POLICY STATEMENT
Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children
Ensuring Comprehensive Care and Jason Rafferty, MD, MPH, EdM, FAAP, COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, SupportCOMMITTEE ON ADOLESCENCE, for SECTION Transgender ON LESBIAN, GAY, BISEXUAL, AND TRANSGENDER and HEALTH Gender- AND WELLNESS Diverse Children and Adolescents As a traditionally underserved population that faces numerous health abstract disparities, youth who identify as transgender and gender diverse (TGD) and their families are increasingly presenting to pediatric providers for education, care, and referrals. The need for more formal training, standardized treatment, and research on safety and medical outcomes often Department of Pediatrics, Hasbro Children’s Hospital, Providence, leaves providers feeling ill equipped to support and care for patients that Rhode Island; Thundermist Health Centers, Providence, Rhode Island; and Department of Child Psychiatry, Emma Pendleton Bradley Hospital, identify as TGD and families. In this policy statement, we review East Providence, Rhode Island relevant concepts and challenges and provide suggestions for pediatric Dr Rafferty conceptualized the statement, drafted the initial providers that are focused on promoting the health and positive manuscript, reviewed and revised the manuscript, approved the final manuscript as submitted, and agrees to be accountable for all aspects development of youth that identify as TGD while eliminating discrimination of the work. and stigma. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of INTRODUCTION Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and In its dedication to the health of all children, the American Academy of external reviewers. However, policy statements from the American Pediatrics (AAP) strives to improve health care access and eliminate Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. disparities for children and teenagers who identify as lesbian, gay, The guidance in this statement does not indicate an exclusive course bisexual,1, transgender,2 or questioning (LGBTQ) of their sexual or gender of treatment or serve as a standard of medical care. Variations, taking identity. Despite some advances in public awareness and legal into account individual circumstances, may be appropriate. protections, youth who identify as LGBTQ continue to face disparities All policy statements from the American Academy of Pediatrics that stem from multiple sources, including inequitable laws and policies, automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. societal discrimination, and a lack of access to quality health care, including mental health care. Such challenges are often more intense for youth who do not conform to social expectations and norms regarding To cite: Rafferty J, AAP COMMITTEE ON PSYCHOSOCIAL gender. Pediatric providers are increasingly encountering such youth and ASPECTS OF CHILD AND FAMILY HEALTH, AAP COMMITTEE ON their families, who seek medical advice and interventions, yet they may ADOLESCENCE, AAP SECTION ON LESBIAN, GAY, BISEXUAL, AND TRANSGENDER HEALTH AND WELLNESS. Ensuring Com lack the formal training to care for youth that identify as transgender and 3 prehensive Care and Support for Transgender and Gender- gender diverse (TGD) and their families. Diverse Children and Adolescents. Pediatrics. 2018;142(4): This policy statement is focused specifically on children and youth that e20182162 identify as TGD rather than the larger LGBTQ population, providing brief, relevant background on the basis of current available research Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 142, number 4, October 2018:e20182162 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 1 Relevant Terms and Definitions Related to Gender Care Term Definition Sex An assignment that is made at birth, usually male or female, typically on the basis of external genital anatomy but sometimes on the basis of internal gonads, chromosomes, or hormone levels Gender identity A person’s deep internal sense of being female, male, a combination of both, somewhere in between, or neither, resulting from a multifaceted interaction of biological traits, environmental factors, self-understanding, and cultural expectations Gender expression The external way a person expresses their gender, such as with clothing, hair, mannerisms, activities, or social roles Gender perception The way others interpret a person’s gender expression Gender diverse A term that is used to describe people with gender behaviors, appearances, or identities that are incongruent with those culturally assigned to their birth sex; gender-diverse individuals may refer to themselves with many different terms, such as transgender, nonbinary, genderqueer,7 gender fluid, gender creative, gender independent, or noncisgender.“ Gender diverse” is used to acknowledge and include the vast diversity of gender identities that exists. It replaces the former term, “gender nonconforming,” which has a negative and exclusionary connotation. Transgender A subset of gender-diverse youth whose gender identity does not match their assigned sex and generally remains persistent, consistent, and insistent over time; the term “transgender” also encompasses many other labels individuals may use to refer to themselves. Cisgender A term that is used to describe a person who identifies and expresses a gender that is consistent with the culturally defined norms of the sex they were assigned at birth Agender A term that is used to describe a person who does not identify as having a particular gender Affirmed gender When a person’s true gender identity, or concern about their gender identity, is communicated to and validated from others as authentic MTF; affirmed female; Terms that are used to describe individuals who were assigned male sex at birth but who have a gender identity and/or expression trans female that is asserted to be more feminine FTM; affirmed male; Terms that are used to describe individuals who were assigned female sex at birth but who have a gender identity and/or expression trans male that is asserted to be more masculine Gender dysphoria A clinical symptom that is characterized by a sense of alienation to some or all of the physical characteristics or social roles of one’s assigned gender; also, gender dysphoria is the psychiatric diagnosis in the DSM-5, which has focus on the distress that stems from the incongruence between one’s expressed or experienced (affirmed) gender and the gender assigned at birth. Gender identity A psychiatric diagnosis defined previously in the DSM-IV (changed to “gender dysphoria” in the DSM-5); the primary criteria include a disorder strong, persistent cross-sex identification and significant distress and social impairment. This diagnosis is no longer appropriate for use and may lead to stigma, but the term may be found in older research. Sexual orientation A person’s sexual identity in relation to the gender(s) to which they are attracted; sexual orientation and gender identity develop separately.
