transcare.ucsf.edu/guidelines/breast-cancer-women).

Transgender health and HIV (https://transcare.ucsf.edu/guidelines/hiv).

Centers for Disease Control and Prevention: HIV and Transgender People (https://www.cdc.gov/hiv/group/gender/transgender/index.html).

I recently was on a panel of experts discussing how to prevent HIV among transgender youth. Preventing HIV among transgender youth, especially transgender youth of color, remains a challenge for multiple reasons – racism, poverty, stigma, marginalization, and discrimination play a role in the HIV epidemic. A barrier to preventing HIV infections among transgender youth is a lack of knowledge on how to provide them with comprehensive sexual and reproductive health care. Here are some tips and resources that can help you ensure that transgender youth are safe and healthy.

sturti/E+

One of the challenges of obtaining a sexual history is asking the right questions to illicit the appropriate history: Focus on organs and activities instead of gender. For example, if you have a transgender male assigned female at birth, ask whether their partners produce sperm instead of asking about the sex of their partners. A transgender male’s partner may identify as female but is assigned male at birth and uses her penis during sex. Furthermore, a transgender male may be on testosterone, but he still can get pregnant. Asking how they use their organs is just as important. A transgender male who has condomless penile-vaginal sex with multiple partners is at a higher risk for HIV infection than is a transgender male who shares sex toys with his only partner.

Normalizing that you ask a comprehensive sexual history to all your patients regardless of gender identity may put the patient at ease. Many transgender people are reluctant to disclose their gender identity to their provider because they are afraid that the provider may fixate on their sexuality once they do. Stating that you ask sexual health questions to all your patients may prevent the transgender patient from feeling singled out.

Finally, you don’t have to ask a sexual history with every transgender patient, just as you wouldn’t for your cisgender patients. If a patient is complaining of a sprained ankle, a sexual history may not be helpful, compared with obtaining one when a patient comes in with pelvic pain. Many transgender patients avoid care because they are frequently asked about their sexual history or gender identity when these are not relevant to their chief complaint.

Here are some helpful questions to ask when taking a sexual history, according to the University of California, San Francisco, Transgender Care & Treatment Guidelines.¹

• Are you having sex? How many sex partners have you had in the past year?
• Who are you having sex with? What types of sex are you having? What parts of your anatomy do you use for sex?
• How do you protect yourself from STIs?
• What STIs have you had in the past, if any? When were you last tested for STIs?
• Has your partner(s) ever been diagnosed with any STIs?
• Do you use alcohol or any drugs when you have sex?
• Do you exchange sex for money, drugs, or a place to stay?

Also, use a trauma-informed approach when working with transgender patients. Many have been victims of sexual trauma. Always have a chaperone accompany you during the exam, explain to the patient what you plan to do and why it is necessary, and allow them to decline (and document their declining the physical exam). Also consider having your patient self-swab for STI screening if appropriate.¹

Like obtaining a sexual history, routine screenings for certain types of cancers will be based on the organs the patient has. For example, a transgender woman assigned male at birth will not need a cervical cancer screening, but a transgender man assigned female at birth may need one – if the patient still has a cervix. Cervical cancer screening guidelines are similar for transgender men as it is for nontransgender women, and one should use the same guidelines endorsed by the American Cancer Society, American Society of Colposcopy and Cervical Pathology, American Society of Clinical Pathologists, U.S. Preventive Services Task Force, and the World Health Organization.^2-4

Cervical screenings should never be a requirement for testosterone therapy, and no transgender male under the age of 21 years will need cervical screening. The University of California guidelines offers tips on how to make transgender men more comfortable during cervical cancer screening.⁵

Contraception and menstrual management also are important for transgender patients. Testosterone can induce amenorrhea for transgender men, but it is not good birth control. If a transgender male patient has sex with partners that produce sperm, then the physician should discuss effective birth control options. There is no ideal birth control option for transgender men. One must consider multiple factors including the patient’s desire for pregnancy, desire to cease periods, ease of administration, and risk for thrombosis.

Most transgender men may balk at the idea of taking estrogen-containing contraception, but it is more effective than oral progestin-only pills. Intrauterine devices are highly effective in pregnancy prevention and can achieve amenorrhea in 50% of users within 1 year,but some transmen may become dysphoric with the procedure. ⁶ The etonogestrel implants also are highly effective birth control, but irregular periods are common, leading to discontinuation. Depot medroxyprogesterone is highly effective in preventing pregnancy and can induce amenorrhea in 70% of users within 1 year and 80% of users in 2 years, but also is associated with weight gain in one-third of users.⁷ Finally, pubertal blockers can rapidly stop periods for transmen who are severely dysphoric from their menses; however, before achieving amenorrhea, a flare bleed can occur 4-6 weeks after administration.⁸ Support from a mental health therapist during this time is critical. Pubertal blockers, nevertheless, are not suitable birth control.

When providing affirming sexual and reproductive health care for transgender patients, key principles include focusing on organs and activities over identity. Additionally, screening for certain types of cancers also is dependent on organs. Finally, do not neglect the importance of contraception among transgender men. Taking these principles in consideration will help you provide excellent care for transgender youth.

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at the Children’s Hospital of Pittsburgh. He said he had no relevant financial disclosures. Email him at [email protected].

References

1. Transgender people and sexually transmitted infections (https://transcare.ucsf.edu/guidelines/stis).

2. CA Cancer J Clin. 2012 May-Jun;62(3):147-72.

3. Ann Intern Med. 2012;156(12):880-91.

4. Cervical cancer screening in developing countries: Report of a WHO consultation. 2002. World Health Organization, Geneva.

5. Screening for cervical cancer for transgender men (https://transcare.ucsf.edu/guidelines/cervical-cancer).

6. Contraception. 2002 Feb;65(2):129-32.

7. Rev Endocr Metab Disord. 2011 Jun;12(2):93-106.

8. Int J Womens Health. 2014 Jun 23;6:631-7.

Resources

Breast cancer screening in transgender men. (https://transcare.ucsf.edu/guidelines/breast-cancer-men).

Screening for breast cancer in transgender women. (https://transcare.ucsf.edu/guidelines/breast-cancer-women).

Transgender health and HIV (https://transcare.ucsf.edu/guidelines/hiv).

Centers for Disease Control and Prevention: HIV and Transgender People (https://www.cdc.gov/hiv/group/gender/transgender/index.html).

I am privileged to work in a university hospital system where I have access to colleagues with expertise in LGBT health; however, medical providers in the community may not enjoy such resources. Many transgender and gender-diverse (TGD) youth now are seeking help from their community primary care providers to affirm their gender identity, but many community primary care providers do not have the luxury of referring these patients to an expert in gender-affirming care when their TGD patients express the desire to affirm their gender through medical and surgical means. This is even more difficult if the nearest referral center is hundreds of miles away. Nevertheless, you still can develop the skills and access the tools critical for the health and well-being of TGD youth.

If a TGD youth discloses their gender identity to you, it is critical that you make the patient feel safe and supported. Showing support is important in maintaining rapport between you and the patient. Furthermore, you may be one of the very few adults in the child’s life whom they can trust.

First of all, thank them. For many TGD patients, disclosing their gender identity to a health care provider can be a herculean task. They may have spent many hours trying to find the right words to say to disclose an important aspect of themselves to you. They also probably spent a fair amount of time worrying about whether or not you would react positively to this disclosure. This fear is reasonable. About one-fifth of transgender people have reported being kicked out of a medical practice because of their disclosure of their gender identity.¹

Secondly, assure the TGD patient that your treatment would be no different from the care provided for other patients. Discrimination from a health care provider has frequently been reported by TGD patients¹ and is expected from this population.² By emphasizing this, you have signaled to them that you are committed to treating them with dignity and respect. Furthermore, signal your commitment to this treatment by making the clinic a safe and welcoming place for LGBT youth. Several resources exist that can help with this. The American Medical Association provides a good example on how to draft a nondiscrimination statement that can be posted in waiting areas;³ the Fenway Institute has a good example of an intake form that is LGBT friendly.⁴

In addition, a good way to help affirm their gender identity is to tell them that being transgender or gender-diverse is normal and healthy. Many times, TGD youth will hear narratives that gender diversity is pathological or aberrant; however, hearing that they are healthy and normal, especially from a health care provider, can make a powerful impact on feeling supported and affirmed.

Furthermore, inform your TGD youth of their right to confidentiality. Many TGD youth may not be out to their parents, and you may be the first person to whom they disclosed their gender identity. This is especially helpful if you describe their right to and the limits of confidentiality (e.g., suicidality) at the beginning of the visit. Assurance of confidentiality is a vital reason adolescents and young adults seek health care from a medical provider,⁵ and the same can be said of TGD youth; however, keep in mind that if they do desire to transition using cross-sex hormones or surgery, parental permission is required.

If they are not out to their parents and they are planning to come out to their parents, offer to be there when they do. Having someone to support the child – someone who is a medical provider – can add to the sense of legitimacy that what the child is experiencing is normal and healthy. Providing guidance on how parents can support their TGD child is essential for successful affirmation, and some suggestions can be found in an LGBT Youth Consult column I wrote titled, “Guidance for parents of LGBT youth.”

If you practice in a location where the nearest expert in gender-affirming care can be hundreds of miles away, educate yourself on gender-affirming care. Several guidelines are available. The World Professional Society for Transgender Standards of Care (SOC) focuses on the mental health aspects of gender-affirming care. The SOC recommends, but no longer requires, letters from a mental health therapist to start gender-affirming medical treatments and does allow for a discussion between you and the patient on the risks, benefits, alternatives, unknowns, limitations of treatment, and risks of not treating (i.e., obtaining informed consent) as the threshold for hormone therapy.⁶ This approach, known as the “informed consent model,” can be helpful in expanding health care access for TGD youth. Furthermore, there’s the Endocrine Society Clinical Practice Guidelines⁷ and the University of California, San Francisco, Guidelines,⁸ which focus on the medical aspects of gender-affirming care, such as when to start pubertal blockers and dosing for cross-sex hormones. Finally, there are resources that allow providers to consult an expert remotely for more complicated cases. Transline is a transgender medical consultation service staffed by medical providers with expertise in gender-affirming care. Providers can learn more about this valuable service on the website: http://project-health.org/transline/.

Working in a major medical center is not necessary in providing gender-affirming care to TGD youth. Being respectful, supportive, and having the willingness to learn are the minimal requirements. Resources are available to help guide you on the more technical aspects of gender-affirming care. Maintaining a supportive environment and using these resources will help you expand health care access for this population.
 

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

1. Injustice at every turn: A report of the national transgender discrimination survey (National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011).

2. Psychol Bull. 2003 Sep;129(5):674-97.

3. “Creating an LGBTQ-friendly practice,” American Medical Association.

4. Fenway Health Client Registration Form.

5. JAMA. 1993 Mar 17;269(11):1404-7.

6. Int J Transgenderism 2012;13:165-232.

7. J Clin Endocrinol Metab. 2017 Nov 1;102(11):3869-903.

8. “Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People,” 2nd edition (San Francisco, CA: University of California, San Francisco, June 17, 2016).

I am privileged to work in a university hospital system where I have access to colleagues with expertise in LGBT health; however, medical providers in the community may not enjoy such resources. Many transgender and gender-diverse (TGD) youth now are seeking help from their community primary care providers to affirm their gender identity, but many community primary care providers do not have the luxury of referring these patients to an expert in gender-affirming care when their TGD patients express the desire to affirm their gender through medical and surgical means. This is even more difficult if the nearest referral center is hundreds of miles away. Nevertheless, you still can develop the skills and access the tools critical for the health and well-being of TGD youth.

If a TGD youth discloses their gender identity to you, it is critical that you make the patient feel safe and supported. Showing support is important in maintaining rapport between you and the patient. Furthermore, you may be one of the very few adults in the child’s life whom they can trust.

First of all, thank them. For many TGD patients, disclosing their gender identity to a health care provider can be a herculean task. They may have spent many hours trying to find the right words to say to disclose an important aspect of themselves to you. They also probably spent a fair amount of time worrying about whether or not you would react positively to this disclosure. This fear is reasonable. About one-fifth of transgender people have reported being kicked out of a medical practice because of their disclosure of their gender identity.¹

Secondly, assure the TGD patient that your treatment would be no different from the care provided for other patients. Discrimination from a health care provider has frequently been reported by TGD patients¹ and is expected from this population.² By emphasizing this, you have signaled to them that you are committed to treating them with dignity and respect. Furthermore, signal your commitment to this treatment by making the clinic a safe and welcoming place for LGBT youth. Several resources exist that can help with this. The American Medical Association provides a good example on how to draft a nondiscrimination statement that can be posted in waiting areas;³ the Fenway Institute has a good example of an intake form that is LGBT friendly.⁴

In addition, a good way to help affirm their gender identity is to tell them that being transgender or gender-diverse is normal and healthy. Many times, TGD youth will hear narratives that gender diversity is pathological or aberrant; however, hearing that they are healthy and normal, especially from a health care provider, can make a powerful impact on feeling supported and affirmed.

Furthermore, inform your TGD youth of their right to confidentiality. Many TGD youth may not be out to their parents, and you may be the first person to whom they disclosed their gender identity. This is especially helpful if you describe their right to and the limits of confidentiality (e.g., suicidality) at the beginning of the visit. Assurance of confidentiality is a vital reason adolescents and young adults seek health care from a medical provider,⁵ and the same can be said of TGD youth; however, keep in mind that if they do desire to transition using cross-sex hormones or surgery, parental permission is required.

If they are not out to their parents and they are planning to come out to their parents, offer to be there when they do. Having someone to support the child – someone who is a medical provider – can add to the sense of legitimacy that what the child is experiencing is normal and healthy. Providing guidance on how parents can support their TGD child is essential for successful affirmation, and some suggestions can be found in an LGBT Youth Consult column I wrote titled, “Guidance for parents of LGBT youth.”

If you practice in a location where the nearest expert in gender-affirming care can be hundreds of miles away, educate yourself on gender-affirming care. Several guidelines are available. The World Professional Society for Transgender Standards of Care (SOC) focuses on the mental health aspects of gender-affirming care. The SOC recommends, but no longer requires, letters from a mental health therapist to start gender-affirming medical treatments and does allow for a discussion between you and the patient on the risks, benefits, alternatives, unknowns, limitations of treatment, and risks of not treating (i.e., obtaining informed consent) as the threshold for hormone therapy.⁶ This approach, known as the “informed consent model,” can be helpful in expanding health care access for TGD youth. Furthermore, there’s the Endocrine Society Clinical Practice Guidelines⁷ and the University of California, San Francisco, Guidelines,⁸ which focus on the medical aspects of gender-affirming care, such as when to start pubertal blockers and dosing for cross-sex hormones. Finally, there are resources that allow providers to consult an expert remotely for more complicated cases. Transline is a transgender medical consultation service staffed by medical providers with expertise in gender-affirming care. Providers can learn more about this valuable service on the website: http://project-health.org/transline/.

