Good GP care for transgender children: The parents’ perspectives

Abstract

Background

As more general practitioners (GPs) are consulted to navigate inclusive care for transgender and gender diverse (trans) children and young people, the experiences of families seeking care for trans children can inform GP practice.

Aims

The aims of this study were to understand the experiences of parents of trans children in their interactions with GPs when seeking care for their children; to inform GPs about families’ experiences of good care; and to complement existing guidelines and resources for GPs on affirmative trans healthcare for children.

Methods

This was a nation-wide, qualitative, constructivist study using semi-structured in-depth interviews, which was nested in a larger study on experiences of parents with a trans child across a range of Australian services and agencies. Eighteen parents of trans children in Australia were interviewed, recruited from online support and advocacy networks for parents of trans children.

Results

We found that although parents valued ongoing care from their family GP, some had to seek a new GP because they had or feared a negative reaction from their regular GP, or their regular GP did not have the knowledge to support their family. Parents sought GPs who would validate their child and affirm their child’s gender. Parents expected practical care from GPs such as referrals to gender-affirming specialists and other health practitioners, routine clinical procedures, and letters of support to services and agencies. Qualities that parents valued in a GP were a respectful manner, listening, putting the child first, asking appropriate questions, and being willing to learn.

Discussion

GPs that understand trans healthcare for children across a range of health areas and can respond positively in a respectful and matter of fact way to families are in short supply. Parent knowledge can inform GPs to support trans children in line with the Australian Standards of Care.

Keywords:

• Children
• gender affirmation
• general practice
• parenting
• transgender

Introduction

General Practitioners (GPs) play an important role for families in primary care and in navigating access to other health care. For parents of transgender and gender diverse (trans) children and young people, GPs are often an initial point of contact in their journey of the child’s gender affirmation (Chaplyn et al., 2024). We use the term ‘trans children’ to encompass children from birth to 18 who are gender fluid, gender diverse, or both trans and binary gendered (Horton, 2022b). The Australian Standards of Care for trans children set out the role of the GP as “vital in facilitating a smooth process” (Telfer et al., 2020, p. 26). Gender-affirming care from GPs is also beneficial when parents visit the GP with their trans children for reasons that are not directly related to gender identity.

Experiences of parents with trans children with GPs indicated room for improvement. In England, Rickett et al. (2021) found among the 85% of families with a gender diverse child who consulted their GP, 65% felt their concerns had been taken seriously, 24% felt they had received good advice, but only 16% thought that their GP had the knowledge they required. GPs referred 59% of the families to other services, but many parents had to provide the GP with information on the services they needed. Families also reported being sent to unnecessary services (Chaplyn et al., 2024). Parents may encounter GPs with pathologizing attitudes (Horton, 2023a). In an Australian survey of trans young people and parents of trans children (Strauss et al., 2017), only 54.7% of respondents were satisfied with the GP they accessed. Many reported that GPs had been “arrogant” or “rude, disrespectful and judgemental” (p. 97), and some GPs had refused gender-affirming treatment. Parents reported seeing multiple GPs and other healthcare specialists on their journey to access care, and having to tell their story over and over which is distressing (Strauss et al., 2017).

Effective GPs for adult trans people are signified by their use of affirming names and pronouns, knowledge to refer to other gender-affirming practitioners, and ability to build long term relationships with patients (Franks et al., 2023). Knowledgeable GPs are able to navigate the complex pathways which often delay access to trans healthcare (Chaplyn et al., 2024). However, the absence of training in trans healthcare leads to the scarcity and inaccessibility of experienced GPs (Strauss et al., 2017). Some GPs are respectful, open minded, and want to be helpful, but may not have experience or the know-how (Strauss et al., 2017). A willingness to learn is important for GPs in providing trans healthcare to young people and their parents (Bartholomaeus et al., 2021), and informal mentoring of GPs providing trans adult care can mitigate the lack of training and be “transformational” to their practice (Franks et al., 2023, p. 3260). Goulding et al. (2024) identified a lack of interventions that educate healthcare practitioners on the experiences of trans young people, and little co-production, with those with lived experience, of interventions to educate practitioners. Parents often take on the role of educating GPs (Chaplyn et al., 2024) but their perspectives are not always given enough attention in informing best practice. This paper reports on the accounts of parents of trans children of their interactions with GPs in Australia, to complement existing guidelines (Telfer et al., 2020) and provide a resource for GPs on affirmative trans healthcare for children.

