August 2019, Volume XXXIII, No 5

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The Gender Health Program

Partnering with youth and families

hile nearly 3% of Minnesota high school students identify as gender diverse, many of them do not know where to turn when it comes to finding culturally sensitive, gender-affirming care. Also, despite recent advances in health care, transgender and gender-diverse youth continue to face significant health disparities, including higher rates of harassment, discrimination, homelessness, and suicidality. This growing population of children and adolescents is also known to be medically underserved, as patients and families often don’t know where to go or how to access care, or have to wait months or drive several hours to get questions answered and access medical services.

As part of Children’s Minnesota’s commitment to provide equitable and inclusive care to all children, we have launched the Gender Health Program. This personalized and comprehensive pediatric multispecialty clinic provides transgender and gender-diverse children and their families with medical care and support from pediatric experts they can trust, including experts in pediatric gender health, pediatric endocrinology, and pediatric gynecology.

About the program

Each family that comes to the Gender Health program will start with a gender consultation with one of our physicians. During this initial consultation, children and their families meet with a gender health expert to discuss developmental questions or concerns about gender identity and to develop a personal care plan. Each child and family comes to the program at a different place and with a different path, so this consultation helps to answer questions, discuss goals, and think about next steps. Often youth—especially teenagers—and their families come to this initial consultation with different questions and goals. Our team is committed to helping understand what each child, parent, and family needs before moving forward. We can often help youth and families understand each other and learn to speak a common language as they navigate future steps on their journey.

Parental rejection is a significant risk factor for …  transgender youth.

One key component for most families is appropriate mental health assessment and referrals as needed. Our program includes a social worker/care navigator who participates in the initial intake assessment for each family to help determine what resources are needed. We can connect parents with resources and support for their questions, and can connect youth with individualized support systems. Our goal is to optimize care and outcomes for each patient, especially for those on a journey that involves transition, and to support the mental and physical well-being of the whole child and the whole family. Having a strong support system and a good understanding of what to expect helps youth and families be resilient in the face of change and weather any unexpected twists along the path.

For youth and families who are developmentally ready for medical treatment, we offer a variety of gender-affirming treatment options as part of unique treatment plans to meet individual patient needs.

The onset of puberty, for example, can be difficult for many transgender and gender-diverse adolescents, which is why Children’s offers both pubertal and menstrual suppression. These reversible interventions, delivered via shot or as an implant, pause puberty and/or menstruation for patients as necessary. Patients may also meet with a pediatric gynecologist for a consultation to discuss options to preserve fertility prior to beginning pubertal suppression and/or gender-affirming treatment.

For patients who are in middle to late adolescence, gender-affirming hormone treatment may be appropriate. This hormone treatment creates changes in the body to align with the patient’s gender identity. The decision to move forward with such treatment is made with one of our gender health experts, along with a readiness assessment by a mental health professional to optimize outcomes—and to gauge the support and obtain the consent of parents.

Gender-affirming surgeries are most often performed for patients who are over the age of 18 and are not done at Children’s Minnesota. While Children’s Gender Health Program does not perform these surgeries, we can refer patients to plastic surgeons in the community as needed.

Tips for primary care physicians

Transgender and gender-diverse youth who come to the Children’s Gender Health Program for specialized and expert care continue to receive their primary care—including well-child exams, immunizations, and ill-child visits—through their primary care offices. Primary care clinicians often have questions about how to best provide supportive and affirming care to transgender patients and their families. In turn, transgender and gender-diverse patients and their families often find themselves needing to educate primary care physicians, schools, neighbors, and family members about how to appropriately care for gender-diverse children.

The best approach with any patient and family, including transgender and gender-diverse children, is to treat them how they would like to be treated. Ask each child the name they would like to be called, and the pronoun they use, and be sure to use this name and pronoun at each visit. Educate staff about how to ask each patient what name they would like to be called and what pronoun they use, so that they can do the same; this is especially important for those answering phones, checking in, and rooming patients. It’s also important to remember that we all make mistakes, even when we are trying to do our best. When mistakes happen, we should acknowledge them, apologize, and commit to continuing to get it right in the future.