Working in a major medical center is not necessary in providing gender-affirming care to TGD youth. Being respectful, supportive, and having the willingness to learn are the minimal requirements. Resources are available to help guide you on the more technical aspects of gender-affirming care. Maintaining a supportive environment and using these resources will help you expand health care access for this population.
 

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

1. Injustice at every turn: A report of the national transgender discrimination survey (National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011).

2. Psychol Bull. 2003 Sep;129(5):674-97.

3. “Creating an LGBTQ-friendly practice,” American Medical Association.

4. Fenway Health Client Registration Form.

5. JAMA. 1993 Mar 17;269(11):1404-7.

6. Int J Transgenderism 2012;13:165-232.

7. J Clin Endocrinol Metab. 2017 Nov 1;102(11):3869-903.

8. “Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People,” 2nd edition (San Francisco, CA: University of California, San Francisco, June 17, 2016).

I am privileged to work in a university hospital system where I have access to colleagues with expertise in LGBT health; however, medical providers in the community may not enjoy such resources. Many transgender and gender-diverse (TGD) youth now are seeking help from their community primary care providers to affirm their gender identity, but many community primary care providers do not have the luxury of referring these patients to an expert in gender-affirming care when their TGD patients express the desire to affirm their gender through medical and surgical means. This is even more difficult if the nearest referral center is hundreds of miles away. Nevertheless, you still can develop the skills and access the tools critical for the health and well-being of TGD youth.

If a TGD youth discloses their gender identity to you, it is critical that you make the patient feel safe and supported. Showing support is important in maintaining rapport between you and the patient. Furthermore, you may be one of the very few adults in the child’s life whom they can trust.

First of all, thank them. For many TGD patients, disclosing their gender identity to a health care provider can be a herculean task. They may have spent many hours trying to find the right words to say to disclose an important aspect of themselves to you. They also probably spent a fair amount of time worrying about whether or not you would react positively to this disclosure. This fear is reasonable. About one-fifth of transgender people have reported being kicked out of a medical practice because of their disclosure of their gender identity.¹

Secondly, assure the TGD patient that your treatment would be no different from the care provided for other patients. Discrimination from a health care provider has frequently been reported by TGD patients¹ and is expected from this population.² By emphasizing this, you have signaled to them that you are committed to treating them with dignity and respect. Furthermore, signal your commitment to this treatment by making the clinic a safe and welcoming place for LGBT youth. Several resources exist that can help with this. The American Medical Association provides a good example on how to draft a nondiscrimination statement that can be posted in waiting areas;³ the Fenway Institute has a good example of an intake form that is LGBT friendly.⁴

In addition, a good way to help affirm their gender identity is to tell them that being transgender or gender-diverse is normal and healthy. Many times, TGD youth will hear narratives that gender diversity is pathological or aberrant; however, hearing that they are healthy and normal, especially from a health care provider, can make a powerful impact on feeling supported and affirmed.

Furthermore, inform your TGD youth of their right to confidentiality. Many TGD youth may not be out to their parents, and you may be the first person to whom they disclosed their gender identity. This is especially helpful if you describe their right to and the limits of confidentiality (e.g., suicidality) at the beginning of the visit. Assurance of confidentiality is a vital reason adolescents and young adults seek health care from a medical provider,⁵ and the same can be said of TGD youth; however, keep in mind that if they do desire to transition using cross-sex hormones or surgery, parental permission is required.

If they are not out to their parents and they are planning to come out to their parents, offer to be there when they do. Having someone to support the child – someone who is a medical provider – can add to the sense of legitimacy that what the child is experiencing is normal and healthy. Providing guidance on how parents can support their TGD child is essential for successful affirmation, and some suggestions can be found in an LGBT Youth Consult column I wrote titled, “Guidance for parents of LGBT youth.”

If you practice in a location where the nearest expert in gender-affirming care can be hundreds of miles away, educate yourself on gender-affirming care. Several guidelines are available. The World Professional Society for Transgender Standards of Care (SOC) focuses on the mental health aspects of gender-affirming care. The SOC recommends, but no longer requires, letters from a mental health therapist to start gender-affirming medical treatments and does allow for a discussion between you and the patient on the risks, benefits, alternatives, unknowns, limitations of treatment, and risks of not treating (i.e., obtaining informed consent) as the threshold for hormone therapy.⁶ This approach, known as the “informed consent model,” can be helpful in expanding health care access for TGD youth. Furthermore, there’s the Endocrine Society Clinical Practice Guidelines⁷ and the University of California, San Francisco, Guidelines,⁸ which focus on the medical aspects of gender-affirming care, such as when to start pubertal blockers and dosing for cross-sex hormones. Finally, there are resources that allow providers to consult an expert remotely for more complicated cases. Transline is a transgender medical consultation service staffed by medical providers with expertise in gender-affirming care. Providers can learn more about this valuable service on the website: http://project-health.org/transline/.

Working in a major medical center is not necessary in providing gender-affirming care to TGD youth. Being respectful, supportive, and having the willingness to learn are the minimal requirements. Resources are available to help guide you on the more technical aspects of gender-affirming care. Maintaining a supportive environment and using these resources will help you expand health care access for this population.
 

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

1. Injustice at every turn: A report of the national transgender discrimination survey (National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011).

2. Psychol Bull. 2003 Sep;129(5):674-97.

3. “Creating an LGBTQ-friendly practice,” American Medical Association.

4. Fenway Health Client Registration Form.

5. JAMA. 1993 Mar 17;269(11):1404-7.

6. Int J Transgenderism 2012;13:165-232.

7. J Clin Endocrinol Metab. 2017 Nov 1;102(11):3869-903.

8. “Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People,” 2nd edition (San Francisco, CA: University of California, San Francisco, June 17, 2016).

June is Pride Month in the United States. It is a time in which people take a stand against discrimination and violence against lesbian, gay, bisexual, and transgender (LGBT) people and promote dignity, equality, and visibility of this community. During this time, many cities will be holding events ranging from rallies to parades to not only celebrate sexual diversity and gender variance, but also to serve as a reminder of the work that needs to be done to foster equal treatment for LGBT people. As a medical provider, you have the unique role of advancing this cause – from educating your colleagues on the health needs of this population to advocating for policies that protect their health and well-being. If you’re interested in serving the LGBT community as a medical provider, here are some ways you can show this community your commitment to their health and well-being.

400tmax/iStock Unreleased

Be visible

There will be numerous LGBT Pride events occurring the month of June and even throughout the summer in the United States. They can occur in cities big and small, and they can even be in the city you work in. Visibility matters for LGBT youth. Eight percent of lesbian, gay, and bisexual people report that a health care provider refused to see them because of their sexual orientation and 29% of transgender people report that their health care providers refused to see them because of their gender identity or expression.¹ Therefore, LGBT people will expect discrimination everywhere they go.²

Being present at a Pride event signals to the community that you are willing to serve LGBT people. Many Pride events will allow hospitals and clinics to have a table at the event, but keep in mind that many will prioritize organizations that specifically cater to the LGBT community or that are owned and operated by members of the community. Another way to show the community that you will treat LGBT people with dignity and respect is to list your practice in a database for LGBT-friendly providers. The Gay and Lesbian Medical Association keeps a database of LGBT-friendly medical providers, and many Pride events will advertise businesses and organizations that serve the LGBT community. You may want to consider having your clinic or hospital participate in the Human Rights Campaign (HRC) Health Equality Index (HEI). The HEI is a list of best practices for hospitals and clinics to use that affirm and support LGBT health (such as having gender-neutral bathrooms in facilities). Hospitals and clinics that endorse a high amount or all of these practices are listed as committed to the health and well-being of the LGBT community on the HRC website.
 

Be a part of LGBT Pride

Many LGBT Pride events are supported by local community organizations, most of which are nonprofits. They will need the necessary resources to keep holding these events every year. These resources can include both time and money. Consider donating your time by volunteering at these Pride events. For example, many Pride events hold health screenings, and you can use your skills and knowledge to promote the well-being of the LGBT community. At the same time, make sure that the PRIDE event is created to help serve the community. There is controversy over the commercialization of LGBT Pride events, as some corporate sponsors have been inconsistent in advocating for the LGBT community. Some feel that the commercialization of LGBT Pride ignores the original purpose of the event as a political movement.³ Do some research to make sure that your donation is going to an LGBT Pride event that serves the whole community, not just certain segments of it, and if you feel that it is not, you may consider donating to other LGBT-serving organizations in your community.

Educate yourself

Even when LGBT Pride season is over, the work of promoting the health and well-being of LGBT youth is never done. There are many medical providers who have made it their life’s work doing this. Consider learning more about the role medical providers have played in the health and well-being of the LGBT community, which may serve as an inspiration for your work. The list is long, and includes pioneers such as Ben Barres, MD, PhD, a transgender neurobiologist and physician who transitioned from female to male mid-career and was known for his work on interaction between neurons and glial cells in the nervous system, and Rachel Levine, MD, a physician who became the first transgender woman to serve as Physician General, then Secretary of State, of Pennsylvania.

Other providers have tackled health problems that plagued the LGBT community. Joel D. Weisman, DO, was one of the first physicians to identify the AIDS epidemic and became an advocate for AIDS research, treatment, and prevention, whereas Kevin A. Fenton, MD, PhD, a gay black man, was the director for the National Center for HIV/AIDS at the Centers for Disease Control and Prevention; he helped cultivate strategies to combat the HIV epidemic among gay black men.⁴ Finally, there is Nanette Gartrell, MD, a psychiatrist and researcher who leads the U.S. National Longitudinal Lesbian Family Study. This ongoing, prospective, and influential study was the first to identify that children raised by lesbian mothers had higher levels of social and school/academic competence and significantly lower levels of social problems, rule-breaking behaviors, and aggressive behaviors, compared with children raised by opposite sex parents.⁵

LGBT Pride is a time to recognize the achievements the LGBT community has made in the last couple of decades, and at the same time, it is a reminder that the work to promote health equity for this community remains unfinished. Health care providers have an important responsibility in fostering this work in a responsible and ethical matter. Many medical providers have dedicated their lives to this movement, and even when the LGBT Pride season is over, their mission will continue.
 

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

1. “Discrimination Prevents LGBTQ People from Accessing Health Care,” Center for American Progress, Jan. 18, 2018.

2. Psychol Bull. 2003 Sep;129(5): 674-97.

3. “How LGBTQ Pride Month became a branded holiday,” Vox, Jun 25, 2018.

4. “Dr. Kevin Fenton stepping down after 8 years,” The Georgia Voice, Dec 7, 2012.

5. Pediatrics. 2010;126(1):28-36.

June is Pride Month in the United States. It is a time in which people take a stand against discrimination and violence against lesbian, gay, bisexual, and transgender (LGBT) people and promote dignity, equality, and visibility of this community. During this time, many cities will be holding events ranging from rallies to parades to not only celebrate sexual diversity and gender variance, but also to serve as a reminder of the work that needs to be done to foster equal treatment for LGBT people. As a medical provider, you have the unique role of advancing this cause – from educating your colleagues on the health needs of this population to advocating for policies that protect their health and well-being. If you’re interested in serving the LGBT community as a medical provider, here are some ways you can show this community your commitment to their health and well-being.

400tmax/iStock Unreleased

Be visible

There will be numerous LGBT Pride events occurring the month of June and even throughout the summer in the United States. They can occur in cities big and small, and they can even be in the city you work in. Visibility matters for LGBT youth. Eight percent of lesbian, gay, and bisexual people report that a health care provider refused to see them because of their sexual orientation and 29% of transgender people report that their health care providers refused to see them because of their gender identity or expression.¹ Therefore, LGBT people will expect discrimination everywhere they go.²

Being present at a Pride event signals to the community that you are willing to serve LGBT people. Many Pride events will allow hospitals and clinics to have a table at the event, but keep in mind that many will prioritize organizations that specifically cater to the LGBT community or that are owned and operated by members of the community. Another way to show the community that you will treat LGBT people with dignity and respect is to list your practice in a database for LGBT-friendly providers. The Gay and Lesbian Medical Association keeps a database of LGBT-friendly medical providers, and many Pride events will advertise businesses and organizations that serve the LGBT community. You may want to consider having your clinic or hospital participate in the Human Rights Campaign (HRC) Health Equality Index (HEI). The HEI is a list of best practices for hospitals and clinics to use that affirm and support LGBT health (such as having gender-neutral bathrooms in facilities). Hospitals and clinics that endorse a high amount or all of these practices are listed as committed to the health and well-being of the LGBT community on the HRC website.
 

Be a part of LGBT Pride

Many LGBT Pride events are supported by local community organizations, most of which are nonprofits. They will need the necessary resources to keep holding these events every year. These resources can include both time and money. Consider donating your time by volunteering at these Pride events. For example, many Pride events hold health screenings, and you can use your skills and knowledge to promote the well-being of the LGBT community. At the same time, make sure that the PRIDE event is created to help serve the community. There is controversy over the commercialization of LGBT Pride events, as some corporate sponsors have been inconsistent in advocating for the LGBT community. Some feel that the commercialization of LGBT Pride ignores the original purpose of the event as a political movement.³ Do some research to make sure that your donation is going to an LGBT Pride event that serves the whole community, not just certain segments of it, and if you feel that it is not, you may consider donating to other LGBT-serving organizations in your community.

Educate yourself

Even when LGBT Pride season is over, the work of promoting the health and well-being of LGBT youth is never done. There are many medical providers who have made it their life’s work doing this. Consider learning more about the role medical providers have played in the health and well-being of the LGBT community, which may serve as an inspiration for your work. The list is long, and includes pioneers such as Ben Barres, MD, PhD, a transgender neurobiologist and physician who transitioned from female to male mid-career and was known for his work on interaction between neurons and glial cells in the nervous system, and Rachel Levine, MD, a physician who became the first transgender woman to serve as Physician General, then Secretary of State, of Pennsylvania.

