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Transgender Care
Transgender individuals have a gender identity that differs significantly from the sex they were assigned at birth (see Chapter 133 ). They may experience gender dysphoria , defined as clinically significant distress or impairment in social, school/occupational, or other important areas of functioning associated with incongruence between one's experienced/expressed gender and assigned gender, for at least 6 mo in duration. Gender-affirming care has been shown to alleviate gender dysphoria and may include psychological evaluation and supportive therapy, puberty suppression, feminizing or masculinizing hormone therapy, and surgery. Such care is guided by the Standards of Care for transsexual , transgender , and gender-nonconforming people set forth by the World Professional Association for Transgender Health (WPATH). In addition, the Endocrine Society has issued practice guidelines for endocrine treatment to alleviate gender dysphoria.
Transgender and gender-nonconforming children and adolescents have increased vulnerability to mental health concerns because of social stigma attached to gender nonconformity. Moreover, transgender and gender-nonconforming children and adolescents may present with general health concerns unrelated to their gender identity or gender expression, but may experience barriers to care that include a lack of cultural competence on the part of healthcare providers or the healthcare systems in which they practice. Therefore, to serve the youth and their families adequately, attention to both cultural and clinical competency is critical and should be improved. The American Psychological Association and the American Association of Child and Adolescent Psychiatrists have published practice guidelines to promote improved access to competent care.
Cultural and Clinical Competence
Cultural competence refers to the ability to communicate effectively with patients from various backgrounds. This includes appropriate assessment and clinical documentation of both gender identity (What is your current gender identity?) and sex assigned at birth (What sex were you assigned at birth [on your original birth certificate]?), use of preferred names and pronouns, and availability of all-gender bathrooms. It also includes recognition of and respect for gender diversity: children and adolescents may identify as girl, boy, boygirl, girlboy, transgender, genderqueer, nonbinary, gender fluid, gender questioning, or any other way in which they may describe their gender identity and expression (see Chapter 133 ). Particularly with children and adolescents, it is imperative not to label prematurely a young person's gender identity, but rather allow ample time for them to explore their gender identity and expression.
Clinical competence in transgender care refers to training and experience in providing gender-affirming care to facilitate gender identity development, alleviate any gender dysphoria, and promote resilience in the face of stigma. Care should ideally be provided by an interdisciplinary team or, alternatively, in consultation with other providers involved in the child or adolescent's care. This may include primary care providers, pediatric endocrinologists, and mental health professionals. The WPATH Standards of Care recommend that providers be competent in working with children and adolescents; be able to screen for coexisting mental health concerns; be knowledgeable about gender-nonconforming identities and expressions; and be knowledgeable and engaged in continuing education about the assessment and treatment of gender dysphoria.
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