Increasingly under attack in other states, how gender-affirming care works in Vermont
Around the country, at least 17 states have banned or limited gender-affirming care. In Vermont, the health care for transgender adults and children is protected.
Age-appropriate gender-affirming care for transgender and nonbinary people has support from the American Medical Association and the American Academy of Pediatrics. However, opponents of gender-affirming care have expressed concerns about the lack of data on possible long-term consequences of gender-affirming medical treatments in minors.
Dr. Kimberlee Roy, a clinical child and adolescent psychologist with the UVM Medical Center Transgender Youth Program, spoke with Vermont Edition host Connor Cyrus about what gender-affirming care looks like in her clinic. Their conversation below has been edited for clarity. (Cyrus also spoke with Zpora Perry, social worker, case manager, and co-director of the Ryan White Project at UVM Medical Center HIV/AIDS Comprehensive Care Clinic, and you can listen to that conversation in the audio above.)
Connor Cyrus: Let's just have you start us out by telling us about the work you do with the transgender youth program at UVM Medical Center.
Dr. Kimberlee Roy: The transgender youth clinic is an out-patient program where we see children and adolescents who identify as transgender or nonbinary. They come in for an initial assessment with parents, and we do a full biopsychosocial assessment to assess all the different areas of their lives. And this happens before a medical appointment happens.
What is a biopsychosocial assessment?
Yes, that is a very big word. Biopsychosocial assessment is basically meaning that you are getting a picture of the whole person --- not just a psychological assessment, where you're just asking about their moods, or feelings or behaviors. You're looking at: How are they functioning physically? How are they functioning mentally, in school, family functioning, all those different things to make sure that you know the total person, as much as you can.
Around what age do you start to see patients and families come in for this biopsychosocial assessment?
We've had patients as young as 5 come in for those assessments. We prefer to wait until they're closer to puberty because the medical side of the clinic will not see any children before they go into puberty. But we do some consultation with some younger patients.
Walk us through this assessment process and really what you're looking at.
We're looking primarily at first for an experience of gender dysphoria. We ask kids and teens about their gender journey, how they first came to understand their gender as different and how that has evolved over time, who they came out to first and all those things.
After we've gotten a really good idea of those things, we move into looking at, are there any psychological issues, psychiatric issues, anything that's been diagnosed with, any medications, histories of treatment? Then we look at family functioning. Kids and teens are actually usually looking for something specific. And parents may not be ready for that specific intervention.
What should parents know when their child approaches them and says, "Hey, mom, dad, guardian, parent — I'm not feeling like the person that is on the exterior, I feel different on the inside." What's an appropriate initial response to that?
That is very hard for a lot of people. Parents will say that they're a little bit shocked the first time they heard that. But the best thing you can do is listen to your child with an open mind and let them talk, and don't shut them down. Don't say, "This is not OK, this is not acceptable. This isn't happening. You don't know what you want." Those negative statements will often lead to the adolescent or child shutting down, and not using that adult as a resource.
On the flip side, for adults who might suspect that their child isn't presenting the same gender that they were assigned at birth, is there a way for parents to bring up the conversation if maybe the child isn't ready?
If the child isn't ready, we suggest to parents that they can periodically ask, "Hey, are you OK with the pronouns you're using right now? Do you want to switch them? Have you thought about your name? Is that an OK-name for us to still call you?" Just being very open to having the child lead what they want to do.
"[T]he best thing you can do is listen to your child with an open mind and let them talk, and don't shut them down. Don't say, "This is not OK, this is not acceptable. This isn't happening. You don't know what you want." Those negative statements will often lead to the adolescent or child shutting down, and not using that adult as a resource."Dr. Kimberlee Roy
So there's no sense of pushing children out if they're not ready, or forcing them into conversations.
No, we don't recommend delving in and saying, "No, we really need to figure this out." Because for each person, it's an individualized journey. And they may not be ready, because they don't quite have a concept of it themselves in their head. And sometimes they really need to figure that out before they're ready to talk.
One of those concepts that I think a lot of people, especially transgender youth, might struggle with is gender dysphoria. Tell us about what that is, and what that journey can look like for people who identify as transgender.
Gender dysphoria is essentially a series of feelings that you get, because of how you think of yourself on the inside does not match your outside features. So you may have secondary sex characteristics that don't match what you think of yourself, you may be asked to dress in a way that doesn't match what you think about yourself. And that pressure and those things happening often cause anxiety, depression feelings. A real sense of, "This is wrong, and I'm having a hard time melding the two together. My physical isn't melding with my mental, and I need to find a way to get them on the same page."
