Overview of care for transgender children and youth

Overview of care for transgender children and youth

ARTICLE IN PRESS Overview of care for transgender children and youth Eric C. Weiselberga,b,* and, Shervin Shadianloob,c Over the past decade, more an...

267KB Sizes 0 Downloads 39 Views

ARTICLE IN PRESS

Overview of care for transgender children and youth Eric C. Weiselberga,b,* and, Shervin Shadianloob,c Over the past decade, more and more children and adolescents are identifying as transgender and gender diverse (TGD). Often, they and their parents first turn to their primary care pediatrician for guidance and support. Therefore, in 2018, the American Academy of Pediatrics (AAP) released a policy statement focusing on the health care of TGD youth.4 The AAP acknowledges that many pediatricians have a lack of training in this area and therefore need to increase their knowledge base and expertise in order to provide culturally competent care. While most sexual and gender minority individuals are healthy and well adjusted, some TGD youth are at an increased risk of mental health concerns, including anxiety, depression, substance abuse, eating disorders and suicidality. This is theorized to be due to the experienced or internalized marginalization, stigmatization, victimization, harassment or rejection and not inherent in having gender dysphoria or being transgender. The pediatrician therefore needs to be knowledgeable of, and skilled to screen for, the health disparities that may exist, as well as to be able to support the individual who may disclose

their gender identity status during treatment. Parents and guardians may also turn to the pediatrician for guidance when faced with their child who presents with gender non-conforming behaviors or gender dysphoria. Therefore the pediatrician needs to be able to guide the parents as well, as their acceptance and support of their child’s journey to gender identity is probably the most important protective factor against health disparities encountered. To deliver optimum care for TGD children and youth, the pediatrician needs to establish an office setting that is inclusive, gender-neutral and TGD friendly. By becoming familiar with the diversity of gender expression and identities, use of gender-appropriate terminology, health disparities often encountered and the importance of providing a safe and welcoming environment, issues that are all covered in this article, the primary care pediatrician will be in position to provide comprehensive health care to this often marginalized population. Curr Probl Pediatr Adolesc Health Care 2019; 000:100682

Introduction

rare, with there only being approximately 10,000 individuals in the United States.1 However, during n 1970, Dr. Harry Benjamin, a pioneer in the this past decade, perhaps fostered by the media expotreatment of transgender individuals, wrote that sure of transgender celebrities “the transsexual is often such as Chaz Bono, Caitlyn isolated from anyone who can It is now quite likely that most Jenner and Jazz Jennings, more understand his problem. . .the and more young people are average physician has probably primary care physicians will be coming out as transgender. As in a position to take care of never been confronted pointof 2014, the prevalence of blank with the problem.” He transgender and gender-diverse transgender individuals in the further stated that transsexualUS was estimated to be individuals (Warding) ism was thought to be quite 150 times the number speculated by Dr. Benjamin, or one From the aDivision of Adolescent Medicine, Department of Pediatrics, and half million transgender individuals living in the Cohen Children’s Medical Center, Northwell Health, 410 Lakeville Road, US. This includes about 150,000 youth between the Suite 108, New Hyde Park, NY, United States; bDonald and Barbara ages of 13 and 17 years (0.7%) who identify as transZucker School of Medicine at Hofstra/Northwell, United States; and cDivision of Child and Adolescent Psychiatry, Department of Psychiatry, gender.2 However, more recently the Centers for DisZucker Hillside Hospital, Northwell Health, New Hyde Park, NY, United ease Control and Prevention (CDC) reported that States. 1.8% of adolescents identified as transgender, equal *Corresponding author at: Division of Adolescent Medicine, 410 Lakeville to approximately 275,000 youth.3 Tag edPTherefore, in conRoad, Suite 108, New Hyde Park, NY 11042, United States. E-mail: [email protected] trast to Dr. Benjamin's expectations, It is now quite Curr Probl Pediatr Adolesc Health Care 000;000:100682 likely that most primary care physicians will be in a 1538-5442/$ - see front matter position to take care of transgender and genderÓ 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.cppeds.2019.100682 diverse individuals (Warding).

I

Curr Probl Pediatr Adolesc Health Care, & &&&&

1

ARTICLE IN PRESS In 2018, The American Academy of Pediatrics In the early 20th century, the term transvestism was released a policy statement titled, “Ensuring Compreused to describe someone who assumed the role of the hensive Care and Support for Transgender and Gender desired gender by dress and behavior; with the introDiverse Children and Adolescents,” stating that since duction of medical and surgical interventions, the a transgender identity typically presents in childhood term transsexual was then used to describe someone and adolescence, the pediatrician is now likely to be whose “psychologic gender is the opposite of his anathe first person to whom the parent, guardian or child tomic.”1 However, since transsexuality focuses on one’s sex and not gender, over time this has been will come for guidance and support, and therefore it is replaced in the literature with the term transgender; critical that pediatricians have the understanding and transsexualism is still sometimes used for those who skills to provide culturally sensitive and competent have undergone gender affirming treatment or surhealth care.4 Pediatricians must also be aware of the multiple health disparities within the transgender gery. Furthermore, the binary notion of one being community, in order to provide proper surveillance solely male identified or solely female identified and timely prevention, treatment and support as (either assigned at birth or transgender) has shown to needed. Since transgender individuals are at an be limiting for those whose identity lies outside this increased risk for high risk behaviors, such as subbinary construct.7 Therefore, the term transgender has evolved from a descriptive notion of one’s gender stance abuse, depression, suicide and eating disorders, identity to one of gender expression and hence has pediatricians can face health situations that may lead become an umbrella term to describe “the full range to disclosure along the course of evaluation and treatof people whose gender identity and/or gender role do ment. The Society for Adolescent Health and Medinot conform to what is typically associated with their cine states that providers who work with adolescents sex assigned at birth.”7 Similarly, the World Professhould be trained to recognize the additional stressors sional Association for Transthat transgender adolescents gender Health (WPATH) often face, such as family rejection and victimization, as these World Professional Association defines transgender as a “diverse group of individuals may lead to adverse mental for Transgender Health health outcomes and high-risk (WPATH) defines transgender as who cross or transcend culturally defined categories of genbehaviors; providers should be a “diverse group of individuals der.” “The gender identity of able to provide guidance and who cross or transcend cultur- transgender people differs to care in a safe environment.5 varying degrees from the sex ally defined categories of they were assigned at birth.”8 gender.” Terminology In comparison, the term cisgender (cismale, cisfemale) is used The Gay Liberation Movement, heralded by the Stonewall Riots of 1969, to identify someone whose gender identity and gender brought the once underground Gay and Lesbian comexpression align with one’s assigned gender at birth. munity into the open. Over time, as more individuals There are a myriad of terms presently being used in fought for inclusion, the acronym grew to be the the literature and within communities to describe LGBT (Lesbian Gay Bisexual and Transgender) comone’s identity, and as any label by its own definition munity, and then, continuing to be more inclusive, would be exclusive, new terms are constantly being incorporated those who identify as Queer, Questionintroduced. The 2018 Human Rights Campaign Youth ing, Ally and Intersex; therefore, the terms LGBTQ, Report states that of 4000 transgender youth surveyed, LGBTQQIA, or LGBTQ+ can all be found in use 50% identified as other than transmale or transfemale, today. Each letter represents a unique group, as well meaning outside the binary notion.9 As new terms are continually being introduced into as representing either a person’s sexual identity or acceptance and other terms are falling out of common gender identity, often leading to confusion between use, it would be impossible to be able to provide a the two meanings; however, what is common is the complete list of terms presently being used. Below is shared sexual and / or gender minority status that often a partial list of terminology that providers should be leads to marginalization and related disparities in 6 familiar with: many areas of daily functioning.

