Medical

Often the first place parents go as they try to understand and help their gender-expansive child is a medical professional. This places physicians and nurses in a critically important position.

Doctors, nurses and others professionals in medical settings may well be called upon to address the specific needs related to a transgender or other gender-expansive patient. Often the first place parents go as they try to understand and help their gender-expansive child is their doctor. It is equally important for medical professionals to recognize that a broader level of understanding about gender is critical as they work with any of their young patients. A nurse taking a child’s vitals needs to use accepting and inclusive language as they encounter a boy wearing a dress or carrying a doll. An emergency room physician working with a teenage girl with a buzz cut and boxers must be able to comfortably attend to her patient’s needs.

Whether a child is transgender or simply operating at the margins of gender, medical professionals play a critical role in helping young people, along with their families and other professionals supporting them, come to a deeper understanding of and appreciation for gender diversity. The stance taken by medical professionals during these encounters can have a huge impact on the ultimate health and well being of the child. Even beyond the medical services you may be providing, the relationship that you establish with your gender-expansive patients will be the single most important factor in supporting their health.

Working with Parents

As a medical provider working with a gender-expansive child it is important to recognize that the parents or family may have significant support needs as well. In coming to you, they may simply be looking to understand what is going on for their child. Some will be worried about their child’s safety, or what their gender diverse child implies about their own parenting. Still others will be seeking ways to “fix this.” Is my kid normal? What does it mean that my son wants to wear dresses or play princess? What causes a child to “be this way,” and what are some of the paths moving forward if it continues? These and many more questions will most likely be raised.

While the possible answers to these questions vary, one thing is certain: the medical provider’s ability to reassure parents that their child is okay is crucial. Further, explaining the importance of parental support, and its impact on the ultimate health outcome for their child is essential.

Even as you acknowledge the difficulties they are experiencing, you must also impress upon them the need for their child to know they are loved. A critical part of this process, then, is to create an open space in which the family and child are supported to explore this issue. As a medical provider, this means establishing a safe arena for this exploration to occur, rather than simply telling the family or child what this all means.

An important part of this is to have available clear written and other information about gender diversity, children and youth. Supporting Gender Independent Children and Their Families is an excellent overview of the various issues with which families will need to become familiar as they travel this road.

It also might be tempting to refer these parents and their child to some sort of gender specialist. That may well be appropriate at some point in this process; however, even if such a specialist exists in your area, the fact is that primary care professionals, with their strong relationship with the child and family, are best positioned to help all of them navigate these waters. Pediatricians, adolescent medicine providers and family doctors will frequently be the primary point of contact for these patients. The ability of general practitioners to support the family is essential.

Working with the Patient

Depending on their age, there are a number of key practices for ensuring a positive and inclusive experience for the patient.

Patient Histories

An important first step is the manner in which the provider creates space for the young person to talk about their gender. Sometimes a child’s gender-expansiveness will be obvious. Either the family has shared with you their observations/concerns about their child’s gender, or the child’s gender diversity is perceptible. In these situations, it is important to be affirming of the child’s presentation. For instance, if a child comes into the exam room in clothing stereotypically consistent with the “other” sex, show interest. Questions or comments such as “where do you get cool shoes like that?” “I love the color of that dress,” or “how do you keep your baseball hat’s bill so straight?” will demonstrate openness on your part that can help the patient relax and feel more secure.

But it is also quite common to see no evidence of a young patient’s identification. Perhaps the child or teen lives in a context where it has been made clear that this topic is off-limits. They may feel great shame about their gender, or not even have the words to describe what they are feeling. Thus, the provider needs to open the door for this information to emerge. In taking the patient’s history, consider ways you might elicit information about a child’s emerging gender. Ask open-ended questions about the young person’s toys, activities, styles of dress, and friends. Specifically asking whether the child has questions about gender also establishes a setting where it is clear that gender diversity is ok.

Explaining that there is nothing wrong if a person has questions about their own gender, or sharing your observations about gender and kids in general can be great ways to start a conversation. The patient may not necessarily raise the issues the first time you inquire, but you have set a tone where it is safe to do so in the future. In other words, create as many openings as possible for the young person to communicate any concerns or fears they may have related to their gender.

