Gender-affirming practices for the general paediatrician

CLINICAL VIGNETTES

Case 1

Eva is a 6-year-old who was assigned male at birth. She has asked to be called ‘Eva’, uses she/her pronouns, and has worn dresses for the past 2 years. Her parents are supportive and present to your paediatric clinic to talk about her gender identity, parent support groups, and how they can support Eva’s mental and physical health. You provide the family with appropriate resources to talk about gender, connect them to a local parent support group, and describe the many benefits that an affirming social environment has on gender-diverse children and youth.

Case 2

Jackson is a 12-year-old presenting to your paediatric clinic with his parents to discuss his gender identity. Jackson was assigned female at birth but describes identifying as a boy, using he/him pronouns, and engaging in stereotypically masculine activities since age 9. Jackson notes chest tissue development and recent monthly vaginal bleeding that are causing significant distress and gender dysphoria, impacting his mental health. He describes wanting to stop menstruating and wanting a referral to a gender-specific medical clinic for ongoing medical treatment. Recognizing that the local wait time to access a specialized gender-care clinic is over 6 months, you explore options for menstrual suppression (including hormone blockers) and discuss other forms of care to support his mental health and social transition (binding, packing, etc.).

LEARNING POINTS

• Many paediatricians see transgender or gender-diverse (TGD) children and youth in their practices, either for gender-related care or general health care. Paediatricians are well-positioned to support the healthcare needs of TGD children and youth who may experience barriers to care, such as discrimination and significant wait times for specialized gender-affirming care. The Canadian Paediatric Surveillance Program (CPSP) issued a one-time survey in February 2023 designed to capture information on the care-related needs of TGD children and youth. For more information on the survey, please visit the following website: https://cpsp.cps.ca/surveillance/one-time-surveys.

• The survey showed that most paediatricians across Canada see TGD children and youth in their practices, with 77% of respondents saying they had provided medical care to TGD children or youth in the last year. Commonly cited healthcare needs among these TGD patients included general medical care unrelated to gender, desire for therapy focusing on general mental health, and referral to a specialized gender-affirming medical clinic.

• It is important for paediatricians to know how to support TGD patients and their families, including ensuring the provision of general medical care. While most survey respondents (619 of 874, 71%) described feeling comfortable or very comfortable providing general health care to TGD children and youth, 111 of 874 (13%) felt neutral, and 144 of 874 (16%) reported feeling uncomfortable or very uncomfortable. Further research is required to understand the sources of discomfort and opportunities for this discomfort to be addressed.

• Timely access to gender-affirming care is important for youth experiencing gender dysphoria and paediatricians should be aware of the wait times that can be involved for referrals to specialized clinics. After making a referral to a specialized gender-affirming medical clinic, 26% (104 of 405) of respondents reported that TGD children and youth in their care received specialized care within an average of 6 months, 41% (166 of 405) reported that specialized care was provided in 6 to 12 months, and 33% (135 of 405) reported their patients waited over a year.

• There are many barriers to care for TGD children and youth interested in gender-affirming medical interventions. The most frequently cited physician-identified barriers included long wait times, family-specific barriers (e.g., lack of parental support and poor access to transportation), patient-specific barriers (e.g., fear of stigma, feelings of embarrassment, and parents are unaware), lack of clinics in their area, and lack of knowledge of the referral process.

• What can the general paediatrician do, beyond referring TGD patients to a specialized gender-care clinic?

  • o Learn about gender-affirming care: There are many educational resources available on gender-affirming care. For example, the Canadian Paediatric Society has published a position statement, “An affirming approach to caring for transgender and gender-diverse youth” (1).

  • o Offer parental support and resources: Studies have shown that parental support can have a significantly positive impact on a gender-diverse child. For example, Travers et al. highlight how parental support significantly reduces suicide attempts (57% to 4%) and depressive symptoms (75% to 23%), and significantly improves life satisfaction (33% to 72%), self-esteem (13% to 64%), and adequate housing (45% to 100%) (2). Resources, such as the ‘Families in TRANSition’ document from Central Toronto Youth Services, can be a helpful start (3).

  • o Provide advice on social transition: For many TGD children and youth (e.g., case 1), there may only be an interest in/need to discuss social transition, which might include using an affirmed name and pronouns and exploring clothing and hairstyles that align with their experienced gender. As puberty progresses (e.g., case 2), TGD youth might explore binding, tucking, padding, or packing, and may request your support in doing so safely. Rainbow Health Ontario and Trans Care BC have helpful resources available on their websites (4,5).

  • o Support menstrual suppression/hormone blockers, if appropriate and desired by the patient: Menstruation can be a source of significant gender dysphoria for some TGD youth. Menstrual suppression can mitigate dysphoria for some and can be achieved using various forms of contraception, such as hormonal intrauterine systems, depot injections, continuous use of oral contraceptive pills, contraceptive patches, and rings, or hormone blockers.

Attributes

• Adolescent Medicine

• Paediatrics

• Medical Education

• Gender Identity

FUNDING

No funding to report.

POTENTIAL CONFLICT OF INTEREST

All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

REFERENCES