High Percentage of Transgender Youth Don't Disclose Identity to HCPs

Michael Vlessides

March 11, 2020

Almost of half of all transgender youth deliberately don't disclose their gender identity to healthcare providers outside of a specialized gender clinic, new research shows.

The cross-sectional survey of 153 transgender youth showed that although more than three quarters of respondents had voluntarily disclosed their gender identity to a health-care provider outside of the gender clinic, 46% had nevertheless intentionally avoided disclosure. Interestingly, the study also concluded that parental support appears to play a protective role in mitigating this avoidance behavior.

"We were really surprised by the number of young people who said they intentionally avoided disclosing their identity to a healthcare provider," principal investigator Gina M. Sequeira, MD, told Medscape Medical News.

"Unfortunately, there are data in large, nonclinical samples of transgender adults that suggest that many have had negative experiences in the healthcare setting before," said Sequeira, an adolescent medicine fellow at the University of Pittsburgh Medical Center Children's Hospital in Pennsylvania.

"In light of that data, it's incredibly surprising that young people today are still experiencing such negative reactions from providers and don't feel welcome as their true selves in the healthcare space."

The study was published online February 20 in the Journal of Adolescent Health.

Significant Discrimination, Stigma

Transgender youth face notable societal stigma and discrimination, phenomena that often prevent them from receiving quality healthcare. As such, it's not surprising that these factors have led to significant health disparities and lower healthcare utilization rates among transgender adolescents.

Research shows access to affirming environments and gender-affirming medical care can reduce these trends, but transgender health specialists are rare across the US.

As such, voluntary disclosure of gender identity by transgender youth to nonspecialized healthcare professionals may well maximize the effectiveness, appropriateness, and safety of care they receive.

Such disclosure may also help promote gender-affirming relationships between transgender youth and healthcare providers and allow easier access to transgender health specialists.

Whereas previous research has concluded that the majority of transgender adults believe disclosing their gender identity to healthcare providers is important, no similar studies have been conducted in adolescents.

Similarly, no prior studies have examined the personal and system-level factors that influence youth comfort with gender identity disclosure in the healthcare setting.

Given these gaps in the literature, Sequeira and colleagues set out to determine the prevalence of voluntary disclosure and intentional avoidance to healthcare providers outside of gender clinics; identify factors associated with voluntary disclosure and intentional avoidance; and elucidate strategies to increase comfort with disclosure.

"I had an incident where a young person told me about a conversation he had with his pediatrician about his gender identity," said Sequeira.

"Unfortunately, the response from the pediatrician was quite negative, which got me thinking about the experiences that other transgender youth might be having. The larger question in my mind is how do experiences like this influence the patient's willingness to receive primary care or mental health services?"

What Healthcare Providers Can Do

The cross-sectional survey was administered via electronic tablet and included 204 transgender youth (ages 12 to 26 years) who presented at a multidisciplinary gender clinic in southwestern Pennsylvania between July and November 2018.

Although the survey included 78 items, the current analysis only focused on a subset of disclosure-related questions. These items had been adapted from an existing tool designed to understand the factors that influence the decision of lesbian, gay, and bisexual youth to disclose their sexual orientation in the healthcare setting.

The study's two primary outcome variables were voluntary disclosure and intentional avoidance. Voluntary disclosure occurred when the respondent answered yes to the following question: Have you ever chosen to tell a healthcare provider outside of the gender clinic about your gender identity?

Intentional avoidance, on the other hand, was defined as a positive response to the question: Have there been times you felt it could be important for your healthcare provider to know your gender identity but you avoided telling them?

The researchers also performed logistic regression analyses for each outcome variable to examine factors associated with voluntary disclosure and intentional avoidance.

Of the initial cohort of 204 participants, 153 had complete data for all outcome variables, demographic characteristics, and gender-related characteristics. Of these, 65% identified as transmasculine, 16% as transfeminine, and 19% as nonbinary.