Other providers have tackled health problems that plagued the LGBT community. Joel D. Weisman, DO, was one of the first physicians to identify the AIDS epidemic and became an advocate for AIDS research, treatment, and prevention, whereas Kevin A. Fenton, MD, PhD, a gay black man, was the director for the National Center for HIV/AIDS at the Centers for Disease Control and Prevention; he helped cultivate strategies to combat the HIV epidemic among gay black men.⁴ Finally, there is Nanette Gartrell, MD, a psychiatrist and researcher who leads the U.S. National Longitudinal Lesbian Family Study. This ongoing, prospective, and influential study was the first to identify that children raised by lesbian mothers had higher levels of social and school/academic competence and significantly lower levels of social problems, rule-breaking behaviors, and aggressive behaviors, compared with children raised by opposite sex parents.⁵

LGBT Pride is a time to recognize the achievements the LGBT community has made in the last couple of decades, and at the same time, it is a reminder that the work to promote health equity for this community remains unfinished. Health care providers have an important responsibility in fostering this work in a responsible and ethical matter. Many medical providers have dedicated their lives to this movement, and even when the LGBT Pride season is over, their mission will continue.
 

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

1. “Discrimination Prevents LGBTQ People from Accessing Health Care,” Center for American Progress, Jan. 18, 2018.

2. Psychol Bull. 2003 Sep;129(5): 674-97.

3. “How LGBTQ Pride Month became a branded holiday,” Vox, Jun 25, 2018.

4. “Dr. Kevin Fenton stepping down after 8 years,” The Georgia Voice, Dec 7, 2012.

5. Pediatrics. 2010;126(1):28-36.

June is Pride Month in the United States. It is a time in which people take a stand against discrimination and violence against lesbian, gay, bisexual, and transgender (LGBT) people and promote dignity, equality, and visibility of this community. During this time, many cities will be holding events ranging from rallies to parades to not only celebrate sexual diversity and gender variance, but also to serve as a reminder of the work that needs to be done to foster equal treatment for LGBT people. As a medical provider, you have the unique role of advancing this cause – from educating your colleagues on the health needs of this population to advocating for policies that protect their health and well-being. If you’re interested in serving the LGBT community as a medical provider, here are some ways you can show this community your commitment to their health and well-being.

400tmax/iStock Unreleased

Be visible

There will be numerous LGBT Pride events occurring the month of June and even throughout the summer in the United States. They can occur in cities big and small, and they can even be in the city you work in. Visibility matters for LGBT youth. Eight percent of lesbian, gay, and bisexual people report that a health care provider refused to see them because of their sexual orientation and 29% of transgender people report that their health care providers refused to see them because of their gender identity or expression.¹ Therefore, LGBT people will expect discrimination everywhere they go.²

Being present at a Pride event signals to the community that you are willing to serve LGBT people. Many Pride events will allow hospitals and clinics to have a table at the event, but keep in mind that many will prioritize organizations that specifically cater to the LGBT community or that are owned and operated by members of the community. Another way to show the community that you will treat LGBT people with dignity and respect is to list your practice in a database for LGBT-friendly providers. The Gay and Lesbian Medical Association keeps a database of LGBT-friendly medical providers, and many Pride events will advertise businesses and organizations that serve the LGBT community. You may want to consider having your clinic or hospital participate in the Human Rights Campaign (HRC) Health Equality Index (HEI). The HEI is a list of best practices for hospitals and clinics to use that affirm and support LGBT health (such as having gender-neutral bathrooms in facilities). Hospitals and clinics that endorse a high amount or all of these practices are listed as committed to the health and well-being of the LGBT community on the HRC website.
 

Be a part of LGBT Pride

Many LGBT Pride events are supported by local community organizations, most of which are nonprofits. They will need the necessary resources to keep holding these events every year. These resources can include both time and money. Consider donating your time by volunteering at these Pride events. For example, many Pride events hold health screenings, and you can use your skills and knowledge to promote the well-being of the LGBT community. At the same time, make sure that the PRIDE event is created to help serve the community. There is controversy over the commercialization of LGBT Pride events, as some corporate sponsors have been inconsistent in advocating for the LGBT community. Some feel that the commercialization of LGBT Pride ignores the original purpose of the event as a political movement.³ Do some research to make sure that your donation is going to an LGBT Pride event that serves the whole community, not just certain segments of it, and if you feel that it is not, you may consider donating to other LGBT-serving organizations in your community.

Educate yourself

Even when LGBT Pride season is over, the work of promoting the health and well-being of LGBT youth is never done. There are many medical providers who have made it their life’s work doing this. Consider learning more about the role medical providers have played in the health and well-being of the LGBT community, which may serve as an inspiration for your work. The list is long, and includes pioneers such as Ben Barres, MD, PhD, a transgender neurobiologist and physician who transitioned from female to male mid-career and was known for his work on interaction between neurons and glial cells in the nervous system, and Rachel Levine, MD, a physician who became the first transgender woman to serve as Physician General, then Secretary of State, of Pennsylvania.

Other providers have tackled health problems that plagued the LGBT community. Joel D. Weisman, DO, was one of the first physicians to identify the AIDS epidemic and became an advocate for AIDS research, treatment, and prevention, whereas Kevin A. Fenton, MD, PhD, a gay black man, was the director for the National Center for HIV/AIDS at the Centers for Disease Control and Prevention; he helped cultivate strategies to combat the HIV epidemic among gay black men.⁴ Finally, there is Nanette Gartrell, MD, a psychiatrist and researcher who leads the U.S. National Longitudinal Lesbian Family Study. This ongoing, prospective, and influential study was the first to identify that children raised by lesbian mothers had higher levels of social and school/academic competence and significantly lower levels of social problems, rule-breaking behaviors, and aggressive behaviors, compared with children raised by opposite sex parents.⁵

LGBT Pride is a time to recognize the achievements the LGBT community has made in the last couple of decades, and at the same time, it is a reminder that the work to promote health equity for this community remains unfinished. Health care providers have an important responsibility in fostering this work in a responsible and ethical matter. Many medical providers have dedicated their lives to this movement, and even when the LGBT Pride season is over, their mission will continue.
 

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

1. “Discrimination Prevents LGBTQ People from Accessing Health Care,” Center for American Progress, Jan. 18, 2018.

2. Psychol Bull. 2003 Sep;129(5): 674-97.

3. “How LGBTQ Pride Month became a branded holiday,” Vox, Jun 25, 2018.

4. “Dr. Kevin Fenton stepping down after 8 years,” The Georgia Voice, Dec 7, 2012.

5. Pediatrics. 2010;126(1):28-36.

In recent years, pediatricians have learned more about the diversity of gender identities and gender expressions that exist, but many think they have gaps in their knowledge that need to be filled in order to provide better care to these patients.

On April 3, Pediatric News hosted a Twitter question-and-answer session for the purpose of trying to help pediatricians close some of these gaps, including ones related to the medical and mental health issues particular to LGBT patients. During this session Pediatric News’ LGBT Youth Consult columnists, Gerald T. Montano, DO, MS, and Gayathri Chelvakumar, MD, MPH, responded to four questions about working with children and teens who are lesbian, gay, bisexual, transgender, or questioning (LGBTQ). Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Dr. Chelvakumar, MD, MPH, 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.

The following is an edited version of the Q&A session.
 

Question 1: How do people become aware they are lesbian, gay, bisexual, transgender?

Dr. Montano: For many adolescents, the teenage years are the time that these identities are forming and that questions around sexuality and gender identity may arise. Check out #genderunicorn! It illustrates the spectrum of normal gender and sexual identities that are part of the human experience. Many LGBT people recall how they felt when they were younger but couldn’t find the right words until they were older (usually during adolescence).

Dr. Chelvakumar: Every person’s experience is unique. I have had patients tell me they knew who they were attracted to in kindergarten, and other patients who are still figuring it out in college. It is important to note that every experience is valid.
 

Question 2: How can we address some of the specific health concerns of LGBT youth?

Dr. Chelvakumar: We need to educate ourselves. The American Academy of Pediatrics has a great resource for this, “Ensuring Comprehensive Care and Support for Transgender and Gender Diverse Children and Adolescents (Pediatrics. 2019 Oct. doi: 10.1542/peds.2018-2162).

Dr. Chelvakumar: Some LGBTQ youth are at increased risk of depression, anxiety, and suicidality related to stigma and internal/external transphobia/homophobia, NOT their identities.

Dr. Montano: A lot of LGBT youth report that health care providers fixate on sexual activity, even though that was not the reason why they came to the clinic.

Dr. Chelvakumar: A lot of these youth feel that providers won’t understand their needs or may discriminate against them because of their LGBTQ identity. This is why it is important to make sure our health care spaces are welcoming to everyone.

Dr. Montano: The role of the psychiatrist is not to determine the person’s gender identity or sexual orientation; rather, they should focus on making others feel comfortable with themselves.
 

Question 3: How can we make our clinics a safe space for LGBT youth?

Dr. Chelvakumar: Ensure that ALL clinic staff receive training on culturally affirming care of LGBTQ people. The National LGBT Health Education Center (@LGBTHealthEdCtr) offers some of these resources.

Dr. Montano: Train everyone in the clinic to be sensitive and aware of the needs of LGBT patients; it only takes one person to make a clinical experience horrible for an LGBT person.

Dr. Chelvakumar: To me, culturally affirming care means being aware of the spectrum of identities and experiences of all of our patients/families and being respectful of these identities. I also like the term cultural humility – we must continually learn about these diverse experiences.

Dr. Montano: Remember that if they get upset, these children and teens are not mad at you, they are mad at the situation.

Dr. Chelvakumar: An easy way to show that a clinic is a safe space is to clearly display a nondiscrimination policy, such as “We serve and respect all patients regardless of gender identity, race, sexual orientation, religion, socioeconomic status ... ”

Dr. Montano: Not every LGBT youth will disclose their sexual orientation or gender identity to the provider, even if the clinic appears welcoming. I suggest you begin a conversation with a patient by telling the patient your own pronouns, opening the door to additional conversations.

Dr. Chelvakumar: Many organizations are moving to universally asking questions about gender identity and pronouns. In the pediatric population, this can be difficult given privacy/confidentiality concerns. I usually ask these questions when obtaining my sensitive sexual history.
 

Question 4: What is gender dysphoria, and how is it treated?

Dr. Montano: Gender dysphoria is the distress related to gender identity that does not match sex/gender assigned at birth. Treat the distress, not the identity. There are many ways to treat gender dysphoria. You can provide social support, use pubertal blockers to prevent the development of secondary sex characteristics during adolescence, and/or use hormones or surgery to develop characteristics of the affirmed gender. And there is no “right” treatment for gender dysphoria. Each treatment is tailored to the needs of the youth.

Dr. Chelvakumar: It is important to recognize that each person’s journey/transition is different. Our job as providers is to help them on the path that will help them live their lives as their authentic selves. This may or may not involve taking medication and/or undergoing surgery.

Dr. Montano: Providers should respect the wishes of those who want to affirm their gender identity that makes sense to the patient and not try to impose their own idea of what transitioning should “look like.”

Dr. Chelvakumar: There are many guidelines that exist for patients with gender dysphoria. The World Professional Association for Transgender Health, the Endocrine Society, and University of California, San Francisco’s Center of Excellence for Transgender Health are all excellent resources.
 

In recent years, pediatricians have learned more about the diversity of gender identities and gender expressions that exist, but many think they have gaps in their knowledge that need to be filled in order to provide better care to these patients.

On April 3, Pediatric News hosted a Twitter question-and-answer session for the purpose of trying to help pediatricians close some of these gaps, including ones related to the medical and mental health issues particular to LGBT patients. During this session Pediatric News’ LGBT Youth Consult columnists, Gerald T. Montano, DO, MS, and Gayathri Chelvakumar, MD, MPH, responded to four questions about working with children and teens who are lesbian, gay, bisexual, transgender, or questioning (LGBTQ). Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Dr. Chelvakumar, MD, MPH, 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.

The following is an edited version of the Q&A session.
 

Question 1: How do people become aware they are lesbian, gay, bisexual, transgender?

Dr. Montano: For many adolescents, the teenage years are the time that these identities are forming and that questions around sexuality and gender identity may arise. Check out #genderunicorn! It illustrates the spectrum of normal gender and sexual identities that are part of the human experience. Many LGBT people recall how they felt when they were younger but couldn’t find the right words until they were older (usually during adolescence).

Dr. Chelvakumar: Every person’s experience is unique. I have had patients tell me they knew who they were attracted to in kindergarten, and other patients who are still figuring it out in college. It is important to note that every experience is valid.
 

Question 2: How can we address some of the specific health concerns of LGBT youth?

Dr. Chelvakumar: We need to educate ourselves. The American Academy of Pediatrics has a great resource for this, “Ensuring Comprehensive Care and Support for Transgender and Gender Diverse Children and Adolescents (Pediatrics. 2019 Oct. doi: 10.1542/peds.2018-2162).

Dr. Chelvakumar: Some LGBTQ youth are at increased risk of depression, anxiety, and suicidality related to stigma and internal/external transphobia/homophobia, NOT their identities.

Dr. Montano: A lot of LGBT youth report that health care providers fixate on sexual activity, even though that was not the reason why they came to the clinic.

Dr. Chelvakumar: A lot of these youth feel that providers won’t understand their needs or may discriminate against them because of their LGBTQ identity. This is why it is important to make sure our health care spaces are welcoming to everyone.

Dr. Montano: The role of the psychiatrist is not to determine the person’s gender identity or sexual orientation; rather, they should focus on making others feel comfortable with themselves.
 

Question 3: How can we make our clinics a safe space for LGBT youth?

Dr. Chelvakumar: Ensure that ALL clinic staff receive training on culturally affirming care of LGBTQ people. The National LGBT Health Education Center (@LGBTHealthEdCtr) offers some of these resources.

Dr. Montano: Train everyone in the clinic to be sensitive and aware of the needs of LGBT patients; it only takes one person to make a clinical experience horrible for an LGBT person.

Dr. Chelvakumar: To me, culturally affirming care means being aware of the spectrum of identities and experiences of all of our patients/families and being respectful of these identities. I also like the term cultural humility – we must continually learn about these diverse experiences.

Dr. Montano: Remember that if they get upset, these children and teens are not mad at you, they are mad at the situation.

Dr. Chelvakumar: An easy way to show that a clinic is a safe space is to clearly display a nondiscrimination policy, such as “We serve and respect all patients regardless of gender identity, race, sexual orientation, religion, socioeconomic status ... ”

Dr. Montano: Not every LGBT youth will disclose their sexual orientation or gender identity to the provider, even if the clinic appears welcoming. I suggest you begin a conversation with a patient by telling the patient your own pronouns, opening the door to additional conversations.

Dr. Chelvakumar: Many organizations are moving to universally asking questions about gender identity and pronouns. In the pediatric population, this can be difficult given privacy/confidentiality concerns. I usually ask these questions when obtaining my sensitive sexual history.
 