Sexual Health

When working with teens, it is also important to discuss issues about sexual health. While hopefully part of any history with a patient in this age group, it is critical for transgender and other gender-expansive youth. Becoming sexually active can create risks for these young people beyond those faced by their typically gendered peers.

One very real danger is the possibility of being physically assaulted by a potential sexual partner. Many transgender youth fear revealing their identity to an individual with whom they wish to be intimate, for fear of rejection. For this to come up in the moment can be disastrous if the other person is hostile to the idea. As such, teens need to be coached around disclosure issues with potential partners. If a teen anticipates they will be having sex, it is critical they let someone — an adult, sibling, or friend — know where they are and have a plan for reaching them if things go awry.

Another critical issue is sexual health. Teenagers and young adults have higher rates of sexually transmitted infections (STIs) than any other age group. One of the main reasons is that they frequently have unprotected sex. They are also biologically more likely to develop an infection. In addition, they may be less likely to use health care services that could give them information on how to protect themselves against STIs.

Because of misconceptions about the nature of sexual activities they may be engaged with, some transgender youth believe they are not be vulnerable to STIs. Regardless of whether they are having “traditional” sexual intercourse, gender-expansive teens are at risk for contracting STIs. As with anyone who is considering becoming sexually active, the use of condoms and other barrier methods must be emphasized. It is also important that regardless of an individual’s gender identity, pregnancy remains a vey real possibility. Trans boys can become pregnant and transgender girls can get someone pregnant.

Physical Exams

For many kids, the physical exam can be cause for great anxiety. If the child is gender-expansive, this can be an especially stressful experience. Should a physical exam be necessary, consider foreshadowing it and offering the patient the option of deciding when it will occur. Also be sure to explain why the exam is important, and how it will help you to make sure they are healthy.

Some of your young patients will simply want to get it over with, while others may need to build up their courage. By creating the affirming space described above, you will help your patient relax enough to feel comfortable (or grudgingly willing) to endure the experience. By offering the young person some choice, and therefore control, over the situation, you again demonstrate your awareness of how sensitive this particular aspect of the appointment may be, and your commitment to ensuring that the experience be as positive and respectful as possible.

Medical Intervention Timelines

In some cases, a pre-adolescent or teen patient (and perhaps their parents) may have a clear sense about the medical pathway they hope to travel. The well informed pre-adolescent sees a straight line from using pubertal suppressants to taking cross-sex hormones to undergoing gender affirmation surgery. The teen that has come to recognize their transgender identity recently is immediately ready for hormones. Further, they may have a strong notion about when this will all begin: NOW!

However, for any number of reasons, your professional judgment might well be that it is not time to begin moving down this road. This reality, however medically sound, can be devastating for the child or teen that sees changing their body as the most important aspect of affirming their gender identity. For a young person experiencing significant body dysphoria, the impact is especially intense, and can have significant mental health repercussions. It may well be that the patient and caregivers came into the appointment assuming that the entire process will be a battle, and the fact that they are being told “not yet” may be perceived as affirmation that you will be a gatekeeper standing in their way.

Consequently, it is important for the patient to get some sort of “yes” in the process. Maybe this is an explanation about the steps and processes for medical intervention, with a firm follow-up appointment to determine the patient’s readiness. Perhaps it is putting written materials in their hands, or discussing with them what being ready means and what they can look for in the meantime. You may wish to refer them to resources for how they can achieve the desired effects in more cosmetic ways until medical interventions are appropriate.

You may need to help them recognize that while they are terrified about being “the only kid whose body is not changing” like they want it to, the reality is that there is a wide range of ages over which bodies mature. In many cases, providing resources such as a support group or mental health referral will be necessary to help them deal with the distress of needing to wait. Whatever the strategy, it is imperative that the child be given a sense of moving forward in some way, even if it is simply gathering more information or seeking support in the meantime.

Finally, even as you are being cognizant of your patient’s gender, you must also balance this with recognizing that a young person’s gender is only part of who they are. Your gender-expansive patient may be very comfortable with their sense of self, and their parents may be fully on board. This aspect does not define who the child is; rather, it is only part of who they are.

Treat your gender-expansive patients with the same dignity and respect as you would any young person coming through your door. Your ability to truly see the young patients with whom you are working in their entirety will create a supportive space in which you can focus on keeping them healthy and safe, regardless of their gender.

