​Caring for Gender-Expansive Youth

By Coverys Risk Management
The 1999 movie Boys Don’t Cry is based on the true story of the struggles faced by a female-to-male transgender teen. The protagonist is rejected by his family and eventually by his friends when they discover he is a transgender male. In one telling scene, his girlfriend’s mother refuses to let the injured teen into her home, referring to him as "it." The movie gives a harsh glimpse into some of the challenges faced by teens who are experimenting with their gender identity.
Gender is not binary. The Fenway Institute gender identity demographic guidance includes seven options, and the 2015 Canadian Trans Youth Study (CTYS) includes 17. There are many terms for children who are experimenting with gender identity, including: gender expansive, gender fluid, gender non-conforming, questioning, gender diverse, and gender creative. Regardless of the name, it is common for children to experiment with gender identity. How many of these children will permanently identify as a gender different from the gender designated at birth is a matter of much discussion. According to the American Academy of Pediatrics: In clinical samples, gender dysphoria and cross-gender identification persisted into adulthood in up to 27% of cases, with people assigned female at birth being more likely to persist than those of a male natal sex; however, the frequency of persistence in non-clinical samples is unknown.
Researchers from a number of Canadian universities collaborated on the CTYS to assess the health and wellness of transgender youths between the ages of 14 and 25. Their study, Being Safe, Being Me, provides new insight into this important and vulnerable population. On the positive side, transgender youth who were openly living as their identified gender and those who reported supportive family members and/or friends tended to be happier and engage in fewer at-risk behaviors. Forty-three percent reported they were comfortable or very comfortable with their family doctor, although younger transgender youth were more likely to avoid care because they were “afraid of what the doctor would say or do.”
One of the more troubling findings was the high percentage of suicidal thoughts and suicide attempts reported by the participants, especially those with poor support systems in place, and/or not able to openly express their preferred gender identity. Sixty-five percent of younger youth admitted to seriously considering suicide in the past 12 months, and just over a third had attempted suicide at least once. Over the same period of time, 68 percent reported missing needed mental health care. The attempted suicide rate among transgender youth is more than four times higher than the rate (8 percent) reported by the Centers for Disease Control and Prevention (CDC) for U.S. high school students in 2015.
Strategies to improve care for gender-expansive youth
Obtain training.
Professionals from all healthcare disciplines who deliver services to youth need further training to improve their competency in providing high-quality care, which is more than just “transgender-friendly” care. This should include general education about gender identity and barriers that transgender people face in accessing healthcare and discipline-specific training in appropriate protocols for addressing transgender youth health issues.
The Fenway Institute’s National LGBT (lesbian, gay, bisexual, and transgender) Health Education Center has a variety of printed educational materials, as well as a comprehensive set of web-based set training modules.
Provide an age-specific, gender-neutral office environment.
If the office cannot provide a gender-neutral restroom, ensure children and adolescents feel comfortable and are welcome to choose the restroom they prefer. Collect and record information regarding the child’s preferred name and an older child or adolescent’s preferred pronoun and gender identity. The nickname, gender identity, and pronoun discussion may best be managed by the provider during early exploration of gender expansiveness. All staff members should be prepared to address the child by the child’s preferred name and to use the child’s preferred pronoun. This can be difficult when the parent(s) is (are) not supportive. If social work is not available in the practice, referral or family therapy should be considered.
Ensure the medical record accurately reflects the patient’s preferred name, gender identity, and pronoun. If your office uses an electronic medical record, you may have to identify a workaround as most medical records do not have a field for gender identity or preferred pronoun. Workarounds include using the nickname field, including this information prominently in the social history, and/or using a pop-up window or note field. The National LGBT Health Education Center’s brochure Collecting Sexual Orientation and Gender Identity Data in Electronic Health Records: Taking the Next Steps has detailed instructions on how to collect this data.
Provide access to age-appropriate educational materials. The Human Rights Campaign maintains a comprehensive list of resources and agencies specializing in transgender youth issues.
Consider using a focus group of your older adolescent patients to help you improve your office environment and educate your staff members. Giving your staff the opportunity to ask questions and have them answered by members of the transgender community may help them become more at ease and accept what is considered appropriate by the population and what is considered offensive.
Consider participating in the Healthcare Equality Index, a benchmarking process sponsored by the Human Rights Campaign that can help you identify what you need to do to make your practice more inclusive.
Identify appropriate resources and referrals for transgender youth and their parents. Including the following:
  • Providers, such as pediatric endocrinologists, who have experience in transgender care including puberty suppression and gender-specific hormone replacement therapy.
  • Surgical providers who are familiar with and have expertise in male-to-female breast augmentation and female-to-male mastectomy and chest contouring.
  • Mental health providers with knowledge and experience addressing and treating gender dysphoria.
  • Transgender support groups both for the parents and the child.
Gender-expansive youth face many challenges in their lives, particularly if they choose to formally transition. It is incumbent on healthcare providers to do their best to ensure that access to appropriate gender-affirming healthcare is not one of those challenges.
No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.

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