2

Curr Probl Pediatr Adolesc Health Care, & &&&&

ARTICLE IN PRESS Diagnostic and treatment terminology

Gender identity terminology 













 



Gender Dysphoria: As of 2013, the diagnosis presently in use as per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition10; see below under: IV. Diagnostic Features of Gender Dysphoria. Gender Identity Disorder: Prior diagnosis used as per the DSM-IV; however, as per the WPATH 2010 position statement, “the expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally diverse human phenomenon [that] should not be judged as inherently pathological” and therefore the use of the term disorder should be avoided.8,11 Gender Incongruence: A new term being proposed for updated editions of the DSM which removes “dysphoria” and may better reflect transgender individuals, as dysphoria is not inherent in being transgender, and the depression, anxiety, etc. that one may develop is more often due to stigmatization and discrimination. Gender affirming treatment, gender affirming hormones, gender affirming surgery: (Similarly gender confirming treatment, etc.) To be used when discussing medical and surgical interventions. Other terms such as “sex-reassignment, gender reassignment, sex change” should be avoided as it dismisses the inherent nature of one’s gender identity. Top surgery: Preferred name for procedures that creates a masculinized chest which can include removal of breast tissue, nipple/areola repositioning, and contouring. Bottom surgery: Preferred name for procedures to create gender affirming genitalia. This may include removal of penis and testes; creation of a neovagina (vaginoplasty); creation of a penis using skin and/or muscle flaps and grafts (phalloplasty); and, metoidioplasty, which creates a neophallus from the clitoris, which may have been enlarged from testosterone treatment. Binding: The practice of wearing a restrictive garment (binder) to flatten the chest contour. Tucking: The practice of placing the penis and scrotum posteriorly towards the perineum to create a smooth anterior contour; the testicles may be pushed up into the inguinal canals and may be kept in place by wearing a gaffe. Packing: The practice of wearing a prosthetic penis and scrotum to provide an anterior bulge under clothing.

Curr Probl Pediatr Adolesc Health Care, & &&&&





     

  

Sex assigned at birth: male, female, intersex; by visualization of the genitalia or by chromosome analysis; formerly referred to as assigned gender, natal-gender, biologic gender. Transgender male or affirmed male: female to male transgender; similarly, FTM, transmale, transman, transguy, transboy. Some individuals may use the term “man” or “male” without the trans prefix, emphasizing the lifelong identity of one’s gendered self. Transgender female or affirmed female: male to female transgender; similarly, MTF, transfemale, transwoman, transgirl. As noted above, some individuals may use the term “woman” or “female” without the trans prefix. Genderqueer: identity that does not align with the binary notion of gender. Bigender, pangender, androgyne: both male and female identities. Agender, gender neutral, neutrois, genderless: neither male nor female. Third gender: neither man nor woman, often used in non-Western cultures. Genderfluid/genderflux: flows between male and female identities. Gender non-conforming: gender expression outside of the culturally expected behavior for the assigned gender. Gender non-conforming behavior is a term often used to describe children whose activities, behaviors or likes are socially or culturally typical of the other gender, for example a boy who enjoys playing with dolls. Questioning: those who are uncertain of their sexual or gender identity. Cisgender: one who identifies as their sex assigned at birth, either cismale or cisfemale. Ally: someone who advocates for LGBTQ+ individuals.

Sexual identity Sexual identity refers to the physical, romantic, or emotional attraction one has for another individual. Transgender individuals show the same diversity of attraction as that of cisgender individuals; therefore, for example, it would not be unusual for a transgender woman to be attracted to other women, and hence identify as lesbian. Similarly, a transgender woman if attracted to men may consider herself straight. When

3

ARTICLE IN PRESS one is inquiring about sexual identity of a transgender individual, it should always be asked if they are referencing from the trans-identified self or from their assigned gender.  





 

 

Heterosexual, straight: attraction to someone of the other gender; maintains the binary notion of gender. Homosexual, Gay, Lesbian: Attraction to someone of the same gender; maintains the binary notion of gender. Bisexual: attraction to both male and female genders, but not necessarily simultaneously or equally; again, maintains the binary notion of male/female genders. Pansexual: fluid in sexual attraction; may be towards male, female, trans-male, trans-female, non-binary, etc.; can be outside the binary notion of genders. Sometimes used interchangeably with omnisexual; however, with pansexuality, the gender may not be noticed (gender blind), and with omnisexuality, the gender is noticed. Asexual: does not form sexual attractions to others. Gray-A: between sexual and asexual; may have some sexual attraction to others but at a very low intensity. Demisexual: only experiences sexual attraction after forming a deep emotional attachment. Polyamoruous: to be in open sexual relationships with more than one individual at one time.

Furthermore, aside from LGBTQ, one may see other terms in use, such as GNC (gender non-conforming), TGNC (transgender/gender non-conforming), TGNCNB (transgender/gender non-conforming nonbinary) and TGD (transgender and gender diverse). For the purpose of this article, TGD will be used as per the 2018 AAP policy statement.

Stages of gender development Gender development is a lifelong process, with childhood and adolescent milestones leading to adulthood identity. Interruptions in these stages may have a significant impact on identity formation, family dynamics, interpersonal relationships and mental health.12

Toddler and pre-school children By six months of age, infants are able to differentiate between male and female faces, and by one year can

4

match male and female voices to male and female faces.13 By 18 24 months of age, children show signs of understanding about gender by starting to make choices for their clothes, toys and grooming, conforming or non-conforming with the societal expectation of their assigned sex at birth. It appears that some of these choices transcend through cultures and some are purely culturally dependent. As a child starts preschool, he/she may show a growing tendency to choose peers of a particular gender. A young child’s understanding of gender is heavily influenced by the appearance, or gender expression, of another child; for example, a child who has long hair and wears a dress is typically identified as a girl, whereas a child with short hair and wearing pants may be seen as a boy. At the same time, one’s internal understanding of gender and gender identity slowly starts to develop. This is an essential point in understanding a child’s gender development and evaluating a child with gender non-conforming behavior.

School-age children As a child achieves higher cognitive capacity, he/ she develops a deeper understanding of gender. School age children become more gender savvy, with an expectation of what boys do and what girls do, and have a tendency to play and form social groups with peers of the same birth-assigned gender. The understanding of gender is initially concrete and later the child develops a more abstract concept of gender identity, which seems to follow a biological binary pattern of boy or girl roles. At this stage, children with gender non-conforming behavior start to realize that other children find their behaviors odd, and they may start to be marginalized, rejected by their peers or bullied.14 As children approach puberty, they may start to think about their gender expression and identity outside of the social expectations, and perhaps beyond the binary model.

Pubertal youth Puberty is a pivotal point in gender development. As secondary sexual characteristics develop, cognition becomes more complex and abstract. The physical changes, along with the fantasies and social roles one starts taking, lead to a more in depth understanding (or confusion) of gender. Some children who have presented with gender non-conforming behavior from an early age may continue into adolescence and Curr Probl Pediatr Adolesc Health Care, & &&&&

ARTICLE IN PRESS identify as TGD, whereas others may desist and revert brain occur months apart, it is theoretically possible for to identifying as their sex assigned at birth. Others a discrepancy to occur between genitalia development may just begin to develop TGD behaviors or identity and brain imprinting or gender identity.17 In support of this theory, Rametti and colwithout any prior presentation. leagues performed diffusion tenFor those whose TGD identity For those whose TGD identity sor imaging on 18 transmales, persists or first develops in adolescence, puberty, with the persists or first develops in ado- who had not been exposed to onset of secondary sexual char- lescence, puberty, with the onset gender affirming hormones, and acteristics and menses, can be of secondary sexual characteris- compared them to 24 cisgender males and 19 cisgender females. an extremely distressful time, tics and menses, can be an He found that the white matter with the development of extremely distressful time, with microstructure of the transmales depression, anxiety and suicidality . the development of depression, more closely matched that of the cisgender males.18 Similarly, he anxiety and suicidality also studied 18 transfemales, and Post-pubertal adolescents found that the white matter As pubertal development microstructure fell in between that of cisgender male reaches its final stage, sex (biologic characteristics) and female patterns.19 Several hypotheses have been studied regarding pre-natal androgen activity. One such and gender (behavioral/expressive identities) become area of research focuses on the higher ratio of index finmore distinct entities and one’s gender identity solidiger to ring finger length typically seen in females. This fies. It is understood that most adolescents reach a rearatio seems to be reversed, i.e. more “masculinized,” in sonable level of mental maturity around sixteen years some females with congenital adrenal hyperplasia and of age; gender identity generally remains stable therealso in some female-to-male transgender individuals.20 after, even as gender roles continue to become more Also, a higher prevalence of female-to-male transgender defined into adulthood. individuals have been described among those with polycystic Etiology Gender identity, as with other ovary syndrome.21 Twin studies personality and behavioral The concept that gender develhave also suggested a genetic opment may be independent traits, involves a very complex, component for the development from one’s sexual physical charmultifactorial, polygenic situa- of a transgender/gender-diverse acteristics was first described in identity, at a rate similar to other tion that includes thousands of the literature in the late 1960s. It heritable personality traits.15 genetic variations interacting However, it is more likely that was hypothesized at that time that the divergence of the two with and influencing each other one’s gender identity, as with other personality and behavioral was caused by “absent fathers along with environmental 15 traits, involves a very complex, and overbearing mothers.” The factors actual determination of how multifactorial, polygenic situaone’s gender and sexual identity tion that includes thousands of form remains unknown; research has generally focused genetic variations interacting with and influencing each on various genetic and pre-natal contributions. During other along with environmental factors.15 the first trimester, at about the 7th week of fetal development, sex chromosome genes and autosomal genes Diagnostic features of gender dysphoria influence the development of the fetal genital ridge and The Diagnostic and Statistical Manual of Mental Distubercle into external female genitalia, or, if under the orders, Fifth Edition (DSM-5) defines Gender Dysphoinfluence of testosterone, external male genitalia. If there ria as “an individual’s affective/cognitive discontent is continued production of testosterone in the second triwith the assigned gender.”10 In contrast to the diagnosmester (4th to 5th month), the brain becomes imprinted 16 tic term used in the DSM Fourth Edition, Gender Idenas male, or in the absence of testosterone, female. Given that the sexual development of the genitalia and tity Disorder, the DSM-5 focuses on the clinical Curr Probl Pediatr Adolesc Health Care, & &&&&