This list is not intended to be all inclusive. The pronouns “they” and ”their” are used intentionally to be inclusive rather than the binary pronouns “he” and “she” and “his” and “her.” Adapted from Bonifacio HJ, Rosenthal SM. Gender variance and dysphoria in children and adolescents. Pediatr Clin North Am. 2015;62(4):1001–1016. Adapted from Vance SR Jr, Ehrensaft D, Rosenthal SM. Psychological and medical care of gender nonconforming youth. Pediatrics. 2014;134(6):1184–1192. DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; FTM, female to male; MTF, male to female.
“ ” “ ” “ ” “ ” and expert opinion from clinical and Sex, or natal gender, is a label, refers to the wide array of ways research leaders, which will serve generally male or female, that people display their gender through as the basis for recommendations. is typically assigned at birth on clothing, hair styles, mannerisms, or It is not a comprehensive review of the basis of genetic and anatomic social roles. Exploring different ways clinical approaches and nuances to characteristics, such as genital of expressing gender is common “ pediatric care for children and youth anatomy, chromosomes, and sex for children and may challenge ” ’ that identify as TGD. Professional social expectations. The way others hormone levels. Meanwhile, gender “ ” understanding of youth that identity is one s internal sense of interpret this expression is referred identify as TGD is a rapidly evolving who one is, which results from a to as gender5,6 perception clinical field in which research on multifaceted interaction of biological (Table 1). appropriate clinical management is traits, developmental influences, 3,4 “ ” limited by insufficient funding. and environmental conditions. It These labels may or may not be DEFINITIONS may be male, female, somewhere congruent. The term cisgender in between, a combination of both, is used if someone identifies and or neither (ie, not conforming to a expresses a gender that is consistent binary conceptualization of gender). with the culturally defined norms of “ ” Self-recognition of gender identity To clarify recommendations and ’ the sex that was assigned at birth. discussions in this policy statement, develops over time, much the same Gender diverse is an umbrella term some definitions are provided. way as a child s physical body does. to describe an ever-evolving array of However, brief descriptions of For some people, gender identity labels that people may apply when “ ” human behavior or identities may not can be fluid, shifting in different their gender identity, expression, or capture nuance in this evolving field. contexts. Gender expression even perception does not conform Downloaded from www.aappublications.org/news by guest on September 26, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS to the norms and stereotypes extrapolated from individual states incongruence between their assigned “ ” 23 others expect of their assigned sex. or specialty clinics, and is likely an sex and their gender identity. Transgender is usually reserved underestimate given the stigma for a subset of such youth whose regarding those who openly identify There is no evidence that risk “ ” ’ gender identity does not match their as transgender and the difficulty in for mental illness is inherently assigned sex and generally remains defining transgender in a way that attributable to one s identity of TGD. Rather, it is believed to be persistent, consistent, and insistent is inclusive11 of all gender-diverse ’ over time. These terms are not identities. multifactorial, stemming from an diagnoses; rather, they are personal internal conflict between one s ’ and often dynamic ways of describing There have been no large-scale appearance and identity, limited one s own gender experience. prevalence studies among children availability of mental health services, “ ” and adolescents, and there is no low access to health care providers Gender identity is not synonymous ’ evidence that adult statistics reflect with expertise in caring for youth with sexual orientation, which young children or adolescents. In who identify as TGD, discrimination, refers to a person s identity in 24 the 2014 Behavioral Risk Factor stigma, and social rejection. This relation to the gender(s) to which Surveillance System, those 18 to was affirmed by the American they are sexually and romantically 25 24 years of age were more likely Psychological Association in 2008 attracted. Gender identity and than older age groups to identify (with practice guidelines released in sexual orientation are distinct but 9 8 8 as transgender (0.7%). Children 2015 ) and the American Psychiatric interrelated constructs. Therefore, report being aware of gender Association, which made the being transgender does not imply a incongruence at young ages. Children Beingfollowing transgender statement or gender in 2012: variant sexual orientation, and people who who later identify as TGD report first implies no impairment in judgment, “ ” identify as transgender still identify having recognized their gender as stability, reliability, or general social or as straight, gay,The bisexual, Gender Book etc, on the different at an average age of vocational capabilities; however, these individuals often experience discrimination basis of their attractions. (For more 8.5 years; however, they did not information, , found due to a lack of civil rights protections disclose such feelings until12 an for their gender identity or expression.… at www.thegenderbook .com, is a average of 10 years later. [Such] discrimination and lack of equal resource with illustrations that are civil rights is damaging to the mental used to highlight these core terms MENTAL HEALTH IMPLICATIONS health of transgender and gender variant and concepts.) individuals 26 EPIDEMIOLOGY . Adolescents and adults who identify as transgender have high– rates of Youth who identify as TGD often
In population-based surveys, depression, anxiety, eating13 20 disorders, confront stigma and discrimination, questions related to gender identity self-harm, and suicide. Evidence which contribute to feelings of are rarely asked, which makes suggests that an identity of TGD rejection and isolation that can it difficult to assess the size and has an increased prevalence among adversely affect physical and characteristics of the population individuals with autism spectrum emotional well-being. For example, that is TGD. In the 2014 Behavioral disorder, but this association21,22 is many youth believe that they Risk Factor Surveillance System of not yet well understood. In 1 must hide their gender identity the Centers for Disease Control and retrospective cohort study, 56% of and expression to avoid bullying, Prevention, only 19 states elected to youth who identified as transgender harassment, or victimization. Youth include optional questions on gender reported previous suicidal ideation, who identify as TGD experience identity. Extrapolation from these and 31% reported a previous disproportionately high rates of data suggests that the US prevalence suicide attempt, compared with homelessness, physical violence “ ” of adults who identify as transgender 20% and 11% among matched (at home and in the community),– or gender nonconforming is youth who identified13 as cisgender, substance abuse, 5,and6, 12, high-risk27 31 0.6% (1.4 million), ranging from respectively. Some youth who sexual behaviors. Among