Methods

Study design

This study is part of a larger nation-wide, qualitative, constructivist study using semi-structured in-depth interviews. The main study explores experiences of parents with a trans child across a range of Australian services and agencies (Townley & Henderson, 2024), and this paper reports on parent accounts of interactions with GPs. The study was underpinned by a trans inclusionary theoretical approach (Wesp et al., 2019) which centers embodied knowledge and recognizes that trans people are marginalized by structural inequities.

Ethics

Ethics approval was obtained from the Western Sydney University Human Research Ethics Committee (number H15457).

Author positioning

The first author is a non-binary researcher with a PhD in social policy and parent support. They are also a member of the research partner, parent advocacy group Parents for Trans Youth Equity (P-TYE). The second author is a mixed methods researcher on diversity, equity and inclusion who was trained as a GP overseas but does not practice in Australia. Both authors teach medical students in the Western Sydney University School of Medicine.

Participants and recruitment

The study population was Australian parents with trans children aged up to 25. Study participants were recruited in collaboration with P-TYE. Participants were purposively recruited based on them parenting a trans child or young person. Recruitment was through one parent advocacy network and one parent support network, via closed Facebook pages of parents with a trans child, and then by snowball sampling. Initially planning to recruit around 20 participants, we conducted 15 interviews with 18 parents, where three interviews had a father and a mother from the same family present. There was no reimbursement for participants. Participants have been allocated pseudonyms. In line with ethics protocols, and in order to protect anonymity since parents were likely to participate in the same online support groups, no further demographic information was collected about families other than the state where they lived. Participant families were from four Australian states, with the majority (10 out of 15) residing in New South Wales. Written consent was obtained from all participants.

Interviews

The first author conducted the interviews. The interview questions prompted parents to talk about their experiences with accessing a range of services for their trans children, including gender clinics, other health and medical services, education and government records. Specifically, parents were asked:

• What services or agencies have you interacted with?

• What did these services and agencies do well?

• How could they have done a better job?

• How could these services and agencies have worked better together?

All parents mentioned GPs in answering the first question, and were prompted to discuss their experiences with GPs.

Six interviews took place face to face in private homes where this was practical, and the remaining interviews were conducted online via Zoom. All interviews were audio recorded and transcribed verbatim, then transcripts were de-identified. The participants were offered an opportunity to check the transcripts; only two participants took up this offer and offered extra information or minor amendments.

Analysis

The interviews were coded by the first author and analyzed using NVIVO R1/2020 with “small q thematic analysis” (Braun & Clarke, 2023) which is commonly used in trans health research. In a small q approach, findings are organized around topic summaries, rather than the meaning based interpretive stories that are the themes in Big Q reflexive thematic analysis. Codes were developed using a combination of emergent codes, and a priori coding based on researchers’ knowledge and lived experience. Data pertaining to GP interactions were coded as such, and then organized into topic summaries. The two authors then discussed the analysis during the writing process. The second author co-designed the study, co-framed the analysis, and edited iterative versions of the paper drafted by the first author.

Results

The results are organized into four themes constructed from the data: finding a GP; validating and affirming the child; practical care needed by parents; and qualities of a good GP. These themes indicate that parents considered many aspects before entrusting the care of their trans children to a GP, and indicate how GPs can indicate their willingness to support families, and the knowledge base they require to do this well.

Finding a GP

Parents sought out a GP that they could trust. The GP’s initial reaction when parents raised the child’s gender diversity was paramount for parents. Parents reported that initial responses from GPs ranged from “I saw his whole demeanour change, very judgy” (Bobby) to “she just didn’t flinch” (Michelle) and “he didn’t bat an eyelid” (Ann). This initial reaction was important because parents were often feeling emotionally vulnerable: “Every time you have this conversation to explain yourself to everybody … you hold your breath, wondering if they’re going to be a horrible bigot or accepting … I burst into tears” (Bobby). If the reaction from the GP was negative, such as a GP who would not use the child’s correct pronouns, parents would not return.

