Putting numbers on the rise in children seeking gender care
By ROBIN RESPAUT and CHAD TERHUNE
Filed Oct. 6, 2022, 11 a.m. GMT
Thousands of children in the United States now openly identify as a gender different from the one they were assigned at birth, their numbers surging amid growing recognition of transgender identity and rights even as they face persistent prejudice and discrimination.
As the number of transgender children has grown, so has their access to gender-affirming care, much of it provided at scores of clinics at major hospitals.
Reliable counts of adolescents receiving gender-affirming treatment have long been guesswork – until now. Reuters worked with health technology company Komodo Health Inc to identify how many youths have sought and received care. The data show that more and more families across the country are grappling with profound questions about what type of care to pursue for their children, placing them at the center of a vitriolic national political debate over what it means to protect youth who identify as transgender.
Diagnoses of youths with gender dysphoria surge
In 2021, about 42,000 children and teens across the United States received a diagnosis of gender dysphoria, nearly triple the number in 2017, according to data Komodo compiled for Reuters. Gender dysphoria is defined as the distress caused by a discrepancy between a person’s gender identity and the one assigned to them at birth.
Overall, the analysis found that at least 121,882 children ages 6 to 17 were diagnosed with gender dysphoria from 2017 through 2021. Reuters found similar trends when it requested state-level data on diagnoses among children covered by Medicaid, the public insurance program for lower-income families.
Gender-affirming care for youths takes several forms, from social recognition of a preferred name and pronouns to medical interventions such as hormone therapy and, sometimes, surgery. A small but increasing number of U.S. children diagnosed with gender dysphoria are choosing medical interventions to express their identity and help alleviate their distress.
These medical treatments don’t begin until the onset of puberty, typically around age 10 or 11.
For children at this age and stage of development, puberty-blocking medications are an option. These drugs, known as GnRH agonists, suppress the release of the sex hormones testosterone and estrogen. The U.S. Food and Drug Administration has approved the drugs to treat prostate cancer, endometriosis and central precocious puberty, but not gender dysphoria. Their off-label use in gender-affirming care, while legal, lacks the support of clinical trials to establish their safety for such treatment.
Over the last five years, there were at least 4,780 adolescents who started on puberty blockers and had a prior gender dysphoria diagnosis.
This tally and others in the Komodo analysis are likely an undercount because they didn’t include treatment that wasn’t covered by insurance and were limited to pediatric patients with a gender dysphoria diagnosis. Practitioners may not log this diagnosis when prescribing treatment.
By suppressing sex hormones, puberty-blocking medications stop the onset of secondary sex characteristics, such as breast development and menstruation in adolescents assigned female at birth. For those assigned male at birth, the drugs inhibit development of a deeper voice and an Adam’s apple and growth of facial and body hair. They also limit growth of genitalia.
Without puberty blockers, such physical changes can cause severe distress in many transgender children. If an adolescent stops the medication, puberty resumes.
The medications are administered as injections, typically every few months, or through an implant under the skin of the upper arm.
After suppressing puberty, a child may pursue hormone treatments to initiate a puberty that aligns with their gender identity. Those for whom the opportunity to block puberty has already passed or who declined the option may also pursue hormone therapy.
At least 14,726 minors started hormone treatment with a prior gender dysphoria diagnosis from 2017 through 2021, according to the Komodo analysis.
Hormones – testosterone for adolescents assigned female at birth and estrogen for those assigned male – promote development of secondary sex characteristics. Adolescents assigned female at birth who take testosterone may notice that fat is redistributed from the hips and thighs to the abdomen. Arms and legs may appear more muscular. The brow and jawline may become more pronounced. Body hair may coarsen and thicken. Teens assigned male at birth who take estrogen may notice the hair on their body softens and thins. Fat may be redistributed from the abdomen to the buttocks and thighs. Their testicles may shrink and sex drive diminish. Some changes from hormone treatment are permanent.
Hormones are taken in a variety of ways: injections, pills, patches and gels. Some minors will continue to take hormones for many years well into adulthood, or they may stop if they achieve the physical traits they want.
Hormone treatment may leave an adolescent infertile, especially if the child also took puberty blockers at an early age. That and other potential side effects are not well-studied, experts say.
The ultimate step in gender-affirming medical treatment is surgery, which is uncommon in patients under age 18. Some children’s hospitals and gender clinics don’t offer surgery to minors, requiring that they be adults before deciding on procedures that are irreversible and carry a heightened risk of complications.
The Komodo analysis of insurance claims found 56 genital surgeries among patients ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021. Among teens, “top surgery” to remove breasts is more common. In the three years ending in 2021, at least 776 mastectomies were performed in the United States on patients ages 13 to 17 with a gender dysphoria diagnosis, according to Komodo’s data analysis of insurance claims. This tally does not include procedures that were paid for out of pocket.
A note on the data
Komodo’s analysis draws on full or partial health insurance claims for about 330 million U.S. patients over the five years from 2017 to 2021, including patients covered by private health plans and public insurance like Medicaid. The data include roughly 40 million patients annually, ages 6 through 17, and comprise health insurance claims that document diagnoses and procedures administered by U.S. clinicians and facilities.
To determine the number of new patients who initiated puberty blockers or hormones, or who received an initial dysphoria diagnosis, Komodo looked back at least one year prior in each patient’s record. For the surgery data, Komodo counted multiple procedures on a single day as one procedure.
For the analysis of pediatric patients initiating puberty blockers or hormones, Komodo searched for patients with a prior gender dysphoria diagnosis. Patients with a diagnosis of central precocious puberty were removed. A total of 17,683 patients, ages 6 through 17, with a prior gender dysphoria diagnosis initiated either puberty blockers or hormones or both during the five-year period. Of these, 4,780 patients had initiated puberty blockers and 14,726 patients had initiated hormone treatment.
Youth in Transition
By Robin Respaut and Chad Terhune
Photo editing: Corrine Perkins
Art direction: John Emerson
Edited by Michele Gershberg and John Blanton
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What the Science on Gender-Affirming Care for Transgender Kids Really Shows
Laws that ban gender-affirming treatment ignore the wealth of research demonstrating its benefits for trans people’s health
- By Heather Boerner on May 12, 2022
Editor’s Note (3/30/23): This article from May 2022 is being republished to highlight the ways that ongoing anti-trans legislation is harmful and unscientific.
For the first 40 years of their life, Texas resident Kelly Fleming spent a portion of most years in a deep depression. As an adult, Fleming—who uses they/them pronouns and who asked to use a pseudonym to protect their safety—would shave their face in the shower with the lights off so neither they nor their wife would have to confront the reality of their body.
