For pediatricians, taking good care of children as they navigate puberty and adolescence means listening — and talking — as kids figure out sexuality, identity and relationships. Even those lucky kids with supportive and open-minded parents often find they want to talk through these topics with an adult outside their immediate families, and the primary care visit should be a place to talk about every aspect of the child’s changing body and mind.
The American Academy of Pediatrics is advising doctors to wear Pride stickers, display those rainbow symbols in our clinics, announce our own preferred pronouns and ask patients for theirs. We want to encourage kids to talk honestly about their own sexuality and gender questions, and we want to be sure they get those questions answered in a setting that supports them and protects their confidentiality.
[Click here for the A.A.P. policy statement on good care for L.G.B.T. children and youth and here for the policy statement on good care for gender-diverse children.]
How can parents find a pediatric practice that is welcoming, inclusive and ready to hold those important conversations? Here are some tips for making sure that a child has that expert adult to talk with — and for helping along those discussions at the pediatrician’s office. As a parent, you should feel that you also have access to help and advice, that you and the pediatrician are partnering to help your child.
How to Find an L.G.B.T.Q.-Friendly Practice
When choosing a pediatric provider, keep those future conversations in mind. Charlotte J. Patterson, a professor of psychology at the University of Virginia, wrote in an email, “parents can ask questions about how practitioners handle issues relevant to sexual orientation and gender identity. This can help parents ensure that, whether gay or straight, cisgender or nonbinary, their children will receive safe, inclusive, and supportive medical care.” She also suggested that parents can consult with local groups — PFLAG or L.G.B.T.Q. resource centers — for recommendations about pediatric practices.
Dr. Christopher Harris, the chairman of the American Academy of Pediatrics section on L.G.B.T. health and wellness, suggested that parents and patients could look for visual signs that indicate that a practice is friendly, like “posters on the wall, rainbows, rainbow flags, pronoun stickers on health care provider name tags, signs in the waiting room saying we care for all families.”
And certainly adolescents pick up on all these signals and symbols. On medical Twitter recently, Dr. Anna Downs, a pediatric resident, tweeted about having an adolescent look at the rainbow badge she was wearing and ask excitedly, “So what kind of gay are you!?”
Dr. Ilana Sherer, a pediatrician in Dublin, Calif., who is a member of the executive committee of the A.A.P. section on L.G.B.T. health and wellness, suggested that parents look on a practice’s website for language that indicates that the practice is friendly to everyone, which could include messages about serving different kinds of families, careful attention to pronouns, signals that the office is not making any assumptions.
A practice that is trying to welcome these questions will have thought about what is communicated on the website, at the front desk, and on the forms to be filled in, as well as in the exam room. So parents should listen for the ways that questions are asked on intake forms and in initial interviews: “Are they asking questions in ways that allow somebody who is not straight and binary and cisgender to answer?” Dr. Sherer asked. “Do they understand that gay, straight, bisexual are not the only choices?” Look for doctors who ask open-ended questions, and who understand the diversity of child development, she said, and be wary of comments that “gender kids unnecessarily — are they giving a boy a He-Man sticker or letting him choose?”
Dr. Sherer cares for many families with transgender and gender-diverse children, some who have been in her practice since early childhood, and others who find her because she speaks and writes about this population. “I hear being transgender being talked about like it’s a disorder,” she said. “My transgender kids are some of the kindest, bravest kids I have.” She tries to model for parents how to help and support their children, while also handling their own emotions, which can be complex, she said: “There’s obviously a loss to the parent but it’s not a loss of their child — it’s a loss of who they thought the child was.”
For parents whose children are questioning their gender identity, “don’t be afraid to reach out to your pediatrician,” said Dr. Paria Hassouri, a pediatrician in Los Angeles who provides gender-affirming care, and who has written about her own experience as the parent of a transgender child. “Information is going to empower you to support your child and make decisions down the line.”
The proportion of adolescents who report that they identify as other than heterosexual has been going up. Dr. Patterson was the corresponding author of a commentary published in late May in the journal JAMA Pediatrics, which discussed recent data — in one survey, 14.3 percent of adolescents in 2017 claimed an identity that was “lesbian, gay, bisexual, other, or questioning,” up from 7.3 percent in 2009. The article argued that while greater societal openness may have encouraged more honest answers, these adolescents are still vulnerable to stigma, bullying and abuse, and consequent mental health problems. So a strong and supportive relationship with a medical provider can be really important in helping an adolescent navigate these years.
What to Expect From Your Pediatrician
Parents should expect pediatricians to promise adolescents confidentiality. But there are some situations — especially if the child is at risk of self-harm — where a doctor can’t promise confidentiality; we lay those out clearly with kids.
Parents should expect their children’s doctors to be trained in asking and answering questions about sexual behavior and sexual health, but also about issues of identification and identity.
With adolescents, we’re also asking about identity, self-image, body changes, mental health, friendships, academic performance, risky behaviors (smoking, drugs, alcohol) — the whole complex mix of adolescent activity and adjustment. When she’s talking to patients in the general pediatric clinic, Dr. Hassouri said, she starts by asking, “Do you feel comfortable in your body, how do you identify, what are the gender or genders of the people you are attracted to, rather than ‘Are you gay, straight or bisexual?’”
Asking kids if they feel comfortable in their bodies as an opening question, she pointed out, could mean hearing about gender identity, but it might also open up other body-related concerns about weight or what they perceive as unattractiveness, or the pace of puberty. And as the conversation moves to other aspects of her patients’ lives, she tries to ask about interests and favorite activities in gender-neutral language.
For some kids, she said, those questions of sexual orientation and gender identity can get confused — what begins with wanting to do “something not typical for the gender assigned to them” as young children may be “buried,” and then later on, around puberty, they may first begin to question their sexuality — “maybe I’m bisexual, maybe I’m gay.”
Sometimes those feelings of not fitting in are really about the rigidity of gender expectations. Sometimes children are in fact becoming aware of their emerging sexual orientations — who they will be attracted to. And sometimes they will realize that those early feelings of wanting the “boy clothes” or the “girl toys” actually connect to their own gender identities — how they will identify and who they are.
Support for Parents
Parents should also expect to get support and guidance from their children’s doctor; part of helping children navigate these years is helping their parents be there for them. Dr. Hassouri said that when parents are talking to their own child, her advice is to “really listen to your child and believe what they’re telling you and support them, no matter what stage they are in their gender journey, in their sexuality journey.” And make sure the child is seeing a doctor who will also listen and support them at every stage.
Dr. Sherer tells parents of young children that “there is a lot of fluidity in gender development.” With older children who may be questioning their gender identity, she finds herself modeling for parents how to show support, from discussing preferred pronouns onward. Parents sometimes jump right away to questions of medication and even eventual surgery, she said, when she, as the physician, never starts with those issues; the real question is immediate: “How can we help you feel affirmed in your identity; how can we help you feel good?” Thus, she advises parents to “not focus so much on the result, but on where their kid is in the moment.”
Rather than trying to figure out, “is my kid going to be transgender, is my kid gay?” look at the child right there, right then, who is asking for love and support.
“Parental support and acceptance are very powerful for reducing all sorts of negative outcomes” Dr. Sherer said. This kind of support is associated with better mental health as adolescents grow up and with reduced depression and suicidality. Supportive parents can also help kids who experience bullying or other school problems, and can make sure that their extended families treat them well.
Pediatric practices can help adolescents and families locate resources like the Trevor Project, which offers a hotline for L.G.B.T.Q. youth, the It Gets Better Project or the Family Acceptance Project, which helps families that are ethnically, racially or religiously diverse support L.G.B.T.Q. children.
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