Question 4: What is gender dysphoria, and how is it treated?

Dr. Montano: Gender dysphoria is the distress related to gender identity that does not match sex/gender assigned at birth. Treat the distress, not the identity. There are many ways to treat gender dysphoria. You can provide social support, use pubertal blockers to prevent the development of secondary sex characteristics during adolescence, and/or use hormones or surgery to develop characteristics of the affirmed gender. And there is no “right” treatment for gender dysphoria. Each treatment is tailored to the needs of the youth.

Dr. Chelvakumar: It is important to recognize that each person’s journey/transition is different. Our job as providers is to help them on the path that will help them live their lives as their authentic selves. This may or may not involve taking medication and/or undergoing surgery.

Dr. Montano: Providers should respect the wishes of those who want to affirm their gender identity that makes sense to the patient and not try to impose their own idea of what transitioning should “look like.”

Dr. Chelvakumar: There are many guidelines that exist for patients with gender dysphoria. The World Professional Association for Transgender Health, the Endocrine Society, and University of California, San Francisco’s Center of Excellence for Transgender Health are all excellent resources.
 

In recent years, pediatricians have learned more about the diversity of gender identities and gender expressions that exist, but many think they have gaps in their knowledge that need to be filled in order to provide better care to these patients.

On April 3, Pediatric News hosted a Twitter question-and-answer session for the purpose of trying to help pediatricians close some of these gaps, including ones related to the medical and mental health issues particular to LGBT patients. During this session Pediatric News’ LGBT Youth Consult columnists, Gerald T. Montano, DO, MS, and Gayathri Chelvakumar, MD, MPH, responded to four questions about working with children and teens who are lesbian, gay, bisexual, transgender, or questioning (LGBTQ). Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Dr. Chelvakumar, MD, MPH, 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.

The following is an edited version of the Q&A session.
 

Question 1: How do people become aware they are lesbian, gay, bisexual, transgender?

Dr. Montano: For many adolescents, the teenage years are the time that these identities are forming and that questions around sexuality and gender identity may arise. Check out #genderunicorn! It illustrates the spectrum of normal gender and sexual identities that are part of the human experience. Many LGBT people recall how they felt when they were younger but couldn’t find the right words until they were older (usually during adolescence).

Dr. Chelvakumar: Every person’s experience is unique. I have had patients tell me they knew who they were attracted to in kindergarten, and other patients who are still figuring it out in college. It is important to note that every experience is valid.
 

Question 2: How can we address some of the specific health concerns of LGBT youth?

Dr. Chelvakumar: We need to educate ourselves. The American Academy of Pediatrics has a great resource for this, “Ensuring Comprehensive Care and Support for Transgender and Gender Diverse Children and Adolescents (Pediatrics. 2019 Oct. doi: 10.1542/peds.2018-2162).

Dr. Chelvakumar: Some LGBTQ youth are at increased risk of depression, anxiety, and suicidality related to stigma and internal/external transphobia/homophobia, NOT their identities.

Dr. Montano: A lot of LGBT youth report that health care providers fixate on sexual activity, even though that was not the reason why they came to the clinic.

Dr. Chelvakumar: A lot of these youth feel that providers won’t understand their needs or may discriminate against them because of their LGBTQ identity. This is why it is important to make sure our health care spaces are welcoming to everyone.

Dr. Montano: The role of the psychiatrist is not to determine the person’s gender identity or sexual orientation; rather, they should focus on making others feel comfortable with themselves.
 

Question 3: How can we make our clinics a safe space for LGBT youth?

Dr. Chelvakumar: Ensure that ALL clinic staff receive training on culturally affirming care of LGBTQ people. The National LGBT Health Education Center (@LGBTHealthEdCtr) offers some of these resources.

Dr. Montano: Train everyone in the clinic to be sensitive and aware of the needs of LGBT patients; it only takes one person to make a clinical experience horrible for an LGBT person.

Dr. Chelvakumar: To me, culturally affirming care means being aware of the spectrum of identities and experiences of all of our patients/families and being respectful of these identities. I also like the term cultural humility – we must continually learn about these diverse experiences.

Dr. Montano: Remember that if they get upset, these children and teens are not mad at you, they are mad at the situation.

Dr. Chelvakumar: An easy way to show that a clinic is a safe space is to clearly display a nondiscrimination policy, such as “We serve and respect all patients regardless of gender identity, race, sexual orientation, religion, socioeconomic status ... ”

Dr. Montano: Not every LGBT youth will disclose their sexual orientation or gender identity to the provider, even if the clinic appears welcoming. I suggest you begin a conversation with a patient by telling the patient your own pronouns, opening the door to additional conversations.

Dr. Chelvakumar: Many organizations are moving to universally asking questions about gender identity and pronouns. In the pediatric population, this can be difficult given privacy/confidentiality concerns. I usually ask these questions when obtaining my sensitive sexual history.
 

Question 4: What is gender dysphoria, and how is it treated?

Dr. Montano: Gender dysphoria is the distress related to gender identity that does not match sex/gender assigned at birth. Treat the distress, not the identity. There are many ways to treat gender dysphoria. You can provide social support, use pubertal blockers to prevent the development of secondary sex characteristics during adolescence, and/or use hormones or surgery to develop characteristics of the affirmed gender. And there is no “right” treatment for gender dysphoria. Each treatment is tailored to the needs of the youth.

Dr. Chelvakumar: It is important to recognize that each person’s journey/transition is different. Our job as providers is to help them on the path that will help them live their lives as their authentic selves. This may or may not involve taking medication and/or undergoing surgery.

Dr. Montano: Providers should respect the wishes of those who want to affirm their gender identity that makes sense to the patient and not try to impose their own idea of what transitioning should “look like.”

Dr. Chelvakumar: There are many guidelines that exist for patients with gender dysphoria. The World Professional Association for Transgender Health, the Endocrine Society, and University of California, San Francisco’s Center of Excellence for Transgender Health are all excellent resources.
 

As winter settles in for most of the United States, there are some people who do not have access to adequate shelter from the cold. Currently, there are an estimated 700,000 homeless youth in the United States, which is roughly 1 out of 30 youth.¹Among homeless youth, a disproportionate number of these youth identify as lesbian, gay, bisexual, or transgender (LGBT). The reasons for these disparities are complex, although stigma and discrimination are major factors. Despite the major challenges faced by this population, medical providers can play a role in addressing homelessness among LGBT youth.

bodnarchuk/Getty Images

According to the Department of Education, homeless youth are defined as youth “who lack a fixed, regular, and adequate nighttime residence.”² Although the image of a person sleeping on a bench at a park covered with newspapers comes to mind, it may not be obvious that a youth may be homeless. Sometimes, youth may be sleeping in their cars at night and others may be staying the night at one house and then staying the next night at another house (known as “couch surfing”). Many will be utilizing homeless shelters to sleep in.

Homelessness among LGBT youth is a major problem in the United States. Although LGB (sexual minority) people comprise 2%-7% of the population,³ about one-third of homeless youth identify as LGB or questioning. Additionally, about 4% of homeless youth identify as transgender, compared with 1% of the general youth population in the United States. LGBT youth are at a higher risk for homelessness than are cisgender (gender identity matches with the assigned sex at birth), heterosexual youth. There are even disparities within LGBT youth.

Why are LGBT youth at high risk for homelessness? The most common reason is family rejection of their sexual orientation and/or gender identity.⁴ Some are directly kicked out by their families. Whereas others leave because relationships with their families have become so strained after the child has come out that the environment is no longer tolerable to live in. However, poverty and race may play a significant role in this phenomenon. There is a misperception that families of color are more homophobic or transphobic (disliking or having a prejudice against transsexual or transgender people) than white families because there is a higher proportion of LGBT homeless youth of color. However, what most likely increases the likelihood of family rejection is the strain of poverty, which people of color are more likely to experience. Chronic unemployment or unstable housing makes it very difficult for families to utilize the important skills to accept and support their LGBT child. Whenever a child comes out to their parents, it is a stressful event for the family. Family with stable physical resources (decent income, stable housing) also are more likely to have psychological resources (family cohesiveness, open communication, good parent-child relationships) to manage these types of stress. However, for those with unstable resources, they are unable to tap into their psychological resources to handle the stress of a child coming out to them.⁵ As a result, they resort to rejection. Many parents believe that rejecting their child’s sexual orientation or gender identity will protect them from stigma and discrimination, and they do not realize that rejection can harm their child.^6,7

There are other reasons LGBT youth become homeless. One is untreated mental illness and substance use, mostly likely a result from experiencing stigma and discrimination. Another is that some age out of the foster care system.⁴ Finally, some LGBT youth run away from home because of abuse from their parents, and unfortunately, LGBT youth are more likely to experience abuse from a parent than are heterosexual, cisgender youth.⁸

Furthermore, although there are homeless shelters for youth, many LGBT youth avoid going to homeless shelters out of fear for their own safety. Many homeless shelters are ill equipped to work with LGBT youth, especially in managing other homeless youth who may harass or assault another youth on the basis of their sexual orientation or gender identity.⁴ Additionally, many homeless shelters arrangements are gendered, making it difficult for transgender youth to find a shelter as they may be forced to live with people of their assigned sex of birth, putting them at an increased risk for harassment and violence.⁹

Despite the many challenges faced by homeless LGBT youth, medical providers can play a role in promoting their health and well-being. Screening for homelessness can create opportunities for medical providers to offer resources for immediate needs. Three good questions are: “During the last 12 months, was there a time when you were not able to pay the mortgage or rent on time?” “In the past 12 months, how many places [have you] lived?” and “What type of housing do you currently live in?”¹⁰ Resources for such youth would include the National Coalition for the Homeless, which contains a list of homeless shelters that are equipped to address the needs of LGBT homeless youth.

Medical providers must address some of the root causes of homelessness among LGBT youth. One of them is family rejection. Medical providers can counsel parents of LGBT youth in the importance of family support in protecting their LGBT child from adverse health outcomes. One good resource is the Family Acceptance Project, which teaches parents skills to support their LGBT child. Additionally, medical providers can work with homeless shelters and help them develop best practices for working with LGBT youth. A good place to start is Lambda Legal’s National Recommended Best Practices for Serving LGBT Homeless Youth.

Educating both families and homeless shelters are key in both preventing homelessness and mitigating the effects of homelessness on the health of LGBT youth.

Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

1. “Missed opportunities: Youth homelessness in America,” Chapin Hall at the University of Chicago, 2017. voicesofyouthcount.org.

2. Homelessness & Runaway Youth. Federal Definitions. youth.gov.

3. MMWR Surveill Summ. 2016. doi: 10.15585/mmwr.ss6509a1.

4. “Serving Our Youth 2015: The Needs and Experiences of Lesbian, Gay, Bisexual, Transgender and Questioning Youth Experiencing Homelesness,” The Williams Institute with True Colors Fund, June 2015.

5. Sex Roles. 2013 Jun;68(11-12):690-702.

6. “Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children,” Family Acceptance Project, San Francisco State University, 2009.

7. Pediatrics. 2009 Jan. doi: 10.1542/peds.2007-3524.

8. Am J Public Health. 2011. doi: 10.2105/AJPH.2009.190009.

9. Am J Orthopsychiatry. 2014. doi: 10.1037/h0098852.

10. Pediatrics. 2018. doi: 10.1542/peds.2017-2199.

As winter settles in for most of the United States, there are some people who do not have access to adequate shelter from the cold. Currently, there are an estimated 700,000 homeless youth in the United States, which is roughly 1 out of 30 youth.¹Among homeless youth, a disproportionate number of these youth identify as lesbian, gay, bisexual, or transgender (LGBT). The reasons for these disparities are complex, although stigma and discrimination are major factors. Despite the major challenges faced by this population, medical providers can play a role in addressing homelessness among LGBT youth.

bodnarchuk/Getty Images

According to the Department of Education, homeless youth are defined as youth “who lack a fixed, regular, and adequate nighttime residence.”² Although the image of a person sleeping on a bench at a park covered with newspapers comes to mind, it may not be obvious that a youth may be homeless. Sometimes, youth may be sleeping in their cars at night and others may be staying the night at one house and then staying the next night at another house (known as “couch surfing”). Many will be utilizing homeless shelters to sleep in.

Homelessness among LGBT youth is a major problem in the United States. Although LGB (sexual minority) people comprise 2%-7% of the population,³ about one-third of homeless youth identify as LGB or questioning. Additionally, about 4% of homeless youth identify as transgender, compared with 1% of the general youth population in the United States. LGBT youth are at a higher risk for homelessness than are cisgender (gender identity matches with the assigned sex at birth), heterosexual youth. There are even disparities within LGBT youth.

Why are LGBT youth at high risk for homelessness? The most common reason is family rejection of their sexual orientation and/or gender identity.⁴ Some are directly kicked out by their families. Whereas others leave because relationships with their families have become so strained after the child has come out that the environment is no longer tolerable to live in. However, poverty and race may play a significant role in this phenomenon. There is a misperception that families of color are more homophobic or transphobic (disliking or having a prejudice against transsexual or transgender people) than white families because there is a higher proportion of LGBT homeless youth of color. However, what most likely increases the likelihood of family rejection is the strain of poverty, which people of color are more likely to experience. Chronic unemployment or unstable housing makes it very difficult for families to utilize the important skills to accept and support their LGBT child. Whenever a child comes out to their parents, it is a stressful event for the family. Family with stable physical resources (decent income, stable housing) also are more likely to have psychological resources (family cohesiveness, open communication, good parent-child relationships) to manage these types of stress. However, for those with unstable resources, they are unable to tap into their psychological resources to handle the stress of a child coming out to them.⁵ As a result, they resort to rejection. Many parents believe that rejecting their child’s sexual orientation or gender identity will protect them from stigma and discrimination, and they do not realize that rejection can harm their child.^6,7

There are other reasons LGBT youth become homeless. One is untreated mental illness and substance use, mostly likely a result from experiencing stigma and discrimination. Another is that some age out of the foster care system.⁴ Finally, some LGBT youth run away from home because of abuse from their parents, and unfortunately, LGBT youth are more likely to experience abuse from a parent than are heterosexual, cisgender youth.⁸

Furthermore, although there are homeless shelters for youth, many LGBT youth avoid going to homeless shelters out of fear for their own safety. Many homeless shelters are ill equipped to work with LGBT youth, especially in managing other homeless youth who may harass or assault another youth on the basis of their sexual orientation or gender identity.⁴ Additionally, many homeless shelters arrangements are gendered, making it difficult for transgender youth to find a shelter as they may be forced to live with people of their assigned sex of birth, putting them at an increased risk for harassment and violence.⁹

Despite the many challenges faced by homeless LGBT youth, medical providers can play a role in promoting their health and well-being. Screening for homelessness can create opportunities for medical providers to offer resources for immediate needs. Three good questions are: “During the last 12 months, was there a time when you were not able to pay the mortgage or rent on time?” “In the past 12 months, how many places [have you] lived?” and “What type of housing do you currently live in?”¹⁰ Resources for such youth would include the National Coalition for the Homeless, which contains a list of homeless shelters that are equipped to address the needs of LGBT homeless youth.