What Fleming was experiencing, although they did not know it at the time, was gender dysphoria : the acute and chronic distress of living in a body that does not reflect one’s gender and the desire to have bodily characteristics of that gender. While in therapy, Fleming discovered research linking access to gender-affirming hormone therapy with reduced depression in transgender people. They started a very low dose of estradiol, and the depression episodes became shorter, less frequent and less intense. Now they look at their body with joy.
So when Fleming sees what authorities in Texas , Alabama , Florida and other states are doing to bar transgender teens and children from receiving gender-affirming medical care, it infuriates them. And they are worried for their children, ages 12 and 14, both of whom are agender—a identity on the transgender spectrum that is neither masculine nor feminine.
“I’m just so excited to see them being able to present themselves in a way that makes them happy,” Fleming says. “They are living their best life regardless of what others think, and that’s a privilege that I did not get to have as a younger person.”
Laws Based on “Completely Wrong” Information
Currently more than a dozen state legislatures or administrations are considering—or have already passed—laws banning health care for transgender young people. On April 20 the Florida Department of Health issued guidance to withhold such gender-affirming care. This includes social gender transitioning—acknowledging that a young person is trans, using their correct pronouns and name, and supporting their desire to live publicly as the gender of their experience rather than their sex assigned at birth. This comes nearly two months after Texas Governor Greg Abbott issued an order for the Texas Department of Family and Protective Services to investigate for child abuse parents who allow their transgender preteens and teenagers to receive medical care. Alabama recently passed SB 184 , which would make it a felony to provide gender-affirming medical care to transgender minors. In Alabama, a “minor” is defined as anyone 19 or younger.
If such laws go ahead, 58,200 teens in the U.S. could lose access to or never receive gender-affirming care, according to the Williams Institute at the University of California, Los Angeles. A decade of research shows such treatment reduces depression, suicidality and other devastating consequences of trans preteens and teens being forced to undergo puberty in the sex they were assigned at birth).
The bills are based on “information that’s completely wrong,” says Michelle Forcier, a pediatrician and professor of pediatrics at Brown University. Forcier literally helped write the book on how to provide evidence-based gender care to young people. She is also an assistant dean of admissions at the Warren Alpert Medical School of Brown University. Those laws “are absolutely, absolutely incorrect” about the science of gender-affirming care for young people, she says. “[Inaccurate information] is there to create drama. It’s there to make people take a side.”
The truth is that data from more than a dozen studies of more than 30,000 transgender and gender-diverse young people consistently show that access to gender-affirming care is associated with better mental health outcomes—and that lack of access to such care is associated with higher rates of suicidality, depression and self-harming behavior. (Gender diversity refers to the extent to which a person’s gendered behaviors, appearance and identities are culturally incongruent with the sex they were assigned at birth. Gender-diverse people can identify along the transgender spectrum, but not all do.) Major medical organizations, including the American Academy of Pediatrics (AAP) , the American Academy of Child and Adolescent Psychiatry , the Endocrine Society , the American Medical Association , the American Psychological Association and the American Psychiatric Association , have published policy statements and guidelines on how to provide age-appropriate gender-affirming care. All of those medical societies find such care to be evidence-based and medically necessary.
AAP and Endocrine Society guidelines call for developmentally appropriate care, and that means no puberty blockers or hormones until young people are already undergoing puberty for their sex assigned at birth. For one thing, “there are no hormonal differences among prepubertal children,” says Joshua Safer, executive director of the Mount Sinai Center for Transgender Medicine and Surgery in New York City and co-author of the Endocrine Society’s guidelines. Those guidelines provide the option of gonadotropin-releasing hormone analogues (GnRHas), which block the release of sex hormones, once young people are already into the second of five puberty stages—marked by breast budding and pubic hair. These are offered only if a teen is not ready to make decisions about puberty. Access to gender-affirming hormones and potential access to gender-affirming surgery is available at age 16—and then, in the case of transmasculine youth, only mastectomy, also known as top surgery. The Endocrine Society does not recommend genital surgery for minors.
Before puberty, gender-affirming care is about supporting the process of gender development rather than directing children through a specific course of gender transition or maintenance of cisgender presentation, says Jason Rafferty, co-author of AAP’s policy statement on gender-affirming care and a pediatrician and psychiatrist at Hasbro Children’s Hospital in Rhode Island. “The current research suggests that, rather than predicting or preventing who a child might become, it’s better to value them for who they are now—even at a young age,” Rafferty says.
A Safe Environment to Explore Gender
A 2021 systematic review of 44 peer-reviewed studies found that parent connectedness, measured by a six-question scale asking about such things as how safe young people feel confiding in their guardians or how cared for they feel in the family, is associated with greater resilience among teens and young adults who are transgender or gender-diverse. Rafferty says he sees his role with regard to prepubertal children as offering a safe environment for the child to explore their gender and for parents to ask questions. “The gender-affirming approach is not some railroad of people to hormones and surgery,” Safer says. “It is talking and watching and being conservative.”
Only once children are older, and if the incongruence between the sex assigned to them at birth and their experienced gender has persisted, does discussion of medical transition occur. First a gender therapist has to diagnose the young person with gender dysphoria .
After a gender dysphoria diagnosis—and only if earlier conversations suggest that hormones are indicated—guidelines call for discussion of fertility, puberty suppression and hormones. Puberty-suppressing medications have been used for decades for cisgender children who start puberty early, but they are not meant to be used indefinitely. The Endocrine Society guidelines recommend a maximum of two years on GnRHa therapy to allow more time for children to form their gender identity before undergoing puberty for their sex assigned at birth, the effects of which are irreversible.
“[Puberty blockers] are part of the process of ‘do no harm,’” Forcier says, referencing a popular phrase that describes the Hippocratic Oath, which many physicians recite a version of before they begin to practice.
Hormone blocker treatment may have side effects. A 2015 longitudinal observational cohort study of 34 transgender young people found that, by the time the participants were 22 years old, trans women experienced a decrease in bone mineral density. A 2020 study of puberty suppression in gender-diverse and transgender young people found that those who started puberty blockers in early puberty had lower bone mineral density before the start of treatment than the public at large. This suggests, the authors wrote, that GnRHa use may not be the cause of low bone mineral density for these young people. Instead they found that lack of exercise was a primary factor in low bone-mineral density, especially among transgender girls.
Other side effects of GnRHa therapy include weight gain, hot flashes and mood swings. But studies have found that these side effects—and puberty delay itself—are reversible , Safer says.
