By Anita Brakman, MS
Senior Director of Education, Research & Training
Physicians for Reproductive Health
New York City
Taylor Rose Ellsworth, MPH
Manager, Education, Research and Training
Physicians for Reproductive Health
New York City
Melanie Gold, DO, DABMA, MQT, FAAP, FACOP
Medical Director, School-Based Health Centers
Columbia University Medical Center
New York City
The healthcare provider’s office is one of the few places where young people can ask questions and address concerns related to gender, sex, and sexuality. Unfortunately, one observational study that looked at audio-recorded conversations between adolescents and their pediatricians during annual visits found that one-third contained no discussion of sexual issues; if mentioned at all, it was for an average of 36 seconds.1
These findings regarding provider-patient interactions during healthcare visits are notably concerning when lesbian, gay, bisexual, and transgender (LGBT) youth face greater physical, mental, and emotional health disparities compared to their heterosexual and cisgender peers. In particular, transgender youth, whose gender identity differs from their biological sex and conventional notions of masculinity and femininity, have increased rates of depression, anxiety, substance abuse, and suicide.1,3 While many LGBT youth develop strength and resiliency to combat societal homophobia and stigma, discriminatory treatment in healthcare settings can exacerbate health disparities.
A 2016 Journal of Adolescent Health study looked at the perspectives of transgender youth and their caregivers on barriers to receiving gender-affirming healthcare. Previous studies had focused on experiences of physicians or adult transgender patients. For transgender youth, adolescence is a developmental period in which many physical, sexual, and emotional changes take place, which can be especially challenging due to societal discrimination, disapproval, and stigma. This insightful study aimed to understand the experiences of 15 self-identified transgender youth (ages 14-22) and 50 caregivers of transgender youth to better inform recommendations for enhanced access to gender-affirming care and treatments, including puberty blockers, cross-sex hormones, and surgery. 4
Six main themes emerged as important barriers to gender-affirming healthcare for transgender youth and caregivers. This article will focus on two themes associated with provider attitudes, knowledge, and behaviors. Provider factors that impede access to care may be remedied with appropriate training and education compared to larger health-systems barriers, such as insurance exclusions.
What Are Some Of The Barriers?
The first central theme found in the Journal of Adolescent Health study was inconsistent use of chosen or preferred name and gender pronoun. This barrier to gender-affirming care supports findings from another recent study that examined adolescent and young adults’ experiences of sexuality communication with physicians. LGBT youth reported feeling shame, isolation and rejection when providers failed to use inclusive, gender-neutral language or made assumptions about their sexuality. When providers used non-inclusive language, adolescent participants felt unaccepted, as opposed to feelings of “relief or elation” when their chosen name and pronouns were used.5
Another main theme found in the study was the lack of accessible providers trained in gender-affirming healthcare for youth.5 Participants described specific provider qualities that were barriers to care: accessibility; trained in providing nonjudgmental care and treatment; up-to-date on the literature; youth-friendly. Transgender youth described the difficulty in finding providers who were accepting new patients, took their insurance, and who were adolescent- and trans-friendly. Participants cited feeling frustrated with lack of provider-training including: use of outdated/offensive language, not asking about gender identity, inadequate knowledge, and judgmental clinical interactions.
Adolescents are extremely perceptive of their providers’ non-verbal cues and body language. When asked about their experiences talking with health providers, LGBT youth report being able to sense physician discomfort through a change in voice patterns, stammering, tone of voice, and facial expressions.6 It is essential that providers be aware of their non-verbal and verbal behaviors in a determined effort to be more accepting and comfortable of their young LGBT patients.
What Needs To Be Done?
Youth-serving healthcare providers have the opportunity and responsibility to provide gender-affirming care to transgender adolescents that supports their true sense of identity in order to lead healthy, fulfilling, and meaningful lives. Moreover, the 2016 American Academy of Pediatrics’ Sexuality Education for Children and Adolescents recommends that pediatricians include discussions of gender identity and sexual orientation when talking about sex, sexuality, and healthy relationships. 7
Avoid misgendering transgender youth, and consistently use patients’ chosen or preferred name and gender pronouns. Providers may find the following script helpful:
- “The name on your chart is listed as _______. What would you like me to call you? What is your preferred name?”
- “What gender pronouns do you prefer I use when we speak? He or she? His or her? Or another pronoun like they, their, or them?”
It is then recommended for providers to universally enter this gender identity data into patients’ electronic medical records.
Another recommendation suggested by adolescent participants was mandatory training for pediatric providers and staff on gender-affirming healthcare and cultural awareness. While further research is needed to define policies and best practices, four training resources for providing adolescent-friendly and culturally appropriate transgender healthcare include:
- Physicians for Reproductive Health Adolescent Reproductive and Sexual Health Education Program module on “Caring for Transgender Youth,” available at http://bit.ly/2eOn0BN;
- National LGBT Health Education Center, available at http://bit.ly/1Nby3fq;
- Massachusetts Transgender Political Coalition, available at http://bit.ly/2eqeKEb; and
- Center of Excellence for Transgender Health, available at http://bit.ly/2eirD3w.
- Alexander S, Fortenberry J, Pollak K, et al. Sexuality talk during adolescent health maintenance visits. JAMA Pediatr 2014; 168(2):163-169.
- Olson J, Forbes C, Belzer M. Management of the transgender adolescent. Arch Pediatr Adolesc Med 2011; 165(2):171-176.
- Society for Adolescent Health and Medicine (SAHM). Recommendations for promoting the health and well-being of lesbian, gay, bisexual, and transgender adolescents: A position paper of the Society for Adolescent Health and Medicine. J Adoles Health 2013; 52(4):506-510.
- Gridley S, Crouch J, Evans Y, et al. Youth and caregiver perspectives on barriers to gender-affirming health care for transgender youth. J Adoles Health 2016; 59:254-261.
- Fuzzell L, Fedesco HN, Alexander SC, et al. “I just think that doctors need to ask more questions”: Sexual minority and majority adolescents’ experiences talking about sexuality with healthcare providers. Patient Educ Couns 2016; 99(9):1467-1472.
- Garofalo R, Katz E. Health care issues of gay and lesbian youth. Curr Opin Pediatr 2001; 13:298-302.
- Breuner C, Mattson G. AAP Committee on Adolescence, AAP Committee on Psychosocial Aspects of Child and Family Health. Sexuality education for children and adolescents. Pediatrics 2016; doi:10.1542/peds.2016-1348.