Many families sought a new GP because they had experienced, or they feared, a negative reaction from their regular GP. Some parents suspected their GP would not respond positively to their trans children, like a parent who thought “it’s going to blow [my regular GP’s] mind”. After seeking trans-friendly GPs, they returned to their regular GP and were pleasantly surprised by an affirming reaction. “I probably shouldn’t have made that assumption about a 70 plus [year old] cis white male, but he’s, all credit to him, he’s been amazing” (Clare). In contrast, three parents reported disillusionment with their regular GP who they thought would be supportive. One compared the poor response from their regular GP who “had been amazing for so long, and then I just realized how something like that challenged him", with the new GP who reassuringly said “Yep, what do you need?” (Bobby).

Others sought a new GP because they found that their regular GP did not have the knowledge to support them. Some parents were helped in their search by recommendations on a trans health website. For another parent, whose child also had a chromosomal aneuploidy, a GP that was local and had the experience and willingness to see her child holistically was particularly important. This parent visited a number of doctors in the area, alone, to assess their response before bringing their child to the practice.

At the same time, continuity of care from a GP that gets to know the family over a long period was valued by parents. One family valued a GP that knew the child from a baby, in a practice with another GP with expertise in trans health care. Another felt ‘lucky’ to have the same family GP from when she was pregnant, where the practice nurse now administered gender-affirming injections for her teen child. Navigating trans affirming healthcare together can strengthen the relationship: “She’s been our GP for 16 years. She knows us all really well, and she knows us even better now” (Catherine).

Validating and affirming the child

Parents sought a GP who would validate their child, see the whole child, and affirm their child’s gender. Parents put their child at the center of decision making and they sought a GP who would also do this. Parents identified ways that GPs validated the child. For example, one GP was reported as saying “Well done. Congratulations for being brave enough to come out” (Catherine), and another said “What I am seeing here is a really clear case of gender euphoria” (Fabian and Gemma). This validation also made parents feel good about their parenting work, rather than judged.

Parents indicated that a base level for affirming GPs was using the child’s preferred pronouns and name; however, further practices also needed to be congruent. Affirming practices were also expected from the clinic as a whole. One parent was told “We can put the note [about preferred name and gender] on the file for you. But we can’t change your Medicare details and stuff” (Merryl). Parents considered some of the “stuff” to be in the control of medical practice, such as a non-binary option on enrollment forms and the use of preferred names by reception staff. These practices signaled to families that the practice was willing to provide holistically affirming trans healthcare. Merryl believed non-affirming practices went against GPs’ duty of care toward the child, and “may not be the best bit of information the child can hear” for their mental health.

Practical care needed by parents

Parents reported several examples of practical care they appreciated GPs providing, especially referrals. Parents sought referrals to a range of services, including children’s gender clinics at hospitals, private care for puberty blockers and hormones given the long waits at public clinics, psychologists, and autism assessments. Many parents had done their research and found where they needed to be referred. Others did not know what the next steps were and wanted the GP to be a “boss” (Fabian and Gemma) who would tell them what could be done and how to do it.

Parents reported that referrals were most effective when the GP had a network of trusted health professionals who would take the best care of the child, for example specialists who were experienced in working with trans children. This factor was beneficial for all healthcare provision, not only for accessing puberty blockers or hormones. One family reported that initially “our GP was fantastic, she said ‘look I am going to refer you to the local social workers … child and family services …, if you are having difficulties raising your kids you can go and chat with them’” (Daisy). Unfortunately, the local child health nurse then attributed the child’s trans identity to being breastfed for too long. This experience demonstrated the need for the GP to be able to refer families to professionals with a knowledgeable, trans affirming approach. Another family did not hear back from a gender clinic to which their child had been referred by their GP, only to find out later from another GP who followed it up that the gender clinic had not received it.

Apart from referrals, parents reported healthcare interventions that GPs could provide in their clinic. Two families obtained prescriptions for period suppressants from their GPs. Gillian explained that: “because his periods were really starting to distress him we looked into that. We’ve had an incredibly supportive family GP and she put him on to [a contraceptive implant] that pretty much stopped his periods” (Gillian). Two families reported that their GP or practice nurse administered puberty blocker or hormone injections prescribed by their endocrinologists. Two families reported that their GPs wrote letters of support for record changes such as Medicare. These actions of practical care were highly valued by the parents.

Qualities of a good GP

Parents appreciated GPs who were knowledgeable and experienced. A good GP “asked all the right questions … knew this stuff” (Catherine) and could explain medical pathways and choices to the adult and child. Particularly important was understanding the urgency of accessing puberty blockers for a pre-teen child. Having experience with trans adult healthcare was usually viewed as valuable, however, there was an extra level of knowledge required to care for trans children. One family felt uncomfortably like the first pediatric “study case” for their GP who only had experience providing care for trans adults.

