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MNAAP Newsletter

Minnesota Pediatrician is published quarterly (February, May, August and November) and is written by pediatricians for pediatricians. The newsletter is mailed and emailed to over 1,000 members.

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September 18, 2019

Angela Kade Goepferd, MD, FAAP

While nearly 3 percent of Minnesota high school students identify as gender diverse, many of them do not know where to turn when it comes to finding culturally sensitive, gender-affirming care. And despite recent advances in health care, transgender and gender-diverse youth continue to face significant health disparities, including higher rates of harassment, discrimination, homelessness, and suicidality.

As part of Children’s Minnesota’s commitment to provide equitable and inclusive care to all children, we launched the Gender Health Program in April. This personalized and comprehensive pediatric multispecialty clinic provides transgender and gender-diverse children and their families with medical care and support from pediatric experts they can trust, including experts in pediatric gender health, endocrinology, and gynecology.

About the program

Each family that comes to the Gender Health Program will start with a gender consultation with one of our physicians. During this initial consultation, children and their families meet with a gender health expert to discuss developmental questions or concerns about gender identity and develop a personal care plan. Each family comes to the program at a different place and with a different path, so this consultation helps to answer questions, discuss goals, and think about next steps. Often youth—especially teenagers—and their families come to this initial consultation with different questions and goals. Our team is committed to helping understand what each child, parent, and family needs before moving forward. We can often help youth and families understand each other and learn to speak a common language as they navigate future steps on their journey.

One key component for most families is appropriate mental health assessment and referrals as needed. Our program includes a social worker/care navigator who participates in the initial intake assessment for each family to help determine what resources are needed. We can connect parents with resources and support for their questions, and can connect youth with individualized support systems. Our goal is to optimize care and outcomes for each patient, by supporting the mental and physical well-being of the whole child and the whole family.

The onset of puberty can be difficult for many transgender and gender-diverse adolescents, and Children’s offers both pubertal and menstrual suppression. These reversible interventions pause puberty and/or menstruation for patients as necessary. Patients may also meet with a pediatric gynecologist for a consultation to discuss options to preserve fertility prior to beginning pubertal suppression and/or gender-affirming treatment.

For patients who are in middle-to-late adolescence, gender-affirming hormone treatment may be appropriate. This hormone treatment creates changes in the body to align with the patient’s gender identity. The decision to move forward with such treatment is made with one of our gender health experts, along with a readiness assessment by a mental health professional to optimize outcomes—and to gauge the support and obtain the consent of parents.

Gender-affirming surgeries are most often performed for patients who are over the age of 18 and are not done at Children’s Minnesota. While Children’s Gender Health Program does not perform these surgeries, we can refer patients to plastic surgeons in the community as needed.

Tips for primary care physicians

While transgender and gender-diverse children and adolescents may come to the Children’s Gender Health Program for specialized and expert care related to their gender identities, they will continue to receive their primary care (including well-child exams, immunizations, and ill-child visits) through their primary care offices. Primary care clinicians often have questions about how to best provide supportive and affirming care to transgender patients and their families.

Ask each child the name they would like to be called, and the pronoun they use, and be sure to use this name and pronoun at each visit.                       

Educate staff about how to ask each patient what name they would like to be called and what pronoun they use, so that they can do the same; this is especially important for those answering phones, checking in, and rooming patients. It’s also important to remember that we all make mistakes, even when we are trying to do our best. When mistakes happen, we should acknowledge them, apologize, and commit to continuing to get it right in the future.

Often, mistakes in calling a patient the correct name or using the correct pronoun are made due to limitations and barriers of the electronic medical record (EMR). Primary care providers should find out the best way to optimize their EMR system to visibly display the preferred or declared name of each child, as well as the pronoun they use. Being misgendered when seeking medical care is a common fear of transgender and gender-diverse patients and their parents, and anything we can do to ensure a smooth and affirming patient care experience will allow children and families to relax and focus on the medical reason for their visit.

Parents often struggle to know how to best support their kids on top of dealing with their own feelings of grief, anger, disappointment, or fear. Primary care clinicians can affirm to parents that asking questions is OK, and seeking supportive resources is encouraged. Parents often need just as much, if not more, room to ask questions and seek support as they learn more about their child’s identity. Parental rejection is a significant risk factor for poor physical and mental health outcomes for transgender youth, including a significantly increased risk of suicide, so clinicians should always encourage parents to consistently reassure their children that they love them, even when they are struggling to understand their expressed identities. Unconditional parental love is the single biggest protective factor to keep transgender and gender-diverse kids healthy and safe.