Medical providers must address some of the root causes of homelessness among LGBT youth. One of them is family rejection. Medical providers can counsel parents of LGBT youth in the importance of family support in protecting their LGBT child from adverse health outcomes. One good resource is the Family Acceptance Project, which teaches parents skills to support their LGBT child. Additionally, medical providers can work with homeless shelters and help them develop best practices for working with LGBT youth. A good place to start is Lambda Legal’s National Recommended Best Practices for Serving LGBT Homeless Youth.

Educating both families and homeless shelters are key in both preventing homelessness and mitigating the effects of homelessness on the health of LGBT youth.

Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

1. “Missed opportunities: Youth homelessness in America,” Chapin Hall at the University of Chicago, 2017. voicesofyouthcount.org.

2. Homelessness & Runaway Youth. Federal Definitions. youth.gov.

3. MMWR Surveill Summ. 2016. doi: 10.15585/mmwr.ss6509a1.

4. “Serving Our Youth 2015: The Needs and Experiences of Lesbian, Gay, Bisexual, Transgender and Questioning Youth Experiencing Homelesness,” The Williams Institute with True Colors Fund, June 2015.

5. Sex Roles. 2013 Jun;68(11-12):690-702.

6. “Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children,” Family Acceptance Project, San Francisco State University, 2009.

7. Pediatrics. 2009 Jan. doi: 10.1542/peds.2007-3524.

8. Am J Public Health. 2011. doi: 10.2105/AJPH.2009.190009.

9. Am J Orthopsychiatry. 2014. doi: 10.1037/h0098852.

10. Pediatrics. 2018. doi: 10.1542/peds.2017-2199.

As winter settles in for most of the United States, there are some people who do not have access to adequate shelter from the cold. Currently, there are an estimated 700,000 homeless youth in the United States, which is roughly 1 out of 30 youth.¹Among homeless youth, a disproportionate number of these youth identify as lesbian, gay, bisexual, or transgender (LGBT). The reasons for these disparities are complex, although stigma and discrimination are major factors. Despite the major challenges faced by this population, medical providers can play a role in addressing homelessness among LGBT youth.

bodnarchuk/Getty Images

According to the Department of Education, homeless youth are defined as youth “who lack a fixed, regular, and adequate nighttime residence.”² Although the image of a person sleeping on a bench at a park covered with newspapers comes to mind, it may not be obvious that a youth may be homeless. Sometimes, youth may be sleeping in their cars at night and others may be staying the night at one house and then staying the next night at another house (known as “couch surfing”). Many will be utilizing homeless shelters to sleep in.

Homelessness among LGBT youth is a major problem in the United States. Although LGB (sexual minority) people comprise 2%-7% of the population,³ about one-third of homeless youth identify as LGB or questioning. Additionally, about 4% of homeless youth identify as transgender, compared with 1% of the general youth population in the United States. LGBT youth are at a higher risk for homelessness than are cisgender (gender identity matches with the assigned sex at birth), heterosexual youth. There are even disparities within LGBT youth.

Why are LGBT youth at high risk for homelessness? The most common reason is family rejection of their sexual orientation and/or gender identity.⁴ Some are directly kicked out by their families. Whereas others leave because relationships with their families have become so strained after the child has come out that the environment is no longer tolerable to live in. However, poverty and race may play a significant role in this phenomenon. There is a misperception that families of color are more homophobic or transphobic (disliking or having a prejudice against transsexual or transgender people) than white families because there is a higher proportion of LGBT homeless youth of color. However, what most likely increases the likelihood of family rejection is the strain of poverty, which people of color are more likely to experience. Chronic unemployment or unstable housing makes it very difficult for families to utilize the important skills to accept and support their LGBT child. Whenever a child comes out to their parents, it is a stressful event for the family. Family with stable physical resources (decent income, stable housing) also are more likely to have psychological resources (family cohesiveness, open communication, good parent-child relationships) to manage these types of stress. However, for those with unstable resources, they are unable to tap into their psychological resources to handle the stress of a child coming out to them.⁵ As a result, they resort to rejection. Many parents believe that rejecting their child’s sexual orientation or gender identity will protect them from stigma and discrimination, and they do not realize that rejection can harm their child.^6,7

There are other reasons LGBT youth become homeless. One is untreated mental illness and substance use, mostly likely a result from experiencing stigma and discrimination. Another is that some age out of the foster care system.⁴ Finally, some LGBT youth run away from home because of abuse from their parents, and unfortunately, LGBT youth are more likely to experience abuse from a parent than are heterosexual, cisgender youth.⁸

Furthermore, although there are homeless shelters for youth, many LGBT youth avoid going to homeless shelters out of fear for their own safety. Many homeless shelters are ill equipped to work with LGBT youth, especially in managing other homeless youth who may harass or assault another youth on the basis of their sexual orientation or gender identity.⁴ Additionally, many homeless shelters arrangements are gendered, making it difficult for transgender youth to find a shelter as they may be forced to live with people of their assigned sex of birth, putting them at an increased risk for harassment and violence.⁹

Despite the many challenges faced by homeless LGBT youth, medical providers can play a role in promoting their health and well-being. Screening for homelessness can create opportunities for medical providers to offer resources for immediate needs. Three good questions are: “During the last 12 months, was there a time when you were not able to pay the mortgage or rent on time?” “In the past 12 months, how many places [have you] lived?” and “What type of housing do you currently live in?”¹⁰ Resources for such youth would include the National Coalition for the Homeless, which contains a list of homeless shelters that are equipped to address the needs of LGBT homeless youth.

Medical providers must address some of the root causes of homelessness among LGBT youth. One of them is family rejection. Medical providers can counsel parents of LGBT youth in the importance of family support in protecting their LGBT child from adverse health outcomes. One good resource is the Family Acceptance Project, which teaches parents skills to support their LGBT child. Additionally, medical providers can work with homeless shelters and help them develop best practices for working with LGBT youth. A good place to start is Lambda Legal’s National Recommended Best Practices for Serving LGBT Homeless Youth.

Educating both families and homeless shelters are key in both preventing homelessness and mitigating the effects of homelessness on the health of LGBT youth.

Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

1. “Missed opportunities: Youth homelessness in America,” Chapin Hall at the University of Chicago, 2017. voicesofyouthcount.org.

2. Homelessness & Runaway Youth. Federal Definitions. youth.gov.

3. MMWR Surveill Summ. 2016. doi: 10.15585/mmwr.ss6509a1.

4. “Serving Our Youth 2015: The Needs and Experiences of Lesbian, Gay, Bisexual, Transgender and Questioning Youth Experiencing Homelesness,” The Williams Institute with True Colors Fund, June 2015.

5. Sex Roles. 2013 Jun;68(11-12):690-702.

6. “Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children,” Family Acceptance Project, San Francisco State University, 2009.

7. Pediatrics. 2009 Jan. doi: 10.1542/peds.2007-3524.

8. Am J Public Health. 2011. doi: 10.2105/AJPH.2009.190009.

9. Am J Orthopsychiatry. 2014. doi: 10.1037/h0098852.

10. Pediatrics. 2018. doi: 10.1542/peds.2017-2199.

It has been known for decades that sex and gender cannot be determined solely by birth anatomy and chromosomes.¹ Over the past decade, the medical community has been able to better understand the biologic underpinnings of gender identity, and we are gaining a better appreciation for the diversity of gender identities and gender expressions that exist.

Gender expression can be defined as the manner in which an individual chooses to present their gender to others through physical appearance and behaviors, such as style of hair or dress, voice or movement.² Gender nonconformity (GNC) is when an individual’s gender expression does not fully conform with societal expectations often based on an individual’s sex assigned at birth. It is important to note that gender expression is independent of gender identity and may or may not align with gender identity. For example, a person whose sex assigned at birth is female may adopt hairstyles and clothing that are considered more masculine and enjoy activities that are typically associated with masculinity (for example, sports) yet identify as female. The majority of research to date focuses most on transgender individuals, broadly defined as those whose gender identity does not fully align with the sex assigned at birth.^3,4 As our understanding of gender expression and GNC expands, more research is emerging on the prevalence of gender nonconformity in youth and potential associations with various health outcomes.

Stigma, discrimination, and harassment are known to have documented effects on health. GNC youth have been shown to experience discrimination and harassment at rates higher than their gender conforming peers.^5,6 A recent study by Lowry et al. sought to examine the association between GNC and indicators of mental distress and substance use in adolescents.⁷ The authors analyzed a subset of cross-sectional data from more than 6,000 youth who had participated in the Youth Risk Behavior Surveillance–United States, 2015 (YRBS) in three large urban school districts (two in California and one in Florida). In addition to the standard YRBS questions, students at these three school districts were asked about their gender expression using the following question: “A person’s appearance style, dress, or the way they walk or talk may affect how people describe them. How do you think people at your school would describe you?” Based on responses, youth were categorized on a 7-point GNC scale with 1 being most gender conforming (a very feminine female student or very masculine male student) to 7 being most GNC (a very masculine female student or a very feminine male student). The study sample was ethnically diverse with 16% of students identifying as white non-Hispanic, 19% identifying as black non-Hispanic, and 55% identifying as Hispanic of any race.

In the study population, approximately one in five students reported either moderate (students who described themselves as equally feminine and masculine) or high (female students who described themselves as very/mostly/somewhat masculine or male students who described themselves as very/mostly/somewhat feminine) levels of GNC. Among female students, moderate GNC was significantly associated with feeling sad and hopeless, seriously considering attempting suicide, and making a suicide plan. However, in female students substance use was not associated with GNC. Among male students, suicidal thoughts, plans, and attempts all demonstrated a linear increase with GNC, with the greatest prevalence occurring in male students expressing high levels of GNC. Prevalence of substance use, specifically nonmedical use of prescription drugs, cocaine use, methamphetamine use, heroin use, and intravenous drug also was associated with high GNC in male students. Study authors hypothesize that these differences occur because GNC male youth experience more overt harassment, compared with GNC female youth, but further study is needed.

Our understanding of the diversity of gender expressions present in youth populations continues to evolve. Findings from this study add to a growing body of evidence demonstrating a relatively high prevalence of GNC in youth populations, and potential health disparities these youth may face. This study underscores the need for continued study in this area. Family support and acceptance have been demonstrated to be strong protective factors for transgender-, lesbian-, and gay-identified youth. Studies identifying protective factors for GNC youth are needed.⁴

As health care providers, we need to continue to ask patients and families about gender identity and be aware of gender expression. When youth present as GNC, we should recognize that they may be at increased risk and, in addition to assessing overall mental health and risk for substance use, also assess for degree of social/familial support and potential stressors.4 We also should continue to advocate for support systems within schools sensitive to the needs of GNC students, as these may be a potential avenue to improve overall mental health for students. It is important to continue to expand our understanding of the diverse gender identities and expressions of the youth we serve. This hopefully will allow us to identify not only potential risk factors and health disparities, but also protective factors that can help better inform the development of effective interventions so all youth can reach their full potential.

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. Email her at [email protected].

References

1. “WPATH (World Professional Association of Transgender Health) Board Responds to Federal Effort to Redefine Gender,” press release, Oct. 23, 2018.

2. “LGBTQ+ Definitions” at Trans Student Educational Resources.3. J Sex Res. 2013;50(3-4):299-317.

4. JAMA Pediatr. 2018 Nov 1;172(11):1010-1.

5. Psychol Sex Orientat Gend Divers. 2016 Dec;3(4):489-98.

6. J Adolesc Health. 2016; 58(2)(supple):S1-2.

7. JAMA Pediatr. 2018 Nov;172(11):1020-8.

It has been known for decades that sex and gender cannot be determined solely by birth anatomy and chromosomes.¹ Over the past decade, the medical community has been able to better understand the biologic underpinnings of gender identity, and we are gaining a better appreciation for the diversity of gender identities and gender expressions that exist.

Gender expression can be defined as the manner in which an individual chooses to present their gender to others through physical appearance and behaviors, such as style of hair or dress, voice or movement.² Gender nonconformity (GNC) is when an individual’s gender expression does not fully conform with societal expectations often based on an individual’s sex assigned at birth. It is important to note that gender expression is independent of gender identity and may or may not align with gender identity. For example, a person whose sex assigned at birth is female may adopt hairstyles and clothing that are considered more masculine and enjoy activities that are typically associated with masculinity (for example, sports) yet identify as female. The majority of research to date focuses most on transgender individuals, broadly defined as those whose gender identity does not fully align with the sex assigned at birth.^3,4 As our understanding of gender expression and GNC expands, more research is emerging on the prevalence of gender nonconformity in youth and potential associations with various health outcomes.

Stigma, discrimination, and harassment are known to have documented effects on health. GNC youth have been shown to experience discrimination and harassment at rates higher than their gender conforming peers.^5,6 A recent study by Lowry et al. sought to examine the association between GNC and indicators of mental distress and substance use in adolescents.⁷ The authors analyzed a subset of cross-sectional data from more than 6,000 youth who had participated in the Youth Risk Behavior Surveillance–United States, 2015 (YRBS) in three large urban school districts (two in California and one in Florida). In addition to the standard YRBS questions, students at these three school districts were asked about their gender expression using the following question: “A person’s appearance style, dress, or the way they walk or talk may affect how people describe them. How do you think people at your school would describe you?” Based on responses, youth were categorized on a 7-point GNC scale with 1 being most gender conforming (a very feminine female student or very masculine male student) to 7 being most GNC (a very masculine female student or a very feminine male student). The study sample was ethnically diverse with 16% of students identifying as white non-Hispanic, 19% identifying as black non-Hispanic, and 55% identifying as Hispanic of any race.

In the study population, approximately one in five students reported either moderate (students who described themselves as equally feminine and masculine) or high (female students who described themselves as very/mostly/somewhat masculine or male students who described themselves as very/mostly/somewhat feminine) levels of GNC. Among female students, moderate GNC was significantly associated with feeling sad and hopeless, seriously considering attempting suicide, and making a suicide plan. However, in female students substance use was not associated with GNC. Among male students, suicidal thoughts, plans, and attempts all demonstrated a linear increase with GNC, with the greatest prevalence occurring in male students expressing high levels of GNC. Prevalence of substance use, specifically nonmedical use of prescription drugs, cocaine use, methamphetamine use, heroin use, and intravenous drug also was associated with high GNC in male students. Study authors hypothesize that these differences occur because GNC male youth experience more overt harassment, compared with GNC female youth, but further study is needed.

