Communicating With Patients About Gender
The Carlat Child Psychiatry Report, Volume 11, Number 5&6, July 2020
Alex Keuroghlian, MD, MPH
Director, National LGBT Health Education Center at The Fenway Institute; Director, Massachusetts General Hospital Department of Psychiatry Gender Identity Program; Associate Professor, Harvard Medical School
Dr. Keuroghlian has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CCPR: Welcome, Dr. Keuroghlian. Please tell us what you do.
Dr. Keuroghlian: At The Fenway Institute, I see transgender and gender-diverse (TGD)* patients in the behavioral health department. We also conduct education, training, technical assistance, and implementation with health systems and programs nationwide. I also direct the Gender Identity Program in the Massachusetts General Hospital Department of Psychiatry. At Harvard Medical School, I help incorporate gender and sexual minority content into all courses and clerkships.
*Ed note: For those unfamiliar with the concept of TGD, it is “an umbrella term used to describe anyone whose gender identity or expression is different from that which was assigned at birth or is expected of them by society.” Dr. Keuroghlian’s advocacy occurs alongside concerns about everything from the natural course of play preferences to long-term side effects of hormone treatment. We welcome comments on this complex topic that engenders research, treatment, and policy.
CCPR: Tell us about your research.
Dr. Keuroghlian: We study best practices in caring for TGD patients. Our research found that gender identity conversion efforts are associated with an increase in suicide attempts among TGD people. Exposure to these efforts before age 10 is associated with more than 4 times increased odds of attempting suicide throughout one’s lifetime (Turban JL et al, JAMA Psychiatry 2019;77(1):1–9). Another recent study shows that access to medication for suppression of puberty among TGD people who desire it is associated with significantly lower odds of lifetime suicidal ideation (Turban JL et al, Pediatrics 2020;145(2):e20191725).
CCPR: There are policy debates about these therapies.
Dr. Keuroghlian: Yes, there is a national movement to ban these conversion therapies related to gender identity and sexual orientation. Massachusetts, Colorado, and Utah passed bans in 2019. We estimate that there are almost 200,000 TGD people in the US who have been exposed to these conversion efforts (Turban JL et al, Am J Public Health 2019;109(10):1452–1454). In the fall of 2019, the American Medical Association passed a resolution in favor of a federal ban on conversion.
CCPR: I understand that some states are limiting doctors’ ability to help minors transition to a different gender.
Dr. Keuroghlian: Yes, recent efforts in 15 states would make it criminal to provide what we call “gender-affirming medical care” for minors, or would result in physicians losing their medical license, or would result in parents being reported for child abuse because they sought such care. There is a lot of confusion among clinicians and the general public. These treatments are considered evidence based and have been incorporated into the AACAP Practice Parameters since at least 2012.
CCPR: What is our role in this as clinicians?
Dr. Keuroghlian: All TGD people—children, adolescents, and even adults—need to be psychosocially affirmed in their gender identity. Children as young as 3 or 4 can have a clear sense of what their gender identity is. In those cases, the best practice is to follow the child’s lead in terms of their gender identification, pronouns, name they choose to go by, and gender expression with regard to clothing.
CCPR: So we need to ask about it.
Dr. Keuroghlian: All health care practices ought to have at least screening questions related to gender identity. Sometimes a parent or guardian may come in with questions about their young child’s gender expression, and in other instances important conversations may start with a clinician asking the child: “Some kids feel like a girl; some kids feel like a boy; some kids feel like something else. What do you feel like? There’s no right or wrong answer.” Then you could say, “Should I call you she, he, they, or something else?” The child may or may not have a clear answer, and if they don’t, that’s fine. You’re not going to do any damage by asking. It’s a perfectly healthy thing for them to think about.
CCPR: What about parents?
Dr. Keuroghlian: Clinicians can ask parents if they have any thoughts or observations related to the child’s gender identity or gender expression. You can say: “I have this conversation with all parents to ensure you have the tools to fully support your child in their gender identity and gender expression.” This framing makes it clear that the best practice in terms of parenting and medical care is a gender-affirming approach.
CCPR: When do you consider medical treatment?
Dr. Keuroghlian: Once kids hit Tanner Stage II, there’s the possibility of pubertal suppression with gonadotropin hormone–releasing agonists. We found access to these medications is associated with significantly decreased odds of suicidal ideation. The prevalence of lifetime suicide attempts among TGD people in the US is as much as over 40%, which is alarmingly high (2015 US Transgender Survey; www.ustranssurvey.org). Whether or not youth want or are able to access medical intervention, it’s important to have genuine affirmation at home, at school, and in the surrounding community.
CCPR: What about “rapid-onset gender dysphoria”?
Dr. Keuroghlian: There was a recent study where the researchers asked parents about their children’s gender identity or dysphoria but did not actually ask the children, giving the impression that youth are identifying as TGD only because they’ve heard the idea from peers—a social contagion hypothesis. The overwhelming majority of TGD adolescents continue to identify that way into adulthood. We published research on youth no longer identifying as TGD and subsequently identifying as cisgender. As far as we can tell, this is very rare, and the couple of youth I have met in this group do not regret having identified as TGD. They do not regret starting on gender-affirming hormone therapy, either, and they describe this as an important component of their gender journey (Turban JL and Keuroghlian AS, J Am Acad Child Adolesc Psychiatry 2018;57(7):451–453; Turban JL et al, JAMA Pediatr 2018;172(10):903–904). Most youth we see who discontinue hormone therapy do so involuntarily, because they can no longer access treatment or do so safely.
CCPR: Does hormone therapy have risks?
