Developmental Approaches to Caring for Transgender & Gender Diverse Pediatric & Adolescent Patients Michelle Forcier MD MPH Professor Pediatrics, Alpert School of Medicine Brown University, Providence RI Here is What a Standard Slide Looks Like . With bulleted text . And sub bullets 2 Objectives . Discuss human development w gender perspective . Discuss how patient centered, developmental paradigms to gender might reduce bias and stigma that create disparities and lead to risks . Provide initial strategies for appropriate and competent care . Understand the role of providers in promoting culture changes that respect diversity 3 DisclosuresDISCLOSURES • Consultant Planned Parenthood • Royalties Up To Date • All medications off label • I am an optimist Why Talk About Gender with Kids? . Professional responsibility . AMA, AAMC, AAFP, AAP, SAHM, APA . Recommend training on LGBTQIA health . Exclusion of coverage illegal in some states . Lack of formal medical training no longer “good excuse” . Pediatric responsibility . Anticipatory guidance & prevention . Future planning . Models & promotes diversity, equity for all children Reproductive Justice under the Social Justice Umbrella 5 CDC Behavioral Risk Factor Surveillance System (BRFSS) 2016 National estimate transgender persons . 0.6% =1.4 million . Range 0.3% ND to 0.8% HI . Highest 18-24 versus older adults This survey does not include < 18 youth 6 Sexual Orientation and Gender Identity of Middle School Students Transgender Gender Identity 1.3% Non_Hetero Sexual Orientation 15.9% Shields JP, et al. “Estimating population size and demographic characteristic of LGBT youth in 7 middle schools.” J Adol Hlth. 2013:248-50. Perpective: Gender Care is Primary Care Patient Centered Listen to our patients Consent Based Address patient identified needs, concerns, goals Primary Care 100% of patients experience gender!! 8 Reproductive Justice Framework: Intersectionality of Our Children’s Health Care Rights 1. Bodily autonomy 2. Right to self determine 3. Right for safe, healthy environment with opportunity to develop potential 4. Responsibility for most marginalized Especially fitting for children & adolescents SisterSong 1997 … Developmental Paradigm Gender, sexuality are universal, normalized Variance is expected aspect of biology & human Patient- development centered Diversity not = deviance but celebrated Consent-based Developmental care Meet patient goals (nothing to “diagnose” or “treat”) Address, reduce minority stress Advocate, empower ALL children Model, elevate cultural expectations 10 11 Awareness of Gender Identity Between ages 1 and 2 Conscious of physical differences between sexes ~ 3 years old Can label themselves as a girl or boy By age 4 Gender identity relatively stable, recognize gender constant 12 All pre-pubertal children play with gender expression & roles Passing interest or trying out gender-typical behaviors Gender Play Interests related to other/opposite sex Few days, weeks, months, years Behaviors and expression may be nonconforming, but children can still feel they are in right-gendered body 13 Gender Diversity Persistent Diverse Consistent Fluid Insistent Nonconforming Cross gender expression, Agender role playing Non binary Wanting other gender Refuses to ascribe to body/parts typical masculine or Not liking one’s gender & feminine assignments body (gender dysphoria) Can change, shift 14 Are we doing our part? Missed Opportunities for Screening & Identification 2 Contemporary Pediatric Studies AlexanderWhere SC et al. JAMA Pediatr. 2014 is gender???Henry-Reid Pediatrics 2010;125:e741-747. How Often do Pediatricians Ask About Sexual Orientation During Adolescent Well Visits? . Time spent talking about sexuality . 35% spent ZERO time . 30% spent 1-35 seconds . 35% spent more than 36 seconds Increasing Evidence 1. Early identification has known benefits >> potential risks 2. Parent & family acceptance offer critical protective factors Short & long term healthier outcomes 3. Child health professionals can improve early support & improve resources 17 Who & When to “Screen”? . All children! . Developmental stages . Opportunity for improving child/family communication & support . Diverse or nonconforming gender expression . Concerns/problems with . Mood . Behavior . Social 18 Ask! Parent(s) Ask! Patient • Child play, hair, dress • Do you feel more preferences like a girl, boy, neither, both? • Concerns with these • How would you like • Concerns with to play, cut your behavior, friends, hair, dress? getting along at school, school • What name or failure, bullying, pronoun (he for boy, anger, sadness, she for girl) fits you? isolation, other? • What does it mean to be girl, boy, both, neither? 