Although positive steps have been taken in recent years, transgender and gender-diverse youth are still a medically underserved population, experiencing a variety of health disparities. The Children’s Gender Health Program offers transgender and gender-diverse children and their families a place to go for exclusively pediatric, comprehensive, compassionate medical care when they have questions about their gender. With this program, Children’s continues to strive to be every family’s essential partner, and to ensure that transgender and gender-diverse children can grow up happy, healthy, safe, and strong.

 

About the Author

Angela Kade Goepferd, MD, FAAP, is the medical director of Children’s Minnesota’s Gender Health Program, the director of Medical Education and vice chief of staff for Children’s Minnesota, and a general pediatrician in the Children’s Minneapolis Primary Care clinic. An advocate for advancing equitable health care for all children, Dr. Goepferd works to ensure a positive human experience for patients, families, and professional staff, and has been an engaged member and leader on several committees, strategic planning teams, and other initiatives across the organization.

Lori DeFrance, MD, FAAP

I am grateful to have a cabin on Ojibway Lake just outside of Ely, Minnesota. It is a very quiet lake with a Boundary Waters-like landscape where I can truly relax and recharge. I hope that all of you have had the opportunity to do the same over the summer.

At the 2019 American Academy of Pediatrics (AAP) Annual Leadership Forum, elimination of non-medical exemptions to vaccination was voted as the number one priority. AAP President Dr. Kyle Yasuda has stated, “Given the measles outbreaks, prioritizing the elimination of non-medical exemptions is a timely undertaking.”

The leaders of our chapter, along with our lobbyist, Eric Dick, and Immunization Work Group Chair Dr. Dawn Martin, kept the wheels turning this summer as we pursued a timeline for eliminating non-medical exemptions for vaccines in the state of Minnesota. This was identified as a chapter priority last year and will likely be a marathon undertaking. We have good news in that we have identified Minnesota legislators who are willing to co-author a bill. This will require no small measure of diligence and courage on their behalf as we move forward.  A highlight in our advocacy path was a telephone conference in July with Senator Richard Pan, who is a pediatrician and state senator in California.  Three years ago, he co-authored a bill that prohibited “any public or private elementary or secondary school, childcare center, day nursery, nursery school, family day care home or development center” from admitting children who have not been fully immunized against several diseases. His words to us during the phone call were a treasure trove of information on how to proceed.

Here are some pearls from the conversation with Senator Pan:

1) Science is important, but it isn’t always effective in winning the hearts or votes of legislators. The face of the bill should be families and children in our communities who are vulnerable to vaccine-preventable infectious diseases and who are fierce advocates of vaccinations.

2) He used the phrase “community immunity” rather than herd immunity. We like this catchy version!

3) Public health comes first and foremost. When anti-vaxxers start to talk about personal freedom, remember that state and federal law rightly allows the government to protect the health of the community.

4) Building a coalition of like-minded organizations, including those in health care, schools and business will be important in strengthening this mission.

The headlines regarding the measles outbreak of 2019 are winding down as I write this letter.  But one thing we know for sure is that another measles outbreak in Minnesota is only a matter of time. Other vaccine-preventable diseases are always on our radar, too. We must remain steadfast in protecting children from infectious diseases that may result in harm and death. I invite you to be a part of this chapter initiative. Please contact me or any of our board of directors members if you have families that would like to step forward and participate. Consider signing up for the MNAAP Immunization Work Group. Email your legislators to support this bill when it is introduced. Be available for testimony to the legislature. Become a MNAAP board of directors member!

All of your efforts have an indelible impact on the families and children that we serve.

Thank you,

Lori DeFrance, MD, FAAP

MNAAP President

Eric Dick, MNAAP Lobbyist

While the summer and fall of a non-election year are generally a quiet time for state legislators and advocates alike, it’s a perfect time to make or reinforce relationships with your legislators. Though the start of the 2020 Minnesota legislative session is many months away, the work of being an advocate for healthier kids, adolescents, and families does not take a vacation.

State legislators are back in their districts for the autumn and will be into the winter. Many legislators are hosting town hall meetings with constituents and knocking on doors to build support in anticipation of close races once the November 2020 election arrives. These are terrific opportunities to remind legislators to invest in child and adolescent health and safety.

