The right of transgender minors to access gender-affirming care has sparked debate across the United States.With aUS Supreme Courtrulingupholding Tennessee’s banon the practice, experts say, activists will probably be emboldened to enact even more restrictions.
Currently,about 40%of trans youth live in a state that restricts access to gender-affirming care, according to KFF, a health policy and research organization. Major medical associations support access to such care at all ages, saying it can be lifesaving.
Tennessee is among the 27 states that have passed bans on gender-affirming health care for transgender children and teenagers, according to aCNN analysisof data from theMovement Advancement Project,a nonprofit think tank that advocates for LGBTQ rights.
Until this year, thefederal government describedearly gender-affirming care as “crucial to overall health and well-being” for trans and nonbinary children and adolescents. But the Trump administrationhas been cracking downon access.
Soon after President Trump took office, he issued an executive order called“Protecting Children from Chemical and Surgical Mutilation.”It characterized gender-affirming care as “immoral, unjust, and disproven” and ordered the US Department of Health and Human Services to complete a review of evidence used to support its practice. That report – which was created by authors whom HHS refused to name – was issued May 1.
That month, HHS Secretary Robert Kennedy Jr.sent a letterto health care establishments telling them to ignore long-held science-based professional guidelines and instead rely on the his agency’s review even though the document says that “it is not a clinical practice guideline.”
The HHS review was highly critical of the science used to inform the practice of gender-affirming care. When it was released, the American Academy of Pediatrics said it was “deeply alarmed,” and organization President Dr. Susan Kressly said it “misrepresents the current medical consensus and fails to reflect the realities of pediatric care.”
Additionally, at the start of LGBTQ+ Pride month, theFBI tweetedthe number for a tip line toreport providers that offer certain gender-affirming careservices for minors.
Gender-affirming care is a multidisciplinary approach that includes medically necessary and scientific evidence-based practices to help a person safely transition from their assigned gender – the one a clinician assigned them at birth, based mostly on anatomic characteristics – to their affirmed gender – the gender by which the personwants to be known.
Although the term gender-affirming care came into the public’s lexicon fairly recently, Dr. Madeline Deutsch,directorof the UCSF Gender Affirming Health Program, said the practice has been around for some time and is basedon decadesof scientific research.
Major mainstream medical associations – including theAmerican Medical Association, theAmerican Psychiatric Association, theEndocrine Society, theAmerican Psychological Association, theAmerican Academy of Pediatricsand theAmerican Academy of Child & Adolescent Psychiatry– have affirmed the practice of gender-affirming care and agree that it’s the gold standard ofclinically appropriatecare that can providelifesavingtreatment for children and adults.
“While we are always assessing the strength of the evidence for this kind of care, every major US medical association has found that the medical evidence is strong and in support of centers that provides this kind of care and have been doing so for decades,” said Dr. Kellan Baker,executive directorof the Whitman-Walker Institute, a health care organization that works on LGBTQ+ issues.
Last year, an extensive but controversial research review in the UK called the use of puberty-delaying medications into question, saying that the rationale for early puberty suppression was “unclear” and that any benefit for mental health was supported by “weak evidence.” Although the review — known as theCass Reviewfor Dr. Hilary Cass, the pediatrician who conducted it — has come undersharp criticismfrom several scholars and practitioners, it promptedthe UKto ban puberty blockers for use in trans patients.Other childrenwho enter early puberty still have access to the medication.
The process typically starts with a conversation between a clinician and the individual. If the patient is a child, the conversation will also include the caregivers when possible.
“It’s to really get a better sense of what’s bringing them into the clinic,” said licensedclinical psychologistDr. Melina Wald, who co-founded the Gender Identity Program at Columbia University Medical Center. “We are also looking to understand the child’s understanding of their own gender, gender expression and a history related to that.”
After experts determine what the person needs, a multidisciplinary group of clinicians will design a plan just for them. Depending on the person’s age, care can include mental health care and support groups, legal help and sometimes medical help like hormones or surgery when a person is past puberty.
