I first met Ayanna[*], a young transgender woman (meaning she was assigned to the male sex at birth, but identifies as female), when she was 16. She had just been released from a juvenile detention center and was referred to me for treatment due to a positive HIV test. During her first visit, I learned so much about the challenges she faced due to her gender identity and new HIV diagnosis. She had a history of abuse and neglect from her biological family, who were not supportive of her identity. She was engaging in “survival sex” (trading sex for money, food, or a place to stay) in order to pay for street procedures (e.g., silicone injections) and hormones, both of which she mistakenly thought she could never get from a doctor. She was facing physical violence from sexual partners and harassment from the police and other authorities. Thankfully, our multidisciplinary team has been able to provide Ayanna with the medical care she needs for her HIV infection and gender-affirming hormone therapy in a safe and supportive environment, but there are still so many obstacles when she leaves our clinic. While I still treat Ayanna today, I can go months, or even a year, without seeing her due to changes in her life, such as homelessness or incarceration for prostitution charges. Despite all of her challenges, I am constantly amazed by her resilience and her ability to survive and face life’s challenges on her own – something no young person should have to do.
I began caring for gender non-conforming youth[†] over eight years ago during my training as a pediatrician and adolescent medicine specialist. Many of these youth were similar to Ayanna – mostly older adolescents and young adults who were homeless or had no support from their families or communities. When I talked to colleagues at that time about my patients’ unique struggles, few, if any, of my fellow providers even knew what it meant to be transgender or gender non-conforming. The concept of “gender non-conforming” was not pervasive in general societal consciousness.
Fast-forward eight years, and most Americans know who Caitlyn Jenner and Laverne Cox are. They may watch shows like the Emmy-winning Transparent. While we are in the midst of a major change in societal understanding of the lives of gender non-conforming people, these individuals still face significant barriers to achieving optimal health and well-being. This is particularly true for gender non-conforming children and adolescents, who are often left out of the conversation.
Since its inception less than two years ago, The Children’s Hospital of Philadelphia’s Gender and Sexuality Development Clinic has served over 250 children and adolescents, ranging in ages 5-24, and their families. Each day in clinic, I continue to learn more about the challenges faced by gender non-conforming youth, and what it truly means to provide comprehensive health care services and support for these young people and their families. In addition to continuing to care for young people like Ayanna, I have also now been fortunate to meet many gender non-conforming children and adolescents who have families that love and support them in their identities across the gender spectrum. However, even for young people whose families are behind them every step of the way, there are still many issues to address. For example, John, a young transgender male patient of mine, is now attending a cyber-school because of bullying. Unfortunately, this is the norm for a large portion of our patients. Additionally, despite multiple appeals, coverage of John’s prescription for testosterone therapy has been denied by his insurance company, which has stated that his particular plan does not include services or medications for “gender transition.” This is despite the fact that testosterone and other gender-affirming hormone therapies are recommended by the World Professional Association of Transgender Health and The Endocrine Society guidelines. Luckily, John’s family can pay for his medication, but many other families are not so lucky.
Providing the recommended medical care and other supports and protections for gender non-conforming youth can also be a matter of life and death. More than 40% of transgender individuals attempt suicide at some point in their lives and the numbers of murders, particularly of young transgender women of color, continue to rise. Right here in Philadelphia, over the course of just a few months, multiple gender non-conforming youth were admitted to our hospital for suicide attempts, which were thankfully unsuccessful, and two young transgender women were tragically murdered.
Because of my professional experience in caring for gender non-conforming youth, I, along with my colleagues, decided to create an Evidence to Action brief entitled Ensuring Comprehensive Care and Support for Gender Non-Conforming Children and Adolescents that provides information and recommendations for practitioners, administrators, and policymakers to improve the health and well-being for gender non-conforming youth. We hope that this brief, and our work at CHOP’s PolicyLab and the Gender and Sexuality Development Clinic, can help address some of the many challenges faced by gender non-conforming youth, both within and beyond the health care system. Ayanna, John, and other gender non-conforming youth deserve to grow up to be happy, healthy, and productive adults who can be their true gender selves, live without fear and disappointment, and feel their identity is not only supported, but celebrated.
[*] The cases discussed here are a composite of many and do not present identifying information of any single patient
[†] “Gender non-conforming” is a broader, more inclusive, term than “transgender.”