Our understanding of the diversity of gender expressions present in youth populations continues to evolve. Findings from this study add to a growing body of evidence demonstrating a relatively high prevalence of GNC in youth populations, and potential health disparities these youth may face. This study underscores the need for continued study in this area. Family support and acceptance have been demonstrated to be strong protective factors for transgender-, lesbian-, and gay-identified youth. Studies identifying protective factors for GNC youth are needed.⁴

As health care providers, we need to continue to ask patients and families about gender identity and be aware of gender expression. When youth present as GNC, we should recognize that they may be at increased risk and, in addition to assessing overall mental health and risk for substance use, also assess for degree of social/familial support and potential stressors.4 We also should continue to advocate for support systems within schools sensitive to the needs of GNC students, as these may be a potential avenue to improve overall mental health for students. It is important to continue to expand our understanding of the diverse gender identities and expressions of the youth we serve. This hopefully will allow us to identify not only potential risk factors and health disparities, but also protective factors that can help better inform the development of effective interventions so all youth can reach their full potential.

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. Email her at [email protected].

References

1. “WPATH (World Professional Association of Transgender Health) Board Responds to Federal Effort to Redefine Gender,” press release, Oct. 23, 2018.

2. “LGBTQ+ Definitions” at Trans Student Educational Resources.3. J Sex Res. 2013;50(3-4):299-317.

4. JAMA Pediatr. 2018 Nov 1;172(11):1010-1.

5. Psychol Sex Orientat Gend Divers. 2016 Dec;3(4):489-98.

6. J Adolesc Health. 2016; 58(2)(supple):S1-2.

7. JAMA Pediatr. 2018 Nov;172(11):1020-8.

It has been known for decades that sex and gender cannot be determined solely by birth anatomy and chromosomes.¹ Over the past decade, the medical community has been able to better understand the biologic underpinnings of gender identity, and we are gaining a better appreciation for the diversity of gender identities and gender expressions that exist.

Gender expression can be defined as the manner in which an individual chooses to present their gender to others through physical appearance and behaviors, such as style of hair or dress, voice or movement.² Gender nonconformity (GNC) is when an individual’s gender expression does not fully conform with societal expectations often based on an individual’s sex assigned at birth. It is important to note that gender expression is independent of gender identity and may or may not align with gender identity. For example, a person whose sex assigned at birth is female may adopt hairstyles and clothing that are considered more masculine and enjoy activities that are typically associated with masculinity (for example, sports) yet identify as female. The majority of research to date focuses most on transgender individuals, broadly defined as those whose gender identity does not fully align with the sex assigned at birth.^3,4 As our understanding of gender expression and GNC expands, more research is emerging on the prevalence of gender nonconformity in youth and potential associations with various health outcomes.

Stigma, discrimination, and harassment are known to have documented effects on health. GNC youth have been shown to experience discrimination and harassment at rates higher than their gender conforming peers.^5,6 A recent study by Lowry et al. sought to examine the association between GNC and indicators of mental distress and substance use in adolescents.⁷ The authors analyzed a subset of cross-sectional data from more than 6,000 youth who had participated in the Youth Risk Behavior Surveillance–United States, 2015 (YRBS) in three large urban school districts (two in California and one in Florida). In addition to the standard YRBS questions, students at these three school districts were asked about their gender expression using the following question: “A person’s appearance style, dress, or the way they walk or talk may affect how people describe them. How do you think people at your school would describe you?” Based on responses, youth were categorized on a 7-point GNC scale with 1 being most gender conforming (a very feminine female student or very masculine male student) to 7 being most GNC (a very masculine female student or a very feminine male student). The study sample was ethnically diverse with 16% of students identifying as white non-Hispanic, 19% identifying as black non-Hispanic, and 55% identifying as Hispanic of any race.

In the study population, approximately one in five students reported either moderate (students who described themselves as equally feminine and masculine) or high (female students who described themselves as very/mostly/somewhat masculine or male students who described themselves as very/mostly/somewhat feminine) levels of GNC. Among female students, moderate GNC was significantly associated with feeling sad and hopeless, seriously considering attempting suicide, and making a suicide plan. However, in female students substance use was not associated with GNC. Among male students, suicidal thoughts, plans, and attempts all demonstrated a linear increase with GNC, with the greatest prevalence occurring in male students expressing high levels of GNC. Prevalence of substance use, specifically nonmedical use of prescription drugs, cocaine use, methamphetamine use, heroin use, and intravenous drug also was associated with high GNC in male students. Study authors hypothesize that these differences occur because GNC male youth experience more overt harassment, compared with GNC female youth, but further study is needed.

Our understanding of the diversity of gender expressions present in youth populations continues to evolve. Findings from this study add to a growing body of evidence demonstrating a relatively high prevalence of GNC in youth populations, and potential health disparities these youth may face. This study underscores the need for continued study in this area. Family support and acceptance have been demonstrated to be strong protective factors for transgender-, lesbian-, and gay-identified youth. Studies identifying protective factors for GNC youth are needed.⁴

As health care providers, we need to continue to ask patients and families about gender identity and be aware of gender expression. When youth present as GNC, we should recognize that they may be at increased risk and, in addition to assessing overall mental health and risk for substance use, also assess for degree of social/familial support and potential stressors.4 We also should continue to advocate for support systems within schools sensitive to the needs of GNC students, as these may be a potential avenue to improve overall mental health for students. It is important to continue to expand our understanding of the diverse gender identities and expressions of the youth we serve. This hopefully will allow us to identify not only potential risk factors and health disparities, but also protective factors that can help better inform the development of effective interventions so all youth can reach their full potential.

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. Email her at [email protected].

References

1. “WPATH (World Professional Association of Transgender Health) Board Responds to Federal Effort to Redefine Gender,” press release, Oct. 23, 2018.

2. “LGBTQ+ Definitions” at Trans Student Educational Resources.3. J Sex Res. 2013;50(3-4):299-317.

4. JAMA Pediatr. 2018 Nov 1;172(11):1010-1.

5. Psychol Sex Orientat Gend Divers. 2016 Dec;3(4):489-98.

6. J Adolesc Health. 2016; 58(2)(supple):S1-2.

7. JAMA Pediatr. 2018 Nov;172(11):1020-8.

The Atlantic published the article “When Children Say They’re Trans” by Jesse Singal in its July/August edition not too long ago. In this article, the author wrote about the increasing availability of treatments for affirming one’s gender identity and the rising concerns about the risks surrounding those treatments.

LemonTreeImages/Thinkstock

A key issue in the article is the concept of desistance. Desistance is a phenomenon in which individuals no longer feel that their gender identities are incongruent with their physical appearance. Highly related to desistance is detransitioning, a phenomenon in which transgender individuals no longer take the steps (e.g., hormone therapy) to affirm their gender identity. Singal highlights the concern surrounding starting medical treatments to affirm an individual’s gender identity, considering that the changes are irreversible and that it is possible for children to change their minds. Implied in the article is a call for a cautious approach for treating children who identify as transgender because it will be difficult to predict what one’s final gender identity is; however, I believe that a better approach is to support the child in the journey in affirming the gender identity.
 

The evidence on the rate of desistance may not be accurate

One argument for the cautious approach is the often cited statistic that 80% of children with gender nonconforming behaviors do not identify as transgender when they are adults. This is derived from four published studies that track the gender identity of individuals with gender nonconforming behaviors in childhood.^1-4 These estimates may not be accurate, mainly due to these studies’ methodological shortcomings. For example, those who were lost to follow-up were assumed to be cisgender as adults and no efforts were made to verify these individuals’ gender identity.^2-4 I do not intend to thoroughly critique these studies in this column. This is best left to peer-reviewed commentaries (a good example is one written by Newhook et al. 2018).⁵ I worry, however, that some clinicians may dismiss a child’s gender identity based on these studies and recommend to the parents to delay supporting a transition until the child “knows for sure.” The problem with this approach is that it may worsen the health and well-being of transgender youth, as there is growing evidence that transgender children who are supported by their parents are less likely to have mental health problems.^6,7

The reasons for desistance are far more complicated

The common narrative of desistance is that the individuals simply change their minds because they were “confused” during adolescence. However, the truth is more complicated. Children can identify their own gender as early as 2 years old;⁸ however, when a child’s gender identity matches the assigned sex at birth, this is often reinforced. In contrast, if a child’s gender identity does not match the assigned sex at birth, it often is challenged by peers and adults. This challenge by peers, their families, and medical providers may be one of the reasons why transitioning is so difficult for many transgender youth – and many do give up.^3,9 In these cases, some people wait for years, if not decades, to come out again and start transitioning when they finally feel supported and safe – even in their 90s! Other transgender people realize that their gender identity is not on the binary (neither male nor female), so they no longer need cross-sex hormones or surgeries to affirm their gender identity. Finally, others are concerned about the side effects, such as infertility, and feel that the risks for those side effects are not worth it, so they find other, nonmedical or nonsurgical ways to affirm their gender identity or manage their gender dysphoria.

Positive outcomes are more common

Reports of youth detransitioning highlight many physicians’ fears of making a mistake; however, these reports obscure the more common – and positive – outcomes for transgender individuals who took steps to affirm their gender identity. The Report of the 2011 Transition Survey shows that 97% were satisfied with being on hormone therapy and 90% were satisfied with obtaining bottom surgery.¹⁰ Furthermore, there is growing evidence showing that such treatments are associated with better health.¹¹ A study by de Vries et al. found that transgender youth who transitioned in adolescence had less depression and better adjustment as adults.¹² Finally, there is a lack of evidence supporting the concept that someone whose gender identity is fluid over time is any less healthy than those whose gender identity is static over time. Rare outcomes should never be dismissed; however, providers should not use rare events as the primary driver for discouraging evidence-based treatment.

The key is support

I believe that every child’s gender identity should be supported and affirmed. Clinicians can provide this support and affirmation through the following actions:

• At the first visit, clinicians should ask what the child’s hopes and expectations are for pursuing gender-affirming medical treatments.
• Clinicians should allow the child the opportunity to describe and process their gender identity instead of assuming that they are on the binary.
• Clinicians must recognize the varied reasons for desistance – stigma, discrimination, shame, or need to fit within a gender binary – and find ways to address those factors.
• Clinicians should have a thorough discussion with patients and their families about the risks of not supporting the child’s gender identity versus the risk of medical or surgical treatments used to affirm one’s gender identity and process with the child and the family where the values and wishes are within the context of those risks.
• Most importantly, clinicians should emphasize support for whatever decisions the child makes to affirm their gender identity. Providing support is essential in promoting the health and well-being of any child.

Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

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

2. J Am Acad Child Adolesc Psychiatry. 2013 Jun;52(6):582-90.

3. Clin Child Psychol Psychiatry. 2011 Oct;16(4):499-516.

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

5. International Journal of Transgenderism. 2018;19(2):212-24.

6. Pediatrics. 2016 Mar;137(3):e20153223.

7. J Sex Marital Ther. 2010;36(1):6-23.

8. “Adolescence,” 11th ed. (New York: McGraw-Hill Education; 2016).

9. Graduate Journal of Social Science. 2010;7(2):26-43.

10. “Affirming Gender, Affirming Lives: A Report of the 2011 Transition Survey,” Gender Advocacy Training & Education, 2012.

11. Transgend Health. 2016 Jan;1(1):21-31.

12. Pediatrics. 2014 Oct;134(4):696-704.

The Atlantic published the article “When Children Say They’re Trans” by Jesse Singal in its July/August edition not too long ago. In this article, the author wrote about the increasing availability of treatments for affirming one’s gender identity and the rising concerns about the risks surrounding those treatments.

LemonTreeImages/Thinkstock

A key issue in the article is the concept of desistance. Desistance is a phenomenon in which individuals no longer feel that their gender identities are incongruent with their physical appearance. Highly related to desistance is detransitioning, a phenomenon in which transgender individuals no longer take the steps (e.g., hormone therapy) to affirm their gender identity. Singal highlights the concern surrounding starting medical treatments to affirm an individual’s gender identity, considering that the changes are irreversible and that it is possible for children to change their minds. Implied in the article is a call for a cautious approach for treating children who identify as transgender because it will be difficult to predict what one’s final gender identity is; however, I believe that a better approach is to support the child in the journey in affirming the gender identity.
 

The evidence on the rate of desistance may not be accurate

One argument for the cautious approach is the often cited statistic that 80% of children with gender nonconforming behaviors do not identify as transgender when they are adults. This is derived from four published studies that track the gender identity of individuals with gender nonconforming behaviors in childhood.^1-4 These estimates may not be accurate, mainly due to these studies’ methodological shortcomings. For example, those who were lost to follow-up were assumed to be cisgender as adults and no efforts were made to verify these individuals’ gender identity.^2-4 I do not intend to thoroughly critique these studies in this column. This is best left to peer-reviewed commentaries (a good example is one written by Newhook et al. 2018).⁵ I worry, however, that some clinicians may dismiss a child’s gender identity based on these studies and recommend to the parents to delay supporting a transition until the child “knows for sure.” The problem with this approach is that it may worsen the health and well-being of transgender youth, as there is growing evidence that transgender children who are supported by their parents are less likely to have mental health problems.^6,7

The reasons for desistance are far more complicated

The common narrative of desistance is that the individuals simply change their minds because they were “confused” during adolescence. However, the truth is more complicated. Children can identify their own gender as early as 2 years old;⁸ however, when a child’s gender identity matches the assigned sex at birth, this is often reinforced. In contrast, if a child’s gender identity does not match the assigned sex at birth, it often is challenged by peers and adults. This challenge by peers, their families, and medical providers may be one of the reasons why transitioning is so difficult for many transgender youth – and many do give up.^3,9 In these cases, some people wait for years, if not decades, to come out again and start transitioning when they finally feel supported and safe – even in their 90s! Other transgender people realize that their gender identity is not on the binary (neither male nor female), so they no longer need cross-sex hormones or surgeries to affirm their gender identity. Finally, others are concerned about the side effects, such as infertility, and feel that the risks for those side effects are not worth it, so they find other, nonmedical or nonsurgical ways to affirm their gender identity or manage their gender dysphoria.

