Trans kids exist.
In the face of the Trump administration’s escalating hostility to trans people—from its efforts to ban open transgender service in the military to its attacks on trans-related health care to its plans to erase trans identity entirely—it is necessary to vigorously and unambiguously assert that trans people not only exist, but are entitled to equal protection under the law and access to comprehensive, competent, compassionate medical care. And it is necessary to recognize that the needs of trans people extend into childhood.
Last month, the American Academy of Pediatrics (of which I am a member) struck a blow for the dignity of transgender youth, declaring its support for their access to appropriate health care. In a policy statement, the AAP laid out an extensive list of trans patients’ medical needs, along with recommendations to better help medical providers meet those needs. While it does not include detailed protocols for the specific management of trans patients’ medical treatment, the statement affirms in plain language that those needs are real, and it is the obligation of pediatricians to recognize and provide for them.
The statement acknowledges it is difficult to estimate the number of children and adolescents in the United States who are trans and gender-diverse, or TGD, in large part due to stigma associated with being out. However, the fact that these children exist is not in question.
“Children report being aware of gender incongruence at young ages,” the report states. “Children who later identify as TGD report first having recognized their gender as ‘different’ at an average age of 8.5 years; however, they did not disclose such feelings until an average of 10 years later.”
The statement advises providers to support children who assert a gender identity different from their sex assigned at birth and to abandon the outmoded approach of withholding that support until they reach some arbitrary, usually postpubertal age. This “watchful waiting” approach was influenced in part by a small number of studies of children who identified as TGD but did not seek further care as teenagers, commonly referred to as “desisters.”
“More robust and current research suggests that, rather than focusing on who a child will become, valuing them for who they are, even at a young age, fosters secure attachment and resilience, not only for the child but also for the whole family,” the report advises.
Further, it strongly supports medical care that affirms a child’s gender identity and condemns treating TGD patients as disordered or suffering from mental illness. It offers broad recommendations for helping trans children not only in medical settings, but in school and at home as well. And it identifies the harms that can befall these kids when they do not get the care they need.
“We know that all members of the LGBTQ community face greater rates of homelessness, limited access to health care, abandonment from family, and discrimination in all regards,” Dr. Elizabeth Murray, an emergency medicine and child abuse pediatric specialist at Golisano Children’s Hospital at the University of Rochester, told me in response to the new report. “All of these things mean greater likelihood of abuse, trafficking, and untreated medical problems. Untreated simple medical problems can easily become severe problems which land you in the emergency department. The high rates of depression, anxiety, and self-harm in children who are ostracized because of their gender identity often also create medical emergencies, suicides, and suicide attempts.”
Helping TGD children access the care they need means creating a medical environment where providers treat them sensitively and respectfully. Sadly, that doesn’t always happen.
“Our medical encounters have been underwhelming,” Hester Blum, the mother of a nonbinary 12-year-old child, told me. “Providers never get the pronoun right, despite my gentle requests to put it in their file. When my kid had their first physical since coming out, the doctor (a woman we had liked before) was nervous and flustered. I had called the office in advance of the appointment to talk about my kid’s gender identity and was disappointed that the doctor had done zero work, reading, or preparation for the visit.”
It’s no surprise to me that parents like Blum might find the care they receive from their children’s doctors frustrating or outright discouraging. It wasn’t until I was in my fellowship in adolescent medicine that I was taught anything about taking care of trans patients, and even that experience was quite limited. Since finishing my training, everything I’ve learned about how best to meet the needs of my trans and gender-diverse patients has been because I sought it out myself. Although some medical schools are getting better at including LGBTQ medical issues in their curricula, there is still a lot of progress to be made. There are generations of providers working today whose formal education concluded decades ago; a key challenge will be instructing them about developments in this field—and persuading them to abandon old, harmful treatments.
While the new AAP document is only a starting place to ensure that TGD patients’ needs are better met, its publication has been met with a broadly positive reaction.
“The policy brief from the American Academy of Pediatrics is a strong and welcomed statement in support of transgender boys, girls, and nonbinary youth and their families,” said Luc Rizzaro, policy counsel for the National Center for Transgender Equality, in a statement. “The parents of transgender youth face routine harassment by people who deeply misunderstand the medical needs of their children and transgender and nonbinary identities overall. … At a time when the Trump administration is prepared to erase transgender people from the enforcement of civil rights law, the support of groups like AAP is more important than ever.”
“I think the support of the Academy will give added strength to the TGD community by empowering pediatricians to be comfortable talking about gender identity, as well as providing a backbone as to what the risks are when patients who identify as TGD don’t have support,” Dr. Jaime Friedman, a San Diego pediatrician, told me. “Unfortunately, implementing the recommendations, educating physicians, and reaching out to schools and insurance companies takes a long time. But I think it’s a great start!”
Dr. Rachel Levine agreed. “One of the highlights of the document is the use of terms such as gender-fluid and gender-diverse, terms that are becoming more relevant among children and younger generations in discussing the differences in individuals,” she told me. Levine is the secretary of health for the Commonwealth of Pennsylvania and professor of pediatrics and psychiatry at the Penn State College of Medicine. She is trans herself.
“The majority of doctors have relatively little expertise in providing adequate care to transgender and gender-diverse patients,” Levine said. “This is also true for pediatricians. However, the field is certainly progressing, and young graduates who have just finished their residency and education certainly are more exposed to caring for gender-diverse patients. This document is a helpful resource for those providers who do not have a knowledge base on the topic.”
“I don’t think medical providers provide adequate care to sexual minority youth including trans and gender-diverse patients. Do I think this document will be helpful to them? Absolutely!” Dr. John Steever, director of special programs and assistant professor of pediatrics at Mount Sinai Adolescent Health Center, told me. “I think this also helps document why it’s important to take care of these kids and why pediatricians should take care of gender-diverse patients. I also appreciated that treatments such as ‘reparative’ therapy are noted to be harmful to youth and are not to be recommended to patients and families ever.”
Because our patients are children, pediatricians should be uniquely attuned to the needs of the vulnerable and prepared to advocate for them. For far too long, trans kids have been invisible to their providers, either overlooked entirely or subjected to profoundly damaging therapies meant to erase their identities and force conformity to gender norms. While this statement is only a beginning, with the imprimatur of the AAP behind it, it may help medical providers nationwide better care for children whose well-being has been neglected until very recently. At a time when the very existence of trans people is under attack on multiple fronts, our obligation to fight for their health and welfare could not be more pressing.