More than a dozen states have passed laws and more than a dozen are considering laws that ban the gold standard of care for people who identify as transgender, even though every major medical association recommends such care and says it save lives.
Gender-affirming care is medically necessary, evidence-based care that uses a multidisciplinary approach to help a person transition from their assigned gender – the one the person was designated at birth – to their affirmed gender – the gender by which one wants to be known.
By one estimate, more than 58,000 transgender youth 13 and older across the US are facing restricted access or proposals, and could soon lose access to gender-affirming care.
Those 58,000 live in 15 states that have enacted or are considering laws to restrict access by, in some cases, even penalizing health care providers and families who try to get such care, according to UCLA’s Williams Institute, which conducts independent research on sexual orientation and gender identity law and public policy. These states are home to nearly a third of the nation’s transgender youth.
In Texas, Gov. Greg Abbott ordered the Department of Family and Protective Services to investigate any instances of certain procedures used in such care, on the grounds that it is now considered child abuse according to an opinion issued by state Attorney General Ken Paxton. A Texas judge granted the ACLU’s request for a temporary restraining order, preventing the state from enforcing the order for now.
Despite the legislative push to end this kind of treatment, gender-affirming care is a recommended practice for people who identify as transgender, meaning they identify with a gender that is different than the one assigned at birth, or gender-diverse, with a gender expression that doesn’t strictly match society’s traditional ideas about gender.
The gold standard of care
Major medical associations – including the American Medical Association, the American Psychiatric Association, the American Academy of Pediatrics and the American Academy of Child & Adolescent Psychiatry – agree that gender-affirming care is clinically appropriate for children and adults.
The World Professional Association for Transgender Health’s guidelines, which are considered the gold standard and guide gender-affirming care around the world, say it should be a way for people to create “effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being and self-fulfillment.”
People who identify as transgender or gender-diverse often face significant health disparities, as well as serious marginalization and discrimination in health care settings. In 2015, 1 in 4 adults who identified as transgender avoided a needed doctor’s visit because they feared being mistreated, according to the US Transgender Survey from the National Center for Transgender Equality.
Social care for children
For children, gender-affirming care is defined by the American Academy of Pediatrics as developmentally appropriate, nonjudgmental treatment that’s provided in a safe clinical space. The care is individualized and based on peer-reviewed scientific studies that show its effectiveness.
This kind of care takes a multidisciplinary approach. Providers work with counselors and the person’s family, as well as the person themselves. They may also work with the child’s school and community.
When someone needs this care really depends on the person. Some children have a sense about their true gender as early as 3 years old, experts say, others as they move into puberty and still others much later.
A growing number of clinics across the country have been created to specifically provide gender-affirming care, including for children. Many use a similar approach that involves a multidisciplinary team of experts who can tailor make the program to the patient and their needs.
At the Gender Identity Program at Columbia University Medical Center, Director Melina Wald says, the process usually starts with a phone call. The family speaks with an intake coordinator and completes a brief screening to give an initial assessment of where the child is in their development. Depending on the age of the child, they may also participate.
Next, the clinic schedules the family for a couple of visits with the team’s mental health care professionals. At the first appointment, the team gauges the family’s and child’s needs.
“It’s to really get a better sense of what’s bringing them into the clinic,” Wald said. “We are also looking to understand the child’s understanding of their own gender, gender expression, and a history related to that.”
The team also determines whether there are any additional mental health needs. A 2018 study on transgender youth found that the prevalence of mental health problems was sevenfold higher than among their cisgender peers. A 2019 study of transgender adults found that they had higher levels of anxiety and depression. And a 2019 survey found that 54% of transgender and nonbinary youth in the US reported considering suicide that year, and 29% made an attempt.
The mental health problems don’t stem from their identity itself but often happen because of social discrimination and what’s known as minority stress, a growing number of studies show. Stigma, marginalization, discrimination, bullying, harassment and even violence can lead to feelings of isolation and rejection.
At Wald’s clinic, after the initial screening and appointments, staffers offer feedback and their clinical impressions to the child and family. They then offer a specific treatment plan tailored for that child, based on who they are, how they identify and where they are developmentally.
“That treatment plan can include individual therapy. It can include parent support. We have an adolescent group for trans and nonbinary teens, and we also have a parent support group run by one of the psychologists on our team,” Wald said.
This part of the care will help with the social transition, said Dr. Madeline Deutsch, medical director of the UCSF Gender Affirming Health Program.
At this point, the child could start using a chosen name and pronoun. They may wear different clothing. This practice helps the young person have the confidence to present in the way that feels more genuine to them, Deutsch said.
“It’s very individualized and usually involves a mix of decision-making by parents and guardians and then maybe other stakeholders, like if the parents are accessing mental health care or if the school becomes involved to kind of help talk things through,” Deutsch said. “Usually, it’s like a no-harm-done thing. So some of it depends on the parent’s level of comfort and the community that they’re living in.”
The physical aspect of care
Deutsch said that when children get to a certain stage of puberty – diagnosed by a medical provider – and still have a persistent, well-documented sense of that their gender does not align with the one assigned at birth, depending on the child’s age, they may move forward with reversible pubertal suppression, commonly called puberty blockers.
“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.”
Puberty blockers can reduce the distress that may happen when a child develops secondary sexual characteristics such as breast growth, protrusion of the Adam’s apple or voice change. 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.
This part of the process may also include hormone therapy that can lead to gender-affirming physical change, but again, the care plan is flexible, Deutsch said.
“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.”
With gender-affirming care, the team of experts will work with the young person and the family throughout the process to decide what treatment is appropriate.
The process can take several years, or it can move faster if a child is in the “throes of puberty” and has been struggling for a long time, Deutsch said. There is still an assessment of what’s needed.
Other options include voice and communication therapy. There are also gynecological and reproductive options, but most people get these treatments when they are older, if they opt to have surgery at all. Gender-affirming surgery could include facial feminization or what’s known as facial gender surgery.
Some may choose what’s commonly called top surgery, which for transgender men and nonbinary people removes breast or chest tissue, or genital reconstructive procedures, also known as bottom surgery. Generally, these are not procedures adolescents would need, Wald said.
Legal part of care
Legal interventions can include a change in name or gender on a person’s legal documents.
How easy this is, or if it’s even possible, depends on where the person lives. The rules vary by state.
Changes to documents can include a person’s birth certificate, Social Security card, passport or driver’s license.
Why care is necessary
“For transgender and nonbinary children and adolescents, early gender-affirming care is crucial to overall health and well-being,” the US Health and Human Services Department Office of Population Affairs says. Delaying care can exacerbate stressors and health problems for kids.
Some critics of the process suggest that children should wait until adulthood to transition, but the American Academy of Pediatrics says this is an outdated approach. It assumes that gender identity is fixed at a certain age, but research shows that it’s healthier to value a child for who they are rather than for what they will become.
The association says this approach helps children feel safe “in a society that too often marginalizes or stigmatizes those seen as different” and strengthens family resiliency.
Wald says that waiting to transition can create additional psychological distress for a child and can raise a child’s risk of depression, suicidality, self-harm or substance misuse.
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“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,” Wald said.
And although they’re at higher risk of mental health issues, not all transgender or nonbinary youth have them. If they do, they don’t have to struggle with these issues for life if they can get the right kind of care and have supportive adults around them.
“These children and teens can be incredibly resilient,” Wald said. “With support and access to care, they will thrive and can be just as successful as any kid.”