How does the medical community address gender dysphoria?
There are a variety of things. Of course, near and dear to me as a psychologist, we always recommend therapy. Because talking to a trusted person about what's going on in your head, without worrying about, you're offending someone, or you're going change your mind or something, it's talking about it and coming to terms with it.
After that, there are different things that the medical community can do to help relieve some of that gender dysphoria. If a child or an adolescent who has gone into puberty, wants to stop physical changes from happening, medical doctors will give them a puberty blocker, if that's appropriate. So what that does, is it stops development of secondary sex characteristics. It basically stops testosterone or estrogen from being produced in the body and keeps you from going any further than you have.
After that, if you're old enough, as you grow up as an adolescent and are still having a lot of dysphoria, then the discussion of hormones — cross-gender hormones — comes in, when you go on testosterone, when you go on estrogen, and there's a lot of long conversations about that. As teens and young adults who are much older, then you can talk about any surgical interventions that may be appropriate.
These are all examples of gender-affirming care, what you just described. Can you take a step back? And can you just tell us broadly, what gender-affirming care means and what it means specifically in your industry?
Gender-affirming care is a very broad term that means that your medical team believes you and understands what to do. It can be as simple as when you talk to your primary care provider or pediatrician that they say, "What pronouns would you like to use? Would you like to change your name and our charts?" And making sure that occurs, so that the whole staff addresses the teenager appropriately. It's knowing, OK, I need to send this person to the gender clinic to talk about interventions that they may qualify for or need. On the mental health side, it's very much acceptance and listening.
You mentioned doctors, and other health care professionals using the correct pronouns. How important is that for children, that adults use the pronouns that they asked them to use?
It is incredibly important. It is one of the first things that has to be worked on, is getting the people around the child or adolescent to use the correct pronouns and preferred name. That is, that is a huge step. Research has found that that kind of affirming practice, those kinds of affirming practices in the adults really help with the person not developing depression, or anxiety or other issues.
"It is one of the first things that has to be worked on, is getting the people around the child or adolescent to use the correct pronouns and preferred name. That is, that is a huge step. Research has found that that kind of affirming practice, those kinds of affirming practices in the adults really help with the person not developing depression, or anxiety or other issues."Dr. Kimberlee Roy
Can you roughly tell us how many people we're talking about when it comes to transgender youth? According to Pew Research [Center], less than 2% of adults identify as transgender, and about 5% of youth identify as transgender or nonbinary. Does Vermont follow those trends in terms of what you're seeing?
We see a higher rate of at least initial assessment of these things. I think that the youth in Vermont feel a little bit better than in many places, that they're free to explore their gender identity. So, they may first present as nonbinary, or say, "I think I am really male." And they may change their mind over time, which is why we always recommend therapy first, before we do anything medical. And so I think the population is a little bit higher in Vermont. We are now finding that families are fleeing other states and coming here for care.
What does that mean for the infrastructure that we have to take care of transgender youth?
As anyone who has tried to get an appointment can tell you, we have a very long waitlist right now. We took a slight pause in our waitlist and stopped scheduling because we did not have enough doctors to take care of the youth who were presenting. We could do the initial assessment, but we could not do the follow up that needed to happen. We were just approved to hire a new doctor, a new psychologist, a social worker and a nurse. It is in the plans to increase our services, because we really don't have enough to meet the need.
What are some of the myths people have about transgender care?
One that always gets me is the thought that we are doing surgery on children. We are not doing surgery on children. We are not giving children hormones. This is a long process. It's not like you come in for your medical appointment and you're handed a prescription. There are checks and balances in the system to make sure that everybody has all the information, everybody's comfortable. The myth is that you can come in and just get a prescription for testosterone or estrogen and go on your way. And that's really not happening, at least here.
How often do these patients change their minds about how they identify?
We know that people who have gone through medical transition, it's about 1-2% of those people want to detransition. For adolescents and kids, there's usually a kind of progression — often kids will tell me that they came out as nonbinary because they thought it would be easier for their parents, and then they came out as trans. So that could be seen as a change, but we see it more as just an evolution in their journey. I'm not really sure what the numbers are, but it is pretty low.
The University of Vermont Health Network is an underwriter of Vermont Public.
Broadcast at noon Thursday, June 8, 2023; rebroadcast at 7 p.m.