#23: Gender Affirming Care

April 14, 2021 | By Justin Berk

Gender Care is Primary Care!

Summary

Gender affirming care– time to refer your patient? Think again! Primary care pediatrician, Professor of Pediatrics at Brown Medicine, and Gender and Sexuality expert Dr. Michelle Forcier MD, MPH introduces us to practicing a patient-centered consent-based model of gender affirming care in the primary care setting. Dr. Forcier teaches us how to use a developmental model of gender identity for all of our patients, how clinics can create a safe and supportive environment,  breaks down the variety of social, legal, medical, and surgical options that can be a part of gender affirmation, and how to support families in loving and supporting their kids and adolescents.

Credits

• Written and Produced by: Becca Raymond-Kolker
• Infographic: Becca Raymond-Kolker
• Cover Art: Chris Chiu MD
• Hosts: Chris Chiu MD; Justin Berk MD
• Editor:Justin Berk MD; Clair Morgan of nodderly.com
• Guest(s): Michelle Forcier, MD

Gender Affirming Care Pearls

1. Gender care is primary care!
2. Gender describes an internal sense of self and who a person is. Gender is part of normal development and gender diversity is normal and expected. 
3.  Pediatricians should be asking all kids at developmental nodal points about their gender as part of anticipatory guidance and screening.
4. Gender affirmation may consist of some combination of legal, social, medical, and/or surgical affirmation. 
5. Patient-Centered Consent-Based Care helps us offer care that meets patients’ goals safely. 
6. Supportive families are protective. Kids who are safe and loved at home do well. 

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Gender Affirming Care Notes 

How to Take a Gender History

Enter any new patient encounter by being genuinely happy to see patients. Introduce yourself with name and pronouns and invite everyone else in the room to do the same. Before meeting patients, normalize asking patients their pronouns at the front desk and on phone encounters and never make assumptions about what pronouns patients might use.

Creating an Affirming Environment

Displaying pronouns on provider badges or pronoun pins can be helpful in making patients feel more comfortable. Remember that patients can be very nervous at a first gender appointment! Medicine has a history of gatekeeping access to gender care, and also patients may have had negative experiences surrounding their gender identities. It’s really important for clinics to be explicitly supportive to set the stage for patients to feel safe and comfortable. Part of creating an affirming clinic is creating an affirming model of care. The Gender Road Map is a paradigm of patient-centered consent-based care which puts power and control in the patients hands.

Gender Identity as Part of Child Development

Gender is part of biology and development and, like with all of biology, diversity is normal and expected! Pediatricians should be asking all kids at developmental nodal points about their gender as part of anticipatory guidance and screening. As a part of a conversation about known developmental stages of childhood and adolescence, pediatricians should be engaging patients in conversations surrounding gender, rather than waiting for a kid to say that they are worried that something doesn’t feel right or be a problem. Pediatricians have the unique skill set to talk in the language of their patients, and can use this skill to ask developmentally appropriate questions to patients about how they experience their gender and how they feel about their gender.

Sex and Gender: What are they?

Gender describes an internal sense of self and who a person is. Language isn’t always adequate because identities are so expensive. Gender identity is how one identifies. Gender expression is different from gender identity and those may or may not align. Sex assigned at birth is another different term that describes the medical establishment’s perception of a neonate beased on external genitalia, but even that is often not sufficent to describe the wide range of intersex persons. 

Sex is also about sexuality, behaviors, activities and attractions.

Using Affirming Language

Start by asking any patient how they identify. Their terms, their identifications, and their descriptions should guide the language providers use. When parents use pejorative language in the clinic, this is a hard stop and merits immediate education. With parents, we call them in with a zero bullying policy and make sure that the clinic space is one in which everyone is treated with respect. Helping parents using correct pronouns is a way to help parents let their kids know they are supported, and it is important to model that in clinic. A 2018 article by Russell et al shows that when parents use the correct name and pronouns for their kids, those kids are protected against suicidality. Just using names and pronouns is a totally reversible, evidence-based approach for parents in supporting trans* and gender-diverse kids. 

