“We fear that CPS is going to take them away,” the mother of my patient chokes with tears. My patient on the inpatient pediatric wards looks at me with guarded eyes. I can still see the markings on their neck where they tried to strangle themselves. They were intubated in the pediatric ICU. This transgender patient and their family have gone through a living hell only to come out again on the other side with the realization that their home state is passing laws and attacking families and physicians in an attempt to ban them from receiving care. Providers and clinics that provide the type of care that might have prevented another suicide attempt are shutting down in this state, being attacked by the GOP.
A colleague sees a preschooler in the building next door to me for a well-check. The parent is convinced that their preschooler is transgender because he wore a dress like his older sisters. My colleague patiently tries to explain the phases of typical childhood development, including this stage where children are still trying to determine whether they are boys or girls. My colleague explains that wearing a dress at this age may be developmentally appropriate and does not mean the child is transgender.
In yet another patient room, a father with a very fundamentalist Christian conservative upbringing has panic in his voice – his daughter, a freshman in high school, is in a small charter school where the majority of kids identify as transgender.
The fear and confusion are palpable and erupt as anger, tears, and frustration. Instead of people talking with each other about their child’s unique personality and situation, there are stark party lines that are drawn, and questioning either side is seen as treason.
As a pediatrician, I question the extent to which the AAP is fostering an open dialogue regarding gender-affirming care. To be clear, I firmly believe there is a small percentage of teenagers who benefit from the use of puberty blockers and hormones, but I am also concerned that the number of teenagers saying they are transgender is rising (some studies place that number at around 1 in 9), and that not all of the teenagers I talk with who claim to be transgender are the same. Some teenagers are convinced they are the incorrect gender to the point they want to cut off the offending body part. Some of them are just not sure what gender they are and use “they/them” pronouns. Some teenagers are simply dissatisfied with the American cultural norms associated with being male or female. These groups are very different, yet we may call them all “transgender” if that is what the teenager asks to be called. We have guidelines for starting puberty blockers no earlier than 12 years old, and yet the reality for many children is that puberty is starting earlier and earlier (as early as 9 years old). Is it developmentally appropriate to put a fourth-grader on puberty blockers because they say they are transgender? The research on hormones and puberty blockers is not of high quality (lack of RCTs and meta-analyses) and does not look at longitudinal data to see what happens when potentially greater numbers of patients are placed on hormones and puberty blockers and what happens in adulthood. There is not much transparency or publicity into the screening process for obtaining these drugs. If this were any other situation, physicians would do what we usually do – we are skeptical; we push for better data; we are open and transparent about what we know and what we don’t know about medications (and we have to be in pediatrics because there are so few trials done on children). We also do what’s best for our patients with the best evidence we have. After the third or fourth time of seeing the same teenager who is transgender hospitalized for a suicide attempt, hormones and puberty blockers are frankly less dangerous than death.
During the pandemic, brilliant and compassionate scientists provided data to decrease deaths. But as a community of medical professionals, we delivered these proclamations in a vacuum, failing to grasp the larger context of the pandemic. There was a context of complete societal disruption that we failed to address with our beautifully diagrammed charts and numbers. The same thing is happening again: our context is a societal and sociological shift in how our culture thinks about transgender people. The method of inclusion of transgender teenagers is currently asking every teenager if they are a boy or a girl or non-binary or a million other labels they can choose from. How does that affect the patients we care for who are not transgender? Why are there whole schools of kids who are saying they are transgender? These are sociological questions that we are ill-equipped to address as pediatricians, but that we must acknowledge when we write our beautifully meticulous charts and guidelines about the care of transgender youth. My impression is that it is still very difficult to get hormones and puberty blockers, and that most of gender-affirming care is calling people by the pronouns and names they wish to be called. Point blank, society is fearful that we are inappropriately treating large numbers of children with hormones that may not need them. We need to address that fear.
Suppose we want to be successful as pediatricians in caring for transgender patients. In that case, we need to remember the lessons we learned from the pandemic:1) Over-explain what you are doing to the public and why, 2) Be honest with the public about the quality of data, 3) Be honest with the public about what you know with certainty and what is not certain, 4) Get involved politically – politicians are not doctors. They should not be making decisions about pandemics or gender-affirming care.
The whole country needs to be able to have an open discussion with each other that is not based on fear, culture wars, and power struggles, but it can start with us as pediatricians. We need to be open with the public and with each other. We need to be able to disagree with each other in a respectful manner. One of my favorite adolescent physicians showed me the simple value of acceptance and openness so needed in caring for transgender teens, whether you are a physician or a parent. Let’s start there – openness and acceptance are sorely needed at this time in history.
The author is an anonymous physician.
