Book review
Reviewed by Sergio Peñalver Férez 
Universitat Jaume I-IULMA, Spain
Michelle Forcier, Gerrit Van Schalkwyk, and Jack L. Turban, present their multidisciplinary, collaborative volume Pediatric Gender Identity: Gender-affirming care for Transgender & Gender Diverse Youth in 2020. In it, the editors offer a broad overview of the current research, clinical recommendations, and conceptual frameworks in the field concerning affirmative care for transgender and gender diverse (TGD) youth. In addition, more insight is provided on diversity support and resiliency encouragement, along with discussions about primary and specialty care, neurodevelopmental and psychosocial needs of TGD, and recognized hormonal and surgical recommendations. In this review, I will describe the main contents of the volume according to four sections: foundational knowledge, psychosocial and supportive approaches, clinical care and treatment, and cultural and legal perspectives. The first section covers Chapters 1 to 4; the second section, from
Chapter 5 to 10; the third section, from Chapter 11 to 17; the remaining chapters are discussed in the last section.
The first four chapters align the increased recognition of TGD youth on a sociopolitical scope with the work within the medical and mental health communities to widen current knowledge and best cater for the needs of this marginalized population. Chapter 1 presents essential terminology regarding gender (e.g. gender identity, gender expression, transgender…) with crucial attention to the ever-evolving nature of gender diverse youth’s self-identities through language. The notion of “affirmative care” is detailed through specific guidelines within medical practitioner-patient discourse (e.g. asking for the name and pronouns) without shifting this practice into a scenario in which the patient’s role is to educate and support the provider.
The purpose of Chapter 2 is to establish a foundation regarding transgender youth’s epidemiology for health care providers according to the increasing number of TGD people present across numerous contexts. Studies are mentioned evidencing the existence of TGD adolescents and adults across several states in the United States of America and New Zealand, concluding that there is no correlation between TGD youth identities and the local particular environment of the areas in which these studies were carried out. Among the issues regarding the high risk of mental health concerns, the alarming suicidality rate, whether through ideation or attempt, are put down in numbers for adults and teenagers (Grossman & D’Augelli, 2007; see also Toomey et al., 2018). A noticeable focus is placed upon social vulnerabilities TGD youth face regarding socioeconomic status, physical and sexual safety, and overall health. With this, the author points out the continuity of these risk factors into adulthood and how they worsen when race and cultural identity are incorporated into the formula.
The remaining chapters in this section, Chapters 3 and 4, offer an overview of the scientific approach to gender identity and development from an evolutionary perspective and the neurobiological mechanisms underlying gender diversity. On the one hand, Chapter 3 briefly overviews the historical evolution of studied related to childhood gender development and provides relevant insight on the manifestation of gender roles (Rafferty et al., 2018) and the major contributors to gender. On the other hand, Chapter 4 expands on the previous chapters’ notions by reviewing literature approaching gender diversity through neurobiology. This includes varying findings related to genetic factors, early sexual differentiation, adolescent brain, and the effects of hormone treatment on TDG youth compared to treatment-naive ones.
Moving away from the genetically-driven approach to TGD youth, the following five chapters tap into psychological and supportive approaches. Chapters 5 and 9 delve into factors related to stress, mood, and anxiety, among other mental health concerns. Chapter 5 expands the minority stress model to include TGD identities, and from this new standpoint, applies its different factors to this community. Likewise, it notes supporting sources (e.g. parents, schools, peers, as well as medical providers) and the importance of their affirmative-approach stance to reduce negative health outcomes and boost resilience among TGD youth and their families.
Chapters 7 and 8 focus on the creation of safe spaces in settings related to health and therapy and how their starting point is located within primary care. Chapter 7 recognizes the vulnerable condition in which TGD patients find themselves, which may be marked by parental rejection (Klein & Golub, 2016), peer hostility (Russell et al., 2011), and diverse forms of minority stress, notwithstanding the internalized transphobia they may be experiencing (Rood et al., 2017). As transhealth providers, the focus must be placed on the patient, as they are experts in their own thoughts and feelings. These notions are extended in Chapter 8, which departs from the crucial role primary care providers have in ensuring mental, physical, and social health among their patients. Of special mention is the screening tool provided in this chapter for adolescent and young adult guidance for gender diverse youth that health professionals could benefit from.
Continuing with the structure of the manual, Chapter 9 discusses other difficulties that may be faced among TGD people, with Chapter 10 focusing on neurodevelopmental concerns. Different studies are presented using a variety of measurements to examine coexisting related difficulties, such as social anxiety disorder, major depression, oppositional defiant disorder, specific phobias, and disorders related to anxiety, mood, and disruption (de Vries et al., 2011). In addition to these mental health issues, other factors may lead to the application of a gender-affirmative treatment, including the capacity to make decisions on the adolescent’s end after browsing treatment options and choosing according to their values and preferences, as well as the level of acceptance of their social environment. As an extension of the previous one,
Chapter 10 introduces transgender and gender diverse youth care with co-occurring neurodiversity. It introduces notions related to the autism spectrum disorder, and its co-occurrence with (T)GD explained through biological, psychological, and social factors, as well as ways to assess and treat children and adolescents under this profile.
The third section introduces different treatments and procedures TGD youth may undergo from their prepubertal stages up until early adulthood. As preliminary knowledge, some theoretical background is introduced in Chapter 11; from this, it is worth recommending the section on staff engagement and education, which provides specific details on how to avoid assumptions we make about gender in the way we use everyday language and how to adjust to these presumptions.