The fall is also a terrific time to invite your legislator to your clinic or a neighborhood coffee shop to urge them to support the issues that matter to pediatricians and their young patients. I am always eager to assist with scheduling a visit or to offer background, talking points, or tips on being an effective advocate.

MNAAP leadership has been busy this summer advocating for stronger immunization laws. While the most recent and dangerous national measles outbreak lingered, MNAAP leaders have been meeting with key legislators and advocating within their clinics and health systems to support fixing Minnesota’s weak immunization requirement. MNAAP staff has been similarly busy meeting with potential allies, health care professional associations, patient advocates, and other immunization advocacy leaders. We face an uphill climb to fix the law, but the chapter has received an encouraging level of support.

Several MNAAP leaders held a conference call with California State Senator Richard Pan, a pediatrician and the author of legislation to repeal California’s personal belief exception (PBE). Dr. Pan shared with the group his experience, encouraging the MNAAP to build a broad coalition of advocates and allies. Read Dr. Lori DeFrance’s “Word from the President” (page 3) for specific takeaways from our conversation.              

To make a healthier Minnesota, we must start now. As autumn arrives and winter looms, take the time to make or build a connection with your legislator.  It’s as simple as an email, a phone call, or a cup of coffee and it matters.   

June 13, 2019

Legislators, like students cramming for a big test or project, often work best under the pressure of deadlines. That was the case this legislative session, too, as it took an old-fashioned “all-nighter” for legislators to complete the work of the 2019 legislative session. Legislators, called back to the Capitol for a special session by Governor Walz on May 24, worked for more than 20 hours straight to complete the work for the year.

The MNAAP had a very strong legislative session. Most notably, the chapter played a leading role in the successful effort to repeal the sunset of the provider tax. The tax, used to support funding for Medical Assistance and MinnesotaCare as well as other access and public health programming, had been slated to be repealed on Dec. 31, 2019, however the Legislature’s actions now extend the tax indefinitely. The MNAAP joined a group of more than 150 health care providers, hospitals, social justice advocates, labor unions, and others in the robust campaign to preserve funding for these important programs.

Investments in pediatric mental health, another chapter priority, was also an area that saw strong results. The Health and Human Service (HHS) budget saw a significant investment in school-linked mental health funding in 2020 and beyond, and funding was also appropriated for mental health services delivered in homeless shelters. Robust funding for suicide prevention was adopted, as was authorization for the Department of Human Services to add up to 80 additional residential mental health beds.  An important measure to strengthen the state’s laws that mandate parity for mental health services was also adopted into law.

The session saw a number of other notable wins. Advocacy by pediatricians saw the innovate, effective “Reach Out and Read” program receive funding in 2020 and 2021, as part of a new emphasis on disparities in prenatal care. Two important tobacco control proposals – state funding for a nicotine cessation services and an extension of clean indoor air requirements to include e-cigarettes – also became law.  And while the move to increase the age at which individuals may purchase tobacco and nicotine products from 18 to 21 did not become law, this session saw significant progress. A newly created task force on rare diseases will bring together health care leaders (including at least one pediatrician) to provide advice on research, diagnosis, treatment, and education related to rare diseases.     

Unfortunately, several other MNAAP priorities were less successful. A MNAAP-supported effort to reduce death and injury by firearms could not draw support in the Senate despite a forceful lobbying effort by advocates and the House of Representatives. The chapter was also unable to secure funding to improve the state’s immunization rates.

A House-led effort to fund education and outreach efforts in communities with lower rates of immunization was not included in the budget bill, and a related proposal in the Senate came up short, too. The good news is that no anti-vaccine proposals became law, despite lobbying by anti-vaccine legislators and advocates. Regrettably, a MNAAP-supported effort to bar the use of so-called “conversion therapy” for minors was also rejected by the Senate.

The increased profile of pediatricians and the MNAAP was another highlight of the 2019 session.  Pediatricians testified on almost a dozen different bills or issues, and a nearly equal number of letters of support were distributed to policy makers. Coupled with the action alerts to lend the chapter’s support to the provider tax fight, the 2019 session saw a very active and vibrant chapter. The pediatric community was well represented by the terrific pediatricians who participated in these efforts.

With the 2019 session having concluded, the chapter will begin building our game plan for the 2020 session very soon. The 2020 legislative session starts on Feb.11, 2020, and there are innumerable threats and opportunities awaiting pediatricians and the state’s most vulnerable patients.

About the Author

Eric Dick is MNAAP’s lobbyist. 

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