Physicians have an obligation to care for all patients equitably, but the ethics of caring for pediatric LGBTQ+ patients can be challenging to navigate, especially for physicians in training. For starters, how does one define gender-affirming care? And what are physicians legally required to do when caring for youth seeking transgender medical treatments?
An education session, “Issues of ethical importance: Health care for pediatric LGBTQ+ patients,” was recorded for the November 2021 AMA Section Meetings and provides some answers to these questions.
“Gender-affirmative care,” also called gender-affirming care, “is a model of care and an approach to the patients and families that we work with,” said Jason Rafferty, MD, MPH, a child psychiatrist and pediatrician at Hasbro Children’s Hospital, in Providence, Rhode Island. “It’s not necessarily a protocol. It's not guided steps.”
More than anything, it’s about supporting patients as they seek medical affirmation, as well as social and even legal affirmation. “There's a number of different ways that we can intervene to help support and help you in terms of presenting your true, authentic self from a physical and emotional perspective,” Dr. Rafferty said.
According to Aron C. Janssen, MD, “gender-affirming care is patient-led,” noting that there's no single, objective outcome for somebody seeking a sense of identity.
“Being trans, being cis, being gender nonbinary, being anywhere on the spectrum of identity—is just as good as anywhere else. It's not our job to dictate how people should be developing, but to understand and be with them as they are exploring their sense of self throughout this process,” said Dr. Janssen, vice chair of clinical affairs in the Pritzker Department of Psychiatry and Behavioral Health at the Ann & Robert H. Lurie Children’s Hospital of Chicago.
The AMA has collaborated with the Fenway Institute to create CME modules on topics related to care for patients who are lesbian, gay, bisexual, transgender, queer, intersex, asexual and all sexual and gender minorities.
The resources are part of the AMA Ed Hub™, an online learning platform that brings together high-quality CME, maintenance of certification, and educational content from trusted sources, all in one place—with activities relevant to you, automated credit tracking and reporting for some states and specialty boards. Learn more about AMA CME accreditation.
“Another framework that we often bring to it is narrative ethics,” Dr. Rafferty said. This requires listening to the patient’s story and then teasing out a system of values, desires and goals for treatment. The key, though, is to encourage and empower the patient to take the lead through “a process of authoring and interpretation and translation.”
One of the goals is to foster autonomy, but this has to be done in a developmentally informed way, keeping in mind where the child is physically and cognitively.
“It's important to understand some kids may be more concrete; some kids may be more abstract,” Dr. Rafferty said. “Kids may be coming at this from different cognitive angles or understandings or capacities.”
Learn more about the Advisory Committee on LGBTQ Issues, which highlights LGBTQ news and topics related to patients and physicians.
Access to gender-affirming care is endangered by legislative efforts to interfere with the delivery of that care, Dr. Janssen said, adding that “almost half the states in this country are in the process of enacting legislation that will bar care for transgender youth.”
The AMA recently urged governors to oppose state legislation that would prohibit medically necessary gender transition-related care for minor patients.
Parents are the keystone in the patient-physician relationship, Dr. Rafferty said.
“The situations that I feel the worst about are the ones when a parent says, ‘Well, I'm going to back off and not be involved because I feel like no one's listening to me. I feel like my opinion doesn't matter,’” Dr. Rafferty said. “I really feel in those situations like you've lost such a valuable opportunity for input and perspective.”
Learn more about why anti-transgender bills are a dangerous intrusion on medicine.