Lack of knowledge and experience was not equated to poor practice where the GP demonstrated willingness to learn. Bobby explained that:

not every GP is going to be, they didn’t study that, they’re not a gender expert. They’re not gender diverse, and that’s not their specialty … so what I needed at that point would have been just someone to go … ‘That’s not an area I know a lot about. Would you like help finding someone? maybe I can speak to [a colleague], and I suppose I can look into information about someone that does know more than I do’. … I don’t expect them to know everything. But I would have expected maybe that, even hold their opinions aside and just maybe point me in the right direction instead of making me feel like the worst mother ever”.

When a GP did not have adequate knowledge or experience of affirming pathways, parents “appreciate the honesty” of disclosure (Rita and Stan). One GP was reported to openly say “I don’t have any experience with trans patients”, but the parent was satisfied because “[the GP] happily gave us referrals to the psych and all that sort of stuff. And [the GP said:] ‘if there’s something I can help you with, please let me know.’” (Catherine). A parent commended their GP who said “I promise next time I will be better at it” (Ann), in contrast to a GP who “hadn’t done the homework to work out where you go, who you speak to, what happens next” (Fabian and Gemma).

Lack of knowledge on the part of GPs was sometimes extreme. Ann also recalled a visit to a different GP with her pre-teen child for a urinary tract infection, where the GP asked: “What am I going to find? When I look down here? Has she already had gender reassignment surgery?” Ann expressed shock at the question, and related that “[the GP] goes ‘Well, I don’t know anything about it’. I said ‘You are a doctor!’” Such incidents led parents to call on GPs to educate themselves, and not to wait until they have a trans pediatric patient to do so.

Parents valued GPs who were respectful, “matter of fact” (Gillian), “frank” (Catherine) and kind to their child. Ann’s chosen GP had a “nice calm mannerism. And he listened. I felt he was listening to everything I said … showing respect”. Merryl explained how her GP had been helpful: “she’s just very gentle in her questioning. ‘So why, why do you feel that?’ ‘How has that happened for you?’ And … she actually asked, ‘How can I support you?’ She didn’t try to … change your mind”. Donna described a conversation to develop a mental health care plan with her child which was “gentle … understanding and acknowledging” and “very disarmingly done … not, there’s something wrong with you … [but] we want you to be really well … so that’s why I’m gonna ask some kind of tricky questions”. In one instance, the GP had been able to build such a good relationship with a teen that the teen requested to visit the GP without their parents to discuss their mental health and how to manage their self-harming behavior. This description was strikingly different from some examples from other parents of GPs discussing the child from a deficit framework, even when the child was present.

Parents also valued GPs who discussed and advised on their child’s care including how transgender matters were related to other matters, rather than “everyone’s working in silos” (Clare). The need for this broad perspective was reported in cases like urinary tract infections or dehydration from bathroom avoidance at school, or trauma from bullying and harassment, or where, “to make things a little bit more complicated” (Jodie), transgender children were also neurodiverse, gifted, or had a disability. Alice reported that her child’s gender-affirming psychologist did not do assessments for neurodiversity, and another professional had to then be involved. Alice also said: “I want [my GP] to see the interconnections, … to be proactive …, [for example] no one has … raised the issue of whether he should be put on the pill”, concluding that “[GPs think] that if they refer him to the gender clinic, that the gender clinic take care of all that.” Unfortunately, parents reported that gender clinics might not provide integrated care, for example one gender clinic told a family they could not provide mental health support for their child.

Discussion

Accessing gender-affirming medical care is more than a medical decision, but a decision about gender identity (Daley et al., 2019). Our results confirm that parents listen to and follow the lead of their child (Horton, 2023b), and we found that they also seek a GP who will do the same. Knowing that children who are validated have improved wellbeing (Horton, 2022a; Russell et al., 2018), parents seek a GP who validates their child’s gender. Like trans adults (Franks et al., 2023), as a baseline, children need their preferred name and pronouns to be used.