19 Gender Screening “Tools” 20 Images taken from The Gender Book, are publically available on the book’s website, www.thegenderbook.com Gender & sexual development are natural parts of Remind Youth human development & Parents Gender & sexual expression vary … What Gender & sexual diversity are different than risk Is ?? “Healthy” Open, honest communication is critical to healthy decision-making, behaviors, support, and access to care 22 Historical Approaches to TGD Children Gender identity stable No treatment until 18 Initiate puberty with hormones (after full pubertal experience) congruent with gender identity GCS Living in Asserted Gender Allow some experience puberty, to Gender identity stable age 15-16 or Tanner 4, then start Start GnRH analogues at Tanner 2 GnRH analogues or hormones Initiate hormones several years later https://ceitraining.org/ 23 Seminal Puberty Blocker Work : Early Intervention Delemarre-van de Waal, Cohen Kettenis (2006) Early blocking of puberty followed by cross gender hormone replacement At follow-up, all 54 patients were satisfied with their pubertal development ▫ No patients decided to stop GnRH agonist therapy ▫ All patients eligible decided to take cross gender hormones ▫ There were no adverse events from GnRH agonists No suicides No street hormones Reconfirmed over time…. OlsonKR 2016, deVries AL 2014, Steensma TD 2013, deVries AL 2012, Spack NP 2012, deVries AL 2011, Steensma TD 2011, Steensma TD 2013, Malpas J 2011, Teurk CM 2012, Bussey K 2011, DeVries 2010, Wallien MS 2008, Drummon 2008, Zucker 2005, Green 1987, Davenport24 1986 Ryan CJ; 2010, 2009 N=245 LGBT Retrospective assess family accepting behaviors in response to gender & sexual minority status Predicts improved Protects against . Self esteem Depression . Social support Substance use . General health status Suicidality 25 NIH Patient Reported Outcome TransYouth Project Measurement Information System Large-scale (>150 children) longitudinal study transgender children, 25 states Significantly lower than TGD children in previous studies (2016) 73 children, ages 3-12 (2017) 116 trans, 122 controls, 72 sibs Symptoms of depression, anxiety ages 6-14 Rates depression (50.1) and anxiety (54.2) Symptoms of depression, self worth No higher than 2 control groups same Siblings & cis age- and gender-matched children Slightly higher anxiety Olson KR, Durwood L, DeMeules M, et al. Mental Health of Transgender Dunwood L, McLaughlin KA, Oslon KR. Mental Health and Self-Worth in Children Who Are Supported in Their Identities. Pediatrics. Socially Transitioned Transgender Youth. J Am Acad Child Adolesc Psych. 2016;137(3):e20153223 2017 Feb;56(2):116-123. 26 Minoritized person Suicide, Substance Use, SES Disadvantage, Stigma Victimization Minority Stress Theory Prejudice, Discrimination, Abuse, Anxiety, Lack of Acceptance, Depression Isolation, Esteem, Resources Minority Stress Adapted from O’Hanlan, et al (1997). A review of the medical consequences 27 of homophobia with suggestions for resolution. JGLMA;1:25-39.) Countering Minority Stress Early identification Social stigma Resources, connection, Minority support . Familial rejection stress Change cultural Social isolation appreciation for diversity Fear of physical attacks Pro-diversity . Resiliency Improved Health Outcomes Identity congruent with Mental health anatomy/physiology Social Puberty in gender identified. Medical living safely in identified gender Financial Educational 28 Talking with all children about their gender Supporting authentic development to improve quality of life development Children with gender diversity or questions • Establish early, strong social support • See when concerns identified, ideally BEFORE puberty • Gives providers time to engage with family and patient, build rapport & trust • Offer relief to patient worried about upcoming puberty 29 • Facilitate emotional, social, physical state that more closely represents individual’s sense of self • Experience single puberty congruent with internal identities • Prevent unwanted &/or permanent secondary gender/sex characteristics • Reduce need for future medical, surgical interventions • Reduce depression, anxiety, risk-taking facilitates mental health supports Consider “blocking” puberty • Effects fully reversible • “Buys time” for parents to learn more & adjust • “Buys time” for patient & prevent unwanted secondary physical changes • Sends message of hope 30 Starting Gender Affirming Medical Care Puberty Blockers Timing Assess needs & goals identity & “phenotype” 1. Is the youth ready? . Physical (Tanner stage) 2. Is the parent(s) ready? . Psychological . Social 3. Tanner stage 4. 2nd gender characteristics Patient-centered consent process 5. Is age congruent w peers? . Review benefits, risks, common & uncommon side effects 6. What is current, predicted, .