0.3% in North9 Dakota to 0.8% identify as TGD also experience the 3 million HIV testing events that in Hawaii. On the basis of these gender dysphoria, which is a were reported in 2015, the highest data, it has been estimated that specific diagnosis given to those percentages of new infections were ∼ 0.7% of youth ages 13 to 17 years 10 who experience impairment in peer among women32 who identified as ( 150000) identify as transgender. and/or family relationships, school transgender and were also at
This number is much higher than performance, or other aspects of particular risk30 for not knowing their previous estimates, which were their life as a consequence of the HIV status. Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 142, number 4, October 2018 3 GENDER-AFFIRMATIVE CARE
of evidence that suggests that using particularly from pediatric to adult In a gender-affirmative care model an integrated affirmative model providers. results in young people having (GACM), pediatric providers offer DEVELOPMENTAL CONSIDERATIONS developmentally appropriate fewer mental health concerns care that is oriented toward whether they ultimately24,36, 37 identify ’ as transgender“ . ” understanding and appreciating the “ ” youth s gender experience. A strong, In contrast, conversion or Acknowledging that the capacity nonjudgmental partnership with reparative treatment models for emerging abstract thinking youth and their families can facilitate are used to prevent children and in childhood is important to exploration of complicated emotions adolescents from identifying as conceptualize and reflect on identity, and gender-diverse expressions transgender or to dissuade them gender-affirmation guidelines are while allowing questions and from exhibiting gender-diverse being focused on individually tailored interventions on the basis of the concerns to be5 raised in a supportive expressions. The Substance environment. In a GACM, the Abuse and Mental Health Services physical and cognitive development45 •following• messages are conveyed: Administration has concluded of youth who identify as TGD. ’ Accordingly, research substantiates transgender identities and that any therapeutic intervention with the goal of changing a youth s that children who are prepubertal diverse gender expressions do not and assert an identity of TGD know •• constitute a mental disorder; gender expression33 or identity is inappropriate. Reparative their gender as clearly and as variations in gender identity consistently as their developmentally approaches have been proven38 to and expression are normal be not only unsuccessful but also equivalent peers who identify as aspects of human diversity, and cisgender and benefit from the deleterious and are considered– 46 binary definitions of gender do not same level of social acceptance. outside the mainstream of 29,39 42 always reflect emerging gender traditional medical practice. This developmental approach to •• identities; “ gender affirmation is in contrast to The AAP described reparative ’ ” the outdated approach in which a gender identity evolves as an approaches43 as unfair and “ ” child s gender-diverse assertions interplay of biology, development, deceptive* . At the time of this •• socialization, and culture; and writing, conversion therapy was are held as possibly true until an banned by executive regulation arbitrary age (often after pubertal if a mental health issue exists, onset) when they can be considered it most often stems from stigma in New York and by legislative “ statutes in 9 other states as well valid, an approach that authors of and negative experiences 44 ” as the District of Columbia. the literature have termed watchful rather than27,33 being intrinsic to waiting. This outdated approach the child. Pediatric providers have an does not serve the child because The GACM is best facilitated essential role in assessing gender critical support is withheld. Watchful through the integration of medical, concerns and providing evidence- waiting is based on binary notions of mental health, and social services, based information to assist youth gender in which gender diversity and including specific resources and families in medical decision- fluidity is pathologized; in watchful making. Not doing so can prolong and supports24 for parents and waiting, it is also assumed that families. Providers work together or exacerbate gender dysphoria notions of gender identity become ’ and contribute to abuse and to destigmatize gender variance, 35 fixed at a certain age. The approach promote the child s self-worth, stigmatization. If a pediatric is also influenced by a group of facilitate access to care, educate provider does not feel prepared to early studies with validity concerns, families, and advocate for safer address gender concerns when they methodologic flaws, and limited community spaces where children occur, then referral to a pediatric or follow-up on children who identified are free to develop and explore mental health provider with more as TGD and, by adolescence, 5 expertise is appropriate. There is “ ” their gender. A specialized did not seek further45,47 treatment gender-affirmative therapist, little research on communication ( desisters ). More robust and when available, may be an asset in and efficacy with transfers in care current research suggests that, helping children and their families for youth who identify as TGD, rather than focusing on who a child build skills for dealing with gender- will become, valuing them for who based stigma, address symptoms of * For more information regarding state-specific they are, even at a young age, fosters ’ laws, please contact the AAP Division of State anxiety or depression, and reinforce34,35 Government Affairs at stgov@ aap.org. secure attachment and resilience, the child s overall resiliency. not only for the5,45, child48, 49 but also for the There is a limited but growing body whole family. Downloaded from www.aappublications.org/news by guest on September 26, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS MEDICAL MANAGEMENT