Positive outcomes are more common

Reports of youth detransitioning highlight many physicians’ fears of making a mistake; however, these reports obscure the more common – and positive – outcomes for transgender individuals who took steps to affirm their gender identity. The Report of the 2011 Transition Survey shows that 97% were satisfied with being on hormone therapy and 90% were satisfied with obtaining bottom surgery.¹⁰ Furthermore, there is growing evidence showing that such treatments are associated with better health.¹¹ A study by de Vries et al. found that transgender youth who transitioned in adolescence had less depression and better adjustment as adults.¹² Finally, there is a lack of evidence supporting the concept that someone whose gender identity is fluid over time is any less healthy than those whose gender identity is static over time. Rare outcomes should never be dismissed; however, providers should not use rare events as the primary driver for discouraging evidence-based treatment.

The key is support

I believe that every child’s gender identity should be supported and affirmed. Clinicians can provide this support and affirmation through the following actions:

• At the first visit, clinicians should ask what the child’s hopes and expectations are for pursuing gender-affirming medical treatments.
• Clinicians should allow the child the opportunity to describe and process their gender identity instead of assuming that they are on the binary.
• Clinicians must recognize the varied reasons for desistance – stigma, discrimination, shame, or need to fit within a gender binary – and find ways to address those factors.
• Clinicians should have a thorough discussion with patients and their families about the risks of not supporting the child’s gender identity versus the risk of medical or surgical treatments used to affirm one’s gender identity and process with the child and the family where the values and wishes are within the context of those risks.
• Most importantly, clinicians should emphasize support for whatever decisions the child makes to affirm their gender identity. Providing support is essential in promoting the health and well-being of any child.

Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

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

2. J Am Acad Child Adolesc Psychiatry. 2013 Jun;52(6):582-90.

3. Clin Child Psychol Psychiatry. 2011 Oct;16(4):499-516.

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

5. International Journal of Transgenderism. 2018;19(2):212-24.

6. Pediatrics. 2016 Mar;137(3):e20153223.

7. J Sex Marital Ther. 2010;36(1):6-23.

8. “Adolescence,” 11th ed. (New York: McGraw-Hill Education; 2016).

9. Graduate Journal of Social Science. 2010;7(2):26-43.

10. “Affirming Gender, Affirming Lives: A Report of the 2011 Transition Survey,” Gender Advocacy Training & Education, 2012.

11. Transgend Health. 2016 Jan;1(1):21-31.

12. Pediatrics. 2014 Oct;134(4):696-704.

The Atlantic published the article “When Children Say They’re Trans” by Jesse Singal in its July/August edition not too long ago. In this article, the author wrote about the increasing availability of treatments for affirming one’s gender identity and the rising concerns about the risks surrounding those treatments.

LemonTreeImages/Thinkstock

A key issue in the article is the concept of desistance. Desistance is a phenomenon in which individuals no longer feel that their gender identities are incongruent with their physical appearance. Highly related to desistance is detransitioning, a phenomenon in which transgender individuals no longer take the steps (e.g., hormone therapy) to affirm their gender identity. Singal highlights the concern surrounding starting medical treatments to affirm an individual’s gender identity, considering that the changes are irreversible and that it is possible for children to change their minds. Implied in the article is a call for a cautious approach for treating children who identify as transgender because it will be difficult to predict what one’s final gender identity is; however, I believe that a better approach is to support the child in the journey in affirming the gender identity.
 

The evidence on the rate of desistance may not be accurate

One argument for the cautious approach is the often cited statistic that 80% of children with gender nonconforming behaviors do not identify as transgender when they are adults. This is derived from four published studies that track the gender identity of individuals with gender nonconforming behaviors in childhood.^1-4 These estimates may not be accurate, mainly due to these studies’ methodological shortcomings. For example, those who were lost to follow-up were assumed to be cisgender as adults and no efforts were made to verify these individuals’ gender identity.^2-4 I do not intend to thoroughly critique these studies in this column. This is best left to peer-reviewed commentaries (a good example is one written by Newhook et al. 2018).⁵ I worry, however, that some clinicians may dismiss a child’s gender identity based on these studies and recommend to the parents to delay supporting a transition until the child “knows for sure.” The problem with this approach is that it may worsen the health and well-being of transgender youth, as there is growing evidence that transgender children who are supported by their parents are less likely to have mental health problems.^6,7

The reasons for desistance are far more complicated

The common narrative of desistance is that the individuals simply change their minds because they were “confused” during adolescence. However, the truth is more complicated. Children can identify their own gender as early as 2 years old;⁸ however, when a child’s gender identity matches the assigned sex at birth, this is often reinforced. In contrast, if a child’s gender identity does not match the assigned sex at birth, it often is challenged by peers and adults. This challenge by peers, their families, and medical providers may be one of the reasons why transitioning is so difficult for many transgender youth – and many do give up.^3,9 In these cases, some people wait for years, if not decades, to come out again and start transitioning when they finally feel supported and safe – even in their 90s! Other transgender people realize that their gender identity is not on the binary (neither male nor female), so they no longer need cross-sex hormones or surgeries to affirm their gender identity. Finally, others are concerned about the side effects, such as infertility, and feel that the risks for those side effects are not worth it, so they find other, nonmedical or nonsurgical ways to affirm their gender identity or manage their gender dysphoria.

Positive outcomes are more common

Reports of youth detransitioning highlight many physicians’ fears of making a mistake; however, these reports obscure the more common – and positive – outcomes for transgender individuals who took steps to affirm their gender identity. The Report of the 2011 Transition Survey shows that 97% were satisfied with being on hormone therapy and 90% were satisfied with obtaining bottom surgery.¹⁰ Furthermore, there is growing evidence showing that such treatments are associated with better health.¹¹ A study by de Vries et al. found that transgender youth who transitioned in adolescence had less depression and better adjustment as adults.¹² Finally, there is a lack of evidence supporting the concept that someone whose gender identity is fluid over time is any less healthy than those whose gender identity is static over time. Rare outcomes should never be dismissed; however, providers should not use rare events as the primary driver for discouraging evidence-based treatment.

The key is support

I believe that every child’s gender identity should be supported and affirmed. Clinicians can provide this support and affirmation through the following actions:

• At the first visit, clinicians should ask what the child’s hopes and expectations are for pursuing gender-affirming medical treatments.
• Clinicians should allow the child the opportunity to describe and process their gender identity instead of assuming that they are on the binary.
• Clinicians must recognize the varied reasons for desistance – stigma, discrimination, shame, or need to fit within a gender binary – and find ways to address those factors.
• Clinicians should have a thorough discussion with patients and their families about the risks of not supporting the child’s gender identity versus the risk of medical or surgical treatments used to affirm one’s gender identity and process with the child and the family where the values and wishes are within the context of those risks.
• Most importantly, clinicians should emphasize support for whatever decisions the child makes to affirm their gender identity. Providing support is essential in promoting the health and well-being of any child.

Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

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

2. J Am Acad Child Adolesc Psychiatry. 2013 Jun;52(6):582-90.

3. Clin Child Psychol Psychiatry. 2011 Oct;16(4):499-516.

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

5. International Journal of Transgenderism. 2018;19(2):212-24.

6. Pediatrics. 2016 Mar;137(3):e20153223.

7. J Sex Marital Ther. 2010;36(1):6-23.

8. “Adolescence,” 11th ed. (New York: McGraw-Hill Education; 2016).

9. Graduate Journal of Social Science. 2010;7(2):26-43.

10. “Affirming Gender, Affirming Lives: A Report of the 2011 Transition Survey,” Gender Advocacy Training & Education, 2012.

11. Transgend Health. 2016 Jan;1(1):21-31.

12. Pediatrics. 2014 Oct;134(4):696-704.

June 28, 1969, is the day that many consider to be the origin of the modern LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer/Questioning) movement.¹ At that time, it was not uncommon for police officers to conduct raids on bars frequented by LGBTQ patrons, but this night was different. This night the patrons of the Stonewall Inn fought back. The subsequent violent clashes fueled the national organization of groups concentrated on the goal of advocating for LGBTQ rights. On June 28th, 1970, protests to commemorate the events at Stonewall occurred; many refer to these as the first Pride events. Since then the month of June has been seen as the unofficial Pride month for the LGBTQ community. These events began as demonstrations for equal rights and protections for LGBTQ individuals, but over time, events have grown also to become a celebration of queer lives and sexuality.²

Josve05a/Getty Images

Ways to get involved

Find out about local Pride events in your community and consider attending or volunteering. One of the contributing factors to LGBTQ health disparities is limited access to competent care. Many LGBTQ youth and adults have reported experiences of discrimination in the health care setting.^3,4 When we, as health care providers, are visible at Pride events, we can have important effects on our local communities by showing them that we recognize and affirm LGBTQ identities.

Consider asking your organization or institution to provide support at local Pride events, post messages of support during Pride month, or host educational sessions about the care of LGBTQ youth.

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 Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at [email protected].

Resources

Human Rights Campaign/Pride: You can learn more about the history of Pride and events in your state and community at www.hrc.org/pride.

How to contact your elected officials: You can find contact information for your local, state, and federal government representatives at www.usa.gov/elected-officials.

National LGBT Health Education Center: You can find educational resources to help optimize care of LGBT patients at www.lgbthealtheducation.org/.

U.S. Transgender Survey: You can read the report from a survey of almost 28,000 transgender respondents in the U.S. Specific information is available about experiences with health care; state level reports also available at www.ustranssurvey.org/reports/.
 

References

1. GLAAD Pride Month Resource Kit for Jounalists: www.glaad.org/publications/pridekit

2. Human Rights Campaign: History of LGBT Pride. www.hrc.org/blog/the-history-of-lgbt-pride-from-1970-to-now

3. The Report of the 2015 U.S. Transgender Survey (Washington, DC: National Center for Transgender Equality, 2016).

4. Healthy People 2020: Lesbian, Gay, Bisexual and Transgender Health.

June 28, 1969, is the day that many consider to be the origin of the modern LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer/Questioning) movement.¹ At that time, it was not uncommon for police officers to conduct raids on bars frequented by LGBTQ patrons, but this night was different. This night the patrons of the Stonewall Inn fought back. The subsequent violent clashes fueled the national organization of groups concentrated on the goal of advocating for LGBTQ rights. On June 28th, 1970, protests to commemorate the events at Stonewall occurred; many refer to these as the first Pride events. Since then the month of June has been seen as the unofficial Pride month for the LGBTQ community. These events began as demonstrations for equal rights and protections for LGBTQ individuals, but over time, events have grown also to become a celebration of queer lives and sexuality.²

Josve05a/Getty Images

Ways to get involved

Find out about local Pride events in your community and consider attending or volunteering. One of the contributing factors to LGBTQ health disparities is limited access to competent care. Many LGBTQ youth and adults have reported experiences of discrimination in the health care setting.^3,4 When we, as health care providers, are visible at Pride events, we can have important effects on our local communities by showing them that we recognize and affirm LGBTQ identities.

Consider asking your organization or institution to provide support at local Pride events, post messages of support during Pride month, or host educational sessions about the care of LGBTQ youth.

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 Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at [email protected].

Resources

Human Rights Campaign/Pride: You can learn more about the history of Pride and events in your state and community at www.hrc.org/pride.

How to contact your elected officials: You can find contact information for your local, state, and federal government representatives at www.usa.gov/elected-officials.

National LGBT Health Education Center: You can find educational resources to help optimize care of LGBT patients at www.lgbthealtheducation.org/.

U.S. Transgender Survey: You can read the report from a survey of almost 28,000 transgender respondents in the U.S. Specific information is available about experiences with health care; state level reports also available at www.ustranssurvey.org/reports/.
 

References

1. GLAAD Pride Month Resource Kit for Jounalists: www.glaad.org/publications/pridekit

2. Human Rights Campaign: History of LGBT Pride. www.hrc.org/blog/the-history-of-lgbt-pride-from-1970-to-now

3. The Report of the 2015 U.S. Transgender Survey (Washington, DC: National Center for Transgender Equality, 2016).

4. Healthy People 2020: Lesbian, Gay, Bisexual and Transgender Health.

June 28, 1969, is the day that many consider to be the origin of the modern LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer/Questioning) movement.¹ At that time, it was not uncommon for police officers to conduct raids on bars frequented by LGBTQ patrons, but this night was different. This night the patrons of the Stonewall Inn fought back. The subsequent violent clashes fueled the national organization of groups concentrated on the goal of advocating for LGBTQ rights. On June 28th, 1970, protests to commemorate the events at Stonewall occurred; many refer to these as the first Pride events. Since then the month of June has been seen as the unofficial Pride month for the LGBTQ community. These events began as demonstrations for equal rights and protections for LGBTQ individuals, but over time, events have grown also to become a celebration of queer lives and sexuality.²

Josve05a/Getty Images

Ways to get involved

Find out about local Pride events in your community and consider attending or volunteering. One of the contributing factors to LGBTQ health disparities is limited access to competent care. Many LGBTQ youth and adults have reported experiences of discrimination in the health care setting.^3,4 When we, as health care providers, are visible at Pride events, we can have important effects on our local communities by showing them that we recognize and affirm LGBTQ identities.

Consider asking your organization or institution to provide support at local Pride events, post messages of support during Pride month, or host educational sessions about the care of LGBTQ youth.

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 Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at [email protected].

Resources

Human Rights Campaign/Pride: You can learn more about the history of Pride and events in your state and community at www.hrc.org/pride.

How to contact your elected officials: You can find contact information for your local, state, and federal government representatives at www.usa.gov/elected-officials.

National LGBT Health Education Center: You can find educational resources to help optimize care of LGBT patients at www.lgbthealtheducation.org/.

U.S. Transgender Survey: You can read the report from a survey of almost 28,000 transgender respondents in the U.S. Specific information is available about experiences with health care; state level reports also available at www.ustranssurvey.org/reports/.
 

References

1. GLAAD Pride Month Resource Kit for Jounalists: www.glaad.org/publications/pridekit

2. Human Rights Campaign: History of LGBT Pride. www.hrc.org/blog/the-history-of-lgbt-pride-from-1970-to-now

3. The Report of the 2015 U.S. Transgender Survey (Washington, DC: National Center for Transgender Equality, 2016).

4. Healthy People 2020: Lesbian, Gay, Bisexual and Transgender Health.

In March 2018, the Human Rights Campaign (HRC), an advocacy organization dedicated to improving the lives of LGBTQ people, released its 11th Annual Healthcare Equality Index. The HEI is an indicator of how inclusive and equitable health care facilities are in providing care for their LGBTQ patients. My own institution, Children’s Hospital of Pittsburgh, scored very high on this index and received the “Leader in LGBTQ Healthcare Equality” designation. The process of receiving this designation is very rigorous, and I am proud of my institution for making great strides in expanding health care access for LGBTQ patients, especially transgender patients. However, this is no time to rest on one’s laurels, as many transgender people still experience challenges and barriers in navigating the health care system.

