Under the Rainbow: Characterizing Integrated Behavioral Health Services with Gender Diverse Youth in a Pediatric Primary Care (PPC) Setting

Abstract

Objective: Research indicates the importance of providing gender-affirming care in pediatric primary care (PPC) settings, where transgender and gender diverse (TGD) youth may initially disclose gender and mental health concerns (Guss et al., 2019). This study aimed to characterize gender-affirming care in primary care by qualitatively coding actions of behavioral health clinicians (BHCs) and primary care providers (PCPs). Methods: Participants from a large, residency training, PPC clinic seen between January 2019 and February 2023 were selected by purposive sampling from BHCs clinical cases and clinical informatics in electronic medical record (EMR) software using gender markers as selection criteria. Participants were ages 3–19 years old (N = 56, Mage = 12.41 years, SD = 3.16), and most identified as transgender female (23%) or transgender male (23%). A preliminary chart review was used to develop a codebook for thematic content analysis, which was conducted on electronic health records from primary care visits. Results: Of the 70% of participants who received depression screening, 39% endorsed clinically elevated depression symptoms. Findings suggested that PCPs most often document referring to a gender specialty clinic, while BHCs are typically involved for mood or risk concerns, and provide general rather than gender specific resources. Conclusions: Results suggest that PCPs and BHCs address gender identity in a non-standardized fashion and inform effective practice transformation to enhance gender-affirming care within PPC settings.

Implications for Impact Statement

This study found that pediatric primary care providers and behavioral health clinicians were inconsistent in their approaches to primary care visits and documentation practices when meeting with transgender/gender diverse youth (TGD). Findings suggest that primary care and integrated behavioral health providers would benefit from utilizing more standardized, gender-affirming approaches in primary care, given the barriers to care and mental health needs of TGD youth.