related to LGBTQ health issues, suspended, then20,57, 58endogenous puberty including information for children will resume. Pediatric primary care providers who identify as TGD and families, are in a unique position to routinely Often, pubertal suppression creates reveals inclusivity and awareness. inquire about gender development an opportunity to reduce distress Generally, patients who identify as in children and adolescents as part50 of that may occur with the development recommended well-child visits and TGD feel most comfortable when of secondary sexual characteristics to be a reliable source of validation, they have access to a gender-neutral and allow for gender-affirming care, support, and reassurance. They restroom. Diversity training that including mental health support are often the first provider to be encompasses sensitivity when for the adolescent and the family. aware that a child may not identify caring for youth who identify as It reduces the need for later surgery TGD and their families can be because physical changes that are as cisgender or that there may be ’ distress related to a gender-diverse helpful in educating clinical and otherwise irreversible (protrusion identity. The best way to approach administrative staff. A patient- of the Adam s apple, male pattern gender with patients is to inquire asserted name and pronouns are baldness, voice change, breast directly and nonjudgmentally about used by staff and are ideally reflected growth, etc) are prevented. The in the electronic medical record 52,53 their experience and27, feelings51 before available data reveal that pubertal applying any labels. without creating duplicate charts. suppression in children who identify The US Centers for Medicare and as TGD generally leads to improved Many medical interventions can be Medicaid Services and the National psychological functioning in offered to youth who identify as TGD – Coordinator for Health Information adolescence and young and their families. The decision of 20,57 59 Technology require all electronic adulthood. whether and when to initiate gender- health record systems certified affirmative treatment is personal Pubertal suppression is not under the Meaningful Use incentive ’ and involves careful consideration program to have the capacity to without risks. Delaying puberty of risks, benefits, and other factors beyond one s peers can also be confidentially collect54, 55 information unique to each patient and family. on gender identity. Explaining stressful and can lead to lower Many protocols suggest that clinical and maintaining confidentiality self-esteem60 and increased risk assessment of youth who identify procedures promotes openness and taking. Some experts believe that as TGD is ideally conducted on an genital underdevelopment may trust, particularly with1 youth who ongoing basis in the setting of a identify as LGBTQ. Maintaining a limit some61 potential reconstructive collaborative, multidisciplinary safe clinical space can provide at options. Research on long-term approach, which, in addition to the least 1 consistent, protective refuge risks, particularly62 in terms63 of bone patient and family, may include the for patients and families, allowing metabolism and fertility, pediatric provider, a mental health is currently limited and provides authentic gender expression and 57,64, 65 provider (preferably with expertise exploration that builds resiliency. varied results. Families often in caring for youth who identify as Pubertal Suppression look to pediatric providers for help TGD ), social and legal supports, in considering whether pubertal ’ and a pediatric endocrinologist suppression is indicated in the or adolescent-medicine6,28 gender context of their child s overall well- specialist, if available. There is Gonadotrophin-releasing hormones beingGender as Affirmation gender diverse. no prescribed path, sequence, or have been used to delay puberty end point. Providers can make every since the 1980s for central56 effort to be aware of the influence of precocious puberty. These As youth who identify as TGD their own biases. The medical options reversible treatments can also be reflect on and evaluate their gender also vary depending on pubertal and used in adolescents who experience identity, various interventions Clinicaldevelopmental Setting progression. gender dysphoria to prevent may be considered to better align development of secondary sex their gender expression with their characteristics and provide time up underlying identity. This process of “ In the past year, 1 in 4 adults who until 16 years of age for reflection, acceptance, and, for some, ’ ” identified as transgender avoided a the individual and the family to intervention is known as gender “ ” necessary doctor s visit because31 of explore gender identity, access affirmation. It was formerly referred fear of being mistreated. All clinical psychosocial supports, develop to as transitioning, but many ’ office staff have a role in affirming coping skills, and further define view the process as an affirmation a patient s gender identity. Making appropriate treatment goals. If and acceptance of who they have flyers available or displaying posters pubertal suppression treatment is always been rather than a transition Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 142, number 4, October 2018 5 TABLE 2 The Process of Gender Affirmation May Include≥ 1 of the Following Components Component Definition General Age Rangea Reversibilitya Social affirmation Adopting gender-affirming hairstyles, clothing, Any Reversible name, gender pronouns, and restrooms and other facilities Puberty blockers Gonadotropin-releasing hormone analogues, During puberty (Tanner stage 2–5)b Reversiblec such as leuprolide and histrelin Cross-sex hormone therapy Testosterone (for those who were assigned Early adolescence onward Partially reversible (skin texture, female at birth and are masculinizing); muscle mass, and fat deposition); estrogen plus androgen inhibitor (for those irreversible once developed who were assigned male at birth and are (testosterone: Adam’s apple feminizing) protrusion, voice changes, and male pattern baldness; estrogen: breast development); unknown reversibility (effect on fertility) Gender-affirming surgeries “Top” surgery (to create a male-typical Typically adults (adolescents on case- Not reversible chest shape or enhance breasts); by-case basisd) “bottom” surgery (surgery on genitals or reproductive organs); facial feminization and other procedures Legal affirmation Changing gender and name recorded