He, She, They: Pediatricians Should Ask Kids About Gender Identity

Until recently, pediatricians have relied upon the practice of classifying adolescents according to their birth-assigned sex. But a new study in the medical journal Pediatrics suggests that practice is outdated.

According to the study, nearly 3 percent of 9th and 11th graders are transgender or gender-nonconforming. That is, 3 percent of these students are gender atypical: they either do not identify with their assigned gender or have gender expressions that conflict with stereotypical expectations — preferring, for example, to be called by gender-neutral names or pronouns, or moving fluidly between masculine and feminine presentations, or desiring gender-related medical interventions, such as hormone therapy or top surgery.

Even supposing a very conservative estimate, it is likely that nearly a million American children are or will soon be gender atypical.

The number of children, in and of itself, does not place demands on pediatricians. But gender atypical youth are more likely than their peers to experience poor physical health and are at higher risk of long-term mental health challenges, including depression, anxiety, self-harm and suicide.

it is likely that nearly a million American children are or will soon be gender atypical.

This situation is exacerbated by the fact that, according to the Pediatrics study, these young people often mistrust health care providers, because they are afraid their gender identity — or their expression of it — will be misunderstood.

Given the overwhelming data about the increased risks children with gender atypical identities, it’s especially important for a pediatrician’s office to be a nonjudgmental, safe space. And there may be a simple solution.

When teenagers go to the doctor for a physical exam, there are certain recommended screening questions every pediatrician asks that assess for potential medical problems. These questions are expansive and intended to track key factors in a teen’s lifestyle and environment, including their relationships with family and friends, depression, cigarette use and sexual activity.

Why not include questions about gender identity during adolescent wellness visits? A simple screening question can be a way for doctors to demonstrate that they care and ensure that the doctor’s office is a place these youth can turn to for knowledge, advice and support. It also cues doctors and parents, early on, to the potential risks – including mental health issues, barriers to medical care, potential for facing discrimination in daily life — that these young people may face.

Asking this simple question can be life-saving for young people, who may be struggling silently with feelings of alienation and isolation and other concerns their peers don’t have. Take Max, an agender teenager, who doesn’t identify as male or female, featured in this NPR story. Max describes frustrations with getting friends and family to use the gender-neutral pronouns, “they," as well as contemplating suicide in response to gender-targeted bullying at school.

according to a 2014 national survey, 41 percent of transgender and gender non-conforming people have attempted suicide

Max's experiences are far from unusual: according to a 2014 national survey, 41 percent of transgender and gender non-conforming people have attempted suicide, a number vastly higher than the 4.1 percent of people in the general U.S. population who report ever attempting suicide. The same study also found that more than half of gender atypical people experience gender-related school bullying, and 60 percent have been refused care by a health care provider.

While some pediatricians might worry about adding a question that affects less than 3 percent of adolescents, this worry would overlook precedent. The HIV rate for youth is less than 0.03 percent, and yet it would be unthinkable to remove screening questions about HIV from wellness exams. Being gender atypical is not in and of itself a health concern, of course, but the sooner a doctor is aware, the sooner they can intervene if necessary.

Some may object to gender identity screening on moral or religious grounds (as some have objected on similar grounds to sex education). But that misses the point. Pediatricians don’t ask about sexual activity, drug use, depression or anything else to pass judgment — they do so to promote a child’s health. In this way, gender identity screening questions are no different.

Recognizing gender atypical youth, intervening in a supportive and positive way, and treating psychological issues that can accompany transgender and gender non-conforming identities can have real effects on the health and well-being of youth. Gender atypical youth, with the support of their doctors alongside that of families, communities, and schools, can have health outcomes approaching that of their peers.