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More families are seeking care for gender-questioning children and teens

Kaiser Permanente pediatric transgender clinic sees the evidence in sharp rise in referrals


The number of children and teens referred for care at a Kaiser Permanente Northern California pediatric transgender clinic rose fourfold between 2015 and 2017 and continued to rise in 2018, new research shows.

Carlo Hojilla, RN, PhD, research fellow at Kaiser Permanente Division of Research

“Our findings highlight the growing demand for pediatric transgender and gender nonconforming care,” said Carlo Hojilla, RN, PhD, a research fellow with the Kaiser Permanente Division of Research in Oakland and the University of California, San Francisco. Hojilla and pediatric resident Ted Handler, MD, MBA, were co-lead authors on research published in the journal Pediatrics October 16.

“The shift in the cultural conversation around gender identity has supported these increases in referrals, as have shifts in insurance benefits after the Affordable Care Act,” Handler said. The ACA prohibited health insurers from denying coverage based on gender identity in 2010.

The authors tallied pediatric clinic referrals in 2015, when 56 children and teens sought care. Referrals nearly quadrupled to 194 in 2017 and were on track to continue rising, with 154 referrals counted in the first half of 2018.

Ted Handler, MD, pediatric resident, Kaiser Permanente Northern California

“There is clearly a significant need in the community,” said Kaiser Permanente gynecologist Eve Zaritsky, MD, senior author on the Pediatrics paper. “These kids have real health needs and we need to respond to them.”

For the 50 younger children in the study, those under age 8, referrals were generally for mental health care. For those between ages 9 and 13 (82 patients), referrals were for mental health services, puberty suppression, or cross-sex hormones. Young people who have not yet undergone puberty can take medication to delay it, giving them time to better understand their gender identity.

The study population included 374 referrals for older teenagers, ages 14 to 17, many of whom wanted to discuss surgical gender affirmation. Decisions around surgical interventions were guided by a patient-directed care model informed by the World Professional Association for Transgender Health Standards of Care. Treatment with hormones or surgery is undertaken only after a lengthy process that involves consultation with a pediatric endocrinologist, gender therapist, the patient’s own physician, and family, the study authors said.

“Treatment is a process to reaffirm our patients’ true gender identities that they have held over a long period of time,” Handler said. “This is done under the expert supervision of our gender therapists and other specialists.”

Failing to offer treatment for people with gender dysphoria carries risks of depression, substance abuse, and suicide, the authors said.

The study reported referrals to the Proud Clinic but did not determine whether treatment was actually provided. The authors are working on new research to answer such questions.

Zaritsky said she hopes the research will help increase physicians’ awareness of their young patients’ gender identity issues and consider specialist referral. Most of the pediatric transgender clinic’s referrals are from word of mouth.

The study was funded by National Institutes of Health grants.

Other coauthors are Reshma Varghese and Whitney Wellenstein, MD, with Kaiser Permanente Northern California obstetrics and gynecology, and Derek Satre, PhD, with the Kaiser Permanente Division of Research and the University of California, San Francisco, Department of Psychiatry.




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