Care of transgender youth: culture war topic or focus for compassionate care?
Lynne Maxwell MD and Myron Yaster MD
I (MY) was reading the morning news with a cup of coffee about 2 weeks ago when I saw a news blurb that the chairman of the Department of Pediatrics at Texas Children’s Hospital, Dr. Catherine Gordon, resigned. I thought to myself this is pretty weird…why would national news wires report that a Pediatrics chair in Texas resigned? OK, I know Texas Children’s Hospital is a jewel in the crown, but I mean this kind of thing happens all of the time and is hardly “national news worthy”. And then I realized that I had just read an article by her in Pediatrics on the care of transgender youth (her area of expertise is pediatric endocrinology and adolescent medicine and she is the Director of the Gender Medicine Clinic)….hmmm, and the governor of Texas essentially made the medical management of these children a criminal offense…Ah hah! 2+2 = 4. She didn’t “resign”… she was “fired” plain and simple. Because I was so enraged by this and the criminalization of medicine and the euphemism that she resigned, I asked Lynne Maxwell to be the primary reviewer for the PAAD. Perhaps cooler heads would prevail, perhaps not. Myron Yaster MD
Original article
Catherine M Gordon. Caught in the Middle: The Care of Transgender Youth in Texas. Pediatrics. 2022 Mar 31. doi: 10.1542/peds.2022-057475. PMID: 35355080
An experience common to all of us caring for children in the perioperative environment is the initial interaction with the patient and family when you meet them and introduce yourself. Prior to this introduction, we review the chart for both medical and personal/social history. One element that is highlighted is the patient’s name and commonly there is a notation about what the patient prefers to be called (e.g., Christopher John – prefers to be called CJ). A good doctor/patient/family relationship is facilitated by using the patient’s preferred form of address in your introduction. “Good morning CJ, I’m Dr. X” rather than “Good morning Christopher John, I’m Dr. X”. Another aspect of identity is gender identification, which may also be highlighted in the medical record and may be different from the identity recorded in previous encounters. Just as we should address the patient by their preferred name, we should address/refer to them as their preferred gender.
The focus of today’s PAAD is the original article/commentary by Dr. Catherine Gordon from Texas Children’s Hospital in the journal Pediatrics. Recently, the state of Texas has essentially criminalized transgender medical care by labeling it child abuse. This legislation affects both parents and physicians for such care. At the time of this publication. Missouri and Arizona have also banned gender-affirming care. This criminalization has occurred despite the fact that Texas Children’s Hospital’s staff were using evidenced-based medication practices in appropriately aged patients and after a period of behavioral counseling and social transition. Nevertheless, the institution felt that its physicians and clinic staff were vulnerable to prosecution and “put a brief and temporary pause on certain elements of our transgender program”, which remains in effect to this day. Other elements of the program, such as psychological and medical counseling, were continued, and the clinic remains open.
Decades ago, gender dysphoria was more common in the context of children who were born with what was referred to at that time as “ambiguous genitalia” for whom the gender assigned was determined early in life by doctors and parents and who frequently underwent surgeries to make their genitalia conform to the assigned gender. After many years of this practice, many of these children grew up to feel that their gender was opposite to that which they had been assigned, which created difficult problems, including mental health issues, for both the patient and family.1
Today we encounter children whose gender identification is different from that assigned at birth, not because of endocrine or anatomical differences but who have discomfort with their assigned gender which becomes apparent during childhood. These children are referred to as “transgender” the definition of which is “denoting or relating to a person whose sense of personal identity and gender does not correspond with their birth sex.” (Oxford English dictionary). Just as the endocrine/anatomic population of gender dysphoria patients discussed above had mental health consequences, including depression and suicidality, the current population suffers these consequences as well.2,3 The existence of these children has unfortunately become a topic of political (culture war) debate, and this focus has become a source of pain to these children and their families. Unfortunately, some of the reporting and commentary on this issue contains hyperbole and mischaracterization of both the trends in the prevalence of this condition and the consequences of family, medical and behavioral interventions undertaken on behalf of these children.4 A recent review the epidemiology of gender dysphoria provides accurate information on prevalence, which has increased, but not to the degree some journalists have claimed. 5
Although journalists and politicians have focused on hormonal treatments (puberty blockers) and surgery as targets for opprobrium, the care provided in clinics for these youth, focus early in life on “social transition” which is behavioral in nature and does not involve medication or surgery. Such social transition steps have been found to lead to better social and behavioral health for youth and families.6 In addition, although some writers have challenged the permanence of such gender transitions, an article pre-published just this week shows that the majority of these children maintain their chosen gender identity 5 years after gender transition.7 In addition, it should be noted that puberty blocking medications are reversible as is shown by their longstanding use in children with precocious puberty.
As pediatric anesthesiologists, it is not our role to judge the gender identification of our patients and the role their families play in supporting transition. It is our role to educate ourselves about the vulnerability of this patient/family population and to accept and affirm their identity while providing perioperative care.
Finally, the Society for Pediatric Anesthesia just released a position statement on the medical care of transgender youth:
https://pedsanesthesia.org/statement-on-transgender-care/#:~:text=TGD%20youth%20are%20under%20attack,affirming%20care%20for%20TGD%20youth
The SPA statement concludes: “As perioperative medical professionals and patient safety advocates, we have a duty to protect and care for all vulnerable pediatric populations. TGD youth are under attack across our country and deserve our protection. Now is the time to stand up, make our voices heard, and uphold our ethical standards in the face of injustice.
Specifically, we call on our members to:
· increase their understanding of gender-affirming care for TGD youth
· remain vigilant of the current anti-trans legislative trends, especially legislation specific to their state
· support the efforts of pediatricians and mental health practitioners who provide age-appropriate, gender-affirming care to TGD youth
· ensure equitable access to gender-affirming care, noting that the inability to access such care can result in morbidity and mortality.
Please send your thoughts to either John Fiadjoe or Myron (myasterster@gmail.com) and we’ll post in a reader response.
Lynne Maxwell MD and Myron Yaster MD
References
1. Reiner WG, Gearhart JP: Discordant sexual identity in some genetic males with cloacal exstrophy assigned to female sex at birth. N Engl J Med 2004; 350: 333-41
2. Gordon CM: Caught in the Middle: The Care of Transgender Youth in Texas. Pediatrics 2022
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: 489-495
4. Douthat R: How to make sense of the new LGBTQ culture war. New York Times, 2022;; April 13., New York Times, 2022
5. Zucker KJ: Epidemiology of gender dysphoria and transgender identity. Sex Health 2017; 14: 404-411
6. Olson KR, Durwood L, DeMeules M, McLaughlin KA: Mental Health of Transgender Children Who Are Supported in Their Identities. Pediatrics 2016; 137: e20153223
7. Olson KR, Durwood L, Horton R, Gallagher NM, Devor A: Gender Identity 5 Years After Social Transition. Pediatrics 2022