I Wish They Knew Something about My Body: A Participatory Arts-Based Study with Gender Creative Children in the Healthcare Context

Background: Gender creative children experience high rates of stigma, victimization, and low self-esteem, which may ultimately result in healthcare avoidance and unfavorable physical and mental health outcomes. Gender affirmation and support from family is the most protective factor for gender creative children, and pediatric healthcare providers may play an important role in facilitating this support. The healthcare experiences of elementary-aged gender creative children are largely absent from the literature, with most accounts relying on adult-proxy reports. In this collaborative study we used an innovative arts-based method to understand what helps gender creative children feel safe to express gender-related thoughts, feelings, and experiences, who they talk to about their health and gender, and how they experience, anticipate, or perceive medical visits.

Methods: Informed by the presenting author’s lived experiences, we conducted a qualitative, arts-based, and community-engaged study using a Draw-and-Tell Conversations, a method that enables children to communicate through drawing, writing, and telling their stories in response to interview questions. We purposively sampled elementary-aged gender creative children (n=10) residing in an urban region in the Northwestern United States. Participants were predominantly white (83% white, 17% American Indian and Alaskan Native), neurodiverse (66%), and upper-middle class (100% of caregivers have graduate degrees). Half of participants identified as nonbinary, 33% as trans-female, and 17% as trans-male. Participants drew pictures of the important people in their lives and of a medical visit. Drawings served as stimuli for conversations about healthcare experiences. Caregivers completed a survey about their child’s demographics and their pediatric provider to help contextualize findings. We transcribed interviews verbatim and used reflexive thematic content analysis with a mixed inductive and deductive approach at a semantic level. Themes were reviewed with community partners for methodological triangulation.

Results: Participants expressed varying degrees of discomfort in medical settings and craved a greater sense of control and agency, despite having supportive caregivers and providers. Participants endorsed having supportive confidants with whom they could discuss their gender and health and most preferred that caregivers met separately with providers when questions arose about their child’s gender. Drawing prior to talking helped participants formulate their ideas and express themselves with confidence. Drawings represented “world making,” offering a window into children’s beliefs in the magical and imaginary as sources of comfort and meaning-making.

Conclusions and Implications: There are missed opportunities to positively impact children’s health and caregiver-child relationships when gender creative children’s perspectives are overlooked in the pediatric healthcare context. This collaborative and interdisciplinary study with gender creative children, their families, community-based organizations, and clinicians and academics in social work, pediatrics, and medicine provides first-hand accounts of how children navigate their gender identity in relation to others, as well as the role pediatric providers may have in supporting children’s conception of gender identity and sense of affirmation. Findings may inform future research approaches to engage younger children and have valuable clinical implications for improving care, support, and health outcomes for gender creative children and their families, as well as for other children whose voices are often disregarded in medical contexts.