on Any Reversible birth certificate, school records, and other documents a Note that the provided age range and reversibility is based on the little data that are currently available. b There is limited benefit to starting gonadotropin-releasing hormone after Tanner stage 5 for pubertal suppression. However, when cross-sex hormones are initiated with a gradually increasing schedule, the initial levels are often not high enough to suppress endogenous sex hormone secretion. Therefore, gonadotropin-releasing hormone may be continued in accordance with the Endocrine Society Guidelines.68 c The effect of sustained puberty suppression on fertility is unknown. Pubertal suppression can be, and often is indicated to be, followed by cross-sex hormone treatment. However, when cross-sex hormones are initiated without endogenous hormones, then fertility may be decreased.68 d Eligibility criteria for gender-affirmative surgical interventions among adolescents are not clearly defined between established protocols and practice. When applicable, eligibility is usually determined on a case-by-case basis with the adolescent and the family along with input from medical, mental health, and surgical providers.68–71
35 ≥68 from 1 gender identity to another. Health and Endocrine Society can best support families by Accordingly, some people who have recommendations and include 1 of anticipating and discussing such “ gone through the process prefer to the following elements (Table 2): complexity proactively, either ” “ call themselves affirmed females, in their own practice or through ” 1. Social Affirmation: This is a males, etc (or just females, males, enlisting a qualified mental health “ ” reversible intervention in which etc ), rather than using the prefix provider. children and adolescents express trans-. Gender affirmation is also partially or completely in their used to acknowledge that some 2. Legal Affirmation: Elements of asserted gender identity by individuals who identify as TGD a social affirmation, such as a adapting hairstyle, clothing, may feel affirmed in their gender name and gender marker, become pronouns, name, etc. Children without pursuing medical or surgical official on legal documents, such 7,66 who identify as transgender and interventions. as birth certificates, passports, socially affirm and are supported identification cards, school Supportive involvement of parents in their asserted gender show no documents, etc. The processes and family is associated with increase in depression and only for making these changes depend better mental67 and physical health minimal (clinically insignificant) on state laws and may require outcomes. Gender affirmation increases in anxiety compared48 specific documentation from among adolescents with gender with age-matched averages. pediatric providers. dysphoria often reduces the Social affirmation can be emphasis on gender in their lives, complicated given the wide range 3. Medical Affirmation: This is allowing them to attend to other of social interactions children the process of using cross-sex developmental tasks, such as have (eg, extended families, peers, hormones to allow adolescents academic success, relationship school, community, etc). There who have initiated puberty building, and64 future-oriented is little guidance on the best to develop secondary sex planning. Most protocols for approach (eg, all at once, gradual, characteristics of the opposite gender-affirming interventions creating new social networks, biological sex. Some changes are incorporate World Professional or affirming within existing partially reversible if hormones Association of Transgender networks, etc). Pediatric providers are stopped, but others become Downloaded from www.aappublications.org/news by guest on September 26, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS irreversible once they are fully but unplanned pregnancies have who identified as transgender
developed (Table 2). been reported, which emphasizes were denied insurance coverage31 the need for ongoing contraceptive because of being transgender. 4. Surgical Affirmation: Surgical counseling with youth who identify The burden of covering medical approaches may be used to 72 as TGD. expenses that are not covered feminize or masculinize features, HEALTH DISPARITIES by insurance can be financially such as hair distribution, chest, or devastating, and even when expenses genitalia, and may include removal are covered, families describe high of internal organs, such as ovaries levels of stress in navigating and or the uterus (affecting fertility). In addition to societal challenges, 78 submitting claims appropriately. These changes are irreversible. youth who identify as TGD face In 2012, a large gender center in Although current protocols several barriers within the health Boston, Massachusetts, reported typically reserve surgical care system, especially regarding 35,68 that most young patients who interventions for adults, they access to care. In 2015, a focus identified as transgender and were are occasionally pursued during group of youth who identified as deemed appropriate candidates for adolescence on a case-by-case transgender in Seattle, Washington, ’ recommended gender care were basis, considering the necessity revealed 4 problematic areas related unable to obtain it because of such and benefit to the adolescent s to health care: denials, which were based on the overall health and often including 1. safety issues, including the lack premise that gender dysphoria was multidisciplinary input from of safe clinical environments a mental disorder, not a physical medical, mental health, and – and fear of discrimination by one, and that treatment was not surgical providers as well as from 24 69 71 providers; medically or surgically necessary. the adolescent and family. 2. poor access to physical health This practice not only contributes to For some youth who identify as services, including testing for stigma, prolonged gender dysphoria,77 TGD whose natal gender is female, sexually transmitted infections; and poor mental health outcomes, menstruation, breakthrough but it may also lead patients to seek 3. inadequate resources to address bleeding, and dysmenorrhea can nonmedically supervised treatments24 lead to significant distress before mental health concerns; and that are potentially dangerous. Furthermore, insurance denials can or during gender affirmation. The 4. lack of continuity74 with American College of Obstetrics providers. reinforce a socioeconomic divide and Gynecology suggests that, between those who can finance the This study reveals the obstacles many although limited data are high costs of uncovered care and youth who identify as TGD face in 24,77 available to outline management, those who cannot. accessing essential services, including menstruation can be managed the limited supply of appropriately without exogenous estrogens by The transgender youth group in trained medical and psychological using a progesterone-only pill, Seattle likely reflected the larger TGD providers, fertility options, and a medroxyprogesterone acetate population when they described how insurance coverage denials for shot, or a progesterone-containing 74 obstacles adversely affect self-esteem 72 gender-related treatments. intrauterine or implantable device. and contribute to the perception
