Canadian Paediatric Society releases position statement on transgender and gender-diverse youth

The Canadian Paediatric Society has released a position statement on caring for transgender and gender-diverse youth (TGD). It’s meant to help pediatricians and primary-care providers create “an affirming approach to routine healthcare provision for all youth,” it said. It also offers more information for providers who wish to treat patients with hormone-blocking agents and gender-affirming hormones. A growing number of young people identify as transgender or gender-diverse, creating a greater demand for gender-related care within pediatric healthcare. But those healthcare professionals often don’t have the training, knowledge and comfort to care for them. Read: For transgender kids, a frantic rush for treatment amid bans in the U.S. The Canadian Paediatric Society (CPS) recommends that “gender-affirming care must be upheld as a standard of care for TGD youth” and that healthcare providers adopt an affirming approach to all children and youth. They should also learn the information needed to counsel TGD children on their options for medically affirming care or refer them to such care if that’s not possible. And Canadian pediatric and pediatric subspecialty training programs should offer more training about affirming care. The statement says providers who have the necessary knowledge and skills can start and maintain TGD youth on hormone-blocking agents and gender-affirming hormone therapy. And it says healthcare providers should advocate for timely access to specialized gender-related care and for schools and extracurricular activities to be safe and inclusive of TGD children. Read: EXPLAINER: How common is transgender treatment regret, detransitioning? TGD youth in Canada Studies from high-income countries estimate that between 1% and 4% of adolescents identify as transgender, and a recent study that asked about gender identity but didn’t use the term “transgender” with school-aged youth found 9.2% of respondents said there was a difference between the sex they were assigned at birth and their experienced gender. TGD youth are more likely to have depression, anxiety and eating disorders and to self-harm or kill themselves. That’s thought to be partly because of the stress from being a minority group with a stigmatized identity; Canadian TGD youth, for example, report high levels of harassment and violence. Having supportive parents, early social transitions for those who wish to have them, and inclusive, non-judgmental interactions with the healthcare system may mitigate some of the risks of adverse health outcomes. Read: Suicidality among sexual minority and transgender adolescents—is this important? How gender identity develops Gender identity first appears in early childhood: by preschool, children recognize gender roles, often playing with toys stereotypically associated with their gender and befriending children of the same gender. Healthcare providers should encourage parents of children at this age to provide a safe environment for gender exploration and “not make assumptions about future gender identity,” CPS says. Recent research suggests some children are aware of a mismatch between their gender identity and their assigned sex at as young as two or three. By age six or seven, children’s understanding of gender includes the idea that it’s an identity separate from external features and appearances. Many children continue to like same-sex peers and gender-stereotyped toys throughout middle childhood, but they might have a toned-down outward expression of their gender. At this age, some TGD children can show a strong sense of gender identity and prefer peers, objects and activities that match the gender they identify with. Others aren’t aware of the difference between their assigned and experienced gender until puberty or beyond. All children’s ability to understand gender continues to become more sophisticated as they age, with puberty being especially important. It can trigger a reflection on whether youth’s assigned and experienced genders align. Read: Early transgender identity tends to endure, study suggests What is gender dysphoria? Gender dysphoria is the distress that can come from a difference between an individual’s experienced gender and their assigned sex at birth. Gender dysphoria is included in the DSM-5-TR, but its inclusion is an ongoing debate, the position statement says, explaining that, “Some argue that including the term promotes a binary view of gender and pathologizes gender diversity in a manner that perpetuates stigma. Others assert that its inclusion helps facilitate access to relevant services.” Diagnostic criteria include having a marked incongruence between one’s experienced and expressed gender for at least six months, as manifested in six of eight given ways, and the condition affecting important areas of functioning, such as school. Because prepubescent children experiencing gender diversity might not continue to experience it into adolescence and medical interventions aren’t recommended for children before puberty, the usefulness of diagnosing gender dysphoria or gender incongruence in young children “is particularly contentious,” the statement says. Read: England’s health service says it won’t give puberty blockers to children at gender clinics Adolescents with concerns about gender dysphoria should be given timely access to psychosocial supports and diagnostic assessment. Presenting for medically affirming care at a younger age and earlier pubertal stage has been associated with lower rates of mental health conditions. Youths being diagnosed with gender dysphoria should be reassured that the term is characterizing the distress from having sex assigned at birth not aligned with identified gender, not showing a “pathological” gender identity. Attempts to change a young person’s gender identity, such as conversion therapy, are harmful and should be avoided. Read: Manitoba College provides primer on gender-affirming care Gender-affirming healthcare Clinicians are encouraged to create an affirming space by displaying a mission statement that states the commitment to inclusive care, having waiting room posters that show youths with diverse gender expression, making sure intake forms and questionnaires include diverse options for demographic questions, designating bathrooms as gender neutral, and having medical staff introduce themselves with their names and pronouns. They should also use inclusive language, such as having a spot to note preferred names and pronouns on the patient’s health record and being sure to use them. Staff should be trained in inclusive language. Using neutral terms—for example, asking, ‘Are you in a romantic relationship?’ or ‘Who makes up your family?’ avoids making assumptions, and gender-neutral language can be used during a physical exam, such as saying genitals instead of penis or vagina. Asking for guidance with language, such as, ‘How would you like me to refer to your gender?’ instead of ‘Do you identify as male, female or non-binary?’ And if the healthcare provider makes a mistake with language, they should thank the youth for pointing out the error, apologize and correct themselves. Read: Poll: Do your intake forms allow for a wider range of genders than male and female? They should also provide adolescent-oriented care, which includes engaging the youth in all aspects of their care, ensuring confidentiality but also reviewing its limits with adolescents and caregivers, acknowledging how an adolescent’s life and health experiences intersect, and spending some time alone with adolescents for every visit. It also includes supporting efforts to build the parent-child relationship whenever possible since TGD youth with supportive parents have better mental health outcomes, including a lower risk of suicide. Adolescents can be encouraged to have self-efficacy and encouraged to self-reflect. “An affirming approach should never be directive, but rather, should support the adolescent in identifying and moving along the trajectory that best aligns with their individual goals through facilitated self-exploration and shared decision-making,” CPS explains. All youth can be asked, “How do you describe your gender identity?” For TGD youth, the society recommends asking HEADSS questions, which include asking about home, eating, drugs, sexuality and safety. The position statement provides sample questions for how those could be used for TGD youth, such as ‘Do you ever restrict or increase what you eat to change your body’s appearance to better match your gender identity?’ ‘Are you able to express your gender safely at school?’ And, ‘If you use substances, is this ever related to feelings about gender?’ Read: Complications following gender-affirming surgery can be treated by primary care physicians: study Clinical gender-affirming care The document also includes more information about the clinical components of gender-affirming care. Some youth will only pursue a social transition, while others will be interested in gender-affirming medical interventions. The position statement covers hormone blockers, including eight common ones. “Initially, the clinical objective of prescribing a hormone blocker is to provide a young person with time to further explore their gender identity without pressure or distress related to the ongoing development of secondary sex characteristics, or gendered experiences such as menses or erections” it explains. TGD adolescents who received hormonal suppression as part of a multidisciplinary care approach have better mental health and psychosocial functioning, including lower suicidal ideation over their lives. Risks include slowing bone mineral density accrual, which partially reverses when hormone blockers are stopped and gender-affirming hormone therapy begins or endogenous sex steroid resumes. Doctors should also speak to adolescents about fertility preservation because it can’t be done while on a blocker or in early puberty and might factor into their decisions around timing. Read: Transgender, nonbinary teens at higher risk of suicide compared with peers: study For adolescents who choose to pursue gender-affirming treatments later on, being on hormone blockers prevents irreversible secondary sex characteristics that may need a surgical transition more difficult later and allow for lower doses of gender-affirming hormones for those. The CPS also covers gender-affirming hormone therapy, which uses testosterone esters to create a more masculine appearance and 17β-estradiol for a more feminine one. This therapy should only be given to adolescents diagnosed with gender dysphoria or gender incongruence and who can understand and appreciate both benefits and risks of these medications. Co-existing psychological, medical or psychosocial issues that might interfere should be addressed first to ensure the youth is stable enough to start treatment. While such treatments are considered safe, they can have short- and long-term health risks. Healthcare providers considering prescribing it should familiarize themselves with the risks and recommendations for monitoring. Those who lack the skills or knowledge to prescribe it should offer timely referrals to colleagues who can. Read: Gender-affirming care in Canada comes with barriers and delays These medications create reversible changes, like fat redistribution and mood fluctuations, and irreversible ones, like voice deepening and breast development. When initiated appropriately, gender-affirming hormone therapy is associated with better-perceived well-being and mental health, decreased suicidality and less body dissatisfaction. It should be made clear to adolescents that it’s not a form of contraception. Finally, adolescents are less likely than adults to receive gender-affirming surgery. Still, pediatric healthcare providers should be aware of the most common surgeries and be able to talk about them to teenagers who are interested in them. The most common is chest wall masculinization, known as “top surgery.” “Bottom surgery,” which can include surgery to create a phallus, hysterectomy or vaginoplasty, is restricted to people over 18. Read: B.C. says gender on ID cards can now be changed without doctor's confirmation

Canadian Paediatric Society releases position statement on transgender and gender-diverse youth

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