No medical provider likes to confront the thought of having failed a patient. None of us are perfect, and any honest one of us can think of situations where we missed a diagnosis, should have communicated better, or simply didn’t deliver care as best we could have. It’s not a comfortable place to dwell, but acknowledging where things went wrong is a necessary part of learning how to do better.
When it comes to trans kids, I worry there may be patients I am failing. I worry that I don’t even know when I am failing them.
In August, the St. Louis Children’s Hospital opened a clinic dedicated solely to the comprehensive medical needs of trans children and adolescents. St. Louis is the closest major city to the small town in Missouri where I grew up, and when I read the news I was happy to think about trans kids in my own hometown having a place to access expert specialty care. But before they arrive at a specialty clinic, the care of most trans kids will begin with a pediatric generalist like me, and many may not have feasible access to specialty care at all.
Are general pediatricians doing enough to recognize and treat their trans patients?
All too often, the answer is an easy and obvious “no.”
“We switched pediatricians because our previous pediatrician told us it was not a good idea to ‘let her think she could be a girl,’ ” Ari Moffic told me. Moffic is a Chicago-area rabbi and mother of two children, one of whom is an 8-year-old trans girl.
“This pediatrician,” Moffic said, “had never heard of the term ‘social transition’ ”—a process during which trans people adopt the name and pronouns of their gender identity, often with changes in outward presentation like hairstyle and clothing. “She had no resources to offer us,” Moffic continued. “We saw a psychologist who told us to let her wear pink under her ‘boy clothes’ and to remind her that we all have to wear uniforms of sort. She said we could buy a Barbie, but not the Dream House so as not to encourage her gender nonconformity.”
Every trans and gender-nonconforming child deserves better care than this. The American Academy of Pediatrics has issued strong statements in support of transgender children and youth and contributed to “Supporting and Caring for Transgender Children,” a set of guidelines published last year.
“Reparative therapy attempts to ‘correct’ gender-expansive behaviors, while delayed transition prohibits gender transition until a child reaches adolescence or even older, regardless of their gender dysphoria symptoms,” the 2016 document reads. “While researchers have much to learn about gender-expansive and transgender children, there is evidence that both reparative therapy and delayed transition can have serious negative consequences for children.”
Medical and mental health providers who advise denial, suppression, and conformity as the only options for their trans patients are doing them harm.
However, my concern about the care pediatricians deliver to their trans patients extends beyond those who are recognizably dysphoric or gender nonconforming. I worry we are missing those kids who seem to conform pretty well to gender norms but may inwardly feel uncomfortable with their assigned gender at birth. I worry about patients like Katelyn Burns.
Burns is a trans woman and writer living in Maine. Earlier this year she wrote “I Was Robbed of My Transgender Childhood,” an article about the experiences she missed out on growing up.
“From my earliest moments of self-awareness about my gender identity, I decided it was something I had to hide,” Burns wrote. Later in the piece, she explained: “The most positive memories I have from childhood are those in which my gender didn't matter; the truth is, my girlhood was empty.”
“I had a pretty good idea [I was trans] by the time I was 8,” Burns told me when we spoke recently. “If I had been assigned female at birth, I probably would’ve been a tomboy to be honest with you. I had no desire to play with girl’s toys. I played sports.”
Among the people who took her outward conformance with her assigned gender at face value was her pediatrician. When she began to experience psychological distress at the earliest indications of puberty, including barely noticeable peach fuzz, her feelings never came up in medical visits.
“My doctors just assumed that I was cis and wanted a normal male development, and I didn't,” she said. “Nobody ever just asked, ‘I see you started growing facial hair. How do you feel about that?’ ”
As a pediatrician who wants to deliver the best care possible to my patients, it’s obvious to me that asking about these issues proactively—rather than acting on assumptions based on how a patient presents—would help those who may not present in more overtly nonconforming ways. Equally obvious, unfortunately, are the barriers to doing so.
During every annual checkup I have with an adolescent patient, I spend a portion of one-on-one time with them asking about issues they may want to keep confidential. Among the things I discuss are questions about relationships and sexuality. I’ve had to confront my own internalized homophobia and reluctance to ask about same-sex attraction, and now I ask every patient if they’re interested in the opposite sex, the same sex, or both. I present it as a matter of routine, and thus far no teenage patient has objected to being asked. (The kids, in my experience, are all right.) By asking, I’ve been able to discuss same-sex attractions with some patients who presented in a very heteronormative manner.