5

ARTICLE IN PRESS concern of the dysphoria caused by the incongruence between one’s assigned gender at birth and one’s experienced gender, rather than the identity.10,11 DSM-5 diagnostic criteria for Gender Dysphoria is divided between gender dysphoria in children and gender dysphoria in adolescents and adults.

Gender dysphoria in children  

     

A strong desire or insistence that one is the other gender; A strong preference to wear the typical attire of the other gender, and are resistant to wearing the attire of one’s assigned gender; A strong preference for cross-gender roles in fantasy play; A strong preference for playthings and activities of the other gender; A strong preference for playmates of the other gender; A strong rejection of playthings and activities associated with the assigned gender; A strong dislike of one’s sexual anatomy; A strong desire for the sexual characteristics of one’s experienced gender.

Gender dysphoria in adolescents and adults 



   

A marked incongruence between one’s experienced/ expressed gender and sexual characteristics, or anticipated sexual characteristics; A strong desire to be rid of one’s sexual characteristics, or desire to prevent the development of one’s secondary sexual characteristics; A strong desire for the sexual characteristics of the other gender; A strong desire to be the other gender; A strong desire to be treated as the other gender; A strong conviction that one has the feelings and reactions of the other gender.

For both situations, the incongruence between one’s experienced /expressed gender must be of at least 6 months duration. For gender dysphoria in children, one must have at least six criteria, and for adolescents and adults, must meet at least two criteria.10 Differential diagnosis may include body dysmorphic disorder (in which an individual perceives that a body part is abnormal, but not based on gender), transvestic disorder (in which one derives sexual pleasure by

6

cross-dressing) and schizophrenia with delusional thinking that involves gender.10 In practice, a general guideline theme, though not diagnostic, that has been in use, is that the feeling of one’s gender identity is “insistent, consistent and persistent.” Insistent means that the child is unwavering in the assertation of one’s gender; the child may say “I am a boy. . .I was born in the wrong body” rather than wishing to be a boy. Consistent signifies that the identity remains firm in spite of challenges or difficulties; and, persistent pertains to the identity remaining in place over time.

Desistance As mentioned above under Stages of Gender Development, most children who exhibit gender non-conforming behaviors, or who have a diagnosis of gender dysphoria in childhood, do not continue on to be transgender adults. There are various reports in the literature that state a wide range of percentages for children who persist to be transgender adults, including 2.2% to 30% for birth-assigned males, and 12 50% for birth-assigned females.10 The challenge is that longitudinal research has been limited, with various studies either being cross-sectional or consisting of retrospective interviews of adults. It is unknown why an individual child may desist; however, the presence of severe distress upon the development of, or, fear of development of secondary sexual characteristics as a child enters into puberty typically signifies that the gender dysphoria will continue into adulthood. In a follow-up study of 127 Dutch adolescents who were diagnosed with gender identity disorder as children, those who persisted in their gender dysphoria (37%) had shown a stronger intensity in their gender-variant behavior as children than the desisiters, with a history of insisting that they were the transgendered self, rather than wishing they were the other gender.22 Of those who desist in their gender dysphoria, about two thirds will identify as cis-gender gay, lesbian or bisexual (approximately 60%), and the remainder as cisgender heterosexual.23

Health disparities It has been well recognized that TGD individuals have higher rates of health inequities as compared to the cisgender population. The most frequently researched area is depression, with over 60% of TGD individuals screening positive by use of a research Curr Probl Pediatr Adolesc Health Care, & &&&&

ARTICLE IN PRESS screening tool, and 30% by clinical diagnosis.24 The A major factor is how gender identity information is next most often studied areas are sex and reproductive recorded, if at all, and the great diversity in terminolissues, and then substance abuse; the least studied ogy that is used; it is therefore difficult to compare area is general health issues.24 Most studies to date one study to another. The introduction of the elechave been cross-sectional and therefore it is difficult tronic health record (EHR) has added to the difficulty to determine causality, although larger longitudinal of abstracting gender identity information.30 In a review of 77 studies on TGD issues, the recorded genstudies are under way. However, the mental health der was typically binary, i.e. transmale or transfemale, disparities seen are not considered inherent to being with little focus on non-binary TGD, but rather are thought to individuals. Furthermore, idenbe as a result of stigmatization. The Minority Stress Model, first tification was often limited to The Minority Stress Model, first theorized to explain health theorized to explain health dis- the International Classification disparities among sexual parities among sexual minori- of Diseases (ICD) codes within minorities, states that the ties, states that the chronic stress the EHR, such as gender identity disorder or gender dysphochronic stress arising from the arising from the marginalizaria, as well as transsexualism or marginalization, discrimination, discrimination, rejection, transsexuality, and not substantion, rejection, violence, and transphobia that may be violence, and transphobia that tiated by the subjects’ selfencountered, feared, or inter- may be encountered, feared, or report of identity. Another limitation is that most studies that nalized leads to the presenting internalized leads to the prehave been done with TGD indimental health issues such as senting mental health issues viduals in the United States depression, anxiety, suicide, or such as depression, anxiety, sui- have been performed in coastal substance abuse.6,25,26 The stigmatization seen urban areas and only with those cide, or substance abuse among TGD adults is also a seeking treatment and presentmajor factor for TGD children ing to a specialized center for and youth, who often encounter rejection, marginalitransgender care, and therefore may not reflect a great zation, and verbal or physical abuse at school, in the percentage of those who are TGD across the country, home or within their communities. A 2016 Minnesota including those living in rural areas, who are not seekstatewide survey of over 80,000 high school students ing or do not have access to gender affirming care, or revealed that transgender students, and those with who are homeless.26 gender nonconforming behaviors, were the most likely to experience dysfunction in the home, includMental health: depression, anxiety, suicide ing psychological and physical abuse.27 A 2013 surIn 2011, the Institute of Medicine (IOM) published vey of high school students in New Jersey showed “The Health of Lesbian, Gay, Bisexual, and Transgenthat because of their gender expression, 55% of der People: Building a Foundation for Better UnderLGBT students were verbally harassed, 20% were standing,” which, while highlighting that the majority physically harassed and 6% were physically assaulted of LGBT individuals are mentally healthy and well within the past year.28 Besides sexual, psychologic and physical abuse, gender non-conforming children adjusted, reported that among LGBT youth there is an are also at high risk of developing post-traumatic increased prevalence of depression, anxiety, suicidality, stress disorder (PTSD), which self-harm, anxiety and eating is associated with higher rates Although the data specifically on disorders, as compared to nonof lifetime physical and mental LGBT youth.6 Although the transgender youth was limited, 29 data specifically on transgender health disorders. it was suggested that gender Although published research youth was limited, it was sugon TGD health disparities and affirming treatment may be pro- gested that gender affirming risks have been growing at a treatment may be protective tective against mental health great rate over the past decade, against mental health concerns concerns among TGD youth several challenges persist. among TGD youth. Curr Probl Pediatr Adolesc Health Care, & &&&&

