The Hospital for Sick Children in Toronto, Ontario, recently opened a clinic for transgender youth where an interdisciplinary team aims to provide compassionate, holistic care to a marginalized population with specific health care needs and priorities.
“I think it’s safe to say that we’re behind, especially with Toronto being the largest city in Canada,” says the clinic’s physician lead Dr. Joey Bonifacio.
Indeed, pediatric hospitals in British Columbia, Manitoba, Quebec and Nova Scotia already have transgender adolescent clinics. There is, however, a benefit to being tardy: Bonifacio and his team were able to observe other clinics in Canada and the United States and decide which elements to adopt.
In the Toronto clinic, a team consisting of physicians in adolescent medicine and endocrinology, a nurse practitioner, a nurse and a social worker provide youth and their families with the resources and care they need while allowing for better continuity of care. “Each person is good at what they do,” Bonifacio says, adding that the clinic is a one-stop location for families.
When youth have gender dysphoria, an extreme and persistent discomfort with their biological sex or gender role, they often feel distress, especially as they move into puberty. “If you were to interview transgender adults, a lot of them would say that one of the most difficult times in their life was during puberty,” says Bonifacio.
For this reason, the clinic is designed to work mainly with youth on the verge of puberty to assess their needs and desires. For some patients, the clinic will prescribe hormone blockers to halt puberty. This can buy time for youth to consolidate their gender without the psychological stress of their bodies betraying the way they see themselves.
A patient can decide to resume puberty by quitting the hormone blockers. But if a youth decides to pursue sex change, whether through cross-sex hormones alone or combined with surgery, having used hormone blockers will make the transition easier. If started early enough, they will prevent puberty-related physical changes such as breast development or body hair growth, reducing the need for mastectomies in transgender men and electrolysis in transgender women.
The clinic will provide cross-sex hormones for older youth, around the age of 16, who have been associated with the clinic long enough for the team to determine if it is an appropriate course to take.
The clinic provides more than medical services, however, and is driven by the youth’s needs. “You ask the youth, ‘What exactly can we do for you?’” says Bonifacio. “And it may not be medical management.”
When the team meets with youth, they do a full medical history but also a social history to learn what’s happening at home and at school. They also look into issues that transgender youth struggle with disproportionately, including anxiety and depression.
The clinic can connect youth and their families with resources, as well as help facilitate social transitioning, if that is what the youth wants. This means changing the youth’s gender publicly, which could involve several changes, such as a new name and wardrobe.
Having organized, interdisciplinary care for transgender youth may also help address some of the difficulties they have in day-to-day life. Thirty-six percent of transgender Ontarians said they had suicidal thoughts in the past year, according to the Trans PULSE Project. For transgender people aged 16–24, the rate was 50%. Some transgender youth self-mutilate to make their bodies correspond more closely to how they see themselves.
According to Lesbian, Gay, Bisexual and Transgender (LGBT) human rights organization Egale, many LGBT youth feel unsafe in their schools, especially in washrooms and change rooms. Fear of violence or humiliation is a powerful force, says Bonifacio, and school truancy is a common problem. This only adds to the distress youth with gender dysphoria already deal with.
Transgender children may also lack support from their parents. Two out of three transgender youths’ parents are not strongly supportive, according to the Trans PULSE Project. These youths tend to have lower self-esteem, are more than three times as likely to have symptoms of depression and 60% consider suicide, compared to 35% of those with strongly supportive parents.
The opinions of parents can also vary widely on specific aspects of care for transgender youth, such as the use of hormone blockers. “It’s all over the place,” says Dr. Dan Metzger, a pediatric endocrinologist at British Columbia’s Children’s Hospital, which has provided special care for transgender youth since 1998.
“These kids are at such huge risk,” he adds. “To not have anyone back you up is just horrible.”