Going to the movies is something I have always enjoyed. What I don’t always enjoy is waiting in line to use the bathroom after the movie is over and invariably picking a stall that has run out of toilet paper or that is in need of cleaning. These minor inconveniences in no way compare to the experiences some of my transgender patients have shared with me. Many of my patients tell me that they avoid using bathrooms in public places because of the anxiety they feel at having to pick a bathroom. Do they use the one that matches their sex assigned at birth or the one that matches their gender identity? Will they be safe and free from harassment in either bathroom? Some of my patients tell me they avoid drinking water at school just so they do not have to deal with going to the bathroom there.

Recently there have been bills introduced in several states that seek to deny transgender youth access to sex-segregated spaces including restrooms and locker rooms. These bills stigmatize an already vulnerable population, potentially increasing their risk of negative health outcomes. In a survey of transgender people in Massachusetts, 65% of respondents reported being discriminated against in public accommodations, and this discrimination was associated with poorer mental and physical health outcomes.1

In February of 2016, the American Academy of Pediatrics and several other organizations dedicated to the health and welfare of children came out with a letter to state governors in opposition to these bills.2 It states: “Transgender kids are already at heightened risk for violence, bullying, and harassment, and these bills exacerbate those risks by creating a hostile environment. … In addition, students who would be affected by these bills are among our most vulnerable to experiencing depression and engaging in self-harm, including suicide.”

On May 13, 2016, the U.S. Department of Justice and the U.S. Department of Education jointly issued a letter directing public schools to allow transgender students to use bathrooms that correspond with their gender identity.3 The letter was accompanied by a 25-page document with examples of policies and emerging practices to support transgender students.4

Proponents of these bills state that their purpose is to increase public safety and protect privacy. There are concerns that individuals may take advantage of these policies to sexually harass people in sex-segregated spaces. To date, there are no data to support these claims. In interviews conducted with heads of state police departments in 12 states that have nondiscrimination laws to protect transgender people in public settings, not one of the participants indicated any increase in sexual harassment or abuse in connection with these laws.1 In addition, should any type of harassment occur, it would not be protected under antidiscrimination laws, and perpetrators would be subject to criminal penalties.

What can we do as health care providers to support our patients?

•  Educate ourselves. Keep up to date with best practice guidelines and evidence on how to promote the health and well-being of all children. The National LGBT Health Education Center has many educational resources to help health care providers provide quality care to LGBT patients and families. It is important to be aware of resources to help patients and families be aware of their rights and advocate for themselves in other settings such as school and work. Two organizations that provide this support and information are Trans Youth Family Allies and Lambda Legal .

•  Create safe spaces. Create spaces in our practice settings where children and youth can safely explore their gender identity and gender expression. This can be done by providing access to gender-neutral bathrooms, prominently displaying nondiscrimination policies that are inclusive of gender identity, and modeling recognition of the variety of ways gender can be experienced by asking and using patients’ preferred names and pronouns.

•  Advocate. Advocate for gender-inclusive environments within local youth-serving organizations including schools, medical facilities, and child welfare agencies. Share available information about the potential negative health effects of stigmatization and discrimination in transgender youth.

Together we can work to promote the well-being of all children.

Resources

•  The National LGBT Health Education Center (www.lgbthealtheducation.org/).

•  Trans Youth Family Allies (www.imatyfa.org/).

•  Lambda Legal (www.lambdalegal.org/know-your-rights/youth).

References

1. Policy Brief: State Anti-transgender Bathroom Bills Threaten Transgender People’s Health and Participation in Public Life. Fenway Institute and Center for American Progress, 2016.

2. American Academy of Pediatrics letter on sex-segregated spaces (www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/AAP_HRCLetter.pdf).

3. Department of Justice and Department of Education Dear Colleague Letter on Transgender Students (www.justice.gov/opa/file/850996/download).

4. Department of Education Examples of Policies and Emerging Practices for Supporting Transgender Students (www2.ed.gov/about/offices/list/oese/oshs/emergingpractices.pdf).

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

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