7

ARTICLE IN PRESS Since the publication of the IOM report, there has transmales. As in other reports, self-harm, suicidal ideabeen a growing amount of research in the literature tion and autism spectrum disorder occurred at rates reporting on the mental health issues seen among higher than for non-TGD youth.33 In a large state-wide survey of over 80,000 high school students, 2.7% of the transgender individuals. A 2016 review of the literastudents identified as transgender gender non-conforming ture reported that TGD youth had rates of depression (TGNC). Compared to the cisgender students, the TGNC in the range of 20 40%. Suicide attempts were students had higher rates of substance use, sexual behavreported at 20 30%, suicidal ideation at about 50% ior, bullying victimization and emotional distress, includand non-lethal self-harm at about 20 45%, all signifiing 61.3% reporting suicidal ideation (compared to 20% cantly above the data for non-TGD youth.31 Most early studies on this topic were performed in of the cisgender students) and 31% reporting a prior suiEurope, in which data from centers for transgender cide attempt (compared to 7.1% of the cisgender stucare were collected and compiled. The first study dents). Protective factors, including a feeling of family from the US was reported by Olson, et al.; this study connectedness, positive internal assets, teacher-student looked at baseline psychologic traits of 101 TGD relationship and feeling safe within one’s community, youth (ages 12 24 years) presenting to a transgender were all significantly lower among the TGNC students.34 In a study of almost 300 young transwomen, ages care center in California. Compared to national preva16 29 years, who underwent structured psychiatric lence data, results for the transgender youth were diagnostic interviews, mental health and substance much higher in multiple domains: 24% scored in the use issues were found at a much higher rate than in mild to moderate range and 11% scored in the severe the general US population, with over 40% having one to extreme range on the Beck Depression Inventory or more mental health issues. The diagnosis with the scale, 51% had thought about suicide at some point, highest lifetime prevalence was a history of a major and 30% had attempted suicide at least once. Results depressive episode, at 35.4% (Latina transwomen were also significant for use of alcohol, tobacco and being the highest); also significant was past 30-day cannabis, with over 40% also reporting the use of suicidality at 20%, generalized anxiety (within the other substances of abuse as well.32 While these reports estimate mental health concerns past 6 months) at almost 8%, past year alcohol depenamong transgender youth, they are limited in that most dency at 11.2% and psychoactive substance use at studies have focused on youth who seek treatment at spe15.2%. Of note is that the rate of diagnoses increased cialized centers for transgender care. Therefore, to assess with age, thereby suggesting that early recognition the prevalence of mental health issues among TGD youth and support may be important in the prevention of in the US, regardless of treatment in a specialized center, mental health issues in young transgender women.35 a large multi-centered, health system EHR review was undertaken to look at the prevalence of mental health Eating disorders issues among TGD children between the ages of It has been well documented that eating disorders are 3 9 years and TGD adolescents between the ages of highly prevalent among sexual minorities; there is now 10 17 years. Over 1300 charts were reviewed, with a growing body of research showing that TGD youth 44% of patients identifying as transfemale and 56% as are at high risk as well.36 According to a 2018 survey transmale; 19% were under 10 years of age while 81% done by the Trevor Project, of were 10 17 years of age. slightly over 1000 LGBTQ Among the children 3 9 years Of slightly over 1000 LGBTQ youth surveyed, 40% of those of age, 15% of the transmales youth surveyed, 40% of those who identified as gender nonand 16% of the transfemales had attention deficit disorder and who identified as gender non- conforming or gender queer, and 39% of those who identified 12% of the transfemales and conforming or gender queer, 16% of the transmales had an as transmale, reported having anxiety disorder. Among the ado- and 39% of those who identified been diagnosed with an eating as transmale, reported having disorder.37 lescents ages 10 17 years, the In a review of almost 300,000 most prevalent diagnosis was been diagnosed with an eating US college students, almost 500 depression, occurring in 49% of disorder identified as transgender; these the transfemales and 62% of the

8

Curr Probl Pediatr Adolesc Health Care, & &&&&

ARTICLE IN PRESS students were significantly more likely to report the individuals with GD both may develop an early disruprecent diagnosis of an eating disorder and/or eating distion in the sense of self, with a preoccupation on body ordered behaviors than cis-gender or sexual minority stuimage or related characteristics, which may then impede dents.38 In a retrospective chart review study done at a social skills development in both groups. Those with center for transgender care in Canada, of 97 TGD youth, ASD who also have GD may have a very difficult time in 15% had either a coexisting diagnosis of an eating disorcoping with the incongruence between sense of self and der (95% restrictive type) or eating disorder behaviors physical sexual characteristics or expected normative with no diagnosis recorded. Similar to results of the Trebehaviors per gender assignment, and may not have the vor Project study, those at highest risk were translinguistic, cognitive or emotional skills to process this males.39 Although TGD individuals typically, but not ambiguity, and also may not have the social skills to seek always, have body image concerns that relate to the and form supportive and protective relationships with incongruence between assigned gender and gender idenothers.43 Gender dysphoria among those with ASD may be quite subtle or may merely seem to be disruptive or tity, perhaps transmales have a higher risk of developing aggressive behavior; therefore patients with both condia restrictive eating disorder because weight loss can lead tions would benefit from a mental health provider skilled to the reduction of the two issues that may cause the in both ASD and GD to help guide care. most dysphoria, i.e. menses and breast development or size.39 However, the actual cause for the association between being TGD and developing an eating disorder Substance use is unknown and may be an effect of the social stress As cited in the studies above, TGD youth have a higher model as described above, similar to other health risks. than expected rate of substance Anecdotally, in the authors’ use, which may be at least partly experience, more and more due to inadequate coping skills youth who are presenting for TGD youth have a higher than treatment of an eating disorder expected rate of substance use, related to marginalization, disover the last several years are crimination, anxiety and depresidentifying as TGD or, are dis- which may be at least partly due sion , as per the minority stress closing a TGD identity while in to inadequate coping skills related model. In a California statewide school survey, the rates of subthe course of their treatment and to marginalization, discriminastance use among almost 5000 recovery. tion, anxiety and depression self-identified transgender youth and over 600,000 cis-gender Autism youth were compared. As in other studies, the transgenAmong individuals seeking treatment for gender dysder youth were shown to have a higher life time use of phoria (GD), there appears to be an over-representation cigarettes (21.5% v. 9.3%), alcohol (42.0% v. 30.2%) of individuals who meet criteria for autism spectrum disand marijuana (33.1% v. 20.7%). However, in contrast to order (ASD). While there have been case reports in the other reports, this study also explored the use of other literature in the past associating the two diagnoses, a drugs, including cocaine, amphetamines, ecstasy and pre2010 Dutch study, using DSM-IV criteria, was the first to scription painkillers, and the results were significantly report that among those seeking treatment in a gender higher for each of these drugs among the transgender stuidentity clinic in Amsterdam, 7.8% also met criteria for dents. Results showed that the transgender youth were ASD, as compared to the 1% prevalence of ASD in the 2.5 times more likely to have ever used cocaine/methamgeneral Dutch population.40 Since then, there have been phetamines, almost 3 times more likely to have used numerous other studies reporting a higher than expected inhalants in the past month, and twice as likely to have occurrence of ASD within the TGD population, in both used prescription pain medications in the past month. Inthe US and Europe, with rates of 4.1 to 17.5 times more school use of substances were also significantly higher than what would be expected in the general population.41 for cigarettes, tobacco, alcohol and marijuana.44 In furThe cause for this association is unknown; however, both ther support of the minority stress model as a causative diagnoses do share certain etiologic theories, including factor for high risk behaviors, among high school stuthe roles of fetal androgen exposure and genetic factors.42 dents who participated in the Florida and California 2015 Another similarity is that individuals with ASD and Youth Risk Behaviors Survey (YRBS), the higher use of Curr Probl Pediatr Adolesc Health Care, & &&&&