Gender-affirming hormone therapy often involves taking an androgen blocker (a chemical that blocks the release of testosterone and other androgenic hormones) and estrogen in transfeminine teens, and testosterone supplementation in transmasculine teens. Such hormones may be associated with some physiological changes for adult transgender people. For instance, transfeminine people taking estrogen see their so-called “good” cholesterol increase. By contrast, transmasculine people taking testosterone see their good cholesterol decrease. Some studies have hinted at effects on bone mineral density, but these are complicated and also depend on personal, family history, exercise, and many other factors in addition to hormones.”
And while some critics point to decade-old study and older studies suggesting very few young people persist in transgender identity into late adolescence and adulthood, Forcier says the data are “misleading and not accurate.” A recent review detailed methodological problems with some of these studies . New research in 17,151 people who had ever socially transitioned found that 86.9 percent persisted in their gender identity. Of the 2,242 people who reported that they reverted to living as the gender associated with the sex they were assigned at birth, just 15.9 percent said they did so because of internal factors such as questioning their experienced gender but also because of fear, mental health issues and suicide attempts. The rest reported the cause was social, economic and familial stigma and discrimination. A third reported that they ceased living openly as a trans person because doing so was “just too hard for me.”
The Harms of Denying Care
Data suggest the effects of denying that care are worse than whatever side effects result from delaying sex-assigned-at-birth puberty. And medical society guidelines conclude that the benefits of gender-affirming care outweigh the risks. Without gender-affirming hormone therapy, cisgender hormones take over, forcing body changes that can be permanent and distressing.
A 2020 study of 300 gender-incongruent young people found that mental distress—including self-harm, suicidal thoughts and depression— increased as the children were made to proceed with puberty according to their assigned sex. By the time 184 older teens (with a median age of 16) reached the stage in which transgender boys began their periods and grew breasts and transgender girls’ voice dropped and facial hair began to appear, 46 percent had been diagnosed with depression, 40 percent had self-harmed, 52 percent had considered suicide, and 17 percent had attempted it—rates significantly higher than those of gender-incongruent children who were a median of 13.9 years old or of cisgender kids their own age.
Conversely, access to gender-affirming hormones in adolescence appears to have a protective effect. In one study, researchers followed 104 teens and young adults for a year and asked them about their depression, anxiety and suicidality at the time they started receiving hormones or puberty blockers and again at the three-month, six-month and one-year mark. At the beginning of the study, which was published in JAMA Network Open in February 2022, more than half of the respondents reported moderate to severe depression, half reported moderate to severe anxiety, and 43.3 percent reported thoughts of self-harm or suicide in the past two weeks.
But when the researchers analyzed the results based on the kind of gender-affirming care the teens had received, they found that those who had access to puberty blockers or gender-affirming hormones were 60 percent less likely to experience moderate to severe depression. And those with access to the medical treatments were 73 percent less likely to contemplate self-harm or suicide.
“Delays in prescribing puberty blockers and hormones may in fact worsen mental health symptoms for trans youth,” says Diana Tordoff, an epidemiology graduate student at the University of Washington and co-author of the study.
That effect may be lifelong. A 2022 study of more than 21,000 transgender adults showed that just 41 percent of adults who wanted hormone therapy received it, and just 2.3 percent had access to it in adolescence. When researchers looked at rates of suicidal thinking over the past year in these same adults, they found that access to hormone therapy in early adolescence was associated with a 60 percent reduction in suicidality in the past year and that access in late adolescence was associated with a 50 percent reduction.
For Fleming’s kids in Texas, gender-affirming hormones are not currently part of the discussion; not all trans people desire hormones or surgery to feel affirmed in their gender. But Fleming is already looking at jobs in other states to protect their children’s access to such care, should they change their mind. “Getting your body closer to the gender [you] identify with—that is what helps the dysphoria,” Fleming says. “And not giving people the opportunity to do that, making it harder for them to do that, is what has made the suicide rate among transgender people so high. We just—trans people are just trying to survive.”
IF YOU NEED HELP If you or someone you know is struggling or having thoughts of suicide, help is available. Call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK), use the online Lifeline Chat or contact the Crisis Text Line by texting TALK to 741741.
ABOUT THE AUTHOR(S)
Heather Boerner is a health care and science journalist based in Pittsburgh. Her work has appeared in the Daily Beast , the Washington Post , the Atlantic , and NPR. Follow her on Twitter @HeatherBoerner
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Youth Access to Gender Affirming Care: The Federal and State Policy Landscape
Lindsey Dawson Follow @LindseyH_Dawson on Twitter , Jennifer Kates Follow @jenkatesdc on Twitter , and MaryBeth Musumeci Published: Jun 01, 2022
Numerous states have implemented or considered actions aimed at limiting LGBTQ+ youth access to gender affirming health care. Four states (Alabama, Arkansas, Texas, and Arizona) have recently enacted such restrictions (though the AL, AR, and TX laws all have been temporarily blocked by court rulings) and in 2022, 15 states are considering 25 similar pieces of legislation. At the same time, other states have adopted broad nondiscrimination health protections based on gender identity and sexual orientation. Separately, the Biden administration, which has been working to eliminate barriers and expand access to health care for LGBTQ+ people more generally, has come out against restrictive state policies. This analysis explores the current state and federal policy landscape regarding gender affirming services for youth and the implications of restrictive state laws.
What is the status of state policy restrictions aimed at limiting youth access to gender affirming care?
Four states (Alabama, Arkansas, Texas, and Arizona) recently enacted laws or policies restricting youth access to gender affirming care and, in some cases, imposing penalties on adults facilitating access. Alabama, Arkansas, and Texas have been temporarily blocked from enforcing these laws and policies by court order.
- Alabama. In April 2022, the Alabama governor signed a bill into law that prevents transgender minors from receiving gender affirming care, including puberty blockers, hormone therapy, and surgical intervention. The bill makes it a felony for any person to “engage in or cause” a transgender minor to receive any of these treatments, punishable by up to 10 years in prison or a fine up to $15,000. The bill additionally states that nurses, counselors, teachers, principals, and other administrative school officials shall not withhold from a minor’s parents or guardian that their child’s “perception of his or her gender or sex is inconsistent with the minor’s sex” assigned at birth and shall not encourage a minor to do so. Shortly after enactment, a federal lawsuit challenging the law was filed by four Alabama families with transgender children, two healthcare providers, and a clergy member. Subsequently, the U.S. Department of Justice (DOJ) joined the case as an additional plaintiff challenging the law. This case has been consolidated with another lawsuit filed by two other Alabama families with transgender children, which raises similar challenges. In May 2022, a federal district court entered a preliminary injunction, blocking enforcement of several sections of the Alabama law while the litigation is pending. Specifically, the preliminary injunction applies to the sections of the law that prohibit puberty blockers and hormone therapy. Other sections of the law remain in effect, including the prohibition on surgical intervention and the prohibition on school officials keeping secret or encouraging or compelling children to keep secret certain gender-identity information from children’s parents. When deciding to grant the preliminary injunction, the district court found that the plaintiffs were substantially likely to succeed on their claim that the sections of the law that prohibit puberty blockers and hormone therapy unconstitutionally violate parents’ fundamental right to autonomy under the 14 th Amendment’s due process clause by prohibiting parents from obtaining medical treatment for their children subject to medically accepted standards. The court also fond that the plaintiffs were substantially likely to succeed on their claim that these sections of the law are unconstitutional sex discrimination in violation of the 14 th Amendment’s equal protection clause because the law denies medically necessary services only to transgender minors, while allowing those services for cisgender minors. Additionally, the court found that the plaintiffs were likely to suffer irreparable harm, in the form of “severe physical and/or psychological harm” and “significant deterioration in their familial relationships and educational performance,” if the law was not blocked. The state has appealed the district court’s decision to the 11 th Circuit.
