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Primary Care and Transgender Youth: Care Experiences and the Need for more Comprehensive Care Provision

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Janis Sethness
Janis Sethness
Janis Sethness
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Gina M. Sequeira
Gina M. Sequeira
Gina M. Sequeira
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Abstract

Purpose of Review Transgender and gender diverse (TGD) youth are a growing population. This paper aims to review the perspectives of TGD adolescents, their caregivers, and their providers regarding the care of TGD youth in the primary care setting and discuss how to create affirming clinical environments and provide quality primary care for TGD youth. Recent Findings TGD youth and their caregivers report substantial difficulties finding pediatric primary care providers (PPCPs) who have experience providing affirming care. Similarly, PPCPs report a lack of knowledge and training that limits their confidence in caring for TGD youth. Summary PPCPs are well-positioned to improve health outcomes for TGD youth and provide the support TGD adolescents and their caregivers need. It is important for PPCPs to create inclusive clinical environments, understand the specific health needs of TGD youth, and educate themselves about how to provide affirming care.
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REVIEW
Current Pediatrics Reports (2024) 12:226–237
https://doi.org/10.1007/s40124-024-00335-5
Introduction
An increasing number of children and adolescents identify
their gender as something dierent than their sex assigned at
birth, falling under the umbrella of transgender and gender
diverse (TGD). Currently, there are an estimated 700,000
adolescents and young adults (AYAs) ages 13–24 in the
United States (U.S.) who identify as transgender, which
accounts for 1.3% of the AYA population [1]. Estimates of
youth who identify as gender diverse are greater, ranging
from 7.2 to 9.2% of 13-18-year-olds in surveys utilizing
inclusive gender identity questions [2, 3]. No U.S. popula-
tion-based estimates of the number of TGD children exist.
Like all children and adolescents, this growing popula-
tion of TGD youth requires comprehensive, high-quality
primary care. However, the experiences of TGD AYAs and
their parents or guardians (i.e., caregivers) indicate that
there are several barriers to accessing appropriate preven-
tative and routine care, most notably a lack of provider
knowledge about how to care for TGD youth [4–8]. Pedi-
atric primary care providers (PPCPs) have reported similar
concerns about insucient education on TGD health care
[9–12]. Additionally, emerging legislative restrictions on
the provision of evidence-based gender-arming care limit
TGD youths’ access to pediatric specialty gender clinics,
Abbreviations
TGD Transgender and gender diverse
PPCP Pediatric primary care provider
AYAs Adolescents and young adults
EHR Electronic health record
SOGI Sexual orientation and gender identity
2SLGBTQIA Two–spirit, lesbian, gay, bisexual, trans-
gender, questioning/queer, intersex, and
asexual
SBIRT Substance use, brief intervention, and/or
referral to treatment
STI Sexually transmitted infection
HIV Human deciency virus
PrEP Pre–exposure prophylaxis
Gina M. Sequeira
Gina.sequeira@seattlechildrens.org
1 Seattle Children’s Research Institute, Seattle, WA, USA
2 University of Washington, Seattle, WA, USA
Abstract
Purpose of Review Transgender and gender diverse (TGD) youth are a growing population. This paper aims to review the
perspectives of TGD adolescents, their caregivers, and their providers regarding the care of TGD youth in the primary care
setting and discuss how to create arming clinical environments and provide quality primary care for TGD youth.
Recent Findings TGD youth and their caregivers report substantial diculties nding pediatric primary care providers
(PPCPs) who have experience providing arming care. Similarly, PPCPs report a lack of knowledge and training that limits
their condence in caring for TGD youth.
Summary PPCPs are well-positioned to improve health outcomes for TGD youth and provide the support TGD adolescents
and their caregivers need. It is important for PPCPs to create inclusive clinical environments, understand the specic health
needs of TGD youth, and educate themselves about how to provide arming care.
Keywords Transgender · Gender Diverse · Gender-arming care · Pediatric Primary care
Accepted: 24 September 2024 / Published online: 24 October 2024
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2024
Primary Care and Transgender Youth: Care Experiences and the Need
for more Comprehensive Care Provision
JanisSethness1,2· Gina M.Sequeira1,2
1 3
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Pediatricians are often the first point of contact for TGD adolescents seeking dermatologic care [100]. Dermatologic concerns should be integrated into gender-affirming care rather than treated as secondary to hormone therapy. ...