9

ARTICLE IN PRESS vaping, smoking, alcohol use and binge drinking that was seen among the transgender students were correlated with high rates of sexual and gender harassment.45

Homelessness According to a 2006 report from the National Gay and Lesbian Task Force, 20 40% of all homeless youth identify as LGBT, with an overrepresentation of transgender youth, and one in 5 transgender individuals are at risk for or need shelter assistance at some point. Furthermore, many shelters segregate individuals by gender, thereby leaving transgender youth at a higher risk for victimization or being turned away. The reality, fear or threat of discrimination within some shelters causes homeless transgender youth to be more vulnerable to depression, substance use, school dropout, survival sex, HIV and STIs.46

Sex, sexually transmitted diseases, HIV All of the above factors, (i.e. discrimination, abuse, homelessness, PTSD) can lead transgender youth to engage in several high risk sexual behaviors, including early onset of sexual activity and more lifetime sexual partners; and reporting higher use of alcohol or substance use, less use of contraception, and no condom use at last sexual encounter.47 Of utmost concern is that while HIV rates among the general population have overall been declining, the rate among transfemales, as well as young men of color who have sex with men, continues to rise.48 Further discussion of sexually related health issues appears in Article 3, “Sexual and Reproductive Health Considerations among Transgender and Gender-Expansive Youth.”

Protective factors Although health disparities do exist, it is also important to emphasize that the great majority of LGBTQ individuals are healthy, well-adjusted and productive individuals.6 In response to the stressors discussed in Meyer’s minority stress model, Meyer subsequently proposed protective factors against mental health concerns and high risk behaviors, which include

10

connectedness to one’s family, personal acceptance of one’s identity, safety in one’s environment (school, community) and a supportive peer social group.49 In a survey of over 400 Canadian youth, ages 16 24 years, those who had supportive parents, in comparison to those who stated they lacked support in the home, reported higher life satisfaction (72% v. 33%), less depression (23% v. 75%), less suicidality (4% v. 57%), higher self-esteem (64% v. 13%), and very good overall mental health (70% v. 15%).50 Those who receive gender affirming treatments, such as hormone blockers for young adolescents, gender affirming estrogen or testosterone for the older adolescent, or gender affirming surgery for the adult, also show positive mental health effects from receiving such care, such as a lessening of depression, anxiety and stress, along with improvement in mood, cognitive functioning, emotional stability and overall well-being.51 These points should help lead the health care provider in discussing guidance and support to parents and families with transgender children.

Overview of mental health care in transgender children and youth

The mental health professional’s role is to assess for gender dysphoria; help educate about gender identity, gender expression and treatment options; screen and treat for coexisting mental health concerns; and assess for eligibility and readiness for gender affirming treatment and/ or surgeries.52 Mental health professionals also need to support the exploration, acceptance and comfort of each individual’s gender identity. For young children, this typically involves helping the family to allow the child to express him or herself in a safe, non-judgmental environment. To do so, the mental health professional must assess how much support and/or opposition to the child’s gender expression is present among family members, includAs the child approaches puberty, the mental health pro- ing siblings, and help the family accept that TGD expression is a fessional may have an impor- natural variation of humanity.53 tant role in assessing for As the child approaches puberty, readiness and eligibility for the the mental health professional early pubertal child to receive may have an important role in assessing for readiness and eligihormone blockers, or for the bility for the early pubertal child older adolescent to receive gen- to receive hormone blockers, or der affirming hormones for the older adolescent to receive gender affirming hormones. Curr Probl Pediatr Adolesc Health Care, & &&&&

ARTICLE IN PRESS The benefit of stopping pubertal development early Gender affirming care is not just for the aesthetic improvement in appearance, but this also may lessen mental health issues, Gender affirming care such as anxiety and depression, and allows the mental health professional to continue to explore gender idenComprehensive treatment guidelines for the care of tity development. As the prevalence of mental health transgender and gender diverse individuals have been issues is high among TGD individuals, a critical role published by the WPATH as well the Endocrine Socifor the mental health professional is to assess for malety.8,54 While the hormonal and surgical aspects of care adaptive behaviors and comorbid psychiatric conof TGD youth is typically done through specialized cencerns. They can also guide the individual to develop ters of service, which may include endocrinologists, adoappropriate and protective coping skills and social lescent medicine specialists and surgeons, among others, supports.51 Any comorbid diagnoses should be much of the care, especially at the early stages, can be addressed and managed, as they may interfere with done by the primary care pediatrician. Part of the goal of readiness, decision making and compliance with treatearly treatment is to not “pathologize” the TGD youth; ment. The role of the mental health professional is of therefore, the more that can be done in the primary office the utmost value, and as per the WPATH Standards of the less stigmatized the youth may feel. Gender affirmCare guidelines, they need to be skilled in diagnosing ing care can be categorized in three stages: reversible and treating psychopathology in children and adolesintervention, partially reversible intervention and irrecents, be competent in gender non-conforming expresversible intervention. The reversible interventions availsions and identities and the treatment of gender able to TGD children and adolescents include social dysphoria, and need to maintain cultural competence transitioning and pubertal blockers; the partially reversin working with TGD individuals.8 As mentioned ible intervention is gender affirming hormone treatment; above, the mental health professional is instrumental and the irreversible intervention is gender affirming in assessing for readiness to begin gender-affirming surgery.8 Transgender youth who have undergone treattreatment and in providing an ment with pubertal blockers, eligibility referral letter so such gender affirming pubertal hortreatment can begin. To begin mones and gender affirming surTransgender youth who have gender affirming hormone thergery, have shown steady undergone treatment with apy, usually a referral letter of improvement in psychological pubertal blockers, gender eligibility must be provided. In functioning and normal expectaaffirming pubertal hormones an effort to eliminate further tions of a sense of well-being.55 hurdles in seeking gender and gender affirming surgery, Gender affirming treatment is affirming treatment, some spediscussed in Article 2: “Gender have shown steady improvecialized centers may use an Affirming Medical Care of ment in psychological informed consent model which Transgender Youth.” functioning acknowledges the individual’s right to choose treatment Social transitioning options without the involvement of a mental health professional; however, this is Social transitioning can include the use of a chosen presently not the standard practice, especially for name and preferred pronoun, as well as gender affirmminors. The WPATH guidelines state that for chest ing clothing, hairstyle and other gender supportive (top) surgery, one letter of eligibility from a mental behaviors and preferences. Use of chosen name has health professional is required, and for genital (botbeen shown to lower depressive symptoms, suicidal tom) surgery, two independent letters are required. As ideation and suicidal behavior in TGD children, with access to mental health professionals may be limited, the lowest level of symptoms found among those who ongoing psychotherapy is no longer an absolute are able to use the chosen name in multiple arenas, requirement in order for an individual to receive gensuch as home, school and among friends.56 By parender affirming care, especially for adults; however, a tal report, prepubescent children who have been thorough mental health assessment must be done.8 allowed to live according to their gender identity, and

Curr Probl Pediatr Adolesc Health Care, & &&&&

11

ARTICLE IN PRESS not their sex assigned at birth, have rates of anxiety and depression similar to age matched controls and siblings, and have also found to have less internalizing psychopathology than has been reported in nonsocially transitioned children.57 Furthermore, children who had socially transitioned also reported typical levels of depression, with only slightly higher, though not significant, levels of anxiety, and better self-worth than non-transitioned children.58 Overall, socially transitioned children have marked improvement in their dysphoria and well-being and are given time to “test the waters” of living as the identified gender prior to receipt of gender-affirming treatment.59

Primary health care for TGD youth As discussed above, the pediatrician is often the first person a parent may turn to for consultation when faced with a child that identifies as TGD or who expresses gender nonconforming behaviors.4 Therefore, it is the pediatrician’s responsibility to be able to guide the child and family in a supportive and inclusive manner. The pediatrician is in a unique position to intercede early in order to prevent serious long-term sequalae, since childhood psychologic trauma can often lead to continued maladaptive and high-risk behaviors. Much of the care for the TGD child and adolescent should be done by the primary care provider, with the approach being that TGD children have similar needs to those of cisgender children. The TGD child should not be made to feel stigmatized by having to go to specialized centers, which may be not easily accessible, for care that can be done in the primary care office. The primary care pediatrician may also need to take an active role to help ensure that the school environment is accommodating and safe, which may include advocating for gender neutral bathrooms, or allowing the child to participate in the appropriate gender-identified activities.

