Fellow’s Corner: Asking 1 Question Made All the Difference

It was during a week on inpatient service that I met L. Information I received said L was a “13-year-old girl who presented 3 days ago with weight loss, complaints of dysphagia, poor appetite, and leg weakness.” L had a history of anxiety and depression, having been on multiple psychotropic medications over the past few years. Over the past few days, L had undergone an extensive workup, including a swallow study, endoscopy, head imaging, and myriad labs, all of which were unremarkable.

L was wearing pink glasses and floral pajamas when we met, and had long hair and a markedly flat affect. After talking together with L’s mom, I asked her to step out for a bit so that L and I could talk one-on-one. We began chatting about L’s interests—soccer and electronics—and L began to open up a bit. Eventually I asked a question I’ve gotten in the habit of asking all my adolescent patients as part of a confidential history: “Do you feel more like a girl, more like a boy, somewhere in between, or something else?”

L suddenly became very serious and looked down. “I feel like … a boy,” L whispered. “Thank you so much for sharing that with me,” I said. “Can you tell me more about that?”

It turned out that L identified as a male and would prefer to be referred to with male pronouns. L explained that for the past couple years, he felt like something wasn’t right. “I don’t feel like a girl at all. I’m a boy, trapped in a girl’s body.” His parents didn’t know about this, and he worried it might upset them. “But I can’t make the feeling go away. It’s always there; there’s nothing I can do about it. I’m trapped.” He began to sob.

After he composed himself, L requested my help in talking with his mother. After getting L’s input on what he wanted me to say (and not say), and making sure this was something he wanted to tell his mother about, the next day L and I met with his mom. There were tears, laughter, more tears, and hugs. Thankfully, while L’s mom was quite surprised, she voiced her unconditional love for L and a commitment to learning more about how to best support him.

L’s mood brightened dramatically after this disclosure. Over the next 48 hours his appetite improved, his dysphagia cleared, his strength returned, and he was discharged home. He’s been connected with our Gender and Sexuality Development Clinic, where we have been able to offer a full psychosocial evaluation and support for L and his family. Following professional guidelines for care of transgender youth, we have provided menstrual suppression, and are beginning to discuss possible testosterone therapy. Though L has continued to struggle with anxiety, he has not had recurrence of his somatic symptoms, and his affect remains brighter.

L’s case illustrates a few points.

1. When gender dysphoria isn’t addressed, it can place tremendous stress on a young person, which may manifest in many different ways. Transgender individuals suffer high rates of negative health outcomes, including depression, anxiety, and suicidality. We also see high rates of somatic complaints among transgender youth, including headache, abdominal pain, joint pain, etc. Adverse health outcomes are high among transgender individuals due to minority stress. Minority stress is a phenomenon where stigma toward a group may result in discrimination, victimization, and marginalization, all of which result in chronic stress and in turn yield negative health outcomes.
2. However, transgender youth who are supported in their identities do well! Transgender youth who receive gender-affirming care are protected from many of these negative health outcomes. One of the most important determinants of health for trans youth is parental acceptance. Rates of suicide attempt among trans youth with parents who were accepting of their gender identity were 10-fold lower than youth whose parents were not accepting. Referring to transgender youth by their preferred name has been found to be associated with decreased rates of depression and suicidality. Transgender youth who are permitted to socially transition—presenting as and living in their affirmed gender—have been found to have rates of depression, anxiety, and suicidality similar to age-matched peers. Gender-affirming medical interventions for transgender youth are associated with improvements in mental health and overall well-being.
3. All pediatric providers should have a basic understanding of gender identity and gender diversity. Recent studies show about 1% of youth self-identify as transgender. As a pediatric provider, you have likely cared for several transgender youth already (whether or not you realized it), and will care for many more throughout your career. Asking youth about gender identity is something we suggest incorporating into your routine history-taking. The importance of being prepared to talk with any youth about gender identity is now discussed in the recent version of Bright Futures guidelines from the American Academy of Pediatrics. Just like any changes to a routine, it might feel a bit awkward at first, but once you get into the habit, it feels as natural as any other question you might ask your patients. 
4. Affirm, reassure, and (when needed) refer. When a young person discloses to you that they are transgender or questioning their gender, what should you do?
   1. Affirm: Thank them for sharing with you such an important piece of who they are. Keep a positive and upbeat attitude; after all, they are sharing something special and unique about themselves, not a tragedy. If they use terms you aren’t familiar with, ask them to help you understand what those terms mean to them. If you haven’t already asked about preferred names and pronouns, make sure you do so. Ask the young person if they have ideas for things you might be able to do to help support them.
   2. Reassure: Sometimes transgender youth may feel guilty or bad about their gender identity. Sometimes family members may be shocked, frustrated, sad, or afraid for their young person. As a pediatric provider, your response to these emotions can have a tremendous impact. Reassure youth and families there is nothing wrong with being transgender, that they can still lead healthy, normal lives and go on to achieve their dreams. Explain to families the most important thing they can do is to love and support their child.
   3. Refer: You don’t need to be an expert. If a young person is exhibiting gender dysphoria—distress and discomfort due to the incongruence between their assigned sex and their gender identity—it is important to connect them with the CHOP Gender Clinic or other resources where they can receive psychosocial support and where genderaffirming medical care can be considered.

References and suggested readings

Hembree, W.C., et al. Endocrine treatment of gender-dysphoric/genderincongruent persons: An Endocrine Society clinical practice guideline. Endocr Pract. 2017;23(12):1437.

World Professional Organization for Transgender Health (WPATH) standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th Version. WPATH website. https://www.wpath.org/publications/soc. Accessed October 12, 2018.