New Guidance for Care of Transgender Children, Teenagers

A new policy statement from the American Academy of Pediatrics encourages pediatricians to provide gender-affirmative care and talk with children and families about gender issues from young childhood through adolescence. The statement provides practical information for clinicians and encourages pediatricians to start conversations early.

"[A]ny pediatrician has the skill set necessary to play a vital role in the development of these kids by creating an environment of nurturance and support, which really is the environment that pediatricians are called to [provide] for all children. It really is about gender-diverse kids as much as about any other child that would come into your clinic," lead author Jason Rafferty, MD, MPH, EdM, told Medscape Medical News.

Rafferty, a pediatrician and child psychiatrist at Hasbro Children’s Hospital, Providence, Rhode Island, together with the Committee on Psychosocial Aspects of Child and Family Health and the Committee on Adolescence, Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness, published the new policy statement online September 17 and in the October issue of Pediatrics.

"We also made a conscious effort to make sure to include people at each stage of the review who identified as being part of the transgender and gender-diverse community because we really felt like that was important as well," Rafferty explained.

Gender-Affirmative Care Fosters Supportive Environment for Children, Families

Gender-affirmative care recognizes that differences in gender identity and expression are "normal aspects of human diversity, and binary definitions of gender do not always reflect emerging gender identities," the authors write. When mental health issues do exist, they are usually related to social stigma and negative experiences such as efforts to suppress a child's or adolescent's gender identity.

"It is important to recognize that cross-gender preferences and play is a normal part of exploring gender and relationships for children, regardless of their future gender identity. Routinely touching base on gender as part of routine well-child visits normalizes these discussions and creates an environment of support and reassurance so that all children can feel safe bringing up questions and concerns. It is also important to compassionately empower parents to continue these discussions at home," Rafferty explained.

The American Academy of Pediatrics and numerous other medical and mental health organizations have condemned "reparative" or "conversion" treatment as ineffective and destructive. In 2016, for example, the American Academy of Pediatrics partnered with the Human Rights Campaign and the American College of Osteopathic Pediatricians to publish "Supporting & Caring For Transgender Children," which also denounced the practice.

"A strong, nonjudgmental partnership with youth and their families can facilitate exploration of complicated emotions and gender-diverse expressions while allowing questions and concerns to be raised in a supportive environment," the authors write in the new policy statement.

The statement provides a detailed list of relevant terms and definitions related to gender care. For example, "gender diverse" recognizes the range of gender identities that exists and replaces the term "gender nonconforming, which has a negative and exclusionary connotation," the authors write. The range of gender identities includes those "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, gender fluid, gender creative, gender independent, or noncisgender."

"Other things that are important for the clinical setting are identifying a gender-neutral restroom, prominently displaying recognized symbols that identify the practice as a safe space, having forms that include a line for 'other' when asking about a person’s gender, and making sure staff use and recognize patient-asserted name and pronouns when it is safe and requested," Rafferty explained.

The authors recommend using patient-asserted names and pronouns in medical records. Given the various electronic medical record systems, this can be accomplished in different ways. According to Rafferty, "Some systems will allow for a preferred name or alias that appears alongside the legal name, which alerts providers and office staff. Other systems have areas for care team coordination notes when comments about gender identity can be made and displayed prominently to keep everyone aware."

The main thing clinicians should remember is to avoid creating duplicate charts, he said. "In a provider’s own note and communications, the opening line can explicitly state the patient's name and gender marker assigned at birth and currently asserted. This allows the provider to then use the patient’s asserted name and pronouns throughout the note with clarity," Rafferty added.

Begin Early

Perhaps the first stumbling block for pediatricians is knowing when and how to assess gender identity issues in children.

"Pediatricians are in a very unique position to assess and inquire about gender development as part of the well-child visit, and this should start at an early age by asking children generally about their bodies, feelings, and relationships. Kids start to recognize differences between genders in their bodies and expressions in the outside world as young as preschool. Young kids can talk about their feelings, observations, and fantasy play around gender expression, which pediatricians can help them understand and appreciate.... The best approach to any concerns, specifically about gender, is to nonjudgmentally ask questions that allows the child to talk about their experience and feelings before applying any labels or assumptions," Rafferty said.

When asked for specific examples of questions a pediatrician might ask a child, Rafferty suggested, "[With] the younger child, clinicians can ask, 'What games do you play? Who do you play with? What are your favorite toys, books, movies?' "

Pediatricians can also ask a child about questions or problems they might have with their body, which is an important question even in young children, he adds. Clinicians can also check in with the child with a question such as, "Are you a boy, a girl, or something else?"

"It used to be the case that for children, gender-diverse assertions were held as 'possibly true' and not acknowledged until an age when the child was believed to be old enough to know for sure. This is does not serve the child, because it increases discomfort without offering critical support and understanding. Attempts at predicting or changing who a child may become have shown to be unsuccessful, and even harmful. The best approach for parents is to love and appreciate their child as they are in the moment," said Rafferty.

Meet Parents Where They Are

Conversations with parents are also important. Parents often experience a complex range of emotions on the road to becoming more comfortable and understanding of their child's gender identity. This may occur in stages resembling the grieving process, such as shock, denial, anger, bargaining, and acceptance. At times, two parents may be at different stages in this process.

"Some parents may need their own emotional supports, and gender-affirmative care is most effective in a collaborative system with access to medical care, mental health, and social services, including specific resources for parents and families," he added.

Pediatricians can also help the child understand their parents' concerns and reactions, Rafferty said.

Even when parents are resistant or in disagreement with the pediatrician and other healthcare providers, clinicians can still maintain respect, find common ground with parents, and work from there to help children and families.

Focus on Child's Strength, Resiliency

"Using language and explicitly appealing to a child’s strengths and resiliency, regardless of their gender identity, can have profound effects in promoting positive development," Rafferty said.

"Transgender and gender-diverse children, like all children, need support, love, and care from family, school, and society. When supported and loved as they grow and develop, kids mature into happy and healthy adults," he added.

The American Academy of Pediatrics National Conference and Exhibition this year will feature several sessions on caring for transgender and gender-diverse children and adolescents.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online September 17, 2018.

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