Barriers to care To begin the discussion of providing healthcare in the primary care office, one must first look at the barriers that TGD individuals may face when attempting to receive care. Many TGD individuals are reluctant to disclose their identities for fear of discrimination and rejection, even in health care settings; this is true as well for parents of TGD individuals, due to their own shame, guilt or lack of knowledge. Many TGD individuals are also turned away from medical practices or face verbal

12

and/or physical harassment while seeking health care. Other barriers may include the inconsistent use of identification in EHRs and billing/coding systems, as well as confusion over gender references in laboratory testing. Probably the most significant barrier to care is the lack of experience and education among health care providers and staff and, therefore, culturally sensitive training needs to be made available and utilized in practices and hospital settings.60 Regarding the physician’s comfort in providing care to TGD youth, a survey of adolescent medicine specialists and pediatric endocrinologists cited a lack of clinical training, inadequate insurance reimbursement and not enough qualified mental health specialists; each of these concerns led to a lack of confidence in providing care to TGD youth.61 According to TGD youth enrolled in focus groups, the specific issues that they face, which can impact access to healthcare, include: accessibility (e.g. distance, availability of in-network providers, lack of youth-oriented care); providers’ comfort with working with TGD youth; inconsistent use of chosen name and pronoun; insurance exclusions; and, delayed access and/or age-related exclusions to gender affirming hormones or pubertal blockers.62 In a survey of over 80,000 cisgender and TGD high school students, the TGD youth reported less frequent preventive health care visits and considered themselves to have poorer health, with only 38% of the TGD students, compared to 67% of cisgender students, reporting that their health was very good or excellent. Furthermore, the TGD group missed school more often and had more frequent visits to the school nurse’s office.63 Understanding the social needs, health risks and mental health concerns of TGD youth should guide the health care provider in delivering appropriate care and services. The provider must also be aware of issues that the parent may have, as these may be different than the youth. A survey of patients and their parents showed that TGD youth were interested in finding out information and obtaining services related to gender affirming care, such as pubertal blockers, hormone therapy and/or surgical options. Parents, on the other hand, were mostly concerned about safety at school, mental health issues and family acceptance.64

Use of preferred name and pronouns Within the office setting, use of the chosen name, in lieu of the given birth name, or sometimes referred to as the “dead name,” offers the youth support and Curr Probl Pediatr Adolesc Health Care, & &&&&

ARTICLE IN PRESS reassurance of acceptance within the medical setting. displayed which should emphasize the inclusivity of the Therefore, when meeting with a TGD youth for the office setting; rainbow and transgender flags or decals first time, the provider should can be on display as well, letting always ask for the preferred the youth know that the office is The provider should always name and preferred pronouns, welcoming for all individuals. ask for the preferred name i.e. he/him/his or she/her/ As the patient and family sign hers; some non-binary or genin to register, they should be and preferred pronouns derqueer individuals prefer asked for their preferred name, gender-neutral pronouns such and it should be noted if it is difas they/them/theirs or ze/zir/zirs, among others. ferent from the insurance card, driver’s license or health If an individual has a name or preferred pronoun that record, especially if there has yet to be a legal change in is different than what is on the medical records or insurname. Electronic sign-in sheets should also have a way ance card it is critical that all office staff, including secto identify the preferred name if it is different from retaries, registrars, office assistants, etc., are aware of what may appear on the health record. This is done to this and use the proper name to support the individual avoid any embarrassment the TGD patient may experiand avoid the shame and embarrassment of being called ence if called the wrong name in the waiting room, by the birth name. Electronic health records are slowly especially if gender appearance does not match the catching up with highlighting chosen names and proname on the record. As many offices now use health nouns, although this information may not be clearly questionnaires for the general history, as well as to obvious. Some EHRs allow a special banner to alert screen for medical and mental health risks, care should staff to significant information, of which a name can be be taken that these materials are also inclusive, and included. It is the responsibility of the provider to make allow for gender options, including other than male/ sure that the appropriate name is included throughout female, use of preferred name and that heterosexuality the visit. Until the insurance card is also changed to the or cisgender status should not be assumed. preferred name, laboratory testing or other services may need to be identified with the birth name; if so, the Confidentiality reason should be clearly explained to the individual. Although state laws differ in regard to age of conSome TGD youth, who may not have physically transisent for certain medical and mental health services, tioned in appearance, may be uncomfortable with or adolescents should be offered confidentiality when not ready to be called their preferred name in a public speaking with their health care providers. It should be setting, such as a waiting room, especially if their shared at the beginning of the visit that confidentiality appearance does not match their preferred name. Other will be maintained unless the patient or someone else TGD youth may only be comfortable using their preferred name with their provider but not in front of a paris in danger.66 Confidentiality must be maintained regarding discussions that may be perceived as ent, especially if they do not feel supported. Therefore, “sensitive,” which is supported by the https://doi.org/ before preferred names are included on medical records American Academy of Pediatrics, The American one should always ask the youth when and how they Academy of Child and Adolescent Psychiatry, the want the name used. Society for Adolescent Health and Medicine, The American College of Obstetrics and Gynecology and Office setting the American Medical Association.67 Care must be Primary care for TGD youth starts at the front door. taken to protect confidentiality, not just while taking Transgender children and youth deserve and expect the history, but in regard to documentation in EHRs, the same as do all patients: privacy, confidentiality, billing, insurance claims, and explanation of benefits honesty, respect and competency, and to be treated in (EOB) statements.67 When sensitive information is obtained, it must be emphasized that it is not the a nonjudgmental manner in an inclusive setting.65 The office setting should be welcoming and promote a providers’ role to disclose the gender identity or sexfeeling of trust. Nondiscrimination policies should be ual orientation status to parents or guardians without displayed, which include provisions for gender identity the adolescent’s permission, as this may subject the and sexual orientation. Posters, leaflets and flyers can be youth to family rejection, homelessness or harm.68 Curr Probl Pediatr Adolesc Health Care, & &&&&

13

ARTICLE IN PRESS Taking the history Once confidentiality is explained and understood by the youth and family, then the full history should be done, as with all patients. Parents are needed for discussions of past medical history and family history, as well as to be able to share any health concerns that they may have. It should be noted if parents share a concern or knowledge of gender identity and, if so, if there is a supportive or oppositional stance taken. The youth should then be allowed a private discussion with the provider, to discuss concerns that they may have. As with all youth, a discussion of home, school, activities, peer relationships, sleep and eating patterns should be done, including any history of bullying or harassment. As no two individuals share the same story, the gender history of the individual’s journey so far towards gender identification should be obtained. If the individual identifies as transgender, genderqueer, genderfluid, nonbinary, etc., they should be asked what that term means to them, as this also may have different meanings for different people. The youth should be asked about family knowledge and acceptance of the gender identity and feelings of safety in the home. School safety should be assessed, as should information as to whether the child has disclosed their gender identity at school, using preferred name and pronoun, or gender confirming dress and expression. Also, concerns for safety in the community, workplace, church, clubs, etc. should be obtained. As many transgender youth feel isolated, some may seek friendships online, which my place them at risk for victimization. The youth’s goals of treatment should be explored, both for the present time and the future. If a TGD individual is interested in gender affirming treatment, then discussion should follow regarding goals and expectations, as well as past use of any hormones, street hormones or substances obtained from friends or through the internet. Sexual history should include any past sexual activity including number and gender of partners, type of sexual activity (oral, vaginal, anal; receptive/insertive), use of methods to protect from sexually transmitted infections, past history of sexually transmitted infections, and methods used to prevent pregnancy.69 Further information regarding age of onset of sexual activity, use of alcohol or drugs at time of sexual encounters, violence or forced sexual activity, exchange of sex for money or other items, and use of

14

geosocial networking applications (i.e. “hookup apps”), should also be obtained. As TGD youth are at an increased risk of maladaptive behaviors and psychopathology, all should be screened for use of tobacco, electronic nicotine delivery systems, alcohol, and other substances, including misuse of prescription medications. All patients should also be screened for anxiety, stress, depression, victimization, self-harm and suicidality. Preventive and coping strategies should also be explored, and positive feedback should be given when appropriate.