Another keystone included in this section is Chapter 12, which places psychotherapy as pivotal to approach affirmative care for adolescents found within the gender diversity spectrum. Combined with insight from clinical practice and the growing body of literature on this matter, this chapter provides an overview of different modalities and considerations to transform mental health care into a model that affirms the identities of those seeking support.
In the case of Chapters 13 and 14, treatment paradigms are described to assess prepubertal children and adolescents, respectively. Chapter 13 recognizes the radical transformation regarding children who transgress gender norms, in addition to an increasing number of individuals seeking out services in relation to their gender identity and expression. Among them, a gender affirmative model is progressively gaining traction among practitioners, with the aim of facilitating healthier lives among children struggling with their identities.
This is further developed on Chapter 14, which addresses treatments for gender-diverse teenagers, like administrating Gonadotropin-releasing hormone analogs, gender-affirming hormones, and procedures like gender-affirming surgery during pre-hormone, puberty, as well as adjunctive therapies. In that respect, the chapter authors provide a set of questions and affirmative responses on the medical provider’s end to obtain a gender history about their patients.
The remaining chapters in this section (i.e., Chapters 15, 16, and 17) explore further treatments available for TGD individuals who may want to pursue other gender-affirming therapies. A common concern among the use of these treatments is related to fertility, which is covered in Chapter 15. In addition, some considerations are offered for late adolescence and early adulthood across areas like employment, healthcare, family, and higher education in Chapters 16 and 17.
The last section includes two chapters on national considerations related to the transgender community in the United States and international ones in Africa and a final chapter regarding legal issues and transgender people. Chapter 18 aims at providing information on the equipment of clinicians with relevant caveats to consider for such a diverse community. Among them, the privacy that is entailed within gender exploration is an aspect that oftentimes goes unnoticed. This is explained with insights from a fictional patient who, like many TGD people, requested their clinicians to hold details that they wanted their families or close circles to be unaware of. With this example, importance is placed upon how gender and sexual minority youth must confront stigma and shame, along with their repercussions, through silence, which may explain why this persistent stigma may cause a higher risk of suffering a mental illness.
Despite the accelerating recognition and tolerance toward diverse expressions of sexual orientation, gender identity, and sexuality, Chapter 19 draws attention to how some states and governments on an international scale continue to criminalize homosexuality, restrict certain sexual desires and practices, along with the fulfillment of human rights. Through a case study, insight is provided from the context of children and teenagers’ experience in South Africa regarding the protection, challenges, and cultural development of their gender identity.
The aforementioned context brings this section to an additional chapter delving into legal considerations for TGD youth. Using the federal-focused and state-focused scopes, Chapter 20 exemplifies legal documents that approached gender-identity-based discrimination and its prohibition across all US states. In short, the current panorama over transgender rights is still being fought over in politics and legal administrations, evidencing the need for healthcare professionals to work toward trans-affirmative laws and cultural environments to support this community.
Pediatric Gender Identity: Gender-affirming care for Transgender & Gender Diverse Youth offers a comprehensive and multifaceted approach to understanding and addressing the needs of TGD youth. By covering a wide range of topics according to the four sections designed, it provides a holistic view which healthcare professionals and educators may find valuable to understand the epidemiology, neurobiology, and pathways related to gender development, alongside practical guidance on patient-centred care, primary care, and acute care considerations.
The manual’s exploration of cultural and legal perspectives evidences a nuanced understanding of the broader contexts in which the transgender community navigates, but most importantly the work that remains to be done beyond the healthcare system. In order TDG individuals to be ensured progressively safer environments, affirming care must be transferred into other areas, such as education, workplaces, legal and policy frameworks, as well as media and entertainment services.
REFERENCES
de Vries, A. L. C., Doreleijers, T. A. H., Steensma, T. D., & Cohen-Kettenis, P. T. (2011). Psychiatric comorbidity in gender dysphoric adolescents. Journal of Child Psychology and Psychiatry, 52(11), 1195–1202. https://doi.org/10.1111/j.1469-7610.2011.02426.x
Grossman, A. H., & D’Augelli, A. R. (2007). Transgender youth and life-threatening behaviors. Suicide and Life-Threatening Behavior, 37(5), 527–537. https://doi.org/10.1521/suli.2007.37.5.527
Klein, A., & Golub, S. A. (2016). Family rejection as a predictor of suicide attempts and substance misuse among transgender and gender nonconforming adults. LGBT Health, 3(3), 193–199. https://doi.org/10.1089/lgbt.2015.0111
Rafferty , J., AAP Committee on Psychosocial Aspects of Child and Family Health, AAP Committee on Adolescence, & AAP Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. (2018). Ensuring comprehensive care and support for transgender and gender diverse children and adolescents. Pediatrics, 142(4), e20182162. https://doi.org/10.1542/peds.2023-063756
Rood, B. A., Reisner, S. L., Puckett, J. A., Surace, F. I., Berman, A. K., & Pantalone, D. W. (2017). Internalized transphobia: Exploring perceptions of social messages in transgender and gender-nonconforming adults. International Journal of Transgenderism, 18(4), 411–426. https://doi.org/10.1080/15532739.2017.1329048
Russell, S. T., Ryan, C., Toomey, R. B., Diaz, R. M., & Sanchez, J. (2011). Lesbian, gay, bisexual, and transgender adolescent school victimization: Implications for young adult health and adjustment. Journal of School Health, 81(5), 223–230. https://doi.org/10.1111/j.1746-1561.2011.00583.x
Toomey, R. B., Syvertsen, A. K., & Shramko, M. (2018). Transgender adolescent suicide behavior. Pediatrics, 142(4), e20174218. https://doi.org/10.1542/peds.2017-4218
Received: 17 May 2024
Accepted: 06 June 2024