State of the Art Pediatrics: Talking about Gender

Column Author: Seth Lamb, MD | Pediatric Resident, Children’s Mercy Kansas City 

Michelle Knoll, MD | Pediatric Endocrinologist, Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine 

Column Editor: Amita Amonker, MD, FAAP | Pediatric Hospitalist | Assistant Professor of Pediatrics, UMKC School of Medicine 

As our understanding of gender rapidly evolves, primary care providers need to be up to date on the latest terminology, evidence and practice guidelines. Recent studies show that more and more patients are experiencing their gender in a different way than do their peers.¹ 

The words we use to discuss gender continue to evolve. Using the most up-to-date terminology reduces stigma and can help patients feel more comfortable discussing gender concerns. A patient’s ability to be open about their gender identity could have a profound impact on their mental health. The following definitions are taken from WPATH (World Professional Association for Transgender Health) Standard of Care guidelines, version 8: 

• Transgender is an adjective that describes people whose gender identity is not consistent with their sex assigned at birth. Those who are transgender are given a diagnosis of gender incongruence. 
• Cisgender is an adjective that describes people whose gender identity is consistent with their sex assigned at birth.
• Gender diverse is an umbrella term used to describe anyone that does not identify as cisgender.
• Gender dysphoria is the diagnosis we use to talk about the distress one experiences related to gender incongruence.

The goal of treatment is to reduce gender dysphoria, not to medicalize their gender identity. Not every gender diverse person requires medical treatment. However, for those with severe dysphoria, treatment can improve mental health outcomes. One recent study showed that youth with gender dysphoria are 7.3 times more likely to have mood disorders and 5.5 times more likely to have anxiety disorders compared to their peers without gender dysphoria.² Two additional studies found that approximately 30% of transgender children have attempted suicide.^3,4 In contrast, those who receive puberty blockers and/or hormonal replacement therapy have reduced rates of depression, self-harm, suicidal thoughts and suicide attempts.^3,4 Prepubertal transgender children who are socially transitioned and supported in their gender identity do not have increased rates of depression compared to their cisgender peers.⁵ 

How can a primary care provider assess gender in a patient? First, discuss gender in a developmentally appropriate way. This may mean asking a preschooler “Are you a boy or a girl?” or asking a teenager “What word do you use to describe your gender?” during a confidential exam. It is important to remember that definitions are often inadequate to fully encompass one’s experience, and the patient can further expand on their gender definition. A provider who suspects that a patient’s gender identity may be different than their sex assigned at birth can ask the patient if anything about their gender, body or pubertal development is distressing. If gender dysphoria is suspected, a provider should ask the patient if they have told their parents, and whether they want them to know. Offer resources that patients can read on their own, especially if they are not ready to talk to their parents. Two excellent resources for this are “gender spectrum” and Planned Parenthood.   

Remember to always screen for mental health concerns and suicidal thoughts. Consider referral to a therapist specializing in gender diversity to discuss challenges and mood related to their gender dysphoria, particularly if they are voicing any concerns about self-harm. Additionally, gender clinics, such as those in St. Louis and Kansas City, can also help provide mental health and medical support for patients. Even if a patient or family is not interested in medical management, these clinics are available to provide additional resources and information.  

If you would like to read more about the guidelines or research informing current best practice, the Endocrine Society released guidelines in 2017, and WPATH released WPATH SOC 8 in 2022. The American Academy of Pediatrics also provides guidance regarding care for transgender youth at all stages of development. 

References: 

1. Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgend Health. 2022;23(Suppl 1):S1-S259. doi:10.1080/26895269.2022.2100644 
2. Nunes-Moreno M, Buchanan C, Cole FS, et al. Behavioral health diagnoses in youth with gender dysphoria compared with controls: a PEDSnet study. J Pediatr. 2022;241:147-153.e1. PMID: 34571022. PMCID: PMC8828680. doi: 10.1016/j.jpeds.2021.09.032
3. Connolly MD, Zervos MJ, Barone CJ 2nd, Johnson CC, Joseph CL. The mental health of transgender youth: advances in understanding. J Adolesc Health. 2016;59(5):489-495. PMID: 27544457.doi:10.1016/j.jadohealth.2016.06.012
4. Green AE, DeChants JP, Price MN, Davis CK. Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth. J Adolesc Health. 2022;70(4):643-649. PMID: 34920935.doi:10.1016/j.jadohealth.2021.10.036
5. Tordoff DM, Wanta JW, Collin A, Stepney C, Inwards-Breland DJ, Ahrens K. Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA Netw Open. 2022;5(2):e220978. doi:10.1001/jamanetworkopen.2022.0978