The physical examination The exam room and bathroom should be gender neutral and allow for privacy while disrobing. As some TGD individuals have dysphoria related to their anatomy and sexual characteristics, exposing body parts should only be done when necessary. In this author’s experience, the TGD patient should disrobe and put on an examination gown only when absolutely necessary and with an explanation to the individual why it has to be done. For example, if there is a concern that the individual may be self-harming, it should be explained that examination of the skin is necessary to see the extent and nature of the harm, as well as the stage of healing. The same needs to be done when examining specific body parts. Sexual maturity ratings, as well as testicular, pelvic and breast exams, should be done as generally required for all children and youth, with the understanding, however, that exposing these body parts may be very traumatic. For example, when performing a testicular examination on a transfemale adolescent, the importance of the examination must be clearly explained. The provider should keep the body covered as much as possible and can ask the individual what is the preferred way to have the examination performed while maintaining comfort. One should also inquire about the preferred name for the body part; for example, a transfemale may not be comfortable with the term” testicular exam” but may prefer to call the area using gender neutral terms such as “gonads,” “below,” “bottom” or “down there.” As well, transmales may prefer the term “top” or “chest” to “breasts.” In either case, one should not assume the comfort level of having the examination or use of terms but should take direction from the TGD individual. The provider also should be aware of any garment, such as a chest binder or gaffe, that the patient may be wearing. In general, the patient should be allowed to wear the garment for the exam, unless that area needs to be Curr Probl Pediatr Adolesc Health Care, & &&&&

ARTICLE IN PRESS examined, for example to assess for skin breakdown if someone is wearing the binder for too long or if it is the incorrect size. As for all patients, for sensitive parts of the exam or for the whole examination, a chaperone should be offered. Upon completion of the physical examination, the patient should be allowed to get dressed in privacy once again.

professionals. The AAP recommends that “youth who identify The AAP recommends that as TGD have access to compre“youth who identify as TGD hensive, gender-affirming, and have access to comprehensive, developmentally appropriate gender-affirming, and develop- health care that is provided in a safe and inclusive clinical mentally appropriate health 4 For children and adolescare that is provided in a safe space.” cents, this starts with the primary and inclusive clinical space.” care pediatrician, who may be the first contact for families seeking guidance. Therefore, it is important that pediatricians become well versed in the Summary of the visit health needs that this often marginalized population may At the end of the visit, the youth should be privately face. given any findings that may be considered sensitive. Permission should be asked as to what can and cannot References be shared with parents. Areas of high risk need to be 1. Benjamin H, Ihlenfeld CL. The nature and treatment of transaddressed, and either follow-up appointments should be sexualism. Med Opin Rev 1970;6(11):24–35. made, or the individual should be referred to the appro2. Herman JL, Flores AR, Brown TNT, Wilson BDM, Conron priate specialist. For youth and family seeking to begin KJ. Age of Individuals Who Identify as Transgender in the gender affirming treatment, a conversation should be United States. Los Angeles, CA: The Williams Institute; 2017. held regarding types of treatment available and readiness 3. Johns MM, Lowry R, Andrejewski J. Transgender identity and for treatment, including age and sexual maturity of the experiences of violence victimization, substance use, suicide individual, as that may also dictate eligibility. The prorisk, and sexual risk behaviors among high school students vider should have local resources available for gender 19 States and large urban school districts, 2017. Morb Mortal affirming treatment or can start the process depending Wkly Rep 2019;68:67–71. 4. Rafferty J, AAP Committee on Psychosocial Aspects of Child on knowledge and comfort. Some families may also and Family Health, AAP Committee on Adolescence, AAP request a letter for a legal name change, which can be Section on Lesbian, Gay, Bisexual, and Transgender Health provided by the primary care provider, typically with and Wellness. Ensuring comprehensive care and support for input from a mental health provider. Local youth organitransgender and gender-diverse children and adolescents. zations that can allow TGD youth to socialize in a safe Pediatrics 2018;142(4):e20182162. environment should be encouraged, and many of these 5. Reitman DS, Austin B, Belkind U. Position paper: recommendations for promoting the health and well-being of lesbian, organizations may also have resources for parents. For gay, bisexual and transgender adolescents: a position paper of the parents who have shown support for the TGD child, the society of adolescent health and medicine. J Adolesc credit should be given, as the parents often have had to Health 2013;52:506–10. deal with their own struggles in acceptance. For families 6. Institute of Medicine (US) Committee of Lesbian, Gay, Bisexwho exhibit continued confusion and/or opposition, folual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of lesbian, Gay, Bisexual, and Translow-up support should be offered along with family gender People: Building a Foundation for Better Understanding. counseling.

Conclusions The World Professional Association for Transgender Health (WPATH) states that the overall goal of the Standards of Care for transgender individuals is to achieve “lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being and self-fulfillment.”8 Accomplishing this goal often requires the support of medical Curr Probl Pediatr Adolesc Health Care, & &&&&

Washington, DC: National Academies Press (US); 2011. 7. American Psychological Association. Guidelines for psychological practice with transgender and gender nonconforming people. Am Psychol 2015;70(9):832–64. 8. World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Version 7; 2016 9. Miranda L, Puhl R, Watson Y, Kahn E, Ashland J, Lee M. Human Rights Campaign 2018 LGBTQ Youth Report, 2018. 10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.

15

ARTICLE IN PRESS 11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision Washington, DC: American Psychiatric Association; 2000. 12. Bockting WO, Miner MH, Swinburne Romine RE, Hamilton A, Colemna E. Stigma, mental health and resilience in an online sample of the US transgender population. Am J Public Health 2013;103(5):943–51. 13. Fast AA, Olson KR. Gender development in transgender preschool children. Child Dev 2018;89:620–37. 14. National Center on Parent. Family and Community Engagement. Healthy Gender Development and Young Children: A Guide for Early Childhood Programs and. Professionals. 2018. https://depts.washington.edu/dbpeds/healthy-genderdevelopment.pdf. 15. Polderman TJC, Kreukels PC, Irwig MS. The biologic contributions to gender identity and gender diversity: bringing data to the table. Behav Genet 2018;48:95–108. 16. Bao A, Swaab DF. Sexual differentiation of the human brain: relation to gender identity, sexual orientation and neuropsychiatric disorders. Front Neuroendocrnol 2011;32:214–26. 17. O’Hanlan KA, Gordon JC, Sullivan MW. Biologic origins of sexual orientation and gender identity: impact on health. Gynecol Oncol 2018;149:33–42. 18. Rametti G, Carrillo B, Gomex-Gile E, Segovia S, Gomes A, Guiilamon A. White matter microstructure in female to male transsexuals before cross-sex hormone treatment. a diffusion tensor imaging study. J Psychiatr Res 2011;45(2):199–204. 19. Rametti G, Carrillo B, Gomex-Gile E. The microstructure of white matter in male to female transsexuals before cross-sex hormone treatment. A DTI study. J Psychiatr Res 2011;45(7):949–54. 20. Leinung M, Wu C. The biologic basis of transgender identity: 2D:4D finger length rations implicate a role for prenatal androgen activity. Endocr Pract 2017;23:669–71. 21. O’Hanlan, Baba T, Endo T. Association between polycystic ovary syndrome and female-to-male transsexuality. Hum Reprod 2007;22:1011–6. 22. Steensma TD, McGuire JK, Kreukels BPC, Beekman AJ, CohenKettenis PT. Factors associated with desistance and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc Psychiatry 2013;52:582–90. 23. Gooren LJ. Care of transsexual persons. N Engl J Med 2011;364:1251–7. 24. Reisner S, Poteat T, Keatley J. Global health burden and needs to transgender populations: a review. Lancet 2016;388:412–36. 25. Meyer IH. Minority stress and mental health in gay men. J Health Soc Behav 1995;36:38–56. 26. Valentine SE, Shipherd JC. A systemic review of social stress and mental health among transgender and gender non-conforming people in the united states. Clin Psychol Rev 2018;66:24–38. 27. Beams L. Disparities for lgbtq and gender nonconforming adolescents. Pediatrics 2018;141(5):e20173004. 28. Kosciw JG, Greytak EA, Palmer NA, Boesen MJ. The 2013 National School Climate Survey: The experiences of lesbian, gay, Bisexual and Transgender Youth in Our Nation’s Schools. New York: GLSEN; 2014. 29. Roberts AL, Rosario M, Corliss HL, Koenen KC, Austin SB. Childhood gender nonconformity: a risk indicator for

16

30.

