Pediatricians are increasingly encountering gender-diverse patients but may not always know the best way to approach management and care for this population. A new policy statement from the American Academy of Pediatrics (AAP) outlines best practices to help these young persons move forward in the healthiest way.
The policy statement, published in Pediatrics, outlines a number of recommendations for medical care, psychosocial considerations, and family and community support.1 Jason Rafferty, MD, MPH, EdM, FAAP, a pediatrician and child psychiatrist who practices at the gender and sexuality clinic and at the adolescent health center at Hasbro Children’s Hospital, Providence, Rhode Island, developed the guidance and outlines in the policy a holistic approach for gender-diverse children.
Rafferty says the guidelines were developed because there was a need to articulate what is meant by “gender-affirmative care,” which is based on the belief that all children benefit from love and support.
“The goal of gender-affirmative care is not treatment. It is to listen to the child and, with the help of parents and families, build understanding,” Rafferty says. “Through strong, nonjudgmental partnerships with patients and their families, pediatricians create an environment of safety in which complicated emotions, questions, and concerns related to gender can be appreciated and explored.”
Gender-affirmative care is needed
Rafferty says there is increased recognition that gender-affirmative care is most effective in a collaborative system with access to medical care, mental health, and social services, including specific resources for parents and families, so the policy was created to advocate for resources to promote collaboration and teamwork in this area.
Some of the major highlights of the guidance include the idea that gender diversity and care must be approached from a developmental lens, he says.
“Research suggests that children who assert a gender-diverse identity know their gender as clearly and consistently as their developmentally matched peers and benefit from the same level of support, love, and social acceptance,” Rafferty says. “It used to be the case that for children, gender-diverse assertions were held as ‘possibly true’ and not acknowledged until an age when the child was believed to be old enough to know for sure.”
This kind of thinking has to change, Rafferty says. “This does not serve the child, because it increases discomfort without offering critical support and understanding. Attempts at predicting or changing who a child may become have shown to be unsuccessful, and even harmful,” he says. “Cross-gender preferences and play are a normal part of exploring gender and relationships for children regardless of their future gender identity. The best approach for parents is to love and appreciate their child as they are in the moment.”
Gender diversity is increasing
Prevalence of gender diversity is higher than previously thought, according to the policy statement, with 0.7% of young persons aged 13 to 17 years identifying as transgender. On average, children who are gender diverse begin to become aware of their gender difference around age 8 years, the report notes. This process can be difficult for these children, and Rafferty says transgender individuals report higher rates of depression, anxiety, eating disorders, self-harm, and suicide.
The report notes that 56% of young persons who identified as transgender reported previous suicidal ideation, and 31% reported a previous suicide attempt, compared with 20% and 11% of cisgender youths, respectively. There is no evidence of an association between gender identify or expression and mental illness, Rafferty notes, but rather a presence of psychosocial issues with gender identify stemming from internal conflict on appearance, low access to healthcare providers who support gender differences, discrimination, social stigmas, and social rejection.
The policy statement offers several specific recommendations, such as providing gender-diverse children with comprehensive, gender-affirming, and developmentally appropriate healthcare that is provided in a safe and inclusive clinical space; family-based therapy and support that can recognize and respond to the emotional and mental health needs of parents, caregivers, and siblings of gender-diverse children; respect of a patient’s gender identity in electronic health records; appropriate insurance coverage for care related to the needs of the gender-diverse patient; provider education for best practices in helping this population; and continued research and advocacy by providers and community partners to promote acceptance and appropriate support at all levels.
The policy statement reflects recommendations made by the American Psychological Association, such as accepting that gender identify may differ from an individual’s gender at birth; that gender and sexuality are different yet interrelated; and that individual or provider opinions about gender diversity can affect the care and support they are able to provide to these children.
“All children do best in supportive, loving environments. Gender development is a normal process of identity formation for all children and gender diversity is recognized as a normal aspect of the human experience,” Rafferty says. “However, in the context of gender stereotypes, discrimination, and stigma, the experience of gender-diverse and transgender individuals can be challenging. With children, evidence shows that support or rejection ultimately has little influence on the gender identity of youth, but it may profoundly affect the young person’s ability to openly disclose and discuss identity and feelings. This can negatively impact the child’s mental health and self-esteem.”
Although much of the work in this area falls to parents and support systems at home, Rafferty says that pediatricians play an essential role in promoting the healthy development of transgender and gender-diverse children through affirming the child’s experiences and feelings, providing resources, and supporting families toward understanding and appreciating their child.
“Overall, pediatricians report that gender care, particularly in children and adolescents, is not sufficiently covered in their medical training despite the recognition that gender development should be assessed throughout the schedule of routine well-child visits,” Rafferty says. “A growing field of research suggests that, rather than predict or prevent who a child may become, it is better to value them for who they are now, even at a young age. This fosters secure attachment and resilience.”
Rafferty says he hopes the policy statement will outline best practices for management of gender-diverse youths now and open the door for future research.
“The hope is that this statement will provide guidance toward creating a system of pediatric healthcare where all children and their families feel that, from the moment they walk into a clinic, they will be respected and received in a safe, nonjudgmental manner,” Rafferty says. “The policy advocates that communication, medical record systems, various forms, and even payment plans adapt to reflect the needs of gender-diverse and transgender individuals. The hope is that pediatricians will stand ready to assist in the healthy development of transgender and gender-diverse children.”
This population has a great need, and one that requires ongoing care, he adds.
“Children, teens and young adults who identify as transgender or gender diverse should be clinically assessed on an ongoing basis, preferably with a collaborative team that includes the pediatric provider, a mental health provider, social and legal supports and a pediatric endocrinologist or adolescent medicine gender specialist, if available. Parents and families need to have access to appropriate supports,” Rafferty says. “Pediatricians also have a role in advocating, educating, and developing relationships with school districts and other community organizations to promote acceptance and inclusion of all children.”
1. Rafferty J; Committee on Psychosocial Aspects of Child and Family Health; Committee on Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Policy statement: Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics. 2018;142(4):e20182162.