If estrogen can be tolerated, oral Insurance denials for services related that they are undervalued by74, 77society contraceptives that contain both to the care of patients who identify and the health care system. progesterone and estrogen are more73 as TGD are a significant barrier. Professional medical associations, effective at suppressing menses. Although the Office for Civil Rights including the AAP, are increasingly The Endocrine Society guidelines of the US Department of Health and calling for equity in health care also suggest that gonadotrophin- Human Services explicitly stated in provisions regardless of1,8, gender23, 72 releasing hormones can be used for 2012 that the nondiscrimination identity or expression. menstrual suppression before the provision in the Patient Protection There is a critical need for anticipated initiation of testosterone and Affordable Care Act includes investments in research on the or in combination with testosterone people who75,76 identify as gender prevalence, disparities, biological for breakthrough bleeding (enables diverse, insurance claims for underpinnings, and standards of phenotypic masculinization at a gender affirmation, particularly care relating to gender-diverse lower dose than68 if testosterone among youth who identify as54, 77 populations. Pediatric providers is used alone). Masculinizing TGD, are frequently denied. who work with state government hormones in natal female patients In 1 study, it was found that and insurance officials can play may lead to a cessation of menses, approximately 25% of individuals an essential role in advocating for Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 142, number 4, October 2018 7 ’ stronger nondiscrimination policies which is essential for the child– s denial, anger, feelings of betrayal,89 and improved coverage. self-esteem, social involvement,48,85 87 and fear, self-discovery, and pride. The overall health as TGD. Some amount of time spent in any of these There is a lack of quality research on caution has been expressed that stages and the overall pace varies the experience of youth of color who unquestioning acceptance per se may widely. Many family members also identify as transgender. One theory not best serve questioning youth or struggle as they are pushed to reflect suggests that the intersection of their families. Instead, psychological on their own gender experience racism, transphobia, and sexism may evidence suggests that the most and assumptions throughout this result in the extreme marginalization benefit comes when family members process. In some situations, youth that is experienced among many and youth are supported and who identify as TGD may be at women of color who identify as 79 encouraged to engage in reflective risk for internalizing the difficult transgender, including rejection ’ perspective taking and validate their emotions that family members may from their family and dropping out own and the other s thoughts and be experiencing. In these cases, of school at younger ages (often in 49,82 feelings despite divergent views. individual and group therapy for the the setting of rigid religious beliefs 49,78 80 family members may be helpful. In this regard, suicide attempt rates regarding gender), increased levels81 “ ” of violence and body objectification, among 433 adolescents in Ontario Family dynamics can be complex,
3 times the risk of poverty compared31 who identified as trans were involving disagreement among legal with the general population, 4% among those with strongly guardians or between guardians and the highest prevalence of HIV supportive parents and as high as and their children, which may compared with other risk groups 60% among those whose85 parents affect the ability to obtain consent (estimated as high30 as 56.3% in 1 were not supportive. Adolescents for any medical management or meta-analysis). One model suggests who identify as transgender and interventions. Even in states where that pervasive stigma and oppression endorse at least 1 supportive person minors may access care without can be associated with psychological in their life report significantly parental consent for mental health distress (anxiety, depression, less distress than those who only services, contraception, and sexually and suicide) and adoption of risk experience rejection. In communities transmitted infections, parental behaviors by such youth to obtain with high levels of support, it was or guardian consent is required a sense of validation79 toward their found that nonsupportive families for hormonal and surgical care72, of90 complex identities. tended to increase their support patients who identify as TGD. FAMILY ACCEPTANCE over time, leading to dramatic Some families may take issue with improvement in mental health providers who address gender
outcomes among their children88 who concerns or offer gender-affirming identified as transgender. care. In rare cases, a family may deny Research increasingly suggests that ’ access to care that raises concerns familial acceptance or rejection Pediatric providers can create a about the youth s welfare and safety; ultimately has little influence on the safe environment for parents and ’ in those cases, additional legal or gender identity of youth; however, it families to better understand and ethical support may be useful to may profoundly affect young people s listen to the needs of their children consider. In such rare situations, ability to openly discuss or disclose while receiving reassurance and 83 pediatric providers may want to concerns about their identity. education. It is often appropriate to ’ familiarize themselves with relevant Suppressing such concerns can affect assist the child in understanding the 82 local consent laws and maintain their mental health. Families often find it parents concerns as well. Despite ’ primary responsibility for the welfare hard to understand and accept their expectations by some youth with “ ” of the child. child s gender-diverse traits because transgender identity