LGBTQ + Health
Caring for Transgender and Gender Diverse Youth
R
ecent years have seen an increasing recognition of the human and medical rights of transgender and gender diverse (TGD) people in the United States. As such, there has been an effort in the medical community to increase awareness and knowledge of optimal care for TGD individuals, including young people. TGD people, and particularly TGD people of color, bear a disproportionate burden of morbidity and mortality. It behooves us to do a better job medically, as one step toward a more equitable society. This article will focus on the care of TGD youth, but the reader interested in more detailed care guidelines for both the adult and pediatric populations is encouraged to examine the Endocrine Society’s Clinical Practice Guideline (Hembree, 2017) and the website of UC San Francisco’s Center of Excellence for Transgender Health (UCSF Center of Excellence for Transgender Health, n.d.). Due to the necessarily short format of this article, an in-depth review of the diagnosis and management of gender dysphoria (GD) is not possible. The focus here will be: 1) to define GD and discuss the rationale for treatment; 2) to review the specific modalities of medical treatment for children and adolescents; and 3) to touch briefly on ethical and other considerations the practitioner should attend to when caring for this group of young people.
By Rhamy Magid, MD, FAAP
14
September/October 2020
harassment, homelessness and verbal and physical abuse, among other external stressors and stigma. In the section on treatment below, we will discuss how, even in the absence of pharmacologic interventions, we can help mitigate a significant portion of the mental health burden by simple social interventions such as using preferred names and pronouns. Modalities of Treatment
Gender Dysphoria
GD is defined as the distress experienced due to a conflict between one’s sex assigned at birth and one’s gender identity. It is important to emphasize here that it is the distress which is pathologic and treatable. TGD identity is not a pathology; it is an identity factor. But if there is associated distress (i.e. GD is present) and it goes untreated, there is significant risk for morbidity and mortality. TGD individuals experience substantially higher rates of anxiety, depression, substance use disorder, self-injury, and suicidal thinking and attempts (Olson K. e., 2015). Forty percent of transgender adults report having ever attempted suicide (James, 2016). Among TGD youth, estimates of the prevalence of suicide attempts range from 25-32%. (Olson J., 2015) These mental health comorbidities do not arise from the TGD identity itself, but rather they likely result from a combination of GD and minority stress, as these youth experience a significant amount of peer and family rejection,
Before discussing medical treatment of GD, it is critical to pause and point out that TGD identity does not presume the presence of GD. While some TGD individuals experience GD and desire treatment, a significant proportion do not desire any intervention. It is, therefore, critical for the medical provider to listen to their patients. Explicitly ask about the presence or absence of distress around gender incongruence. Ask about goals of treatment. Do not presume that an individual desires an outward appearance consistent with our society’s prevailing image of “masculinity” or “femininity.” What matters for your patient is what makes them feel whole, with an aligned body-mind existence, thereby reducing or eliminating mental health comorbidities and improving quality of life. Once it is established that the TGD pediatric patient is experiencing GD and does desire treatment, then the treatment offered will depend on their pubertal status and age. Once again, it is critical to listen to the youth and their parents regarding goals of treatment, and not to presume to know the desired outcome based solely on stated gender identity.
MetroDoctors
The Journal of the Twin Cities Medical Society
