Most Teens, Parents, Clinicians Ok With Gender Identity Screening During Wellness Visits: Pilot Stud

When questions about gender were added to the standard pre-visit questionnaire for adolescent wellness visits at a Northern California healthcare network, the majority of teens, parents and clinicians were OK with it, a new pilot study finds.

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A survey given to the more than 300 adolescents, their families and doctors in the study revealed that two thirds of the teens, three quarters of parents and more than 90% of clinicians believed it was important to screen for gender identity in primary care, according to the report published in the Journal of Adolescent Health.

The researchers also found that the odds of teens saying they were gender diverse was substantially higher in the two clinics that added the question than in clinics that did not.

"The take-home message is that teens and parents found this to be a question that was important for us to ask," said the study's lead author, Dr. Josephine Lau, an adolescent medicine specialist at the Kaiser Permanente Medical Center in Hayward, Calif. "The majority of clinicians felt the same way. Only a third had concerns about adding the questions because they would take extra time."

Dr. Lau added, "And even though this was a small pilot study, when we added the questions, it really increased the number of teens who identified as transgender or gender diverse."

Dr. Lau couldn't predict how this strategy would be received elsewhere.

"One of the limitations of the study is that it's a small pilot study in the San Francisco Bay Area," she said. "I don't know if the findings can be generalized to the rest of California or how applicable this would be to the rest of the country."

To explore whether adding questions about gender identity to the standardized Kaiser Permanente Northern California (KPNC) pre-visit "Teen Well Check Questionnaire" would be feasible and acceptable, Dr. Lau and her colleagues set up an experiment in which two pilot clinics would add three questions about gender while the remaining ones in the network did not. Those three questions were: (1) What is your gender?" (2) "What sex were you assigned at birth?" and (3) "If your gender is different from your assigned sex at birth, have you discussed this with your parent(s) or guardian(s)?"

The study included all adolescents aged 12 to 18 who presented for a wellness appointment at a KPNC primary care clinic between July 1, 2018 and June 30, 2019.

In an anonymous survey given to teens, parents and clinicians, 66% of teens, 75.5% of parents and 92.5% of clinicians felt it was important to screen for gender identity. Less than 2% of adolescents and 2.82% of parents found the questions to be offensive, while 36.4% of physicians were concerned it would affect workflow.

Adjusting for age and race/ethnicity, teens had higher odds (aOR=6.91) of reporting gender diversity in the pilot clinics than in the clinics providing usual care.

The questions asked in the pilot study could lead to better outcomes, said Dr. John Steever, an associate professor of pediatrics at the Icahn School of Medicine at Mount Sinai and Mount Sinai's Adolescent Health Center. "A study like this gets the idea of gender diversity out there," Dr. Steever said.

Gender non-conforming kids are at greater risk for suicidal thoughts, suicide attempts, suicide, substance use, STDs, including HIV, and bullying, Dr. Steever said. "If you can bring something like this into the light, it can allow discussion that can give support to these kids," he added.

It's important to recognize gender identity as an important part of someone's mental health, said Dr. Gerald Montano, an assistant professor of pediatrics at the University of Pittsburgh and medical director of the Gender & Sexual Development Program at the UPMC Children's Hospital of Pittsburgh.

"Part of the reason it's important is that a lot of transgender and gender diverse youth have more mental health problems because of dysphoria, stigma and discrimination," Dr. Montano said. "Pediatricians can make referrals not only for hormones, but also for the treatment of anxiety and depression. Additionally, because a lot of parents trust their kids' pediatricians, they have the ability to bridge gaps between the kids and their parents."

While the questions might not be as welcome in other parts of the country as in the Bay Area, they are important to ask, Dr. Montano said. "Regardless of whether the teens are in the Bay Area or a rural community in the Midwest, a lot will face the same problems because of stigma, discrimination and dysphoria," he added. "And physicians are in the unique position to address their mental health needs."

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