It has been well-established that transgender or gender-diverse individuals are at heightened risk of developing negative physical and mental health outcomes (Mason et al., 2021). Despite this, discrimination of this population in medical settings is still ubiquitous in the United States as well as other countries and contributes to the severity of distress associated with gender incongruence (James et al., 2016). Given that gender development begins within the preschool years of a child’s life, it is crucial to explore the implications of how living as a gender minority individual in a heterosexist world may expose children to minority stress and serve as a risk factor for chronic stress throughout the lifespan. This article is intended to 1) specify models of how gender minority stress may elicit chronic stress and health consequences, while 2) highlighting research-informed suggestions for delivering gender-affirming treatment in pediatric medical settings.
Mechanisms of Chronic and Minority Stress
Childhood and adolescence are critical developmental periods in which brain structures undergo significant changes. As a result, the plasticity of these structures makes them vulnerable to disruptions when exposed to severe stressors. Gender dysphoria, defined as significant distress associated with the incongruence between one’s gender identity and sex assigned at birth (American Psychological Association [APA], 2022), represents one pathway that can over-stimulate the physiological stress response (Mason et al., 2021). Current literature on gender dysphoria and gender incongruence describes that they are first experienced between the ages of 10 and 13 due to a mix of biological, psychological, and social factors that are commonly presented at this age (Doyle, 2022; Steensma, 2011). It is important to note, however, that the experience of gender incongruence in of itself does not equate gender dysphoria, and that the latter is used to specifically describe individuals who experience significant burden as a result of gender incongruence (Claahsen-van der Grinten et al., 2021).
The brain structure that produces the stress response is known as the hypothalamic-pituitary-adrenal (HPA) axis, a system of positive and negative feedback that communicates signals between the hypothalamus, pituitary gland, and adrenal glands (DeMorrow, 2018). Collectively, these signals moderate essential physiological processes including hormonal, cardiovascular, and immune system functioning. When confronted with stressful events, the HPA-axis inhibits some of these processes to prioritize cortisol and glucose secretion for the individual to respond effectively to their environment. Chronic HPA-axis activation, therefore, increases baseline cortisol levels and suppresses functioning of adaptive processes over time. Specifically, these hyperactive stress responses have the potential to corroborate the development of cardiovascular disease, growth suppression, hypogonadism, hypertension, visceral-fat accumulation, osteoporosis, obesity, and metabolic syndrome (Crowell et al., 2015; Glaser & Kiecolt-Glaser, 2005) as well as debilitating mental health conditions including anxiety and obsessive-compulsive disorders (Guilliams & Edwards, 2010).
Having a transgender identity is associated with poorer physical and mental health outcomes in comparison to cisgender counterparts (Reisner et al., 2016), and transgender adults exhibit higher baseline cortisol levels compared to controls prior to receiving medical care (Colizzi et al., 2013). Further, children with gender dysphoria have been documented to demonstrate elevated physiological symptoms of anxiety via skin conduction levels during both stressful and non-stressful tasks compared to matched controls (Wallien et al., 2007). This evidence suggests that gender dysphoria elicits biological reactions that may predispose affected individuals to adverse health consequences in the future.
In addition to biological pathways, psychosocial theories have also been posited to explain gender dysphoria as a chronic stressor. Meyer’s (2003) minority stress model states that individuals with a minority status experience both distal and proximal stressors specifically related to their marginalized identity, and that this stress is supplemental to the experience of general life stress. Proximal stressors within this model refer to internal beliefs and subjective experiences, including internalized heterosexism, identity concealment, and expectations of rejection. In contrast, distal stressors describe systemic or objective experiences such as acts of discrimination or violence. Gender minority stress can be experienced at an early age and continue over the course of development. For example, school-aged youths who demonstrate gender non-conforming behavior (GNC) can understand that other children find them “strange” and are subsequently bullied at a higher rate by their peers (Weiselberg et al., 2019). Additionally, one recent study found that transgender adolescents in high school reported higher engagement in risky sexual behaviors such as alcohol or substance use, less use of contraception, and no condom use at their most recent sexual encounter, as well as higher suicide risk than cisgender adolescents (Johns et al., 2019). Notably, rates of HIV are also rising among transgender women while they continue to decrease in the general population (Grant et al., 2010).