- Arkansas . In 2021, on override of Governor Hutchinson’s veto, Arkansas lawmakers passed legislation prohibiting gender-affirming treatment for minors, including puberty blockers, hormone therapy, and gender affirming surgery. The law also prohibits medical providers from making referrals to other providers for minors seeking these procedures. Under the law, medical providers offering gender affirming care or providing referrals for such care to minors may be subject to discipline by relevant licensing entities. The legislation additionally includes a prohibition on private insurance coverage of gender affirming services for minors and a prohibition on the use of public funds, including through Medicaid, for coverage of these services for minors. In May 2021, four families of transgender youth and two physicians challenged the Arkansas law in federal court, arguing that the law is illegal sex discrimination under the 14 th Amendment’s equal protection clause. They also argue that the law violates parents’ right to autonomy protected by the 14 th Amendment’s due process clause and violates the families and physicians’ right to free speech under the 1 st Amendment. The U.S. Department of Justice (DOJ) filed a statement of interest in support of the plaintiffs’ motion for a preliminary injunction in the Arkansas case. DOJ argued that the Arkansas law violates the Equal Protection Clause of the 14 th Amendment because the state law “singles out transgender minors. . . specifically and discriminatorily den[ies] their access to medically necessary care based solely on their sex assigned at birth.” A preliminary injunction was granted in July 2021, temporarily blocking the state from enforcing the law while the case is pending. The court found that the plaintiffs were likely to succeed on all three of their Constitutional claims, and that the law was not substantially related to the state’s interest in protecting children or regulating physicians’ ethics because the law allows the same medical treatments for cisgender minors. The court also found that the plaintiffs will suffer irreparable physical and psychological harm if the law is not blocked. The court also denied the state’s motion to dismiss the case. The state has appealed both of those decisions to the 8 th Circuit, where a decision is currently pending. A group of 19 states filed an amicus brief in support of the state’s appeal. 1 They argue that states have “broad authority” to regulate gender affirming services, because they allege this area is “fraught with medical uncertainties,” contrary to the evidence from the American Academy of Pediatrics and the American Medical Association on which the lower court relied. Another group of 20 states and the District of Columbia filed an amicus brief in support of the plaintiffs. 2 They argue that they and their residents are economically, physically, and mentally harmed by discrimination against transgender people. They also argue that their states “protect access to gender-affirming healthcare based on well-accepted medical standards” and that Arkansas’ law is unconstitutional sex discrimination and “ignores medical consensus as well as decisions made between doctors and their patients.” Litigation in the case continues in the district court, where the case is scheduled for trial during the week of July 25, 2022.
- Texas . In February 2022, Governor Abbott of Texas issued a directive defining certain gender affirming services for youth as child abuse, and calling for investigation of and penalties for parents who support their children in taking certain medications or undertaking certain procedures, which could include the removal of their children. In addition, under the directive, health care professionals who facilitate access to these services could also face penalties and a range of professionals in the state would be mandated to report known use of the specified gender affirming services. While other states with proposed policies to limit youth access to gender affirming care include penalties for parents who facilitate access to these services (see below), no implemented policy ties the parental role to child abuse as the Texas directive does. In the wake of litigation , a state court entered a temporary injunction preventing the state from enforcing the directive while the case is pending. The court found that the governor acted outside his statutory legal authority in issuing the directive, and the plaintiffs will suffer immediate and irreparable injuries, including loss of employment, deprivation of constitutional rights, and loss of medically necessary care. However, the Texas Supreme Court subsequently modified the temporary injunction, finding that the courts lack authority to prevent enforcement of the directive statewide. Instead, the state is prohibited from enforcing the directive only against the plaintiffs involved in the lawsuit while the case is pending. The case is scheduled for trial on July 11, 2022.
- Arizona . In March 2022, Arizona Governor Ducey signed legislation into law that bans physicians from providing gender-affirming surgical treatment to minors. The legislation does not address hormone therapy or puberty blockers.
In addition, since January 2022 15 states introduced a total of 25 bills that would restrict access to gender-affirming care for youth. Provisions in these bills varied considerably and include those that would:
- criminalize or impose/permit professional disciplinary action (e.g. revoking or suspending licensure) on health professionals providing gender-affirming care to minors, in some cases labeling such services as child abuse
- penalize parents aiding in youth accessing gender-affirming care
- permit individuals to file for damages against providers who violate such laws
- limit insurance coverage or payment for gender affirming services or prohibit the use of state funds for such services
Beyond these policies, states have also passed or considered other policies restricting access, including so called “bathroom bills” which restrict access to bathrooms or locker rooms based on sex assigned at birth, the recent Florida “don’t say gay” bill that would prohibit classroom discussion on sexual orientation or gender identity, and laws that limit transgender students’ access to sports. While these policies are not directly tied to health or health care access, their attempts to limit access to social spaces and services and present non-affirming sentiments could negatively impact LGBTQ+ people’s mental health and well-being. For instance, one recent study found that state laws permitting the denial of services to same-sex couples “are associated with increases in mental distress among sexual minority adults.” In addition, and directly related to health care, Florida recently released non-biding guidance recommending against gender affirming care for youth.
What states have introduced protections related to sexual orientation and gender identity in health care?
Though not specific to youth access to gender affirming care, some states have adopted policies that provide health care protections to LGBTQ+ people, including:
- prohibitions on health insurance discrimination based on sexual orientation and/or
- requirements that state Medicaid programs explicitly cover health services related to gender transition
What is federal policy regarding gender-affirming services?
