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MNAAP Newsletter

Gender Nonconformity: Understanding Steps and Care

By Rhamy Magid, MD, FAAP, HCMC

Increasingly, primary care pediatricians, as well as pediatric subspecialists, are caring for youth who identify as transgender or gender nonconforming (GNC). Rather than an increase in prevalence, this phenomenon is more likely a testament to a gradually improving cultural environment, both nationally and in the state of Minnesota.

In the 2016 Minnesota Student Survey, 3 percent of 9th graders and 2 percent of 11th graders considered themselves transgender, genderqueer, genderfluid, or were unsure about their gender identity. We have a responsibility and an opportunity to lift the health and the spirits of one of our most vulnerable patient subpopulations.

In the AAP’s July 2017 Statement in Support of Transgender Children, Adolescents and Young Adults, Drs. Stein and Remley affirm that the Academy “stands in support of transgender children and adults, and condemns attempts to stigmatize or marginalize them…As pediatricians, we know that transgender children fare much better when they feel supported by their family, school and larger community…The AAP supports policies that are gender-affirming for children.”

Gender nonconformity is not pathological, and so not all of your patients who identify as transgender or GNC will desire or need treatment. However, those who experience gender dysphoria do deserve a discussion with you about treatment or referral. Gender dysphoria is defined as the distress that results from incongruence between one’s gender identity and the sex assigned at birth. That dysphoria, in addition to the minority stress experienced by this marginalized group, are together thought to contribute to their increased risk of depression, anxiety, suicide, and substance abuse. Of the parents we meet in our clinic, many, but not all, are familiar with the “41 percent” statistic, the oft-cited percentage of transgender individuals who have attempted suicide. And these parents are appropriately fearful for their children. What we convey to them – and what you as a pediatrician must stress to your families – is that evidence shows the risks of depression and anxiety to be mitigated by simply providing a supportive and loving environment.

Every pediatrician should familiarize him or herself with the AAP’s publication, Supporting and Caring for Transgender Children. Therein, even those providers who do not intend to prescribe pubertal suppressant or gender-affirming hormone medication can learn the basic timelines and treatment options that should be presented to families in the clinic setting. Furthermore, the general pediatrician can take some simple but critical steps toward creating an environment in which children feel safe discussing their gender identity. For example, use of preferred names and pronouns by all providers and ancillary staff is paramount. More challenging, but equally important, is that we strive to set aside the cisgender, binary biases and assumptions we carry as a result of our medical training and our culture. Gender is increasingly coming to be understood as a spectrum, and our patient’s goals accordingly fall on a spectrum.

Below this article, I have included a table from the AAP’s Supporting and Caring for Transgender Children, which gives a very rough timeline of the common steps involved in gender transition. I have also included a bibliography of books for providers, parents and adolescents, which I hope will help to inform and advance our conversations. As pediatricians, we are in a unique position to empower children to be their full selves, and parents to keep their children safe, happy, and full of promise.

Resources:
The Transgender Child – A Handbook for Families and Professionals by Stephanie Brill and Rachel Pepper
Helping Your Transgender Teen – A Guide for Parents by Irwin Krieger
The gender quest workbook – a guide for teens and young adults exploring gender identity by Ryan J Testa PhD, Deborah Coolhart PhD, and Jayme Peta MA

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