Washington, DC -- Adolescence is a critical time of mental and physical development. For gender non-conforming youth, this time period can present very specific questions and challenges to identity. Ob-gyns are often uniquely positioned to support adolescent patients who identify as transgender. In a new Committee Opinion, The American College of Obstetricians and Gynecologists (ACOG) outlines recommendations and guidelines to help ob-gyns approach transgender adolescent patients’ needs with sensitivity and sound medical guidance.
It’s critical for ob-gyns to be familiar with transgender medicine because adolescents with gender dysphoria, or distress caused by the incongruence between one’s expressed or experienced (affirmed) gender and the gender assigned at birth, may first present to their gynecologist. Even when seeing a patient too young to consider hormone therapy, an ob-gyn can offer vital early behavioral health support, educational resources and referrals to specialists. This support helps ensure a more deliberate and smooth transition as patients age and begin to make decisions about how they want to live their life.
“Ob-gyns have the privilege of playing many roles in our patients’ lives. This is never more apparent than working with adolescent patients who are growing rapidly, mentally and physically, toward their adult selves,” said Committee Opinion author, Dr. Veronica Gomez-Lobo MD, Director of Pediatric and Adolescent Obstetrics and Gynecology, Medstar Washington Hospital Center/Children's National Health System. “We have a responsibility to approach transgender adolescents in an informed and thoughtful fashion, positioning ourselves as part of their support network during what can often be a complicated and emotionally fraught process.”
Creating a trusting environment for transgender patients begins from the moment a patient enters a doctor’s office. A medical practice can signal to transgender patients that they are safe and welcome by offering gender neutral forms, brochures and information for sexual minorities in the waiting room, and having sensitive employees at every step – from front desk to exam room.
Beyond the office environment, ob-gyns must prepare to comprehensively address the health of transgender youth. While sexual and reproductive health are an important part of an ob-gyn’s discussion with a transgender patient, there are also significant psychosocial considerations. Unfortunately, transgender youth face higher rates of social and parental rejection, which can often result in increased instances of anxiety, depression, sexual harassment, homelessness and risk-taking behavior. Ob-gyns should be prepared to assess and address these factors, offering patients resources, education and referrals to guarantee their health and safety.
Most importantly, it should be noted that there is no uniform transgender experience. The Committee Opinion covers the wide range of treatment options available for transgender patients, from hormone to surgical therapies. Expressing gender will vary from patient to patient; an ob-gyn’s responsibility is to help each individual make an informed decision that’s right for that patient.
This also includes addressing risk factors. Sexual identities and behavior patterns vary among transgender youth, but STIs are still a reality. Ob-gyns should continue to educate their transgender adolescent patients on safe sex practices and pregnancy prevention, including STI and HIV screening when necessary. Similarly, patients transitioning or transitioned from female to male will in most instances still be living with biologically female internal organs, and will continue to be at risk for ovarian masses, pregnancy and associated complications. Ob-gyns must remain vigilant in discussing, screening and identifying these gynecologic concerns in transgender patients.
Dr. Gomez-Lobo underscored this point. “The essential components of our role as health care providers do not change because an adolescent patient is transgender. Care should always include education about their bodies, deliberate and thoughtful assessment of symptoms or concerns, and preventive care services, like screenings and contraception. We are simply adding more nuanced cultural and medical understanding to those practices.”
The Committee Opinion, #685 “Care for Transgender Adolescents,” will be published in the January issue of Obstetrics & Gynecology.
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Other recommendations issued in the January Obstetrics & Gynecology:
Committee Opinion, #683 “Behavior That Undermines a Culture of Safety”
A key element of an organizational safety culture is maintaining an environment of professionalism that encourages communication and promotes high-quality care. Behavior that undermines a culture of safety, including disruptive or intimidating behavior, has a negative effect on the quality and safety of patient care. Intimidating behavior and disruptive behavior are unprofessional and should not be tolerated. Confronting disruptive individuals is difficult. Co-workers often are reluctant to report disruptive behavior because of fear of retaliation and the stigma associated with “blowing the whistle” on a colleague. Additionally, negative behavior of revenue-generating physicians may be overlooked because of concern about the perceived consequences of confronting them. The Joint Commission requires that hospitals establish a code of conduct that “defines acceptable behavior and behavior that undermines a culture of safety.” Clear standards of behavior that acknowledge the consequences of disruptive and intimidating behavior must be established and communicated. Institutions and practices should develop a multifaceted approach to address disruptive behavior. Confidential reporting systems and assistance programs for physicians who exhibit disruptive behavior should be established. A concerted effort should be made within each organization to educate staff (ie, medical, nursing, and ancillary staff) about the potential negative effects of disruptive and inappropriate behavior. A clearly delineated hospital-wide policy and procedure relating to disruptive behavior should be developed and enforced by hospital administration. To preserve professional standing, physicians should understand how to respond to and mitigate the effect of complaints or reports.
Committee Opinion, #684 “Delayed Umbilical Cord Clamping After Birth”
Delayed umbilical cord clamping appears to be beneficial for term and preterm infants. In term infants, delayed umbilical cord clamping increases hemoglobin levels at birth and improves iron stores in the first several months of life, which may have a favorable effect on developmental outcomes. There is a small increase in jaundice that requires phototherapy in this group of infants. Consequently, health care providers adopting delayed umbilical cord clamping in term infants should ensure that mechanisms are in place to monitor for and treat neonatal jaundice. In preterm infants, delayed umbilical cord clamping is associated with significant neonatal benefits, including improved transitional circulation, better establishment of red blood cell volume, decreased need for blood transfusion, and lower incidence of necrotizing enterocolitis and intraventricular hemorrhage. Delayed umbilical cord clamping was not associated with an increased risk of postpartum hemorrhage or increased blood loss at delivery, nor was it associated with a difference in postpartum hemoglobin levels or the need for blood transfusion. Given the benefits to most newborns and concordant with other professional organizations, the American College of Obstetricians and Gynecologists now recommends a delay in umbilical cord clamping in vigorous term and preterm infants for at least 30–60 seconds after birth. The ability to provide delayed umbilical cord clamping may vary among institutions and settings; decisions in those circumstances are best made by the team caring for the mother–infant dyad.
Committee Opinion #686, Interim Update, “Breast and Labial Surgery in Adolescents”
The obstetrician–gynecologist may receive requests from adolescents and their families for advice, surgery, or referral for conditions of the breast or vulva to improve appearance and function. Appropriate counseling and guidance of adolescents with these concerns require a comprehensive and thoughtful approach, special knowledge of normal physical and psychosocial growth and development, and assessment of the physical maturity and emotional readiness of the patient. Individuals should be screened for body dysmorphic disorder. If the obstetrician–gynecologist suspects an adolescent has body dysmorphic disorder, referral to a mental health professional is appropriate. As with other surgical procedures, credentialing for cosmetic procedures should be based on education, training, experience, and demonstrated competence.