The Biden administration has taken multiple steps to promote access to health care for LGBTQ+ people and to prohibit discrimination on the basis of sexual orientation and gender identity, including:
- On his first day in office, President Biden signed an executive order directing federal agencies to review existing regulations and policies in order to “prevent and combat discrimination” based on gender identity and sexual orientation. The order states that “people should be able to access healthcare…without being subjected to sex discrimination” and views sex nondiscrimination protections as encompassing sexual orientation and gender identity, following the Supreme Court’s Bostock
- On May 10, 2021, also in light of the Bostock ruling, the Biden Administration announced that the Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) would include gender identity and sexual orientation in its interpretation and enforcement of Section 1557’s prohibition against sex discrimination. Section 1557 of the Affordable Care Act (ACA) contains the law’s primary nondiscrimination provisions, including a prohibition on discrimination on the basis of sex by a range of health care entities and programs that receive federal funding. The May 2021 announcement marked both a reversal of Trump Administration policy, which eliminated gender identity and sex stereotyping from the regulations, and an expansion of Obama Administration policy, which included gender identity and sex stereotyping in the definition of sex discrimination but omitted sexual orientation. Following the Bostock ruling, two federal district courts issued nationwide preliminary injunctions, blocking implementation of several provisions of the Trump Administration’s regulations related to Section 1557. Biden Administration implementing regulations on Section 1557 are expected to expand on the May announcement.
In addition to establishing a foundation of nondiscrimination policies for LGBTQ+ people, and participating in the Alabama and Arkansas cases as noted above, the administration has responded specifically to the Texas directive, denouncing it as discriminatory and stating that gender affirming care for youth should be supported as follows:
- Statement from President Biden: The statement from the president states that the administration is “putting the state of Texas on notice that their discriminatory actions put children’s lives at risk. These announcements make clear that rather than weaponizing child protective services against loving families, child welfare agencies should instead expand access to gender-affirming care for transgender children.”
- Statement from Dept. of Health and Human Services (HHS) Sec. Becerra : Becerra’s statement reaffirms “HHS’s commitment to supporting and protecting transgender youth and their parents, caretakers and families” and details action items the administration is taking in response to the Texas directive including those that follow below.
- Following the actions in Texas, HHS’s Administration on Children, Youth and Families issued an Information Memorandum to state child welfare agencies writing that child welfare systems should advance safety and support for LGBTQI+ youth, including though access to gender affirming care.
- Specifically, the guidance states that categorically refusing treatment based on gender identity is prohibited discrimination under Section 1557. The guidance also states that Section 1557’s prohibition against sex-based discrimination is likely violated if a provider reports parents seeking medically necessary gender affirming care for their child to state authorities, if the provider or facility is receiving federal funding. The guidance further states that restricting a provider from providing gender affirming care may violate Section 1557.
- The guidance states that in cases where gender dysphoria qualifies as a disability, restrictions that prevent individuals from receiving medically necessary care based on a diagnosis or perception of gender dysphoria may also violate Section 504 and the ADA.
- It also articulates requirements under the Health Insurance Portability and Accountability Act (HIPAA) that prohibit health plans and providers from disclosing protected health information, such as use of gender affirming physical or mental health care without patient consent, except in limited circumstances.
OCR enforces each of these federal laws, and the guidance states that parents or caregivers who believe their child has been denied health care, including gender affirming care, and health care providers who believe they have been unlawfully restricted from providing such care, may file an administrative complaint for OCR to investigate.
What do major medical societies say about gender affirming services?
Most major U.S. medical associations, including those in the fields of pediatrics, endocrinology, psychiatry, and psychology, have issued statements recognizing the medical necessity and appropriateness of gender affirming care for youth, typically noting harmful effects of denying access to these services. These include statements from the American Medical Association , American Academy of Pediatrics , the Endocrine Society , American Psychological Association , American Psychiatric Association , and the World Professional Association for Transgender Health , among others , which in some cases were specifically issued in response to the Arkansas legislation and Texas directive. Further, 23 medical associations or societies, including those named above, together filed an amicus brief in the case filed against Texas Gov. Abbott opposing the state directive. The brief states that denying gender affirming treatment to adolescents who need them would irreparably harm their health and that enforcing the directive would irreparably harm providers who are forced to choose between potentially facing civil and criminal penalties or endangering their patients. A similar amicus brief was filed in the Arkansas case.
Additionally, the Endocrine Society supports gender affirming care for young people in their clinical practice guidelines , as does the World Professional Association for Transgender Health’s standards of care . Together these guidelines form the standard of care for treatment of gender dysphoria.
What are the implications of access restrictions?
State policies restricting youth access to gender affirming care could have significant health and other implications for LGBTQ+ youth, their parents, health care providers, and, in some cases, other community members:
LGBTQ+ youth : LGBTQ+ youth experience higher rates of depression, anxiety, and suicidality than their non-LGBTQ+ peers. In one CDC study of youth in 10 states and 9 urban school districts, a higher share of transgender students reported suicide risk outcomes across a range of metrics than cisgender students. These include, in the past 12 months: having felt sad or hopeless, considered attempting suicide, made a suicide plan, attempted suicide, or had a suicide attempt treated by a doctor or nurse. Inability to access gender affirming care, such as puberty suppressors and hormone therapy , has been linked to worse mental health outcomes for transgender youth, including with respect to suicidal ideation, potentially exacerbating the already existing disparities. Conversely, access to this care is associated with improved outcomes in these domains. Policies that aim to prohibit or interrupt access to gender affirming care for youth can therefore have negative implications for health in potentially life-threatening ways.
In addition, LGBTQ people report higher rates of negative experiences with medical providers, so creating barriers to gender affirming care could further challenge transgender people’s relationship with the healthcare system.
Finally, with the Texas directive specifically, and in several other states with bills under consideration, youth are vulnerable to secondary trauma, knowing that if they seek such care, their families and providers could be subject to penalties, and, in the case of Texas, children could be separated from their parents.
Parents : In several states with bills under consideration, parents who facilitate access to evidence-based and potentially lifesaving gender affirming services for their children could face penalties. Under the Texas directive, because it is defined as child abuse, parents who facilitate access to gender affirming care for their children, could be subject to penalties, including losing custody of their children. This may place parents in the position of either supporting their children in accessing care supported by medical evidence and facing penalties or denying their children access in an effort not to make their family vulnerable to investigation and potential separation. Each option for parents in this scenario has the potential to be traumatic for the family, and for youth in particular.
Providers: Like parents, providers may be torn between what the medical literature supports is in the best interest of their patients or facing potential sanctions, including violating professional ethics around confidentiality, as in the case of Texas. The American Psychological Association said in a statement that a requirement such as the Texas directive is a violation of both patient confidentiality and professional ethics. Under such circumstances, providers may be forced to decide whether they will provide the highest standard of care for their patients and potentially face sanctions, or obey the state directive but withhold care and potentially violate patient confidentiality and professional ethics. Further, as noted above, the Biden Admiration has stated that HIPAA requirements prohibit providers from disclosing use of gender affirming care without patient consent, except as in narrow circumstances. However, following HIPPA requirements in this case may make providers vulnerable to state sanction under the directive.
