A Q&A with Dr. David Inwards-Breland

Transgender youth have unique medical needs. Finding appropriate care for these patients, and their families, can be challenging.

Seattle Children’s offers the only multidisciplinary clinic in our region for youth who are transgender or gender-nonconforming. Because demand for these services is high, patients are not always able to get scheduled at the Gender Clinic as quickly as they might like.

Dr. David Inwards-Breland, medical director of the Gender Clinic, offers the following advice to providers caring for transgender or gender-nonconforming patients who may be waiting to see a specialist at Children’s.

Thank you to Dr. Wendy Sue Swanson, a pediatrician at The Everett Clinic in Mill Creek, a member of Children’s medical staff, chief of digital innovation for Children’s and author of the Seattle Mama Doc blog, for submitting these questions.

When do children typically establish a sense of their own gender? If it is different from the sex that they are born with, when do you think these children and families need extra support?

By the age of three years old, most children are able to tell you if they are a girl or a boy. They learn that from their parents and society’s defined gender roles.

For those who are gender-nonconforming, it varies. There are some gender-nonconforming children, around ages three or four, who say “I wish I were a girl/boy” and have gender-nonconforming play or dress. Then there are others who state that they are the opposite gender and others still who will go along with what their assigned sex at birth is but will later come out as transgender.

Research shows children have better outcomes when they feel comfortable exploring their gender identity. Regardless of a child’s gender expression, families need support from everyone in their environment – including their school and extended family. They need to know it is okay to have a different gender expression or to socially transition, with name, haircut and/or pronouns.

It is also important for these families to have the support of their primary physician and a mental health counselor, if they need it.

How does the Gender Clinic provide integrated or multidisciplinary care?

Our doctors have special training in adolescent medicine, endocrinology and emotional health. Social workers, nurses and medical assistants are also part of our team.

Our specialists work together to coordinate care when possible. We meet every Tuesday morning to talk about our patients and discuss different opinions and perspectives. We tailor treatments to each patient and family, taking into account age, stage of puberty, desired future treatments, support systems and any health problems.

Because of high demand and the lack of regional medical resources for transgender individuals, wait time for new patients in our clinic can be up to a few months. All patients have a phone intake with a social worker, who serves as their care coordinator. The coordinator triages and can connect them to resources in the community, help schedule assessments with the physicians and answer any questions they might have.

What services do you provide at the Gender Clinic and what do you not provide?

We do pubertal blockers on a case-by-case basis, because it’s not always an option for patients who have finished puberty. When appropriate, we offer three month injections or place a longer-acting blocker called a histrelin implant that lasts about a year.

We also do cross-sex hormones, testosterone and estrogen, on a case-by-case basis.

Surgical treatment of transgender individuals can be part of their overall treatment plan, including “top” surgeries (bilateral mastectomies or breast augmentation) and “bottom” surgeries (hysterectomy or the creation of a penis or vagina). Children’s Gender Clinic does not provide any surgeries, including gender affirming surgeries.

However, we do support top surgeries for transgender males who need them. Our care coordinator helps patients determine their insurance coverage for these procedures.

Patients can get bottom surgery at ages 18 and up. It is very expensive, and there is no bottom surgery offered in Seattle. I’ve had patients get assessments outside of Washington, and I do support them if that is what they want.

We do discuss mental health support to help patients cope with their feelings and concerns related to gender identity and transition. We do not provide ongoing therapy for patients, but we strongly encourage ongoing mental health support from an outside mental health provider or a provider in Children’s Psychiatry Department.

We know transgender youth are at risk for low self-esteem, substance abuse and other emotional and mental health problems. What psychosocial supports do children with gender identity challenges most benefit from?

Having the support of providers who affirms their gender the moment they walk through the door with pronouns and preferred names is huge. And visiting a clinic that specifically addresses gender issues, like Children’s Gender Clinic, helps too.

Support from social workers like ours can address the many different issues that come up with children who are gender-nonconforming, especially if one or both parents are not fully on board.

Offering support to parents, possibly in support groups with other parents, can make a big difference to transgender youth. Children’s hosts a Transgender and Gender-Diverse Children Support Group, which is great for parents, teens and younger children.

Ongoing mental health assistance for the patient, and their parents, can also help. Even if the patient has started treatment, they will likely still face issues during their transition.

How can providers reduce the suffering of youth who have gender fluidity, identify as transgender or have questions about their sexuality or gender identity?

A University of Washington study published in Pediatrics last year found that transgender patients who transition socially – meaning they change their names, dress, hair or pronouns – had similar rates of depression and anxiety as their peers, whose gender identities match the sex that they were assigned at birth.

Meanwhile, ongoing gender dysphoria that is not treated will more likely lead to depression and anxiety.

Let your patients know it is okay for them to be who they are. Don’t make gender-nonconformity taboo. That is very important. Use pronouns correctly and be open with them.

Provide families with resources so they can help their child. Research shows that if a family supports their young person, the patient has less depression and suicidality.

Help create an affirming environment for gender-nonconforming youth. Advocate for making things gender neutral in schools and the greater community.

Online resources for parents and teens:

Online resources for providers: