Providing gender-affirming care in pediatrics

Contemporary Pediatrics® sat down with Johanna Olson-Kennedy, MD, medical director of the Center for Transyouth Health and Development at Children’s Hospital Los Angeles about the best practices for providing gender-affirming care—treatments for supporting a transgender or nonbinary person in their gender transition—for pediatric patients; who should be a part of the team providing that care; and the small ways that practices can show they’re a safe space for all patients.

Q. What are the best practices for providing compassionate gender-affirming care to children and adolescents in the general pediatric office?

A. That question gets broken down into a couple of things. Are we talking about somebody practicing gender care or just anyone practicing pediatrics? Because those are 2 different things. I would think that for general pediatricians, if they’re not comfortable doing gender-specific care, they should refer to someone that is. We have a dearth of training for this work in the general pediatric curriculum, though I think that will change over time. But right now, things such as puberty blockers feel complicated for general pediatricians. So the first thing is to make sure young people are where they’re going to get the most informed care. In the world of gender, it is really important that people understand that having protocols creates more problems than it solves. For a lot of reasons, there are just so many intersecting developmental trajectories that have to be considered when helping people move forward [with transitioning]. And that’s why if you’re not comfortable with the care, don’t do it. The most compassionate care is care that considers the individual, where they are developmentally and chronologically in their gender understanding and consolidation process, and then, where they and their families are in relationship to interventions. And it’s not just 1 overarching thing. It’s individualized.

Q. What are some small changes that pediatricians can enact in their practice to provide a caring and accepting environment for gender-diverse children and teenagers, even if they aren’t providing that care?

A. Just even the small act of having a poster or something similar in your waiting room, that says “We welcome all genders here” or “Tell us about your gender” or handouts with basic information can be really helpful. We think about the impact of those changes on kids that are in the trans community, or in the LGBTQIA+ community, but they actually have an impact on everyone. Because that kind of change, that kind of openness, that kind of welcoming message models for everyone the way that it should be for people within the community, but they’re super important for everyone. Also, do you only ask questions about gender in response to some kind of gender expression that feels maybe a little bit outside the stereotype? Or is this something we ask everyone? With the HEEADSSS [home, education/employment, eating, activities, drugs, sex] exam [psychological screening tool for adolescents], we ask about sexuality. We said everyone 12 and older was getting HEEADSSS, outside the presence of their parents.

So with that in mind, for younger kids, we might ask are you having crushes? Do you have crushes on boys, girls, both, neither? So you can provide them information about health and safety. I think a similar thing about gender. You ask something like, “I’ve known you since you were born and we have assumed you were a girl. Does that does that feel right for you?” It may allow them to disclose something that they wouldn’t have otherwise disclosed. It’s also important to talk about the limits of confidentiality with all of those questions so they know that you’re not going to disclose that information to their parents unless they want you to. One of the tricky things about being trans is that if you want to do anything about it, you have to out yourself to providers so they can get you what you need.

I don’t think there’s great consensus about what age you would ask someone this. The most common thing I’ve heard from parents of my patients is “this wasn’t even on our radar.” Thinking about how we can get parents into a place where they are asking their kids these things more routinely, I think that would also take the medical emphasis off gender, refocusing the conversation about gender in the familial setting, or in the social setting, which is way more relevant for prepubertal kids.

Q. For pediatricians who want to create an affirming medical home for this group of patients, what other professionals would you consider bringing into that medical home?

A. The world of gender work is complicated, right? I always say it takes a village to raise a trans kid. Having networks with mental health providers is really important. Psychiatrists or psychologists or social workers, people who are going to have a little bit more time to spend with kids who need maybe extra support. But I also think if you are going to do gender work within the context of your own pediatric practice, you have to book out enough time. This is not the kind of work you can do in 15-minute visits. Some people create intake forms that give them a lot of information before they meet with the family and the patient.

I also think that either having a really good knowledge of endocrinology or having some endocrinology backup for you if you need it could be really important, depending on the age of patients that you’re taking care of. Another network that’s important is surgeons. Those are all probably good folks to have on your team.

Q. What are your recommendations for pediatricians who want to be advocates for gender-diverse children, outside the exam room?

A. Learn, educate yourself, participate in conferences that talk about trans youth and the care of trans youth. If you hear anti-trans stuff, you can say, “I’m wondering if you have any experience with trans youth? Have you sat in rooms with people? Are you just talking and making assumptions about things?” I think that most providers attend some trainings and conferences and I think it’s worth it to ask, if you’re hearing someone present data, “Is there a consideration about trans kids in this data?” But I also think it’s really important to vote. Now, unfortunately, you have to be politically active if you really want to advocate for the community.

Q. What are the best practices for ensuring a smooth transition from pediatric to adult care when a gender-diverse patient reaches their 18th birthday?

A. I don’t know if there is 1 way I can tell you in our clinic. People don’t leave our practice until they’re 25. We understand 2 things: Adolescence isn’t limited to ending at 18. Secondly, and more relevant for trans youth, many trans youth get bumped off of the developmental trajectory because they’re spending a lot of their brain space and energy managing and navigating gender dysphoria. And because of that, they may not tend to the tasks of development that other cisgender adolescents are tending to. And so a lot of our kids are not learning how to drive, for example; they’re just behind. And so it’s really important that they stay in pediatric services during this time, as they’re more comprehensive. Adult services are oftentimes very truncated. Like suddenly, on your 18th birthday, you’re supposed to be able to understand how to navigate the health care system.

So in our program, when people are about 21 or 22, I start talking about it, telling patients that they can stay with me until they are 25. But after that, they have to graduate out to adult services. And let’s be real, we have a terrible health insurance system in this country. It is not healthy or secure, or a system, right? It’s terrible. And so where you ended up being able to get adult trans-related services is largely dependent on your insurance. So we will think about where they are geographically, what kind of insurance they have, and what kind of insurance they’re likely to get after their they drop off their parent’s insurance, because that’s another thing. That’s weird as we see people to 25. But we also know in a year with the ACA [Affordable Care Act], they’re going to drop off their parent’s insurance, right? So they may have to do 2 transitions of care in the space of a year. Finally, I tell this to all my patients: If you’re struggling to land somewhere on your care, please call, let us help. So that can be really helpful, too.

Q. How can pediatricians support gender-diverse patients who have parents or caregivers who do not support them?

A. It’s probably one of the hardest things for a young person not to have a supportive parent. But I also think that when we talk about support, we need to remember, support is a spectrum. And so there can be someone who is super supportive of their kid using different pronouns or dressing differently, or using a different name, but they absolutely will not support medical intervention for them. That’s a very different parent than a parent that’s saying, “This trans stuff is nonsense.”

It’s important to figure out where the parents are, and again, this does not lend itself to a 15-minute visit. You don’t just have to understand the developmental trajectories of the young person, but you also have to understand the developmental trajectory of the caregiver. This is also one of those reasons to have mental health people on your team because the downstream fallout of gender dysphoria is anxiety and depression. Mental health providers can help give patients the tools to navigate, how to talk to their parents about their gender, how to connect the parents to their gender, their kid’s gender dysphoria. The parents might also feel that they love their kid, but they’re scared. And so it’s really important to try to figure out what the fear is, so that you can dismantle that, and that’s a lot. That’s a lot for a pediatrician to do. Those are really important things.

Another thing, at least in my practice, is I always ask patients, “What name do you want me to use? What pronouns do you want me to use?” I ask that with everyone in the room. I feel really strongly that I need to honor somebody’s authentic sense of self. And so sometimes there’ll be a conversation and the parents are using 1 set of pronouns and I’m using another set of pronouns. But it’s modeling and shaping how people think about this. Parents are such a critical part of that young person’s health and well-being.

Q. Why is gender-affirming care important to ensuring the best possible outcomes for gender-diverse children and teenagers?

A. The science tells us that if people’s gender dysphoria is addressed and treated, their mental health outcomes improve. More and more data has come out over the last 10 years that backs this up with decades of clinical experience that many of us have. You’d be hard pressed to disagree with the idea that parents want the best mental health outcomes for their kids. And I also think there’s sort of a macro and a micro level. The macro level is the right to live authentically. It is a human right. And we also know that when people are able to live authentically, they function better. But then there’s also the micro level, the individual person, and there’s the struggle in gender work. We have a broken world, but we can’t fix the world all at once. And we have a human being who’s suffering, and so we can alleviate some of that suffering. And that’s really important. That’s why we do it.