Teachers and others : In Texas, in addition to health care providers, other mandated reporters, such as teachers, could also face penalties for failure to report youth known to be accessing gender affirming care. The directive also states that ”there are similar reporting requirements and criminal penalties for members of the general public,” extending the policy’s reach to practically anyone with knowledge of youth accessing these services.
The legal and policy landscape regarding youth access to gender affirming care is shifting across the country, with an increasing number of states seeking to limit such access and impose penalties. Such policies may have significant, negative implications for the health of young people. At the same time, these states are at odds with federal law and policy, and in two recent cases courts have temporarily blocked enforcement of such restrictions. Moving ahead, it will be important to watch how state bills still under consideration unfold and the final outcome of cases in Alabama, Arkansas, and Texas. Decisions in these cases could determine how such policies intersect with existing federal policies — including Section 1557’s prohibition on sex based discrimination in health care, federal disability non-discrimination protections, and HIPAA patient privacy protections — as well as providers’ professional ethics standards.
These states include Alabama, Alaska, Arizona, Georgia, Idaho, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, South Carolina, South Dakota, Tennessee, Texas, Utah, and West Virginia.
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These states include California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Carolina, Oregon, Rhode Island, Vermont, and Washington.
Also of Interest
- LGBT+ People’s Health and Experiences Accessing Care
- The Health System Appears To Be Selling LGBT+ People Short
- The Impact of the COVID-19 Pandemic on LGBT+ People’s Mental Health
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What medical treatments do transgender youth get?
Transgender medical treatment for children and teens is increasingly under attack in many states, labeled child abuse and subject to criminalizing bans. But it has been available in the United States for more than a decade and is endorsed by major medical associations.
Many clinics use treatment plans pioneered in Amsterdam 30 years ago, according to a recent review in the British Psych Bulletin. Since 2005, the number of youth referred to gender clinics has increased as much as tenfold in the U.S., U.K, Canada and Finland, the review said.
The World Professional Association for Transgender Health, a professional and educational organization, and the Endocrine Society, which represents specialists who treat hormone conditions, both have guidelines for such treatment . Here’s a look at what’s typically involved.
Children who persistently question the sex they were designated at birth are often referred to specialty clinics providing gender-confirming care. Such care typically begins with a psychological evaluation to determine whether the children have “gender dysphoria,” or distress caused when gender identity doesn’t match a person’s assigned sex.
Children who meet clinical guidelines are first offered medication that temporarily blocks puberty . This treatment is designed for youngsters diagnosed with gender dysphoria who have been counseled with their families and are mature enough to understand what the regimen entails.
‘I know who I am’: Transgender youth on the value of support, respect for their identities
The medication isn’t started until youngsters show early signs of puberty — enlargement of breasts or testicles. This typically occurs around age 8 to 13 for girls and a year or two later for boys.
The drugs, known as GnRH agonists, block the brain from releasing key hormones involved in sexual maturation. They have been used for decades to treat precocious puberty, an uncommon medical condition that causes puberty to begin abnormally early.
The drugs can be given as injections every few months or as arm implants lasting up to year or two. Their effects are reversible — puberty and sexual development resume as soon as the drugs are stopped.
Some kids stay on them for several years. One possible side effect: They may cause a decrease in bone density that reverses when the drugs are stopped.
After puberty blockers, kids can either go through puberty while still identifying as the opposite sex or begin treatment to make their bodies more closely match their gender identity.
For those choosing the second option, guidelines say the next step is taking manufactured versions of estrogen or testosterone — hormones that prompt sexual development in puberty . Estrogen comes in skin patches and pills. Testosterone treatment usually involves weekly injections.
READ MORE: The history behind International Transgender Day of Visibility
Guidelines recommend starting these when kids are mature enough to make informed medical decisions. That is typically around age 16, and parents’ consent is typically required, said Dr. Gina Sequiera, co-director of Seattle Children’s Hospital’s Gender Clinic.
Many transgender patients take the hormones for life, though some changes persist if medication is stopped.
In girls transitioning to boys, testosterone generally leads to permanent voice-lowering, facial hair and protrusion of the Adam’s apple, said Dr. Stephanie Roberts, a specialist at Boston Children’s Hospital’s Gender Management Service. For boys transitioning to girls, estrogen-induced breast development is typically permanent, Roberts said.
Research on long-term hormone use in transgender adults has found potential health risks including blood clots and cholesterol changes.
Gender-altering surgery in teens is less common than hormone treatment, but many centers hesitate to give exact numbers.
Guidelines say such surgery generally should be reserved for those aged 18 and older. The World Professional Association for Transgender Health says breast removal surgery is OK for those under 18 who have been on testosterone for at least a year. The Endocrine Society says there isn’t enough evidence to recommend a specific age limit for that operation.
Studies have found some children and teens resort to self-mutilation to try to change their anatomy. And research has shown that transgender youth and adults are prone to stress, depression and suicidal behavior when forced to live as the sex they were assigned at birth.
Opponents of youth transgender medical treatment say there’s no solid proof of purported benefits and cite widely discredited research claiming that most untreated kids outgrow their transgender identities by their teen years or later. One study often mentioned by opponents included many kids who were mistakenly identified as having gender dysphoria and lacked outcome data for many others.
READ MORE: Giving homeless transgender youth a safe haven from the streets
Doctors say accurately diagnosed kids whose transgender identity persists into puberty typically don’t outgrow it. And guidelines say treatment shouldn’t start before puberty begins.
Many studies show the treatment can improve kids’ well-being, including reducing depression and suicidal behavior. The most robust kind of study — a trial in which some distressed kids would be given treatment and others not — cannot be done ethically. Longer term studies on treatment outcomes are underway.
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Toddlers can’t get gender-affirming surgeries, despite claims
FILE - People attend a rally as part of a Transgender Day of Visibility, Friday, March 31, 2023, by the Capitol in Washington. The Associated Press on Friday, April 21, 2023 reported on social media users falsely claiming a map shows the states where it’s possible for a 3-year-old child to receive gender-affirming surgery. (AP Photo/Jacquelyn Martin, File)
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CLAIM: Map shows the states where it’s possible for a 3-year-old child to receive gender-affirming surgery.
AP’S ASSESSMENT: False. The map shows which states have passed or are considering anti-transgender laws. Children as young as 3 are not qualified to undergo operations to change their gender, medical experts say. Nationally-recognized medical guidelines recommend patients be at least 15 years old to receive the surgeries, and only then in special circumstances.
