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    Affirming gender: Caring for gender-atypical children and adolescents

    Pediatricians are in a powerful position to promote health and provide positive outcomes for children with issues of gender identity and expression.

    Case 1

    Your patient Mark comes to his 3-year-old well-child checkup wearing a dress and also barrettes in his hair. During the visit, you mention to the parents, “I notice Mark’s creative outfit today. Is that something you want to talk more about?” The parents mention that Mark has been wearing this dress every day since his female cousin came to visit. He likes to tell people that his name is “Katie” and that when he grows up he wants to be a girl like his cousin. When adults correct him, he doesn’t really seem to mind, saying, “I’m just playing pretend.”

    Case 2

    It is time for your patient Alex’s 8-year-old well-child checkup. Alex was assigned female at birth, but since he was able to talk, he has been insistent that he is a boy. He was so distressed when adults corrected him that he told his parents he wanted to die. Alarmed, and conscious of what their child was telling them, Alex’s parents facilitated his enrollment in kindergarten as a boy and allowed him to wear typical “boy” clothing. They trained the school staff about gender issues, and his state’s law recognizes gender as a protected class. The children have not had any problems adjusting. Alex is a top student and plays on the boys’ T-ball team.

    Case 3

    Your patient Nicole comes to his 12-year-old well-child visit, and you immediately notice something different. He will not make eye contact beneath his baseball cap. Assigned female at birth, he has told his parents that he is a lesbian. When you meet with Nicole alone, he says that he knows that he is attracted to girls but does not feel like a lesbian. Instead, he feels like a boy (thus the use of male pronouns per his request). He says he has felt this way for a long time but just thought it meant he was a tomboy. Now that he is getting breasts, he has become very depressed about feeling as if he is going through the wrong puberty. 

    Families who are concerned or seeking information about their child’s gender expression or identity often turn to their primary care providers (PCPs) for help. As pediatricians, we are in a powerful position to promote health and positive outcomes for these children; however, few of us have received any formal education or training to grapple with this increasingly common issue.1 The goals of this article are to help the general pediatrician develop a basic understanding of gender, and offer ways to approach gender-expansive and transgender children or adolescents.

    The first step is to examine our own feelings, attitudes, and beliefs about gender and consider how these affect our work with youth. Equally important is educating ourselves on the diversity of gender in our patients and the corresponding interventions available for supporting them. Adopting supportive, affirming practices, such as intake forms that allow for the patient’s preferred name and pronouns (and using them accordingly), is another critically important step for helping young persons feel comfortable. In addition, medical professionals can be effective advocates for their transgender patients’ needs and rights in settings outside the clinic, such as home and school.2

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