Our study findings demonstrate that although parents value ongoing care from their regular GP, actual or feared negative reactions impact this continuity of care. In their search for healthcare, we found that parents might visit multiple GPs (Strauss et al., 2017). Whilst some GPs were rude and disrespectful (Strauss et al., 2017), others were respectful, matter of fact, and kind, which creates a safe space for accessing support (Crowley et al., 2021). An effective GP for trans adults builds a long-term relationship (Franks et al., 2023), and parents also seek this for their trans children. It is imperative for GPs to understand what parents view as a supportive reaction, and for the practice to signal that they are trans affirming.

Corroborating other research (Chaplyn et al., 2024), we found that GPs often did not have the knowledge to support a trans child, and parents are placed in the role of educating the GP. Parents prefer a GP who is knowledgeable enough to be matter of fact and knows the appropriate questions to ask. This requires knowing to avoid ‘trans broken arm syndrome’ where all symptoms are attributed to gender identity (Wall et al., 2023), avoiding overly intrusive questions (Horton, 2023c), but at the same time understanding how trans identity might intersect with other health conditions.

Parents’ expectations for holistic clinical care for their trans children in this study indicate the need for basic principles such as good patient-centered care (Bryce et al., 2022) and inclusive practices (Marjadi et al., 2023). Primary care has an important role in trans health care (Crowley et al., 2021), and we found that this can include administration of hormone or puberty blocker injections and considering and prescribing period suppressants. Our results confirm that an inexperienced GP who is willing to learn is valued (Bartholomaeus et al., 2021), and a starting point in this learning journey is to make timely referrals to affirming, inclusive practitioners that the parent requests.

Health professionals often operate in their own areas of expertise and do not see the whole picture (Maneze et al., 2014). GPs are well placed to make connections between different health disciplines, to see the child holistically, which will facilitate a smooth process as recommended by the Australian Standards of Care (Telfer et al., 2020). Building on Chaplyn et al. (2024), parents need GPs to be able to navigate the complex pathways of trans healthcare for their children.

Effective patient centered care for trans adults requires GPs to have a referring network who are also trans informed (Franks et al., 2023), and we found this is also the case for trans children. Given the importance of informal mentoring for GPs to become knowledgeable about trans health care (Franks et al., 2023), a network of knowledgeable practitioners will also improve GP knowledge.

Previous studies of LGBT parents accessing healthcare for their children have demonstrated that most had positive experiences, even when this was sometimes unexpected (Shields et al., 2012). While our study found one example where a parent had a positive GP interaction they did not expect, poor GP reactions were much more common. This problem was exacerbated by lack of GP knowledge of trans healthcare even when the GP was willing to be supportive. Shields et al. (2012) recommend training healthcare staff, advertising an LGBT-friendly environment, improvements in documentation, and engagement with LGBT organizations. These findings are also applicable to GP practices providing healthcare for trans children. Key differences between supporting children of LGBT parents, and trans children, is that the latter are more stigmatized in society, and require GPs, pediatricians and others to develop an understanding of trans healthcare and how to navigate the associated complex health pathways (Crowley et al., 2021). There is a need for training interventions that support healthcare practitioners to support them in understanding trans youth (Goulding et al., 2024), and our findings can contribute to filling this gap for GPs.

Limitations

This qualitative study recruited families who were all connected to parent support networks and were affirming of their child’s gender. Demographic data on families and parents were not collected due to the need to preserve anonymity in this small, close-knit, and hard-to-reach population. More research is required to capture a broader range of parents and families of trans children, preferably with a mixed-methods approach to obtain generalizable findings. The voices of trans children and young people, which were outside the scope of this study, are important to include in future studies, particularly where parents are not affirming of their trans identity. GPs’ perspectives in supporting parents of trans children were also beyond the scope of this study, and are important to investigate and triangulate with those of parents and children. It would be useful to understand how the age, cultural background and gender identity of the GP impacts on the support they provide, and in what ways previous training on trans inclusive care had prepared them to provide this support. Despite these limitations, this study has added to the literature on the expected roles of GPs in supporting trans children and their parents.

Conclusion

Accounts from parents of trans children about their interactions with GPs highlighted the value of continuity of care, validating and affirming practices, and willingness to learn. This paper provides examples of positive interactions with GPs, and points to the need for GPs to educate themselves in how to deliver holistic patient-centered care for trans children.

Disclosure statement

The first author is also a member of the parent advocacy group who partnered with the University in the research.

Data availability statement

The data for this study will not be shared, as we do not have permission from the participants or ethics approval to do so.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.