Which specialty should take the lead in gender-affirming medical care for minors?
Click Here to Manage Email Alerts
Click here to read the cover story, "Gender care for minors requires teamwork, centers on family."
Endocrinologists need the cooperation with other specialties or types of providers.
Puberty suppression and gender-affirming HT are not complicated treatments, meaning it does not necessarily require training in pediatric endocrinology. But there are some issues that may arise that might require consultation with a pediatric endocrinologist, such as risks of long term puberty suppression therapy on bone health or effect of puberty suppression and gender-affirming HT on height. In these cases, the availability of a pediatric endocrinologist would be ideal.
Nevertheless, it is more crucial that a provider has expertise in seeing transgender children and adolescents, and that they can collaborate with a mental health provider. It can be a general pediatrician, an adolescent medicine pediatrician, family practice physician or a pediatric gynecologist. Those are the other specialties that may have enough experience with this population and this age group that they may be able to prescribe this treatment.
If we limit transgender care for youths to only pediatric endocrinologists, then we are creating a significant barrier because there are just not enough pediatric endocrinologists in the country to see all the youths in this population. There is a lack of pediatric endocrinologists in general for any pediatric endocrine condition, not just transgender care.
Even within the pediatric endocrinology field, there is a minority of providers who see transgender patients. In some states, it may be one per state who has experience in caring for transgender adolescents. The general pediatrician, general practice, pediatric gynecology and adolescent medicine have an overall minimum endocrine expertise to provide gender-affirming medical transgender care to youth.
Ximena Lopez, MD, is medical director of the GENder, Education and Care Interdisciplinary Support (GENECIS) program and an associate professor of pediatrics in the division of pediatric endocrinology at the University of Texas Southwestern and Children's Medical Center. Disclosure: Lopez reports no relevant financial disclosures.
Primary care providers of all types are poised to offer competent gender-affirmative care with appropriate education, training and support during their undergraduate and graduate medical education.
With as many as 10% of high school age youths in one recent study published in Pediatrics reporting that they are exploring gender, gender care becomes a critical component of anticipatory guidance, preventive health and general pediatric medicine. Primary care providers form the core medical home for all age patients, and regular immunizations and health checks for school mean that all youths have regular access to care. Primary care providers understand the developmental trajectories, issues and needs of patients at various ages and life stages and so can incorporate anticipatory guidance questions about gender and sexual identities at various nodal points across the lifespan. With established rapport and continuity of care, primary care providers have an ongoing opportunity to work with patients of all ages, over time, to ask questions and address questions or concerns about gender identity. Primary care providers who care for youths have the added benefit of knowing how to work with families and understand the importance of family support in healthy trajectories for gender-diverse youth.
Arguably, primary care providers caring for children have the most appropriate and comprehensive skills sets for screening, identifying and referring to community resources along with offering a comprehensive approach that incorporates mental, sexual, school, social and community health. Expanding exposure and training in prescribing gender-affirming hormones is an achievable and morally responsible next step, as it can lead to systemic improvements in access and equity. Empowering primary care providers to confidently have meaningful discussions and offer gender-affirming care with all youths and families about gender normalizes varied pathways to explore gender identity and models how to be supportive and an ally.
Reference:
Kidd KM, et al. Pediatrics. 2021;doi:10.1542/peds.2020-049823.
Michelle Forcier, MD, MPH, is a professor of pediatrics at the Alpert School of Medicine, Brown University, Providence, Rhode Island.
Collapse
Read more about
Click Here to Manage Email Alerts