... Pediatricians who care for TGD adolescents can implement clinic-based cultural competency training for TGD patient care which uses evidence-based interventions to improve clinician knowledge, attitudes, and identity-affirming behaviors [101]. Pediatricians should provide educational materials tailored to TGD adolescents' specific care needs, and adopt shared decision-making approaches that empower patient autonomy [100]. Practicing trauma-informed care during acne assessments is aimed at building patient-clinician trust, improving patient engagement with healthcare, and reducing stress during medical visits [16]. ...
Managing Common Dermatologic Needs in Transgender and Gender-Diverse Adolescents
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  • Apr 2025
Purpose of Review Transgender and gender-diverse (TGD) adolescents often face dermatologic concerns during gender-affirming care but may face limited access to dermatologists. This review aims to provide practical guidance for pediatricians on managing common dermatologic needs in TGD adolescents, including acne, hair growth promotion or removal, and post-surgical scarring within the context of gender-affirming care. Recent Findings Acne management should consider the impact of testosterone therapy and chest binding, with treatment options including topical retinoids, benzoyl peroxide, oral antibiotics, combined oral contraceptives, and spironolactone. Topical minoxidil may be considered for the promotion of facial, and scalp hair growth. Hair removal methods and complications such as pseudofolliculitis barbae should be discussed with TGD adolescents seeking temporary or permanent hair removal. Hypertrophic scarring and keloids may occur after gender-affirming chest reconstruction, with management involving topical silicone gel and adhesive silicone sheeting. Summary TGD adolescents may struggle to identify specialists trained in gender-affirming dermatologic care and may delay or avoid care due to past mistreatment in clinical settings. Pediatricians play a key role in managing the dermatologic concerns of TGD adolescents by creating a gender-affirming, safe, and supportive care environment and facilitating early dermatology referrals when appropriate.
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Epidemiology, risk factors, and prevention strategies of HIV, HPV, and other sexually transmitted infections among cisgender and transgender youth: a narrative review
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  • Mar 2024
Adolescents face an increased risk of contracting sexually transmitted infections (STIs) with alarming data especially concerning HIV. Limited data exists for teenagers regarding the influence of their gender identity (GI) and sexual orientation on the risk of STIs. This narrative review aims to analyse the available data to provide a comprehensive overview of STIs incidence and risk factors among adolescents, taking into account the unique circumstances related to various sexual orientations and GIs. Transgender and gender minority (TGM) youth experience more challenges accessing health services compared to cisgender youth. This is often attributed to non-inclusive health environments, barriers to obtaining medical gender affirmation, and an underestimation of sexual risk perception. Literature analysis has revealed that the majority of adolescents, both cisgender and TGM, have limited awareness regarding the risks associated with their sexual behaviors, the most common sexually transmitted diseases, and strategies for prevention, such as PrEP and HPV vaccination. Moreover, a significant portion of pediatricians possess limited knowledge and comfort in addressing various aspects of sexual health, particularly when it involves discussing topics such as sexual orientation, gender identity, and sexual behaviors with sexually active adolescents. This underscores the pressing need for enhanced education for pediatricians, specifically focusing on STIs diagnosis, prevention, and screening.
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An affirming approach to caring for transgender and gender-diverse youth
Article
  • Oct 2023
Increasing numbers of youth identify as transgender or gender-diverse (TGD). Many paediatricians and primary care providers (PCPs) will encounter this population in their practice, either for gender-related care or general health needs. This statement is intended as a resource to guide paediatricians and PCPs in implementing an affirming approach to routine health care provision for all youth. Furthermore, it presents information to assist providers in responding to requests for counselling from TGD youth and their families around potential options for medical transition, and in making referrals to specialized services, if desired and relevant. Finally, as demand for gender-affirming care is anticipated to continue to increase, some health care providers (HCPs) may wish to develop the knowledge and skills required to initiate adolescents on hormone-blocking agents and gender-affirming hormones. This document is not intended to be a clinical practice guideline, but will provide foundational information regarding these potential components of gender-affirming care, recognizing that the needs and goals of individual adolescents may or may not include such interventions. Additional resources relevant to developing the expertise required to provide gender-affirming interventions will also be identified.