31.

32.

33.

34.

35.

36.

37. 38.

39.

40.

41.

42.

43.

44.

45.

childhood abuse and posttraumatic stress in youth. Pediatrics 2012;129:410–7. Lee JG, Ylioja T, Lackey M. Identifying lesbian, gay, bisexual and transgender search terminology: a systemic review of health systematic reviews. PLoS One 2016;11:1–12. Connolly MD, Zervos MJ, Barone C.J. II, Johnson CC, Jospeh CL. The mental health of transgender youth: advances in understanding. J Adolesc Health 2016;59:489–95. Olson J, Schrager SM, Belzer M, Simons LK, Clark LF. Baseline physiologic and psychologic characteristics of transgender youth seeking care for gender dysphoria. J Adolesc Health Care 2015;57:374–80. Becerra-Culqui TA, Liu Y, Nash R. Mental health of transgender and gender nonconforming youth compared with their peers. Pediatrics 2018;141:1–11. Eisenberg ME, Gower AL, McMorris BJ, Rider GN, Shea G, Coleman E. Risk and protective factors in the lives of transgender/gender nonconforming adolescents. J Adolesc Health 2017;61:521–6. Reisner SL, Biello KB, White Hughto JM. Psychiatric diagnoses and comorbidities in a diverse, multicity cohort of young transgender women: baseline findings form project lifeskills. JAMA Pediatr 2016;170:481–6. Coker TR, Austin SB, Schuster MA. The health and health care of lesbian, gay, and bisexual adolescents. Annu Rev Public Health 2010;31:457–77. The Trevor Project. Eating Disorders Among LGBTQ Youth: A 2018 National Assessment. www.TheTrevorProject.org. Diemer EW, Grant JD, Munn-Chernoff MA, Patterson DA, Duncan AE. Gender identity, sexual orientation, and eatingrelated pathology in a national sample of college students. J Adolesc Health 2015;57:144–9. Feder S, Isserlin L, Seale E, Hammond N, Norris ML. Exploring the association between eating disorders and gender dysphoria in youth. Eat Disord 2017;25:310–7. de Vries ALC, Noens ILJ, Cohen-Kettinis PT, van BerckelarOnnes IA, Doreleijers TA. Autism spectrum disorders in gender dysphoric children and adolescents. J Autism Dev Disord 2010;40:90–936. Strang JF, Janssen A, Tishlman A, Leibowitz SF, Kenworthy L, McGuire JK, et al. Letters to the editor: revisiting the link: evidence of the rates of autism in studies of gender diverse individuals. J Am Acad Child Adolesc Psychiatry 2018;57:885–6. Shumer DE, Reisenr SL, Edwards-Leeper L, Tishelman A. Evaluation of asperger syndrome in youth presenting to a gender dysphoria clinic. LGBT Health 2016;3:387–90. Jacobs LA, Rachlin K, Erickson-Schroth L, Janssen A. Gender dysphoria and co-occurring autism spectrum disorders: review, case examples, and treatment considerations. LGBT Health 2014;1:277–82. De Pedro KT, Gilreath TD, Jackson C, Esquea MC. Substance use among transgender students in California public middle and high schools. J Sch Health 2017;87:303–9. Coulter RWS, Bersamin M, Russell ST, Mair C. The effects of gender- and sexuality-based harassment in lesbian, gay, bisexual and transgender substance use disparities. J Adolesc Health 2018;62:688–700.

Curr Probl Pediatr Adolesc Health Care, & &&&&

ARTICLE IN PRESS 46. Ray N. Lesbian, Gay, Bisexual and Transgender Youth: An Epidemic of Homelessness. New York: National Gay and Lesbian Task Force Policy Institute and the National Coalition for the Homeless; 2006. 47. Johns MM, Lowry R, Andrejewski J. Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students 19 States and large urban school districts, 2017. Morb Mortal Wkly Rep 2019;68:67–71. 48. Grant JM, Mottet LA, Tanis JT, Harrison J, Herman JL, Keisling M. National Transgender Discrimination Survey Report on Health and Healthcare. National Center for Transgender Equality and the National Gay and Lesbian Task Force; 2010. 49. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay and bisexual populations: conceptual issues and research evidence. Psychol Bull 2003;129:674–97. 50. Travers R, Bauer G, Pyne J, Bradley K, Gale L, Papadimitiou M. Impacts of strong parental support for trans youth; a report prepared for children’s aid society of toronto and delisle youth services. Trans PULSE 2012:1–5 http://transpulseproject.ca/ wp-content/uploads/2012/10/Impacts-of-Strong-Parental-Support-for-Trans-Youth-vFINAL.pdf. 51. Mizock L. Transgender and gender diverse clients with mental disorder: treatment issues and challenges. Psychiatr Clin North Am 2017;40:29–39. 52. Wylie K, Knudson G, Khan SI, Bonierbale M, Watanyusakul SB. Serving transgender people: clinical care considerations and service deliver models in transgender health. Lancet 2016;388:401–11. 53. Coolhart D, Shipman D. Working toward family attunement: family therapy with transgender and gender-nonconforming children and adolescents. Psychiatr Clin North Am 2017;40:113–25. 54. Hembree WC, Cohen-Kettenis PT, Gooren L. Endocrine treatment of gender-dysphoric/gender-incongruent persons: and endocrine society clinical practice guideline. J Clin Endocrinol Metab 2017;102:3869–909. 55. de Vries ALC, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics 2014;134:696–704. 56. Russell ST, Pollitt AM, Li G, Grossman AH. Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. J Adolesc Health 2018;63:503–5.

Curr Probl Pediatr Adolesc Health Care, & &&&&

57. Olson KR, Durwood L, DeMueles M, McLaughlin KA. Mental health of transgender children who are supported in their identities. Pediatrics 2015;137(3):e20153223. 58. Durwood L, McLaughlin KA, Olson KR. Mental health and self-worth in socially transitioned transgender youth. J Am Acad Child Adolesc Psychiatry 2017;56:116–23. 59. Sheerer I. Social transition: supporting our youngest transgender children. Pediatrics 2016;137(3):e20154358. 60. Roberts TK, Fantz CR. Barriers to quality health care for the transgender population. Clin Biochem 2014;47:983–7. 61. Vance S.R. Jr, Halpern-Felsher BL, Rosenthal SM. Health care providers’ comfort with and barriers to care of transgender youth. J Adolesc Health 2015;56:251–3. 62. Gridley SJ, Crouch JM, Evans Y. Youth and caregiver perspectives on barriers to gender-affirming health care for transgender youth. J Adolesc Health 2016;59:254–61. 63. Rider GN, McMorris BJ, Gower AL, Eisenberg ME. Health and care utilization of transgender and gender nonconforming youth: a population-based study. Pediatrics 2018;141(3):e20171683. 64. Lawlis SM, Donkin HR, Bates JR, Britto MT, Conrad LAE. Health concerns of transgender and gender nonconforming youth and their parents upon presentation to a transgender clinic. J Adolesc Health 2017;61:642–8. 65. Ginsberg KR, Winn RJ, Rudy BJ, Crawford J, Zhao H, Schwartz DF. How to reach sexual minority youth in the health care setting: the teens offer guidance. J Adolesc Health Care 2002;31:407–16. 66. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. In: Hagan JF, Shaw JS, Duncan PM, (eds). Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th ed.., Elk Grove Village, IL: American Academy of Pediatrics, 2017. 67. Burstein GR, Blythe MJ, Santelli JS, English A. Confidentiality protections for adolescents and young adults in the health care billing and insurance claims process; position paper of the society for adolescent health and medicine and the American Academy of Pediatrics. J Adolesc Health 2016;58:374–7. 68. Levine DA, and the Committee on Adolescent. Offices care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics 2013;132:e297. 69. Centers for Disease Control and Prevention. Sexually transmitted disease treatment guidelines, 2015. MMWR Recomm Rep 2015;64:1–137.

17