Gender Care is Primary Care

Pediatricians are well equipped to support their patients with gender affirming care. Any pediatrician can support their patients who are exploring gender, and pediatricians should feel empowered to reach out to colleagues or local centers of excellence to collaborate in a team-based approach to provide gender affirming care. Primary care pediatricians who are comfortable with gender affirming care may do a better job than specialists because they can look at the whole patient and family system and provide anticipatory guidance on peer relationships, parental and familial relationships, and how to disclose at school. Primary care pediatricians is well set up to take care of trans* and gender diverse kids. 

What is Gender Affirming Care?

Gender affirmation can consist of:

• Social Affirmation which can include changing one’s name, pronouns, and/or changing gender expression (hair, clothing, shoes). Social transition is completely reversible and often a great way for kids to explore as part of normal development. 
• Legal affirmation can include making these social changes a part of one’s permanent record such as changing gender markers or names on birth certificates, social security cards, and drivers’ licenses. 
• Medical affirmation consists of a variety of very safe, well tolerated medications. Some medications include puberty blockers (leuprolide, histrelin) which prevent the progression of puberty and are completely reversible when stopped and may prevent from future surgical and medical interventions. Medicaid/Medicare cannot exclude gender coverage as of 2016 which has included expanding coverage of puberty blockers, hormonal therapies, and gender affirming surgeries but this varies by state and with private insurance. Overall, hormonal therapies are safe and there are few irreversible changes that occur with hormonal therapies. Often, irreversible changes are usually desired and wanted for patients. Irreversible changes of testosterone include lower voice, male-pattern hair, and cliteromegaly.  Other possible side effects of testosterone include acne, heat intolerance, increased body odor,  and possibly male pattern hair loss. The irreversible change of estrogen is breast development. Side effects of estrogen include mood changes and changes blot clot risk. [Note: using physiologic dosing of 17-beta-estradiol which is administered sublingually or subcutaneously mitigates clot risk]. Spironolactone and finasteride block testosterone effects on male pattern hair.
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• Surgical affirmation can include, but is not limited to, chest/breast removal or augmentation, hysterectomy, phalloplasty, vaginoplasty, and facial feminization. 

Remember: all different kinds of affirmation are completely up to the individual, and providers should support patients in making the changes they want to without assuming that every patient will want to undergo social, legal, medical, and surgical affirmation.

Talking about Puberty

With any patient, ask what they know about puberty and what they are worried or excited about. Different kids worry about different things. Ask parents when they or the patient’s siblings went through puberty. You can look at their pediatric growth curve to note when patients might be starting to hit the upward trajectory for height velocity which can help predict puberty.  Reassure prepubertal trans* kids that they don’t have to go through “the wrong puberty” as long as they stay in care: this is why it is so important to see patients early on if possible. Pediatricians can help hold some of these worries about puberty and physiological changes that kids may otherwise worry about. Provide counseling to parents about what kinds of changes to watch for that might signal the beginning of puberty. 

Puberty Blockers

Puberty Blockers are medications that allow us to “put a pause button” on puberty and these medications are very safe and completely reversible. These medications give kids and families time to consider next steps and explore their gender identity in a safe way. These medications have long been used in pediatric context for a long time both for precocious puberty and gender care. Puberty blockers are GnRH analogs (Gonadotropin Releasing Hormone): essentially “fake hormones” which sit on the receptors and blocks messaging from the brain to ovaries/testes which makes kids go to prepubertal levels of hormones (or stay at prepubertal levels of hormones). Ideally, kids should start puberty blockers at early Tanner 2 staging. Using puberty blockers at this stage can prevent medical and surgical intervention later in life. Historically, patients have been transitioned off of puberty blockers in late adolescence  for the theoretical bone, brain and heart health benefits of estrogen and/or testosterone; however, data for this is limited and practice may change over time.