Gender Inclusive Practices

Beyond the provider-patient relationship, there are a number of ways in which medical professionals can create a more welcoming space for transgender and other gender-expansive young people seeking services. The various approaches described below provide a sense to gender-expansive young people that their experiences are recognized and validated. Each alone sends a strong signal of acceptance of the great diversity of gender young people may exhibit; together as a whole, they represent an organizational commitment to truly gender inclusive and sensitive medical care. Additionally, these actions are also a great way to educate all of your patients about gender diversity, thus further shifting society’s understanding and acceptance. The Transgender Law Center’s 10 Tips for Working with Transgender Individuals is another excellent resource for working to ensure your practice is gender inclusive.

Staff Training

Nothing says, “welcome” to a gender-expansive youth or family member than a positive, non-judgmental reception. By training front office and support staff about gender identity and expression and kids, you will ensure a more affirming environment for any patient who enters your practice or facility. Gender-expansive children or teens may well be quite nervous when they arrive; the use of a child’s preferred name or pronoun can go a long way to reassuring them that they are in a place where they will receive genuine support and care that recognizes them for who they are. These and other simple practices come about when staff members have an understanding of gender diversity issues that they can apply to their interactions with their young patients.

Intake

One of the important ways to most effectively affirm the identity of gender-expansive individual is to recognize and use their preferred name, gender marker and pronouns, and to provide forms that request these as well. For an excellent overview of these approaches and their importance, see the online seminar by the UCSF Center of Excellence for Transgender Health.

Visual Cues

Another important step is for your clinic and waiting areas to reflect gender affirming messages and themes. Posters that affirm the complexity of gender along with visual images of gender diverse individuals and gender presentations from other cultures around the world help to normalize the notions of gender’s diversity. In viewing these, a young person will recognize your space as one that is working proactively to respect their own experiences. Further, all of your patients, regardless of gender, will have an opportunity to expand their own understandings of this core aspect of self.

Restrooms

Finding bathrooms in which they feel safe is one of the biggest challenges reported by gender-expansive people. Providing gender-neutral restrooms allows these individuals to relax, removing an area that is a frequent cause of anxiety and distress. Whenever possible, removed indicators of “male” and “female” restrooms. If your bathrooms are single stall, simply label them “Bathroom;” even signs that have the male and female symbols together, while an improvement, still reinforce limited, binary notions of gender.

Written, video and online resources

There is a growing body of literature, at multiple reading levels and increasingly translated into languages other than English, that can be made available to families and youth coming to your facility. Additionally, books for children and young adults addressing the topic of gender also reinforce your commitment to recognizing gender diversity. Finally, if possible, have available video clips or online resources that further emphasize your gender inclusiveness commitment.

Medical Issues and Resources

A word of caution as you seek to learn more about responding to the medical needs of gender-expansive children and youth. There are a great many resources for understanding and meeting the specific medical needs of transgender and gender-
expansive children and youth. This page is not intended to serve as a medical primer for the most effective care and protocols for working with transgender children and youth.While these various tools and resources provide guides, the critical issue is to recognize that the specific needs of each child should drive their treatment and care.

Two great resources are webinars conducted by Dr. Johanna Olson, Medical Director, Center for Transyouth Health and Development, Children’s Hospital Los Angeles.

Suppression of Puberty in Peri-pubertal Transgender Youth

Treating Transgender Youth: Basics of Cross-Sex Hormones Three articles from the journal Pediatric Nursing also provide a nice overview of the various medical issues involved with working with transgender and other gender-expansive young people.

Care of the Child with a Desire to Change Gender – Part 1 (Resources: Care of the Child with the Desire to Change Gender copy)

Care of the Child with a Desire to Change Gender – Part 2: Female to Male Transition

Care of the Child with a Desire to Change Gender – Part 3: Male to Female Transition

Another important resource is the growing number of gender centers that are emerging throughout the country and beyond. Many of these share a commitment to integrated, affirmative care for gender expansive children and youth. There area also a number of professional associations, such as The World Professional Association for Transgender Health and the Endocrine Society that offer many resources and guidelines in supporting medical professionals to provide appropriate and supportive care for gender-expansive youth.