THE FACTS: Social media users are sharing a map of the U.S. that purports to show which states are the hardest and which are the easiest to obtain sex change surgery for children as young as 3.
The map shows blue-colored states located mostly along the coasts and the Great Lakes and red-colored states that are mostly in the Midwest and South.
“The dark red states are where it’s hardest to get your 3 year old a sex change operation,” the text above the map claims.
“If you’re thinking about moving this could be helpful,” wrote an Instagram user who shared the map in a post that’s been liked nearly 280,000 times as of Friday. “Get away from the blue.”
But the map is being misrepresented online: it categorizes states according to the type of transgender laws or bills that have been enacted or are under consideration.
Red-colored states are those with the “worst anti-trans laws” while those in blue are the “safest states with protections” for transgender individuals, according to the map’s key, which is visible in small text in the bottom right corner of the image.
Erin Reed, a transgender advocate who developed the map, confirmed to The Associated Press that her graphic is being misrepresented.
She created the “Anti-Trans Legislative Risk” map to track bills moving through state houses across the country, and posted the latest version on her Substack page in March.
“In reality, this is MY map,” Reed later tweeted , sharing a screenshot of the false claim circulating online and adding a large red ‘x’ through it. “It evaluates the risk of anti-trans laws pulling people’s medical care, bans from bathrooms, and more.”
Reed also stressed that sex change operations aren’t permitted on 3 year olds.
“Gender affirming care starts with puberty blockers around age 11-14, and will progress to hormone therapy, with surgeries held off until later,” she wrote in an email to the AP.
Medical experts and LGBTQ advocates agreed, noting that such surgeries aren’t offered until a patient becomes a legal adult, though exceptions are made for minor teens who meet certain criteria.
“The general recommendation is for gender affirming surgeries to be done after age 18 with limited exceptions,” Dr. Michael Irwig, director of transgender medicine at Beth Israel Deaconess Medical Center in Boston, wrote in an email. “The patient should always be of an age where they have adequate maturity including the ability to understand the potential risks and benefits of any treatment.”
The World Professional Association for Transgender Health, a global group that sets standards for medical care of trans youths and adults, recommended last year that hormone treatment start no earlier than 14 years old and surgeries be offered only in rare exceptions in persons as young as 15. Both minimum ages were lower than prior recommendations.
Gender-affirming surgery includes a wide range of procedures, from plastic surgery to change facial features to so-called “top surgery” to change the chest or torso and so-called “bottom surgery” to make changes to genitals.
Teens who are 16 to 17 years old are generally limited to receiving only “top surgeries,” and they must be “consistent and persistent” in their gender identity for years, take gender-affirming hormones for some time and have approvals from both their parents and doctors, according to Aryn Fields, a spokesperson for the Human Rights Campaign, an LGBTQ advocacy group based in Washington, D.C.
“In all cases, gender affirming surgeries are only performed after multiple discussions with both mental health providers and physicians (including endocrinologists and/or surgeons), to determine if surgery is the appropriate course of action,” she wrote in an email.
This is part of AP’s effort to address widely shared misinformation, including work with outside companies and organizations to add factual context to misleading content that is circulating online. Learn more about fact-checking at AP .
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- v.47(2); 2023 Apr
Transgender children and young people: how the evidence can point the way forward
University College, London, UK
Data availability is not applicable to this article as no new data were created or analysed in this study.
The development of gender identity in children from around the age of 3 years is described. Wishes for transgender identity are distinguished from gender-atypical behaviour. Reasons for the recent rise in transgender referrals in the early teen years are discussed. The now widely used protocol developed by the Amsterdam group for assessing transgender children and young people and, where appropriate, offering them puberty blockers, cross-sex hormones and sex reassignment surgery is described. Evidence for the effectiveness of this approach is considered. The competence of young people to give consent to these procedures is discussed. Finally, proposals are made for topics urgently requiring further research.
Children first begin to develop a sense of biological gender at around the age of 2 to 3 years. 1 At this age, they are able to label pictures of boys and girls according to typical presentations of heteronormativity. At 4 years, boys understand that it is the possession of a penis that marks them out as biologically male and girls understand it is the lack of a penis that means they are biologically female. By this age, children have a sense of the stability of biological gender, an understanding that it remains constant with time. From this point up to the age of 6 or 7 years, their judgement of gender in pictures of clothed children is heavily influenced by appearance so that they label boys pictured in dresses as girls and boys with long hair as girls. By 7 years they recognise biological sex as constant and independent of external appearance. 1
By the age of 7 years, therefore, children understand three different concepts related to sex/gender identity: biological sex, self-perceived gender identity and social gender identity. They understand that they and others are biologically male or female, that they and others have a sense of their own gender identity as male or female and that they and others, depending on their appearance and clothing, are usually perceived by others as male or female. As they develop into adolescence and adulthood, people recognise that, with the use of hormones and surgical interventions, some features of biological sex can be changed. Both self-perceived gender identity and social gender identity may also undergo change.
The great majority of young children develop a self-perceived gender identity consonant with their gender assigned at birth, but some, from the age of 3 or 4 years, develop a self-perceived gender identity which is other than that assigned at birth. This sense of another gender identity can be accompanied by a feeling of discomfort or gender dysphoria. There are many autobiographical examples of the first awareness of gender dysphoria. The best known is that written by Jan Morris, who lived as a highly successful male journalist under the name of James Morris until her mid-30s when, following treatment with hormones, she underwent a surgical reconstruction and thereafter lived as a woman. 2 Jan Morris describes very clearly the onset of her gender dysphoria: 2 ‘I was three or perhaps four years old when I realized I had been born into the wrong body and should really be a girl. I remember the moment well, and it is the earliest memory of my life’ (p. 1). Her sense of discomfort with her assigned gender at birth persisted throughout her childhood, adolescence and early adult life. She describes how, when in role as a young man, she used to pray ‘please God make me a girl’ (p. 39). Gender dysphoria persisted throughout her marriage and parenthood. It was only in her late 30s, after she had had gender reassignment surgery, that she felt at ease.
The majority of prepubertal girls and boys have a clear sense of their own gender identity as female or male. This is nearly always consistent with their gender assigned at birth; in some, like Jan Morris, it is not. In a study of adolescents who had been referred to a gender identity clinic in earlier childhood, Steensma et al were able to show that a high proportion of prepubertal children with gender dysphoria did not continue to show such dysphoria after puberty, 3 a finding that had previously been reported by the same group. 4 Further, children who had shown gender-atypical behaviour (see below) without intense gender dysphoria did not generally show gender dysphoria in adolescence. Those with gender dysphoria who had been assigned a female gender at birth were less likely to desist than those assigned a male gender. Those who persisted were much more likely to have a homosexual or bisexual orientation.