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Adolescent and Caregiver Perspectives on Receiving Gender-Affirming Care in Primary Care
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Background: Transgender and gender-diverse (TGD) adolescents experience barriers to receiving gender-affirming care. Delivering services in the pediatric primary care setting may help facilitate improved access. With this study, we aimed to explore TGD adolescents' and caregivers' experiences receiving primary care services and their perspectives regarding gender-affirming care delivery in pediatric primary care. Methods: TGD adolescents aged 14 to 17 and caregivers of TGD adolescents currently receiving gender-affirming medical care participated in 1-hour-long, semi-structured, individual, virtual interviews. Each interview was recorded and transcribed. Transcripts were then individually coded, and themes were generated iteratively by using a reflexive thematic analysis framework. Recruitment of each group continued until thematic saturation was reached. Results: A total of 33 participants (15 adolescents and 18 caregivers) completed interviews. Adolescent participants (mean age of 15.7 years) predominantly identified as transmasculine or trans male (73%), and caregiver participants were predominantly mothers (83.3%). Four themes were identified, which included (1) barriers, such as microaggressions and poor psychosocial support, (2) benefits, such as existing trusted relationships with primary care providers (PCPs) and convenience, (3) improvement strategies, such as training and interdisciplinary collaboration, and (4) opportunities for integrating primary care and specialty gender-affirming care. Conclusions: TGD adolescents and their caregivers reported previous negative interactions with PCPs; however, some desired to receive gender-affirming care in this setting, citing increased convenience, efficiency, and availability. Participants highlighted an ongoing need for further work to provide resources, education, and training to PCPs and their staff and improve PCP-to-specialist communication and collaboration.
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Comparing Sexual Orientation and Gender Identity Documentation Between Adolescent and Pediatric Primary Care Clinics
Article
  • Sep 2023
Purpose: Recent literature suggests that sexual orientation and gender identity (SOGI) documentation is poor. We hypothesized that an adolescent clinic would have higher rates of SOGI documentation than a pediatric primary care clinic. Methods: We performed a single-center, retrospective, observational study of patients ages 10-26 presenting to the primary care or adolescent medicine clinics of a tertiary care hospital from 2019 to 2021. Electronic medical record (EMR) data were analyzed using Python and Stata/MP 16.1. Results: Patients in the adolescent clinic were five times more likely to have to have complete SOGI documentation compared to primary care. Gender diverse youth were over six times more likely to have a recorded sexual orientation than cisgender youth across both clinics. Conclusion: Adolescent providers document SOGI more often than primary care providers. Sexual orientation information for cisgender patients remains poor across environments. This study emphasizes the need for ongoing provider education on SOGI documentation.
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Barriers Pediatric PCP's Identify To Providing Gender-Affirming Care For Adolescents
Article
  • Jun 2023
Purpose: Both affirming environments and access to gender-affirming medical care have a positive impact on the mental health of transgender and gender diverse (TGD) youth, however, many TGD youth experience barriers in accessing this care. Pediatric primary care providers (PCPs) can play an important role in expanding access to gender-affirming care for TGD youth; however, few currently provide this care. The purpose of this study was to explore pediatric PCPs' perspectives regarding barriers they experience to providing gender-affirming care in the primary care setting. Methods: Pediatric PCPs who had sought out support from the Seattle Children's Gender Clinic were recruited via email to participate in semistructured, one-hour Zoom interviews. All interviews were transcribed and then subsequently analyzed in Dedoose qualitative analysis software using a reflexive thematic analysis framework. Results: Provider participants (n = 15) represented a wide range of experiences with respect to years in practice, number of TGD youth seen, and practice location (urban, rural, suburban). PCPs identified both health system and community-level barriers to providing gender-affirming care to TGD youth. Health system-level barriers included: (1) lack of foundational knowledge and skills, (2) limited clinical decision-making support, and (3) health system design limitations. Community-level barriers included (1) community and institutional biases, (2) provider attitudes regarding gender-affirming care provision, and (3) challenges identifying community resources to support TGD youth. Discussion: A multitude of health system and community-level barriers must be overcome in the pediatric primary care setting to ensure that TGD youth receive timely, effective, and more equitable gender-affirming care.
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Care of Transgender and Gender-Diverse Children and Adolescents
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  • May 2023
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Children and adolescents may present with transgender or gender diverse (TGD) identity during the course of development. Pediatricians may be the first health care providers to whom TGD identity is revealed. Pediatricians can optimize health care outcomes by promoting a gender-affirming clinical environment, initiating the evaluation for gender incongruence, supporting social transition, and initiating medical interventions. Clinical practice guidelines are available from the World Professional Association for Transgender Health (WPATH, Standards of Care, version 8, 2022) and the Endocrine Society (2017). This article outlines a general approach to providing social and medical affirming care from the pediatrician's office.
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