Often, mistakes in calling a patient the correct name or using the correct pronoun are made due to limitations and barriers of the electronic medical record (EMR). Primary care providers should find out the best way to optimize their EMR system to visibly display the preferred or declared name of each child, as well as the pronoun they use. Think of situations in your office where these elements may or may not be visible in the EMR system. What do you see in the EMR when you check a family in at the front desk? How about when you open a patient chart? When you send a patient to lab and/or radiology, which name and pronoun is visible in the EMR? Being misgendered when seeking medical care is a common fear of transgender and gender-diverse patients and their parents, and anything we can do to ensure a smooth and affirming patient care experience will allow children and families to relax and focus on the medical reason for their visit.

When children disclose questions about their gender identity, or affirm a gender identity other than that which they were assigned at birth, the best initial response from clinicians and others is to “support without steering.” This allows kids to explore their questions and identities with the knowledge that they can change course as needed.

Parents often struggle to know how to best support their kids on top of dealing with their own feelings of grief, anger, disappointment, or fear. Primary care clinicians can affirm to parents that asking questions is okay, and seeking supportive resources is encouraged. Parents often need just as much, if not more, room to ask questions and seek support as they learn more about their child’s identity. Parental rejection is a significant risk factor for poor physical and mental health outcomes for transgender youth, including a significantly increased risk of suicide, so clinicians should always encourage parents to consistently reassure their children that they love them, even when they are struggling to understand their expressed identities. Unconditional parental love is the single biggest protective factor to keep transgender and gender-diverse kids healthy and safe.

Information and referrals

In addition to providing supportive primary care services, when primary care clinicians need a place to send families for more information and support, they can now refer them to the Children’s Gender Health Program (www.tinyurl.com/mp-gender-health). Referrals can be made by calling our Children’s Physician Access line at 612-343-2121, or by contacting the Gender Health Program directly at 612-813-7950 (phone) or 612-813-7955 (fax). Through this program, Children’s Minnesota will now offer comprehensive, compassionate, personalized, and coordinated care to support transgender and gender-diverse children and their families, wherever their journeys may lead them. Families can rest assured that our clinic will support the unique health care needs of transgender and gender-diverse kids at any age. Wherever a child or family is on their journey, we are committed to following the lead of patients and families and help them find their way forward. The journey will look different for each child, but the outcome should always be the same: to help transgender and gender-diverse kids grow up healthy, happy, safe, and strong.

Summary

Although positive steps have been taken in recent years, transgender and gender-diverse youth are still a medically underserved population, experiencing a variety of health disparities. The Children’s Gender Health Program offers transgender and gender-diverse children and their families a place to go for exclusively pediatric, comprehensive, compassionate medical care when they have questions about their gender. This program offers a wide variety of gender-affirming services, including gender consultations, mental health assessments, pubertal and menstrual suppression, fertility preservation consultations, and gender-affirming hormone treatment, all delivered by a multispecialty team that includes gender health experts, pediatric endocrinologists, pediatric gynecologists, and a social worker. With this program, Children’s continues to strive to be every family’s essential partner, and to ensure that transgender and gender-diverse children can grow up happy, healthy, safe, and strong.

Angela Kade Goepferd, MD, FAAP, is the medical director of Children’s Minnesota’s Gender Health Program, the Director of Medical Education and Vice Chief of Staff for Children’s Minnesota, and a general pediatrician in the Children’s Minneapolis Primary Care clinic. She is an advocate for advancing equitable health care for all children. 

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Angela Kade Goepferd, MD, FAAP, is the medical director of Children’s Minnesota’s Gender Health Program, the Director of Medical Education and Vice Chief of Staff for Children’s Minnesota, and a general pediatrician in the Children’s Minneapolis Primary Care clinic. She is an advocate for advancing equitable health care for all children.