Pediatricians are key in supporting transgender, gender-diverse youths
JasonRafferty, M.D., M.P.H., Ed.M., FAAP
In recent years, “gender identity” has increasingly been recognized as a complex concept
that goes beyond traditional definitions of masculinity and femininity. Society struggles
to adapt to and appreciate the diverse experiences of transgender and gender-diverse
(TGD) individuals, which contributes to intolerance, discrimination and stigma. In
this context, TGD youths and their families increasingly present to pediatric providers
for advocacy, care and referrals.
The Academy stands against stigmatization and marginalization of TGD youths, and emphasizes
the need for their acceptance as members of our families, communities and workforce.
A new policy statement, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children
and Adolescents,uses strengths-based concepts to outline the role of pediatricians in addressing the
needs, challenges and resilience of TGD youths and their families.
The policy, from the Committee on the Psychosocial Aspects of Child and Family Health,
the Committee on Adolescence, and Section on Lesbian, Gay, Bisexual and Transgender
Health and Wellness, is available at https://doi.org/10.1542/peds.2018-2162 and will be published in the October issue of Pediatrics.
Provide gender-affirmative care
TGD individuals have high rates of depression, anxiety, substance use, self-harm and
suicidality. Some youths experience gender dysphoria when the incongruence between
assigned sex at birth and asserted gender identity becomes so distressing that it
impairs the youth in school, relationships and overall functioning. When people feel
they must suppress their genuine self or emotions around their identity, it often
leads to shame and adverse mental health outcomes.
However, there is no evidence that risk for mental illness is inherently due to a
TGD youths, like all children, flourish when they feel supported. Therefore, the policy
emphasizes a gender-affirmative model of developmentally appropriate care oriented
toward understanding and appreciating the gender experience of all youths.
This approach accepts that gender identity and expression are normal aspects of human
diversity, and that binary definitions of male and female do not always reflect emerging
identities. Research shows that regardless of developmental stage, prepubertal children
who assert a TGD identity know their gender as clearly and consistently as their developmentally
equivalent peers and benefit from the same level of validation and social acceptance.
Instead of attempting to predict, prevent or pathologize who a child may become, or
withholding critical support, a gender-affirmative model is aimed at valuing every
child for who they are in the present, even at a young age.
Such care is most effective when it can be delivered within collaborative systems
that ensure access to gender-competent and -affirming primary and specialty medical
care, mental health and social services, including specific resources for parents
Through strong, nonjudgmental partnerships with TGD youths and their families, providers
can facilitate a safe environment for exploration of complicated emotions and gender-diverse
expressions. Providers can ensure that questions and concerns are addressed, while
offering evidence-based information.
As pediatric providers know, caring for children necessitates attending to the family.
In addition to validating the feelings of the patient, it is important to appreciate
how challenging, and at times scary, it can be for family members to realize their
child’s experience and feelings. Research increasingly shows that family efforts at
acceptance or rejection ultimately have little influence on the youth’s gender identity,
but they may profoundly affect the child’s ability to openly discuss concerns about
The gender-affirmation process involves reflection, acceptance and, for some, intervention.
These interventions might include social adaptations (change of name, pronouns, dress,
etc.), changes to legal documents, pubertal suppression, hormones or medications,
and when appropriate, surgical interventions. The decision of whether or when to pursue
various interventions is very personal, and interventions vary depending on pubertal
and developmental progression.
Pediatric providers can help build safer communities through public education and
advocacy regarding transgender rights. Less than half of states have laws prohibiting
discrimination based on gender identity or expression in terms of employment, housing,
public accommodations and insurance benefits. Legal obstacles interfere with changing
one’s name or gender marker. Many TGD youths do not feel safe at school as they face
alarmingly high rates of harassment, victimization and bullying. While explicit anti-bullying
policies, accessible supports and inclusion of lessons on tolerance and acceptance
into the curriculum improve the school environment for TGD youths, such programs are
far from universal.
Overall, pediatric providers can play an important, if not life-saving, role in promoting
the health and development of TGD youths. While every family’s experience is distinct,
the need for nonjudgmental affirmation and empathy is universal. In addition to ensuring
access to comprehensive, gender-affirming and developmentally appropriate care for
TGD youths and their families, the policy also recommends:
development of electronic health records and billing systems that respect the asserted
gender identity of each patient;
insurance plans that offer health care coverage specific to the needs of TGD youths;
increased provider education and clinical research on the emotional and physical health
needs and best practices for the care of TGD youths and their families; and
advocacy with school districts, communities and policymakers to promote acceptance,
inclusion and legal protection for all children without fear of harassment, exclusion
or bullying because of gender expression.
Dr. Rafferty is the lead author of the policy statement and a member of the AAP Section
on Lesbian, Gay, Bisexual and Transgender Health and Wellness.