42. “Oh my God! How did I miss this?” - Barriers to Discussing Pronouns and Gender Identity in Pediatric Primary Care


      Pediatric gender centers have seen a notable increase in demand for gender-affirming care services during the COVID-19 pandemic. This increased need has contributed to delays in youth accessing this time-sensitive care and amplified the importance of primary care providers (PCPs) playing an active role supporting gender diverse youth in the post-pandemic world. To guide interventions to support PCPs in gender-affirming care, we sought to understand how often PCP’s see gender diverse youth in primary care and assess PCP comfort facilitating conversations about gender identity in this setting. The objectives of this study were to (1) understand whether PCPs are routinely discussing pronouns and gender identity with adolescents and (2) explore barriers to and the impact of having such discussions in primary care.


      This project integrated data from a needs assessment survey and from semi-structured, qualitative interviews with pediatric PCPs. The 15-item survey was administered to PCPs in a large, hospital-affiliated, pediatric primary care network in the northeastern US to better understand PCPs experiences providing adolescent healthcare. Hour long, semi-structured interviews were conducted with pediatric PCPs in the pacific northwest using an interview guide developed in partnership with two PCP stakeholders. Survey responses were analyzed descriptively. Interviews were transcribed and analyzed by two authors in Dedoose qualitative analysis software via inductive thematic analysis using an iteratively designed codebook that was adjudicated to consensus.


      Of the pediatric PCPs surveyed (n=85), the majority were pediatricians (67%) and most had been in practice for more than 5 years (75%). Almost all (92%) PCPs reported caring for at least one gender diverse youth in their practice in the last year. However, PCPs reported discussing pronouns (15%) and gender identity (29%) during annual well visits with adolescent patients much less frequently than discussing mood (98%), motor vehicle safety (77%) and sexuality (61%). Relatedly, gender-affirming care (60%) was the topic most frequently selected by PCPs for additional education. In separate PCP interviews, participants (n=15) indicated that while they felt discussions about pronouns and gender identity were important, they experienced specific structural and interpersonal barriers that prevented these conversations from occurring. These barriers included poor health system infrastructure (like forms and electronic health records), staff concerns, uncertainty around language, lack of awareness and fear. PCPs also discussed that when they asked about pronouns and gender identity, it normalized conversations about gender, helped facilitate family support, created welcoming environments in the health system and allowed for earlier identification of youth in need of support.


      Pediatric PCPs recognize the critical role they play in supporting gender-diverse youth and their families, particularly around normalizing conversations about gender identity. However, multiple individual and clinic-level barriers to asking about pronouns and gender identity remain. These results highlight the continued need to provide resources, education and support to PCPs in discussing these topics in the primary care setting to facilitate access to time-sensitive gender-affirming care.

      Sources of Support

      This project was supported by the Seattle Children's Research Institute Career Development and AHRQ K12HS026393-03 (PI: Sequeira).