Dr. Keuroghlian: From a medical standpoint, gender-affirming hormone therapy is considered low risk. There may be some fat redistribution, some hair changes, some vocal changes, but you weigh that against a 40% lifetime risk of attempting suicide.
CCPR: Can you comment on gender fluidity in the autism community?
Dr. Keuroghlian: The truth is, our field understands very little about this, so people have floated different hypotheses without much supporting evidence. More rigorous studies are needed (Thrower E et al, J Autism Dev Disord 2020;50(3):695–706). One hypothesis is that people on the autism spectrum are less preoccupied with social cues and what people think of them, so there is speculation about whether these folks may have more uninhibited expression and exploration of the natural gender diversity that exists among all humans. There are other speculative hypotheses, including one about an inflammatory basis for both autism and gender diversity, related to the reported 4:1 prevalence of autism between boys and girls. The key point is that a gender-affirming clinical approach remains the best practice.
CCPR: How does autism affect our clinical approach?
Dr. Keuroghlian: Take care eliciting the patient’s history of gender identity development and present experience to better understand their lived experience. Some of the ways in which clinicians may assume patients will explain their gender identity during the informed consent process may not be the case for all people on the autism spectrum.
CCPR: About 30 years ago, people were doing MRI studies looking at gender identity and brain structure. Has that research evolved, for instance with fMRI studies?
Dr. Keuroghlian: Those studies were often underpowered and had other methodological flaws, so the jury is out on neurobiological correlates of gender diversity. We need more rigorous studies. That said, scientific research may be unlikely to persuade folks to be more inclusive and gender affirming, so while those are intellectually interesting questions, those studies are not going to address the urgent health needs of TGD people today.
CCPR: What about parents whose beliefs about gender do not fit their child’s experience?
Dr. Keuroghlian: That’s the most crucial challenge clinicians face when working with TGD minors. We put incredible energy into family systems work and support groups for parents and guardians of gender-diverse youth. If a child or adolescent is gender diverse and seeking gender-affirming medical care, they can only access it with consent of all legal guardians in the picture. I think this is true in all 50 states. If one parent won’t consent, that youth won’t receive gender-affirming medical care despite the extremely high risk of a suicide attempt.
CCPR: So what do you tell parents?
Dr. Keuroghlian: We emphasize that evidence shows TGD children who have strongly supportive families are likely to have mental health outcomes comparable to their cisgender peers, and that they thrive socially, academically, and otherwise in a manner comparable to their peers (Simons L et al, J Adolesc Health 2013;53(6):791–793). So strong family support is an incredibly foundational determinant of psychosocial health for TGD people. In our study that came out in January 2020, we showed that even if you control for family support, there is still a difference between being able to access pubertal suppression medication versus an inability to access it (Turban JL et al, Pediatrics [in press]).
CCPR: Do you talk about the risks?
Dr. Keuroghlian: Yes. We tell parents and guardians that their child is at high risk unless affirmed in their gender identity, and that pubertal suppression medication and gender-affirming hormone therapy are low-risk treatments for TGD youth. One approach is to network parents and guardians of TGD youth with folks who seem similar to them and have come around to accepting and affirming their TGD child.
CCPR: How effective is this approach?
Dr. Keuroghlian: We’ve seen parents and guardians reluctantly attend support groups with other folks who seemed reasonable to them, go out to dinner with them after the group, and eventually transform and come around to being strong advocates for their kids. If a parent or guardian is showing up with their child and taking the child’s gender identity seriously enough to be in the office with you, you’re ahead of the game. That’s a wonderful opportunity to model gendering the child appropriately, deliver some family education, and refer the parent or guardian to appropriate resources.
CCPR: What can you tell us about the social impact of stigma?
Dr. Keuroghlian: Gender minority stress and stigma are related to health inequities among TGD youth. TGD people, from early childhood to older adulthood, experience discrimination, victimization, microaggressions, and all too often frank violence at a much higher prevalence than the general population. For some youth, this may adversely impact coping skills and lead them to believe that it’s never going to get better and that nobody can be trusted.
CCPR: Can you say more about stigma’s internal effects on a person?
Dr. Keuroghlian: In the minority stress model, external stigma-related stress can contribute to internal stigma-related stress, such as internalized transphobia, expecting rejection because you’re so used to it, and identity concealment. Minority stress can be associated with higher prevalence of depressive disorders, anxiety disorders, post-traumatic stress disorder, and substance use disorders as a coping mechanism. Per the minority stress model, stigma is associated with decreased self-care, decreased engagement in health care, and down the road a much higher prevalence of various physical health problems.
CCPR: What can we do about this in daily practice?
Dr. Keuroghlian: We can develop basic skills related to sensitive and effective communication with TGD youth, which means asking every child in your practice for the name they go by and their pronouns, and honoring these. Make sure every colleague and employee in your practice knows to reflect that self-determined language back for the youth you serve. And understand that you want to affirm a child’s gender identity, rather than trying to align it with the sex they were assigned at birth.
CCPR: What other resources can we access?
Dr. Keuroghlian: Identify local resources socially for TGD youth and clinical referrals for primary pediatric care. It’s not necessarily the pediatric endocrinologists who prescribe pubertal suppressants or gender-affirming hormone therapy. Increasingly, primary care practices do it. And engage families in the critical family systems therapy work that needs to happen, because strong family support is a critical determinant of health for these kids. Our National LGBT Health Education Center at www.lgbthealtheducation.org has free webinars and over 80 best practice briefs, including several on caring for TGD youth and on mental health. We have recorded talks from our national Advancing Excellence in Transgender Health conference and offer continuing education credits for these materials. People are welcome to reach out to us with any clinical questions.
CCPR: Thank you for your time, Dr. Keuroghlian.