“This is individualized care, not some one-size-fits-all-plan,” Baker said.
A transition plan can be as simple as offering support to someone when they start using different pronouns, change their hairstyle or clothing, or use a different name.
“When we support and allow people to do these things, their lives get better,” Deutsch said.
Mental health care:Often, gender-affirming care will include counseling. A2018 studyfound that the prevalence of mental health problems among transgender youthwas seven times higher than among their cisgender peers.
Mental health problemsdon’t necessarily stemfrom a person’s identity;a growingnumber ofstudies showthat they oftenoccurbecause of social discrimination and what’s known asminority stress. Stigma,marginalization, discrimination, bullying, harassment andviolencecan lead to feelings of isolation and rejection.
People who identify as transgender may also need mental health help just to determine what their identity is, to come to terms with it and to find self-acceptance. Mental health care can also help people come out to their family and friends and develop coping mechanisms so they can be who they are in a world that isn’t always friendly or accepting.
Gender-affirming care,studies show,lowers a person’s odds of depression andsuicidalityand is associated with improved well-being.
Medication and surgery:Some people may also receive age-appropriate medical care like hormone treatments, puberty blockers, voice and communication therapy, gynecologic and urologic care and reproductive treatments.Typically, surgeries areoffered onlyto adults.
The World Professional Association for Transgender Health’sguidelines, which are consideredthe gold standardfor gender-affirming care around the world, say this kind of care should provide a person “safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment.”
When children get to a certain stage of puberty – diagnosed by a medical provider – and still have a persistent, well-documented sense that their gender does not align with the sex assigned at birth, doctors and family may decide tomove forwardwith reversiblepubertal suppression, commonly calledpuberty blockers.
Although not all patients choose this treatment,some researchshows that gender-incongruent youth may feel increased distress when they start to develop secondary sex characteristics.
These gonadotrophin-releasing hormone drugs were first used todelay pubertyfor people with what’s known asprecocious puberty, when a child’s body changes into that of an adult too soon.
Puberty blockers can keep secondary sex traits from developing for a few years, to give the child time to access support, explore their gender identity and develop coping skills, according to the American Academy of Pediatrics. If a patient decides to stop treatment, puberty resumes.
“That just basically puts everything on pause, and children can be on that for a couple of years without any ill effects, and it’s totally reversible,” Deutsch said. “If it’s stopped, then everything just continues where you left off.”
Studies show that puberty blockers can reduce the distress that may happen when a child develops secondary sex characteristics such as breasts, an Adam’s apple or voice changes.Studies showthat transgender adolescents who used puberty blockers were less likely to have suicidal thoughts than those who wanted the treatment but did not get it. Puberty blockers can also make a transition later in life easier, since the person did not develop these secondary sex characteristics.
At this stage in the gender-affirming care process, after a thorough evaluation by a medical professional, a patient may also receive hormone therapy that can lead to gender-affirming physical change.
Puberty blockers can carry some risks, and more long-term studies are needed, according to thePediatric Endocrine Society. Long-term studies on fertility and bone health are limited and provide “varied results,” according to the American Academy of Pediatrics.
The World Professional Association for Transgender Health guidelines say that before giving puberty blockers, the provider must make sure the person has demonstrated a sustained and persistent pattern of gender dysphoria or gender incongruence; they must have the emotional and cognitive maturity to provide informed consent; any coexisting mental health problems that could interfere with treatment or consent need to be addressed; the person needs to be told that there could be reproductive effects, and fertility preservation options should be discussed; and the child must have reached Tanner Stage 2 of puberty, which is when a girl starts to develop breast buds and a boy’s scrotum and testicles begin to increase in size. A pediatric endocrinologist must agree with this decision.