The survey showed that 78% of respondents reported telling a healthcare provider outside of a gender clinic about their gender identity at some point in their lifetime. Perhaps not surprisingly, though, youth reported varying preferences with respect to how they would like to see a conversation about their gender identity begin.

Nearly half (47%) of respondents indicated they would prefer the provider initiate the conversation, and only 25% indicated they would prefer to raise the issue themselves. The remaining respondents said it either made no difference (17%), depended on the situation (9%) or that they were unsure (3%).

Of the 71 respondents who preferred a provider-initiated discussion, 55% said they would prefer that such a discussion take place during the confidential portion of the visit.

The survey also showed that 46% of the youth had never intentionally avoided telling a healthcare provider about their gender identity when they thought it was important.

The Importance of Pronouns

The most common reasons for avoidance were not feeling comfortable talking about it (66%) and not knowing how to raise the issue (65%).

Regression analyses revealed that youth with higher perceived parental support were 17% less likely to avoid disclosing their gender identity than their counterparts without parental support. (odds ratio, 0.83; 95% confidence interval, 0.70 - 0.98).

Respondents were also asked how healthcare settings can make them more comfortable with respect to voluntarily disclosing their gender identity. The survey found that the most common strategies included using their preferred name and pronoun in the waiting room (85%), using forms that allow them to list their preferred name/pronoun (81%) and gender identity (76%), and educating front desk personnel about the importance of using the correct name and pronoun (79%).

The results of the survey highlight the need to create more inclusive spaces for transgender youth in the healthcare setting, particularly as nearly 1 in 4 transgender youth would not voluntarily disclose their gender identity in a healthcare setting outside the gender clinic.

"On a larger scale, young people not feeling like they can access the healthcare system as their true selves says a lot about how far we need to go as a society," Sequeira noted. "This is just a really good example that we still have a lot of room for growth with respect to creating affirming environments for young people of various gender identities."

Sobering though the results are, they also highlight specific opportunities for health systems to improve access to care for transgender youth. Indeed, the two primary reasons youth avoided disclosing their gender identity were related to discomfort.

"It's my hope is that the next generation of medical providers is more interested about this kind of content. There seems to be more and more interest among practicing pediatricians and primary care providers to learn more about how to better support transgender youth in clinical practice," said Sequeira.

Vulnerable, At-Risk Population

Commenting on the findings for Medscape Medical News, Kacie Kidd, MD, who was not involved in the research, said she wasn't surprised by the results, but also recognized their importance.

"Transgender youth face significant discrimination and stigma, and this is made worse by recent legislation targeting their ability to access gender-affirming care," said. Kidd, a fellow in adolescent and young adult medicine at UPMC Children's Hospital.

"This vulnerable group of young people has markedly higher rates of depression, anxiety, and suicidality compared to cisgender peers, but have better health outcomes when they are affirmed in their identity," Kidd said. "Unfortunately, they often face rejection in medical settings by systems and providers who do not recognize the importance of affirmation."

Yet Kidd pointed to steps that healthcare providers and systems can take to demonstrate that they are affirming spaces for transgender youth.

"Some easy steps are to make sure that all staff is trained to use and respect a young person's affirmed name and pronouns," said Kidd. "Nearly all electronic health records allow for inclusion of this information and these inclusive technologies should be adopted universally."

Sequeira noted that even small steps go a long way toward making transgender youth feel more comfortable discussing their gender identity.

"I think we can do things like introduce ourselves with our name and our pronouns, and really trying to be diligent about routinely asking young people if they're interested in talking about their gender and how they identify," she said.

"The more we do that routinely, the more we normalize that this is a safe space and we create an environment for all different gender identities."

The study was funded by the National Institutes of Health, National Center for Advancing Translational Sciences, and the National Institute on Alcohol Abuse and Alcoholism. Sequeira and Kidd have disclosed no relevant financial relationships.

J Adolesc Health. Published online February 20, 2020. Abstract

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