Pediatricians are often the first health professionals that children experiencing gender dysphoria or GNC behaviors are exposed to (Rafferty, 2018). While this is an excellent opportunity for early intervention, many healthcare providers do not have a comprehensive understanding of transgender health and may demonstrate negative attitudes towards transgender patients (Rounds et al., 2013). Qualitative data also shows that many sexual health providers only understand gender diversity within a male-female binary, feel uncertain about transgender youth’s sexual organs during transition, and do not believe that youth could be certain about their gender identity or make informed decisions about changing their physical traits (Lefkowtiz & Mannell, 2017). These types of reactions toward gender diverse youth can generate proximal minority stressors that amplify negative beliefs about their gender experience. If pediatric gender dysphoria is approached in a compassionate and affirming way by healthcare providers, then the risk for chronic stress and its associated illnesses may be mitigated.
Gender-Affirming Treatment Within Medical Settings
As mentioned, children with gender dysphoria may be especially vulnerable to physical and mental health consequences. However, factors that can moderate the effects of minority stress can be implemented through intervention in pediatric settings. These factors include enhanced emotional connection to one’s family, personal acceptance of one’s identity, safety within the environment, and supportive peer groups (Meyer, 2003). Pediatric clinicians can facilitate discussions around these factors with families to help ensure positive outcomes through appropriate recommendations. For many young people with gender dysphoria, receiving medical interventions such as pubertal suppression and gender-affirming hormones with concurrent psychological assistance can be extremely helpful in alleviating minority stress (Mason et al., 2021). Importantly, these procedures may be implemented through multi-disciplinary teams that are composed of specialists in clinical psychology and pediatric endocrinology. Individualized treatment can be emphasized within gender-affirming treatment, meaning that not all young people with gender dysphoria desire medical intervention and each treatment plan is specific to the patient’s needs.
Pubertal suppression is conducted by a pediatric endocrinologist and entails using gonadotrophin-releasing hormone (GnRH) analogues to stop the progression of puberty related to the sex the individual was assigned at birth (Hembree et al., 2017). This intervention is designed to ease gender identity distress while also allowing youth more time to contemplate next steps with the guidance of a mental health professional (Mason et al., 2021). Further, this intervention will prevent unwanted secondary sex characteristics from developing. This outcome is especially helpful because this may subvert the need for future surgeries or procedures and enhance quality of life (Schumer et al., 2016). The use of pubertal blockers has enabled significant improvement in psychological functioning and well-being in gender-expansive young adults in comparison to their state prior to intervention (de Vries et al., 2014).
Another aspect of gender-affirming treatment includes the process of receiving gender-affirming hormones. When accessible in pediatric settings, this treatment is available to the adolescent at 16 years old and the dose increases gradually throughout their development (Hembree et al., 2017). At 18 years old and above, the individual becomes eligible for gender-affirmation surgery if they express the strong desire to do so. If the patient is not satisfied with the effects of previous hormonal treatment or expresses ambivalence about surgery, then gender-affirmation surgery referrals are not encouraged to be made and further evaluation is warranted (Mason et al., 2021). If gender-affirmation surgery aligns with the patient’s treatment goals, then this may be a useful intervention that can become more readily available in pediatric medical settings.
Aside from specific medical procedures, other forms of gender-affirming treatment can be present throughout the individual’s care. Using the patient’s preferred name and pronouns when referring to them is a practice that many providers are becoming more aware of. Likewise, if there is a discrepancy between these identifiers on the electronic health record and the patient’s self-report, then the entire medical team can be informed, and appropriate adjustments can be made to ensure quality care. Providers can also use unspoken tactics for allowing the patient to feel comfortable in a medical setting, such as having posters and flyers that highlight inclusivity being located throughout the waiting room, office, or hallways of the facility. For physical examinations with gender expansive youth, the patient should only disrobe when necessary and be oriented to the reasoning behind such directions. These same procedures are crucial for testicular, pelvic, and breast examinations, considering physical contact with these body parts may be traumatic for the individual (Weiselberg, 2019). When referring to these body parts, the provider may ask whether the patient has a preferred name for them to reduce minority stress exposure, as the technical medical term may induce feelings of dysphoria. Awareness of other gender-affirming clothing or garments the patient may be wearing, such as a binder or packer, is to be treated with respect and permitted to be worn when that bodily area is not being examined (Weiselberg, 2019).
Overall, several pathways exist for the development of chronic stress associated with the experience of gender dysphoria in youth. To encourage more adaptive pathways, there are several methods for providing gender-affirming care in pediatric settings that span from offering certain medical procedures to changing day-to-day interactions. Unfortunately, many of the individuals within the patient’s social system may not adhere by these same principles, and youth experiencing gender dysphoria likely have past negative experiences with health professionals to begin with (Rounds et al., 2013). Although the multidisciplinary pediatric team may not have the ability to extend these practices to all areas of the child’s life, the presence of gender-affirming care in their medical treatment may serve to obstruct gender minority stress and increase future engagement in positive health behaviors.
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