Professional medical guidelines, with some rare exceptions, do not recommend puberty blockers, hormone therapies or surgery for children who have not gone through puberty. If such treatment is indicated, the clinician would first do a thorough evaluation in collaboration with the patient and their caregiver to understand the child’s unique needs.
“I think one of the big myths out there is that there’s a sense that kids are rushed into decisions related to medical care, like hormone therapy or surgery. That’s just not the case,” Wald said.
Deutsch agreed: “Kids don’t make stuff up about this, wanting to become trans because it’s trendy or something,” she said. “Trans youth and trans people in general do not have access to a hormone vending machine.”
Some critics point out that youth who take puberty blockers may change their minds about their gender identity later in life. Several studies have shown most people who opt for gender-affirming caredon’t later regret their choices— includingan October 2022 studyin the Netherlands that found 98% of transgender youth who had started gender-affirming medical treatment in adolescence continued to use those hormones around five or six years later in adulthood. Among 3,306 UK Gender Identity Development Service patients included the Cass Review analysis, fewer than 10 patients detransitioned to their birth-registered gender.
Questions about the benefits of puberty-blocking medications gained fresh attention in October when the author of a federally funded study was quoted as saying she haddelayed publicationof some of her results because of fears that they would be “weaponized” in a heated political climate.
Johanna Olson-Kennedy, medical director at the Center for Transyouth Health and Development at Children’s Hospital of Los Angeles, said thatin the study, which she helped lead, puberty blockers did not appear to improve the mental health of 95 children ages 8 to 16 who were followed for two years to understand their mental and physical functioning as doctors used the medications to delay the physical changes associated with puberty.
Some advocates for gender-affirming care for youth said this is a typical level of caution taken by researchers to carefully present and interpret scientific data. However, researchers said it remains critical to publish data; puberty blockers may have prevented a decline in mental health, even if they didn’t lead to improvement in mental functioning, but it’s impossible to know if the data isn’t released.
If a child identifies as transgender or gender-diverse,research suggeststhat they know their gender as clearly and consistently as their peers who identify as cisgender or the gender they were assigned at birth, even if it conflicts with other people’s expectations about what a typical “boy” or “girl” is.
Some criticsof the process suggest that children should wait until adulthood to transition, but the American Academy of Pediatrics saysin its guidelinesthat this approach is “outdated,” in part because it assumes that gender identity becomes fixed at a certain age, and the approach is based on “binary notions of gender in which gender diversity and fluidity is pathologized.”
The group also argues that the approach was based on early studies with methodological flaws, limited follow-up and validity concerns. More recent research shows that “rather than focusing on who a child will become, valuing them for who they are, even at a young age, fosters secure attachment and resilience, not only for the child but also for the whole family.”
Wald says that waiting to transition can create additional psychological distress for a child and can raise their risk of depression, suicidality, self-harm or substance misuse.
“Withholding intervention means that the child is going to go through a puberty that is discordant with their gender identity and would ultimately mean that later, at the age of 18, there would be changes to their body that they would make it even more difficult,” she said.
“These children and teens can be incredibly resilient,” Wald added. “With support and access to care, they will thrive and can be just as successful as any kid.”
A 2022 analysis of data from the US Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System and its Youth Risk Behavior Survey found that a tiny fraction of people in the United States – about 0.6% of those 13 and older, or about 1.6 million people – identify as transgender, according to theWilliams Institute, a think tank at UCLA Law that provides scientific research on gender identity and sexual orientation.
While the percentage of adults who identify as transgender in the US has remained basically the same, the number of young people who identify as such doubled – to 300,000 – from the last time the Williams Institute did the research in 2016 and 2017. A 2022Pew Research Center surveydetermined that 5.1% of adults younger than 30 are trans or nonbinary.
It may not be a direct comparison, however, as the Williams Institute’s previous survey did not have survey data for younger teens and had to use statistical modeling to extrapolate based on adult data. The report cannot explain why more young people may be identifying as transgender, but it notes that more data has become available about this population.