But numerous trans people told me their sense of difference from their assigned gender emerged well before becoming teenagers. Emmett Schelling, a trans man adopted at age 3, told me his family remembers him getting very upset even as a small child when he was made to wear a dress or wear his hair long. For as long as he can remember, he felt discomfort with his assigned gender. By waiting until adolescence to ask about a patient’s gender development, pediatricians may be failing trans kids.
Many parents might find questions about their child’s gender identity off-putting, if not offensive, and parents or other adult guardians are invariably present during office visits. Even if providers are willing to risk parental alienation by asking outright, they’re unlikely to get an honest answer from kids who fear their parents’ reaction.
“My mom was always there. How could I say something truly unbiased where I wasn't playing to her approval?” Burns said. “I don't know how I would've reacted if my doctor had started asking me about this stuff while my mom was present.”
But just because asking is difficult doesn’t mean we shouldn’t be doing it anyway. And the key to overcoming the barrier may be making it just another part of a routine visit.
“I do think pediatricians should be discussing and screening for gender identity concerns in all children, not just in children with clearly expressed gender nonconformity,” Dr. Elyse Pine, a pediatric endocrinologist, told me. Pine is the trans youth lead physician at Chase Brexton Health Care in Baltimore, and director of their Gender Journeys of Youth program, which delivers care to over 800 trans or gender-nonconforming patients age 6 to 26.
“Asking everyone normalizes the topic and reduces stigma,” Pine said. “I have spoken with pediatricians and other health care providers about having intake forms that ask everyone their preferred name (which is not only a gender thing—my husband uses his middle name and many people have nicknames), and asks everyone their pronouns. It is a small extra step and can reduce so much suffering.”
When it comes to direct screening by a medical provider, Pine advises a different approach at different ages.
“I think that it makes sense to ask parents if they have questions or concerns about their child's gender development starting at age 3,” she said. “That will signal that the pediatrician's office is a safe place to discuss these concerns.”
For patients approaching adolescence, questions about gender identity can be included alongside other sensitive topics during the confidential portion of the visit.
This routine approach to these questions also made sense to the trans people I spoke with. Even if our patients can’t give honest answers at any given visit, we make clear by asking that we’re interested in providing the care they need whenever they are able to express it. We can also potentially prevent undesired changes to their body. While some are quick to point out gender-nonconforming kids who “desist” and again conform to their assigned gender at birth, social transitioning is reversible, while pubertal changes are much less so.
“I would like children to be respected as agents of their own destiny,” Mark Blaho, a trans man, told me. “I’ve noted that a lot of the public discourse surrounding children is motivated by fears of ruining the child’s body, or more specifically, ruining a cis body. My body was ‘ruined’ by puberty, but no one seems to be too concerned about that.”
“I am expected to get surgery to fix my defects, but when we have a child clearly in pain from direct gender dysphoria, medical treatment will ruin their beautiful, natural, ‘clearly desirable’ cis bodies,” he continued. “This stems from the idea that being cis is clearly better than being trans, so hold off all treatment until your child breaks under the strain of their own emotional pain. Then, and only then, can you treat them without fear that you are ruining a cis person (because they're already a trans person and thus broken). This is an incredibly toxic attitude for children and adults, because this flirtation with disaster leads to lost years, lasting trauma and sometimes suicide.”
It may be true that not all gender-nonconforming children are trans, and medical interventions for one may not be appropriate for all. But it is also true that not all trans kids are gender-nonconforming, and by failing to recognize that we are likely failing to help some kids who need it, with both short- and long-term consequences. Our obligation is to meet all our patients’ needs as best we can, not just those needs that are unambiguous, or comfortably within accepted social norms. If we do not make an effort to investigate the needs of trans kids who present as gender conforming, we are never going to be able to help them.
Living as a trans person in a transphobic society requires a great deal of courage. Surely trans and gender-nonconforming patients are entitled a measure of courage from their medical providers, which we can demonstrate by striving to destigmatize questions about gender development. If pediatricians won’t work to change transphobic norms on behalf of our patients, who within the medical community will?