For transgender youth, stigma is just a barrier to healthcare

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Piper, a 17-year-old transgender girl, says she knows she’s lucky.

She lives just outside of Atlanta, with a supportive family and two rescued leopard geckos, Saturn and Juno. Queer Med, a private gender clinic, is a short drive away; Two years ago, she started a gender-affirming hormone regimen there, after five months of asking – a relatively short wait. The treatments precipitated a monumental change in Piper’s perception of herself. “I’m just more confident in my body,” she said. (Piper’s family members have requested that she be identified only by her first name to protect their privacy.)

Things are not perfect. Piper still sees a regular pediatrician for her other health needs, but staff members still sometimes use the wrong pronouns or her old name. Her family’s new insurance plan is not accepted at Queer Med, so they have to pay out of pocket for each visit – around $ 150 plus lab fees.

And the threat that her care will not be available is constant, as Georgia is one of 20 states this year that have introduced bills to ban or restrict gender-affirming treatment to minors. Piper plans to leave the South after high school, out of concern for her health and safety. But everything could be a lot worse, she knows that. “I am so lucky,” Piper said. “A lot of people don’t have the chance.”

Many barriers prevent transgender youth from getting the health care they need, recent study by the journal finds JAMA Pediatrics; these include stigma and discrimination in the health care system as well as legal, economic and social barriers to obtaining gender-affirming care. A Study 2019 by the Centers for Disease Control and Prevention estimated that about 1.8 percent of high school students in the United States identified as transgender.

The JAMA article is the first review of qualitative studies on the experiences of transgender youth in accessing health care. It encompassed 91 studies from 17 countries over several decades and included transgender and non-binary youth aged 9 to 24 – a wide range, made necessary by the extremely limited data on the subject.

“There is currently a huge disconnect between healthcare providers and trans youth,” said Dr Lauren Chong, pediatric intern at the Sydney Children’s Hospitals Network in Australia and author of the journal.

“The results were not at all surprising,” said Talen Wright, a graduate student who studies transgender mental health in the psychiatry division at University College London, who was not involved in the research. “This is powerful proof that things need to change. “

Major medical associations, including the American Medical Association and the American Academy of Pediatrics, have endorsed gender-affirming treatment for adolescents. (However, mmedical directives advise children under the age of 18 to undergo gender-affirming genital surgery.)

But the treatment remains controversial for some healthcare providers, lawmakers and parents precisely because adolescents are involved. Puberty blockers and hormone therapy, the two gender-affirming treatments given to minors, are most effective if taken at the onset of puberty, around age 8 to 14, before age. independent medical consent in most states.

No set of rules dictates when and how transgender adolescents can receive gender-affirming care. But clinicians typically conduct a series of mental health assessments in accordance with care practices, such as those set by the World Professional Organization for Transgender Health Care or the Endocrinology Society. These assessments aim to assess an adolescent’s understanding of themselves and to confirm that a medical intervention makes sense.

“This is to ensure that patients make a fully informed decision that protects their future well-being,” said Dr Chong.

Dr Michele Hutchison, a pediatric endocrinologist at Arkansas Children’s Hospital who was not involved in the research, added, “We want to make sure it’s 100% justifiable and safe, as long as you can do it by medicine.”

For the most part, she says, her young patients are confident in their decision. “By the time these kids come to see me, they’ve known for a long time,” she said.

But some young patients in the JAMA journal criticized what they saw as “access guard” measures in those assessments that restricted timely access to puberty blockers and hormone therapy at some point in time. development where these treatments would be most effective. Some teens said they felt the need to prove they were ‘trans enough’ to get approval, and others expressed frustration when a parent did not approve hormone therapy, thus blocking their treatment. Health care access.

“We need to be very careful about the structural barriers that we ourselves create as providers,” said Dr Gina Sequeira, co-director of the Seattle Children’s Gender Clinic, who was not involved in the research. “The majority of the children I see have already overcome many, many obstacles. “

Transgender patients also face broader barriers to healthcare, according to the journal JAMA. Insurance has proven to be a common and thorny problem; some families have struggled to obtain coverage for puberty blockers, and others have struggled to find a trans-friendly provider in the network. And those who did not have insurance faced high costs.

There are also waiting lists, often several months long, to make an appointment. Dr Cassie Brady, a pediatric endocrinologist at Vanderbilt University in Tennessee who was not involved in the research, said her clinic often had a waiting list of around 50 people. “We are doing everything we can to bring these children in,” she said.

For a transgender youth, the mere prospect of entering a clinic can be overwhelming. A 14-year-old in the review said he felt “petrified“Entering places out of fear that their gender identity will be mocked or rejected. Another teenager said clinicians withheld their identity, calling him “just a phase. “

Hayden Wolff, graduated from Tufts University in Massachusetts in 2021, began his medical transition at 18. He recalls a visit to his school’s clinic, where his electronic health records were out of date.

“Here I am with a high fever, trying to get treatment, and I’m wrong in front of everyone in the room,” Mr. Wolff said.

The review authors also noted that more research is needed on the long-term effects of gender-affirming treatments. When Mr Wolff met doctors in Boston, he was asked not to take hormones if he was concerned about his fertility. California doctors told her not to worry, even though they weren’t sure about the long-term results.

“You have to make decisions without a lot of information and data,” Wolff said.

He decided to freeze his eggs. The doctor who saw him in Boston had never treated a transgender patient before and made Mr Wolff feel like a “trans specimen,” he said. Nurses at the clinic asked Mr. Wolff invasive questions unrelated to the egg freezing procedure.

“The lab nurses were asking me if I was going to have my penis after this, which ultimately doesn’t concern them,” he said. “If you’re a kid, you don’t feel like you have the power to say to someone, ‘You make me uncomfortable’. “

Clinicians said it wouldn’t take much to start improving the healthcare experience of young transgender patients. For example, patients should be allowed to state their name and gender before seeing a doctor. “It touched me the most as a trans person who received medical attention, waiting for her to call my wrong name or address me as ‘sir’,” said Dr Baer. Karrington, pediatric resident at Seattle Children’s.

In the examination room, Dr Chong said, doctors and attendants should use gender-neutral terminology and avoid terms like “ovaries” and “uterus.” “You can just say reproductive organs,” she said.

Dr Sequeira noted that transgender youth of color, as well as rural youth, are disproportionately under-represented in pediatric gender clinics. “The future of this work is to make it accessible to the young people we are not currently serving,” she added.

Telemedicine could help close that gap, she noted, and doctors in all fields could be better trained on how to care for transgender patients. Dr Karrington said during the pediatric training they only learned about trans health care as part of the teen rotation, which did not apply to young trans children being treated elsewhere in the hospital. .

Transgender adolescents and clinicians both expressed a desire to see more transgender providers, who could share their life experiences with their young patients. Dr Karrington, who is the first transgender resident in their program, said they can count the number of transgender pediatricians they know on both hands. In Atlanta, Piper’s doctor at Queer Med is transgender, which she found heartwarming. “They know what I’m going through and they can attest to the fact that it’s improving,” Piper said.

While Piper hopes more transgender people will become doctors, she wants to become a zoologist, inspired by her geckos. “It’s my calling,” she said. “I have known this for a long time. “


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