In the absence of guidelines, how do you approach gender care for nonbinary children?
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Click here to read the cover story, "Gender care for minors requires teamwork, centers on family."
More caution should be taken when prescribing hormone therapy or surgery for nonbinary children.
For care with nonbinary children, there are no guidelines, there is very little experience, and all the knowledge we have is anecdotal. There is also not enough research.
But that does not mean that nonbinary children should not receive puberty suppression or gender-affirming HT. They might need these interventions because they also can suffer from gender dysphoria that can be alleviated with puberty suppression or hormone treatment. This is based on the experience that we as experts have in the field.
However, more caution needs to be taken when deciding whether to proceed with gender-affirming therapies. More time might be needed to decide on the medical intervention, particularly one that could have permanent effects, such as gender-affirming HT or surgery. For pubertal suppression, because it is overall reversible, there is not as much controversy over starting that for a nonbinary person. But for surgery or HT, collaboration with a mental health provider that can evaluate and follow up with the patient before and during treatment would be ideal.
One option is to start HT at lower doses or to increase doses more slowly than with someone who is not nonbinary. This can give a nonbinary minor more time to make sure that this is the right decision and that the path taken is the correct one for them.
Ximena Lopez, MD, is medical director of the GENder, Education and Care Interdisciplinary Support (GENECIS) program and associate professor of pediatrics in the division of pediatric endocrinology at the University of Texas Southwestern and Children’s Medical Center.
Guidelines do not have the same overarching value as listening to patients.
As scientists, health care providers understand that, as with every other aspect of biology and development, every person’s gender identity will be unique to the individual. By taking a developmental perspective, providers can approach diversity and difference as a normative aspect of all human development and decrease assumptions and pathologizing approaches of the past that harmed our patients. This appreciation allows providers to better understand the issues and approaches to care for nonbinary children.
While guidelines offer consolidated information, data and review of established practices, they are only tools. By asking the patient to detail their gender identity and goals, including what causes joy or dysphoria, we avoid assumptions and make clear we are listening and respecting their voice and experience, which is specific and unique to them.
Taking a resiliency approach to screening and counseling allows providers opportunities to help youths acknowledge and capitalize on their strengths, promote open and healthy decision-making, and create a shared pathway whereby parents and providers can help youths navigate their gender journey.
Nonbinary youths so often articulate sophisticated questions and creative concepts about their experience in navigating a diverse gender identity. Providers need to prioritize meeting the patient where they are at, carefully and thoughtfully incorporating present and future needs — but not withholding care over our own fears of making a mistake, blame and guilt, or the less common possibility of a patient’s gender journey taking an unforeseen turn in the future. Most gender hormone effects are not permanent and those that are, also occur in cisgender persons (women with low voices and hair, men with chest tissue). Gender surgeries do not occur in prepubertal youths and are far less common in adolescents than in adults. Nonbinary patients require that we listen carefully and work with them to develop a gender pathway that makes sense to them. Our nonbinary children most of all just ask families and providers to respect their understanding and experience, honor their body autonomy and integrity, and provide safe places for them to grow.
Michelle Forcier, MD, MPH, is a professor of pediatrics at the Alpert School of Medicine, Brown University, Providence, Rhode Island.
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