The right of transgender minors to access gender-affirming care has sparked debate in many parts of the United States, and it’s now heading to the US Supreme Court.
The court will hear oral arguments Wednesday on a challenge, brought by young people who identify as transgender and their families, to a law in Tennessee that bans gender-affirming medical care for minors.
What is gender-affirming care?
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 person wants to be known.
Although the term gender-affirming care came into the public’s lexicon fairly recently, Dr. Madeline Deutsch, director of the UCSF Gender Affirming Health Program in San Francisco, said the practice has been around for some time and is based on decades of scientific research.
Major mainstream medical associations – including the American Medical Association, the American Psychiatric Association, the Endocrine Society, the American Psychological Association, the American Academy of Pediatrics and the American Academy of Child & Adolescent Psychiatry – have affirmed the practice of gender-affirming care and agree that it’s the gold standard of clinically appropriate care that can provide lifesaving treatment 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 director of the Whitman-Walker Institute, a health care organization that works on LGBTQ+ issues.
This 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.” The review — known as the Cass Review for Dr. Hilary Cass, the pediatrician who conducted it — has prompted providers in the UK to scale back their use of the treatment. However, its methodology have come under sharp criticism from some scholars and practitioners.
What does gender-affirming care look like?
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 family when possible.
“It’s to really get a better sense of what’s bringing them into the clinic,” said licensed clinical psychologist Dr. Melina Wald, co-founder and former clinical director of the Columbia 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 for them. Depending on the person’s age, care can include mental health 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. A 2018 study found that the prevalence of mental health problems among transgender youth was seven times higher than among their cisgender peers.
Mental health problems don’t necessarily stem from a person’s identity; a growing number of studies show that they often occur because of social discrimination and what’s known as minority stress. Stigma, marginalization, discrimination, bullying, harassment and violence can 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 and suicidality and 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 are offered only to adults.
The World Professional Association for Transgender Health’s guidelines, which are considered the gold standard for 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.”
What are puberty blockers and hormones?
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 to move forward with reversible pubertal suppression, commonly called puberty blockers.
Although not all patients choose this treatment, some research shows that gender-incongruent youth may feel increased distress when they start to develop secondary sex characteristics.
These gonadotrophin-releasing hormone drugs were first used to delay puberty for people with what’s known as precocious 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 show that 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.
Are there risks to puberty blockers?
Puberty blockers can carry some risks, and more long-term studies are needed, according to the Pediatric 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 that most people who opt for gender-affirming care don’t later regret their choices — including an October 2022 study in 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 had delayed publication of 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 that in 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.
Why would children and adolescents need gender-affirming care?
If a child identifies as transgender or gender-diverse, research suggests that 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 critics of the process suggest that children should wait until adulthood to transition, but the American Academy of Pediatrics says in its guidelines that 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.”
How many people identify as trans?
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 the Williams Institute, a think tank at UCLA Law that provides scientific research on gender identity and sexual orientation.
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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.
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.