From Puberty Blockers to Gender Hormones

Patients on puberty blockers (who haven’t already undergone puberty once) can be slowly titrated up in amounts of gender hormones while continuing puberty blockers to emulate biological models of hormonal increases. This allows a great amount of control over the amount of gender hormones to the stage of reaching physiological adult levels. Patients on puberty blockers  that have already undergone a first puberty can be started on higher doses of gender hormones to catch up to age-matched peers. 

Supportive Families are Protective

Gender diversity is part of human diversity, and identity formation is part of childhood and adolescence. Providers can normalize gender diversity in the primary care setting by asking all patients about gender identity, sexual identity, identity and roles in families and at work. We can model this perspective around kids and their families. This is helpful because we know that kids who can’t speak to their parents openly are healthier. The focus on parents is critical: it is important to create common ground with parents that we both want their children to be safe, healthy, and happy. If a kid has to hide from their parents who they are or are refused by their parents, kids suffer. Parents need to be present for their child and process their own emotions and get support separately.  Expert Opinion: Kids who are safe and loved at home do well. 

Take home points:

• Gender care is primary care. Everyone in development across the lifespan is dealing with their gender. If gender affirming care actually becomes part of primary care that will greatly enhance equity and access. 
• Patient-Centered Consent-Based Care helps us offer care that meets patients goals safely. 
• Trauma Informed Care is essential for trans, gender divers, and LGBTQ  patients. Society and medicine itself has inflicted trauma on our patients and it is important to address this overtly in the patient encounter.

Citations

1. Rafferty J et al. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics. 2018 Oct;142(4):e20182162. doi: 10.1542/peds.2018-2162. Epub 2018 Sep 17. PMID: 30224363.
2. Rafferty JR, Donaldson AA, Forcier M. Primary Care Considerations for Transgender and Gender-Diverse Youth. Pediatr Rev. 2020 Sep;41(9):437-454. doi: 10.1542/pir.2018-0194. PMID: 32873559.
3. Russell ST, Pollitt AM, Li G, Grossman AH. Chosen Name Use Is Linked to Reduced Depressive Symptoms, Suicidal Ideation, and Suicidal Behavior Among Transgender Youth. J Adolesc Health. 2018 Oct;63(4):503-505. doi: 10.1016/j.jadohealth.2018.02.003. Epub 2018 Mar 30. PMID: 29609917; PMCID: PMC6165713.
4. Sorbara JC, Ngo HL, Palmert MR. Factors Associated With Age of Presentation to Gender-Affirming Medical Care. Pediatrics. 2021 Mar 15:e2020026674. doi: 10.1542/peds.2020-026674. Epub ahead of print. PMID: 33722987.

Links

1. Clan of The Cave Bear by Ursula Leguin
2. Queer Health Pod
3. The Moon And Stars: Prescriptions For Dreamers by Valerie June
4. Clive Barker 
5. Open Door Health in Providence, RI
6. Fenway x HRC: TransECHO Training for the whole clinic staff 
7. Your local providers can help you grow your own experience and expertise in gender care. 

Goal

Listeners will develop a framework for understanding and providing evidence-based gender affirming care from a primary care pediatrics perspective. 

Learning objectives

After listening to this episode listeners will…  

1. Define gender identity and describe a developmental model of gender identity 
2. Develop a welcoming and safe clinic environment and model of gender affirming care
3. Describe the modalities of gender affirmation: legal, social, medical and surgical. 
4. Be familiar with evidence-based medical and social interventions to improve wellbeing of trans/gender diverse youth
5. Recognize the importance of using correct name and pronouns with trans*/gender diverse use
6. Describe the benefits and side effects of commonly used medicines for gender affirmation
7. Feel comfortable counseling families on supporting their trans and gender diverse kids

Disclosures

Dr Forcier is an author for UpToDate and Springer, a clinician for Planned Parenthood, and their spouse is an employee of Takada. The Cribsiders report no relevant financial disclosures. 

Citation

Raymond-Kolker, R. Forcier, M. Chiu C, Berk J. “Gender Affirming Care”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ 4/14/21.