AlexRaths/Thinkstock

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

Resources

• HRC HEI: If you’re interested in learning what policies are inclusive and equitable for LGBT patients, check out the HRC HEI scoring criteria. It’s a good place to start if you want to expand health care access for transgender individuals.
• To find out more about the health care legal protections transgender individuals are entitled to, check out the National Center for Transgender Equality.

References

1. Psychol Bull. 2003 Sep;129(5):674-97.

2. “Injustice at every turn: A report of the National Transgender Discrimination Survey.” (Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.)

3. J. Adolesc Health. 2018 Apr. doi: 10.1016/j.jadohealth.2018.02.003.

4. Int J Transgenderism. 2008. doi: 10.1300/J485v08n02_08.

5. Transgend Health. 2016 Nov 1;1(1):238-49.

In March 2018, the Human Rights Campaign (HRC), an advocacy organization dedicated to improving the lives of LGBTQ people, released its 11th Annual Healthcare Equality Index. The HEI is an indicator of how inclusive and equitable health care facilities are in providing care for their LGBTQ patients. My own institution, Children’s Hospital of Pittsburgh, scored very high on this index and received the “Leader in LGBTQ Healthcare Equality” designation. The process of receiving this designation is very rigorous, and I am proud of my institution for making great strides in expanding health care access for LGBTQ patients, especially transgender patients. However, this is no time to rest on one’s laurels, as many transgender people still experience challenges and barriers in navigating the health care system.

AlexRaths/Thinkstock

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

Resources

• HRC HEI: If you’re interested in learning what policies are inclusive and equitable for LGBT patients, check out the HRC HEI scoring criteria. It’s a good place to start if you want to expand health care access for transgender individuals.
• To find out more about the health care legal protections transgender individuals are entitled to, check out the National Center for Transgender Equality.

References

1. Psychol Bull. 2003 Sep;129(5):674-97.

2. “Injustice at every turn: A report of the National Transgender Discrimination Survey.” (Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.)

3. J. Adolesc Health. 2018 Apr. doi: 10.1016/j.jadohealth.2018.02.003.

4. Int J Transgenderism. 2008. doi: 10.1300/J485v08n02_08.

5. Transgend Health. 2016 Nov 1;1(1):238-49.

In March 2018, the Human Rights Campaign (HRC), an advocacy organization dedicated to improving the lives of LGBTQ people, released its 11th Annual Healthcare Equality Index. The HEI is an indicator of how inclusive and equitable health care facilities are in providing care for their LGBTQ patients. My own institution, Children’s Hospital of Pittsburgh, scored very high on this index and received the “Leader in LGBTQ Healthcare Equality” designation. The process of receiving this designation is very rigorous, and I am proud of my institution for making great strides in expanding health care access for LGBTQ patients, especially transgender patients. However, this is no time to rest on one’s laurels, as many transgender people still experience challenges and barriers in navigating the health care system.

AlexRaths/Thinkstock

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

Resources

• HRC HEI: If you’re interested in learning what policies are inclusive and equitable for LGBT patients, check out the HRC HEI scoring criteria. It’s a good place to start if you want to expand health care access for transgender individuals.
• To find out more about the health care legal protections transgender individuals are entitled to, check out the National Center for Transgender Equality.

References

1. Psychol Bull. 2003 Sep;129(5):674-97.

2. “Injustice at every turn: A report of the National Transgender Discrimination Survey.” (Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.)

3. J. Adolesc Health. 2018 Apr. doi: 10.1016/j.jadohealth.2018.02.003.

4. Int J Transgenderism. 2008. doi: 10.1300/J485v08n02_08.

5. Transgend Health. 2016 Nov 1;1(1):238-49.

As we providers begin to gain a better understanding of the complexities of gender identity and expression, studies examining the health of transgender and gender-nonconforming (TGNC) youth are emerging. Multiple studies have demonstrated the mental health disparities that TGNC youth face, but more studies examining other health risks and disparities are needed.

Prevalence of TGNC students higher than expected

The 2.7% prevalence of TGNC youth in this sample is higher than previously reported. Previous studies looking at prevalence rates of TGNC youth often dichotomized gender identities into binary (masculine or feminine) groups and were not inclusive of nonbinary and questioning identities. This may have led to underestimation of the size of this population.^2,3 This study assessed for TGNC identities by asking, “Do you consider yourself transgender, genderqueer, gender fluid, or unsure about your gender identity?” Given the prevalence of TGNC identities in this sample, it is likely that TGNC youth will be encountered in general pediatric practice. As such, it is important that we as providers continue to build our competency in working with this population.
 

Statistically significant differences in health status were identified

Almost two-thirds (62%) of TGNC youth identified their health as poor, fair, or good as opposed to very good or excellent, compared with one-third (33.1%) of cisgender youth. Over half (52%) of TGNC youth reported staying home from school because of illness at least once in the past month, compared with 43% of cisgender youth. About 60% of TGNC youth reported a preventive medical check-up in the past year, compared with 65% of cisgender youth. In terms of long-term health problems, TGNC youth reported higher rates of long-term physical (25% vs. 15%) and mental health (59% vs. 17%) problems than did their cisgender peers.

Role of perceived gender expression

A unique aspect of this study was that it sought to examine the effect of perceived gender expression (the way others interpret a person’s gender presentation; their appearance, style, dress, or the way they walk or talk) on health status and care utilization. Categories of perceived gender expression included very or mostly feminine, somewhat feminine, equally feminine and masculine, somewhat masculine, or very or mostly masculine. The prevalence of TGNC adolescents with an equally feminine and masculine gender expression was highest for both those assigned male (29%) and assigned female (41%) at birth, compared with other perceived gender presentations.

TGNC youth who were perceived to have a gender expression that was incongruent with the sex assigned at birth were at higher risk of reporting poor health status. For example, in TGNC participants who were assigned male at birth, those perceived as equally feminine and masculine (49%) or somewhat masculine (58%) were significantly more likely to report having poorer general health than those with a very masculine perceived gender expression (32%).
 

Suggestions for providers

The authors of the study and the accompanying commentary by Daniel Shumer, MD, MPH, suggest that there are things we as health care providers can do to address these barriers.

• Recognize that health disparities exist in this population. Individuals perceived as gender nonconforming may be vulnerable to discrimination and have difficulty accessing and receiving heath care, compared with their cisgender peers.
• Screen for health risks and identify barriers to care for TGNC youth while promoting and bolstering wellness within this community.
• Continue to promote access to gender affirming care. Data suggest that children who receive gender affirming care achieve mental health status similar to that of their cisgender peers.^3,4,5
• Continue to develop an understanding of how youth understand and express gender.
• Nonbinary youth face unique barriers when accessing health affirming services because of fears that their gender identity may be misunderstood. These barriers lead to delays in seeking health care services, which may lead to poorer outcomes. As providers, educating ourselves about these diverse identities and being respectful of all patients’ identities can help reduce these barriers.

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 Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. Pediatrics. 2018 Feb 5. doi: 10.1542/peds.2017-1683.

2. J Adolesc Health. 2017 Oct;61(4):521-6.

3. Pediatrics. 2018. doi: 10.1542/peds.2017-4079.

4. Pediatrics. 2014 Oct;134(4):696-704.

5. Pediatrics. 2016 Mar;137(3):e20153223.

As we providers begin to gain a better understanding of the complexities of gender identity and expression, studies examining the health of transgender and gender-nonconforming (TGNC) youth are emerging. Multiple studies have demonstrated the mental health disparities that TGNC youth face, but more studies examining other health risks and disparities are needed.

Prevalence of TGNC students higher than expected

The 2.7% prevalence of TGNC youth in this sample is higher than previously reported. Previous studies looking at prevalence rates of TGNC youth often dichotomized gender identities into binary (masculine or feminine) groups and were not inclusive of nonbinary and questioning identities. This may have led to underestimation of the size of this population.^2,3 This study assessed for TGNC identities by asking, “Do you consider yourself transgender, genderqueer, gender fluid, or unsure about your gender identity?” Given the prevalence of TGNC identities in this sample, it is likely that TGNC youth will be encountered in general pediatric practice. As such, it is important that we as providers continue to build our competency in working with this population.
 

Statistically significant differences in health status were identified

Almost two-thirds (62%) of TGNC youth identified their health as poor, fair, or good as opposed to very good or excellent, compared with one-third (33.1%) of cisgender youth. Over half (52%) of TGNC youth reported staying home from school because of illness at least once in the past month, compared with 43% of cisgender youth. About 60% of TGNC youth reported a preventive medical check-up in the past year, compared with 65% of cisgender youth. In terms of long-term health problems, TGNC youth reported higher rates of long-term physical (25% vs. 15%) and mental health (59% vs. 17%) problems than did their cisgender peers.

Role of perceived gender expression

A unique aspect of this study was that it sought to examine the effect of perceived gender expression (the way others interpret a person’s gender presentation; their appearance, style, dress, or the way they walk or talk) on health status and care utilization. Categories of perceived gender expression included very or mostly feminine, somewhat feminine, equally feminine and masculine, somewhat masculine, or very or mostly masculine. The prevalence of TGNC adolescents with an equally feminine and masculine gender expression was highest for both those assigned male (29%) and assigned female (41%) at birth, compared with other perceived gender presentations.

TGNC youth who were perceived to have a gender expression that was incongruent with the sex assigned at birth were at higher risk of reporting poor health status. For example, in TGNC participants who were assigned male at birth, those perceived as equally feminine and masculine (49%) or somewhat masculine (58%) were significantly more likely to report having poorer general health than those with a very masculine perceived gender expression (32%).
 

Suggestions for providers

The authors of the study and the accompanying commentary by Daniel Shumer, MD, MPH, suggest that there are things we as health care providers can do to address these barriers.

• Recognize that health disparities exist in this population. Individuals perceived as gender nonconforming may be vulnerable to discrimination and have difficulty accessing and receiving heath care, compared with their cisgender peers.
• Screen for health risks and identify barriers to care for TGNC youth while promoting and bolstering wellness within this community.
• Continue to promote access to gender affirming care. Data suggest that children who receive gender affirming care achieve mental health status similar to that of their cisgender peers.^3,4,5
• Continue to develop an understanding of how youth understand and express gender.
• Nonbinary youth face unique barriers when accessing health affirming services because of fears that their gender identity may be misunderstood. These barriers lead to delays in seeking health care services, which may lead to poorer outcomes. As providers, educating ourselves about these diverse identities and being respectful of all patients’ identities can help reduce these barriers.

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 Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. Pediatrics. 2018 Feb 5. doi: 10.1542/peds.2017-1683.

2. J Adolesc Health. 2017 Oct;61(4):521-6.

3. Pediatrics. 2018. doi: 10.1542/peds.2017-4079.

4. Pediatrics. 2014 Oct;134(4):696-704.

5. Pediatrics. 2016 Mar;137(3):e20153223.

As we providers begin to gain a better understanding of the complexities of gender identity and expression, studies examining the health of transgender and gender-nonconforming (TGNC) youth are emerging. Multiple studies have demonstrated the mental health disparities that TGNC youth face, but more studies examining other health risks and disparities are needed.

Prevalence of TGNC students higher than expected

The 2.7% prevalence of TGNC youth in this sample is higher than previously reported. Previous studies looking at prevalence rates of TGNC youth often dichotomized gender identities into binary (masculine or feminine) groups and were not inclusive of nonbinary and questioning identities. This may have led to underestimation of the size of this population.^2,3 This study assessed for TGNC identities by asking, “Do you consider yourself transgender, genderqueer, gender fluid, or unsure about your gender identity?” Given the prevalence of TGNC identities in this sample, it is likely that TGNC youth will be encountered in general pediatric practice. As such, it is important that we as providers continue to build our competency in working with this population.
 

Statistically significant differences in health status were identified

Almost two-thirds (62%) of TGNC youth identified their health as poor, fair, or good as opposed to very good or excellent, compared with one-third (33.1%) of cisgender youth. Over half (52%) of TGNC youth reported staying home from school because of illness at least once in the past month, compared with 43% of cisgender youth. About 60% of TGNC youth reported a preventive medical check-up in the past year, compared with 65% of cisgender youth. In terms of long-term health problems, TGNC youth reported higher rates of long-term physical (25% vs. 15%) and mental health (59% vs. 17%) problems than did their cisgender peers.

Role of perceived gender expression

A unique aspect of this study was that it sought to examine the effect of perceived gender expression (the way others interpret a person’s gender presentation; their appearance, style, dress, or the way they walk or talk) on health status and care utilization. Categories of perceived gender expression included very or mostly feminine, somewhat feminine, equally feminine and masculine, somewhat masculine, or very or mostly masculine. The prevalence of TGNC adolescents with an equally feminine and masculine gender expression was highest for both those assigned male (29%) and assigned female (41%) at birth, compared with other perceived gender presentations.

TGNC youth who were perceived to have a gender expression that was incongruent with the sex assigned at birth were at higher risk of reporting poor health status. For example, in TGNC participants who were assigned male at birth, those perceived as equally feminine and masculine (49%) or somewhat masculine (58%) were significantly more likely to report having poorer general health than those with a very masculine perceived gender expression (32%).
 

Suggestions for providers

The authors of the study and the accompanying commentary by Daniel Shumer, MD, MPH, suggest that there are things we as health care providers can do to address these barriers.

• Recognize that health disparities exist in this population. Individuals perceived as gender nonconforming may be vulnerable to discrimination and have difficulty accessing and receiving heath care, compared with their cisgender peers.
• Screen for health risks and identify barriers to care for TGNC youth while promoting and bolstering wellness within this community.
• Continue to promote access to gender affirming care. Data suggest that children who receive gender affirming care achieve mental health status similar to that of their cisgender peers.^3,4,5
• Continue to develop an understanding of how youth understand and express gender.
• Nonbinary youth face unique barriers when accessing health affirming services because of fears that their gender identity may be misunderstood. These barriers lead to delays in seeking health care services, which may lead to poorer outcomes. As providers, educating ourselves about these diverse identities and being respectful of all patients’ identities can help reduce these barriers.

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 Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. Pediatrics. 2018 Feb 5. doi: 10.1542/peds.2017-1683.

2. J Adolesc Health. 2017 Oct;61(4):521-6.

3. Pediatrics. 2018. doi: 10.1542/peds.2017-4079.

4. Pediatrics. 2014 Oct;134(4):696-704.

5. Pediatrics. 2016 Mar;137(3):e20153223.