for immediate of personal beliefs, social pressure, acceptance after coming out, SAFE SCHOOLS AND COMMUNITIES 49,83 ’ and stigma. Legitimate fears family members often proceed may exist for their child s welfare, through a process of becoming more ’ safety, and acceptance that pediatric comfortable and understanding of Youth who identify as TGD are providers need to appreciate and the youth s gender identity, thoughts, becoming more visible because address. Families can be encouraged and feelings. One model suggests gender-diverse expression is to communicate their concerns that the process resembles grieving, increasingly admissible in the and questions. Unacknowledged wherein the family separates from media, on social media, and concerns can contribute to shame their expectations for their child to in schools and communities. and hesitation in regard to offering84 embrace a new reality. This process Regardless of whether a support and understanding, may proceed through stages of shock, youth with a gender-diverse Downloaded from www.aappublications.org/news by guest on September 26, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS identity ultimately identifies as and respected at school, but for consistent across districts. In 2015, transgender, challenges exist in youth who identify as TGD, this can GLSEN found that 43% of children nearly every social context, from be challenging. Nearly every aspect who identified as LGBTQ reported lack of understanding to outright of school life may present safety feeling unsafe at school because of rejection, isolation, discrimination, concerns and require negotiations their gender expression, but only and victimization. In the US regarding their gender expression, 6% reported that their school had
Transgender Survey of nearly including name/pronoun use, use official policies to support youth ’ 28 000 respondents, it was found of bathrooms and locker rooms, who identified as TGD, and only that among those who were out sports teams, dances and activities, 11% reported that their school s as or perceived to be TGD between overnight activities, and even peer antibullying policies had specific 91 kindergarten and eighth grade, groups. Conflicts in any of these protections for gender expression. ’ 54% were verbally harassed, areas can quickly escalate beyond Consequently, more than half of 24% were physically assaulted, the school s control to larger debates the students who identified as and 13% were sexually assaulted; among the community and even on a transgender in the study were
17% left school31 because of national stage. prevented from using the bathroom, maltreatment. Education names, or pronouns that aligned with The formerly known Gay, Lesbian, and advocacy from the medical their asserted gender at school. and Straight Education Network community on the importance A lack of explicit policies that (GLSEN), an advocacy organization of safe schools for youth who protected youth who identified as for youth who identify as LGBTQ, identify as TGD can have a TGD was associated with increased conducts an annual national survey significant effect. reported victimization, with * to measure LGBTQ well-being in more than half of students who At the time of this writing, only US schools. In 2015, students who identified as LGBTQ reporting verbal 18 states and the District of identified as LGBTQ reported high harassment because of their gender Columbia had laws that prohibited rates of being discouraged from expression. Educators and school discrimination based on gender participation in extracurricular administrators play an essential expression when it comes to activities. One in 5 students who role in advocating for and enforcing employment, housing, public identified as LGBTQ reported such policies. GLSEN found that accommodations, and insurance being hindered from forming or when students recognized actions benefits. Over 200 US cities have participating in a club to support to reduce gender-based harassment, such legislation. In addition to lesbian, gay, bisexual, or transgender both students who identified as basic protections, many youth students (eg, a gay straight alliance, transgender and cisgender reported who identify as TGD also have to now often referred to as a genders a greater connection to staff and navigate legal obstacles when it and sexualities alliance) despite such 91 feelings of safety. In another study, comes to legally changing their54 clubs at schools being associated schools were open to education name and/or gender marker. with decreased reports of negative regarding gender diversity and In addition to advocating and remarks about sexual orientation were willing to implement policies working with policy makers or gender expression, increased when they were supported by to promote equal protections feelings of safety and connectedness external agencies, such as medical for youth who identify as TGD, at school, and lower levels of 92 professionals. pediatric providers can play an victimization. In addition, >20% of important role by developing a students who identified as LGBTQ Academic content plays an familiarity with local laws and reported being blocked from writing important role in building a organizations that provide social about LGBTQ issues in school safe school environment as well. work and legal assistance to youth yearbooks or school newspapers The 2015 GLSEN survey revealed who identify as TGD and their or being prevented or discouraged that when positive representations families. by coaches and school staff from of people who identified as LGBTQ participating in sports because of School environments play a were included in the curriculum, their sexual orientation or gender significant role in the social and 91 students who identified as LGBTQ expression. emotional development of children. reported less hostile school Every child has a right to feel safe One strategy to prevent conflict environments, less victimization * For more information regarding state-specific is to proactively support policies and greater feelings of safety, laws, please contact the AAP Division of State Government Affairs at stgov@ aap.org. and protections that promote fewer school absences because inclusion and safety of all students. of feeling unsafe, greater feelings However, such policies are far from of connectedness to their school Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 142, number 4, October 2018 9 RECOMMENDATIONS community, and an increased with school districts and interest in high school graduation other community organizations 91 The AAP works toward all children and postsecondary education. to promote acceptance and * and