During a patient visit, a worried parent confides that her 5-year-old son enjoys dressing up in his sister’s clothes and insists that he’s a girl. Is this a phase he’ll outgrow? Or is there reason to be concerned?
There isn’t an easy answer to these questions, but Lee Ann Conard, RPh, DO, MPH, and her team can help with the diagnosis and treatment in the Transgender Health Clinic, open multiple days each month at various Cincinnati Children’s locations.
“Gender isn’t a dichotomy,” says Conard, “but our society says it is. There’s a box for boys filled with certain standards of behavior, and a box for girls with its own requirements. But transgender and gender-nonconforming patients don’t always fit in one or the other. They may be in the opposite box or somewhere in between.”
The Transgender Clinic is designed for patients who have gender dysphoria, meaning they experience a marked incongruence between their gender identity and their sex assigned at birth that is associated with significant distress or impairment..
“Gender is different than sexual orientation,” explains Conard. “Sexual orientation is about whom you’re attracted to – male, female or both. You can be a transgender person and be heterosexual, gay, lesbian or bisexual.”
Patients at Risk
Conard estimates that approximately 2 percent to 3 percent of the population is transgender.
“Gender can be fluid when you’re growing up,” she explains. “Eighty-five percent of kids with gender issues won’t end up being transgender, but they do have a high chance of being gay or lesbian.”
She adds, "All pre-pubertal children play with gender expression and roles. We know it’s a deeper issue when the child is persistent, consistent, and insistent in identifying themselves as a gender different from their sex assigned at birth.”
Pediatricians can help kids feel more comfortable about figuring out who they are by asking the right questions. For example, asking a patient if they consider themselves male or female can open the door to a bigger conversation. Most kids come to know their gender identity through their own process of self-discovery, Conard says.
Keeping the lines of communication is important with every patient, but especially with transgender kids.
“This population has a higher rate of suicide, suicide attempts, homelessness, substance abuse, sexually transmitted infections and obesity,” says Conard. “Often, they are bullied at school. Some have even been bullied by their healthcare providers. They are worried about being accepted by their families, about whether it’s safe to be ‘out’ or not. They may have anxiety and depression and a lack of optimism about their future.”
All of these factors contribute to poorer physical health. Transgender kids are less likely to see a doctor because it feels awkward.
“Sometimes the name on their insurance is not the name they identify with on a day-to-day basis. But we have to use that name if insurance is going to pay the claim. But there are sensitive ways of handling the situation,” says Conard. “It’s also important that these kids still go for their annual physicals and screenings.”
What You Can Do to Help
Support for families is key. “For parents, finding out your child is transgender is almost like a death,” says Conard. “One mother said, ‘I had three girls. Now I have a boy and two girls.’ It takes parents time to get used to the idea. Siblings are often on board with the change, but they get teased at school. When a patient comes ‘out,’ it can be a very dangerous time. The patient may be abused and forced from the home.”
Pediatricians can help by maintaining a welcoming space in their office – a waiting room that reflects the full diversity of patients and families, unisex bathrooms, if possible, and frontline staff who are trained in how to be sensitive to the needs of transgender patients.
“I especially want pediatricians to know that gender issues are always weighing heavily on these kids’ minds. So, make sure you check in on their mental health. Make sure they’re safe and that they have a safety plan.”
Best Practices for a Transgender-Affirming Environment
- When addressing patients, avoid using gender terms like “sir” or “ma’am.” Example: “How may I help you today?”
- When talking about patients, avoid pronouns and other gender terms. Or use gender neutral words such as “they.” Never refer to someone as “it.” Example: “Your patient is here in the waiting room.” “They are here for their 3 o’clock appointment.”
- Politely ask if you are unsure about a patient’s preferred name. Example: “What name would you like us to use?” “I would like to be respectful – how would you like to be addressed?”
- Ask respectfully about names if they do not match in your records. Example: “Could your chart be under another name?” “What is the name on your insurance?”
- Did you goof? Politely apologize. Example: “I apologize for using the wrong pronoun. I did not mean to disrespect you.”
- Ask only for information that is required. Example: Ask yourself – what do I know? What do I need to know? How can I ask in a sensitive way?
Source: National LGBTQIA+ Health Education Center, a program of the Fenway Institute
Standards of Care – Treatment Protocols