adolescents, regardless of At the time of this writing, 8 states inclusion of all children without gender identity or expression, had laws that explicitly forbade fear of harassment, exclusion, receiving care to promote optimal teachers from even discussing or bullying because of gender 54 physical, mental, and social well- LGBTQ issues. expression; being. Any discrimination based on MEDICAL EDUCATION gender identity or expression, real 7. that pediatricians have a role in or perceived, is damaging to the advocating for policies and laws socioemotional health of children, that protect youth who identify One of the most important ways families, and society. In particular, as TGD from discrimination and to promote high-quality health the AAP recommends the following: violence; care for youth who identify as TGD and their families is increasing 1. that youth who identify as TGD 8. that the health care workforce the knowledge base and clinical have access to comprehensive, protects diversity by offering experience of pediatric providers gender-affirming, and equal employment opportunities in providing culturally competent developmentally appropriate and workplace protections, care to such populations, as health care that is provided in a regardless of gender identity or recommended by the recently safe and inclusive clinical space; expression; and released guidelines by the 2. that family-based therapy 9. that the medical field and federal Association93 of American Medical and support be available to government prioritize research Colleges. This begins with the recognize and respond to the that is dedicated to improving the medical school curriculum in areas emotional and mental health quality of evidence-based care for such as human development, sexual – needs of parents, caregivers, youth who identify as TGD. LEAD AUTHOR health, endocrinology, pediatrics, and siblings of youth who and psychiatry. In a 2009 2010 identify as TGD; Jason Richard Rafferty, MD, MPH, EdM, FAAP survey of US medical schools, it was found that the median number of 3. that electronic health records, CONTRIBUTOR billing systems, patient-centered hours dedicated to LGBTQ health Robert Garofalo, MD, FAAP was 5, with one-third of US medical notification systems, and clinical research be designed to respect schools reporting no LGBTQ COMMITTEE ON PSYCHOSOCIAL ASPECTS the asserted gender identity of curriculum94 during the clinical OF CHILD AND FAMILY HEALTH, 2017–2018 years. each patient while maintaining confidentiality and avoiding Michael Yogman, MD, FAAP, Chairperson During residency training, there duplicate charts; Rebecca Baum, MD, FAAP is potential for gender diversity to Thresia B. Gambon, MD, FAAP be emphasized in core rotations, 4. that insurance plans offer Arthur Lavin, MD, FAAP especially in pediatrics, psychiatry, coverage for health care that Gerri Mattson, MD, FAAP family medicine, and obstetrics and is specific to the needs of Lawrence Sagin Wissow, MD, MPH, FAAP gynecology. Awareness could be youth who identify as TGD, promoted through the inclusion of including coverage for medical, LIAISONS psychological, and, when topics relevant to caring for children Sharon Berry, PhD, LP – Society of Pediatric who identify as TGD in the list of indicated, surgical gender- Psychology core competencies published by affirming interventions; Ed Christophersen, PhD, FAAP – Society of Pediatric Psychology the American Board of Pediatrics, 5. that provider education, including certifying examinations, and Norah Johnson, PhD, RN, CPNP-BC – National medical school, residency, and Association of Pediatric Nurse Practitioners relevant study materials. Continuing continuing education, integrate Amy Starin, PhD, LCSW – National Association of education and maintenance of core competencies on the Social Workers certification activities can include emotional and physical health Abigail Schlesinger, MD – American Academy of topics relevant to TGD populations needs and best practices for the Child and Adolescent Psychiatry as well. care of youth who identify as TGD * For more information regarding state-specific and their families; STAFF laws, please contact the AAP Division of State Karen S. Smith Government Affairs at stgov@ aap.org. 6. that pediatricians have a role in James Baumberger advocating for, educating, and developing liaison relationships Downloaded from www.aappublications.org/news by guest on September 26, 2021 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS COMMITTEE ON ADOLESCENCE, STAFF ACKNOWLEDGMENTS 2017–2018 Karen Smith Cora Breuner, MD, MPH, FAAP, Chairperson SECTION ON LESBIAN, GAY, BISEXUAL, AND Elizabeth M. Alderman, MD, FSAHM, FAAP We thank Isaac Albanese, MPA, and Laura K. Grubb, MD, MPH, FAAP TRANSGENDER HEALTH AND WELLNESS Jayeson Watts, LICSW, for their Makia E. Powers, MD, MPH, FAAP EXECUTIVE COMMITTEE, 2016–2017 thoughtful reviews and contributions. Krishna Upadhya, MD, FAAP Lynn Hunt, MD, FAAP, Chairperson Stephenie B. Wallace, MD, FAAP Anne Teresa Gearhart, MD, FAAP ABBREVIATIONS Christopher Harris, MD, FAAP LIAISONS Kathryn Melland Lowe, MD, FAAP Chadwick Taylor Rodgers, MD, FAAP Laurie Hornberger, MD, MPH, FAAP – Section on AAP: American Academy of Ilana Michelle Sherer, MD, FAAP Adolescent Health Pediatrics Liwei L. Hua, MD, PhD – American Academy of Child and Adolescent Psychiatry FORMER EXECUTIVE COMMITTEE MEMBERS GACM: gender-affirmative care Margo A. Lane, MD, FRCPC, FAAP – Canadian Ellen Perrin, MD, MA, FAAP model Paediatric Society GLSEN: Gay, Lesbian, and Meredith Loveless, MD, FACOG – American College LIAISON Straight Education of Obstetricians and Gynecologists Joseph H. Waters, MD – AAP Section on Pediatric Network Seema Menon, MD – North American Trainees Society of Pediatric and Adolescent LGBTQ: lesbian, gay, bisexual, Gynecology transgender, or STAFF CDR Lauren B. Zapata, PhD, MSPH – Centers for questioning Disease Control and Prevention Renee Jarrett, MPH TGD: transgender and gender diverse DOI: https://doi.org/10.1542/peds.2018-2162
Address correspondence to Jason Rafferty, MD, MPH, EdM, FAAP. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2018 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
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Downloaded from www.aappublications.org/news by guest on September 26, 2021 Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents Jason Rafferty, COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, COMMITTEE ON ADOLESCENCE and SECTION ON LESBIAN, GAY, BISEXUAL, AND TRANSGENDER HEALTH AND WELLNESS Pediatrics 2018;142; DOI: 10.1542/peds.2018-2162 originally published online September 17, 2018;
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