A sense of gender identity must be distinguished from the presence of gender-atypical behaviour, which may occur with or without gender dysphoria. Gender-atypical behaviour (boys behaving like girls and having interests generally regarded as feminine and vice versa ) is not uncommon in the general population. In a total population study, using a standardised instrument, Golombok et al were able to identify 112 boys and 113 girls aged 3.5 years who showed gender-atypical behaviour to an extreme degree. 5 This represented about 2.2% of the population studied (S. Golombok, personal communication, 5 Jan 2021). Especially for girls, there was considerable continuity between gender-atypical behaviours at 3.5 years and such behaviour at the age of 13 years. These investigators do not report whether any of the children in their study were referred for gender dysphoria. The prevalence of 2.2% for gender-atypical behaviour needs to be contrasted with the much less frequent prevalence of 1 per 6800 Dutch adolescents aged 12 to 18 years who requested medical help for gender dysphoria. 6
Gender dysphoria and the onset of sexual feelings
Between 9 and 13 years of age, children start to experience sexual feelings arising from their genitalia. This onset of sexual feelings coincides with biological changes known as gonadarche. At this point, as a result of changes in the hypothalamus and pituitary, the gonads begin to secrete the sex hormones, testosterone and oestradiol, in relatively small quantities. This results in a modest growth of hair around the pubes and in the armpits and growth of the penis and breasts respectively. Spontaneous penile erections and clitoral excitement occur. Around 2 years later, positive feedback occurs in the hypothalamo–pituitary–gonadal axis which stimulates the testes to produce much larger amounts of testosterone and the ovaries to secrete more oestradiol, leading to menstruation. These hormonal changes also result in much more intense experience of sexual desire.
In the majority of children, sexual attraction is heterosexual but around 10% of 16- to 44-year-old adults report some previous sexual contact with a member of the same sex. 7 Most of those who experience homosexual attraction are not transgender. Usually, they have not even shown gender-atypical behaviour; they have been typically masculine, if boys, and feminine, if girls. Transgender boys usually, but not always, feel attraction to others of the same natal sex, i.e. they have homosexual feelings, and transgender girls similarly feel attracted by others of the same natal sex. Inevitably, these sexual feelings are often associated with some degree of confusion and uncertainty. For most transgender boys and girls, however, homosexual feelings have the effect of confirming the child in their transgender role: ‘If I'm really a girl, it isn't surprising I'm attracted to boys’, a transgender natal boy might say to himself and vice versa for girls. But some transgender children develop sexual attraction for others of the opposite natal sex, again with the creation of confusion and uncertainty over the transgender role.
Adolescence and gender identity
Adolescence is a social construction, i.e. it is a phase of life defined by society. 8 In Western society, it is regarded as beginning at the onset of biological puberty. Its end is not, however, defined biologically, but usually by a social criterion such as the age at which the individual develops significant autonomy. In practice, most psychologists, clinicians and members of the general public equate adolescence with the teen years, from 13 to 19, although many young people are well into biological puberty by 13 years and will have completed the biological changes of puberty well before 19 years. Recently, Sawyer and colleagues in an influential article have argued for an expanded and more inclusive definition of adolescence corresponding with the longer period of transition from childhood to adulthood now experienced by young people in Western society. They suggest that the period of 10 to 24 years is more consistent with this experience. 9 It is of relevance that there is considerable variation in ages at onset and termination of biological puberty, some young people normally starting at 10 or 11 years old and others not completing puberty until their later teen years. Relatively recent neuroscientific studies have pointed to the fact that rapid biological changes occur in the brain during the teen years, 10 but these are by no means specific to this phase of life. 11
The general public regard various behaviours as characteristic of adolescence. These may be summarised as impulsiveness, a tendency to take risks, moodiness and fractious relationships with parents. The public image of adolescents accords with this view of ‘the typical adolescent’. It is certainly the case that some teenagers show these characteristics, but population studies suggest that they make up no more than about 10–15% of this age group, 12 although they are certainly the most conspicuous. Another important and, in the context of this article, the most relevant feature of adolescence is thought to be self-questioning about identity. Young people of this age are seen as preoccupied with the question ‘Who am I?’, a question relating to all aspects of their identities, including their gender and sexuality. Such self-questioning is not experienced in intense form by most teenagers. The prevalence of ‘identity problems’ was found to be 14.3% in a group of 15- to 18-year-old American high school students 13 and a similar prevalence of ‘identity distress’ was found in a study of Flemish adolescents and young people aged 14–30 years. 14 The considerable increase in exposure of teenagers in the past 10 to 15 years to social media replete with references to gender identity would make it surprising if there had not been at least some increase of such self-questioning and confusion in this area.
Teenage presentation of transgender
Clinics serving the adolescent transgender population observed a change in the referral pattern after about 2005. Most notably, the gender identity clinic in Toronto, Canada, reported a dramatic increase in referrals at that time. 15 At the Portman Clinic in London (part of the Tavistock and Portman NHS Trust) referrals increased very significantly from 2009 to 2016. 16 At the Tampere University Hospital, Finland, referrals between 2011 and 2013 far exceeded the number expected from the findings of epidemiological studies. 17 This had not been the case previously. There were two other changes in the referral pattern over this period. First, previously, roughly equal numbers of boys and girls had been referred, whereas the increase was associated with much higher numbers of those who had been assigned female gender at birth. Second, previously, the rates of mental ill health among referred children had been about the same as in the general population, 18 whereas now much higher rates of psychiatric disorder, including autism, were reported. 14 , 16
It is therefore clear that from 2005 in Toronto and a few years later in other centres, the characteristics of patients referred to transgender clinics in their early and mid-teen years changed very significantly. In considering the reasons for this new pattern, Aitken et al 15 suggest that one possibility is that, during this period, societal factors made it easier for gay and lesbian youth and their families to seek clinical care. It could be argued, those authors say, that it became easier for girls to ‘come out’ than boys. It might therefore be easier for girls to opt for a transgender identity. Although there is no evidence to this effect, transgender natal girls who found themselves attracted to girls at puberty might have also found it easier to come out as transgender than hitherto. This implies that the increased presentation at adolescence was of girls who had experienced gender dysphoria since their early years. There is another possibility. It is that girls in their teens who are showing mental health problems for other reasons might, searching for an answer to their identity problems or distress, be influenced by social media to question for the first time their gender identity and to see gender change as an answer to their mental dilemmas. This might be more likely if they had previously shown ‘tomboyish’ behaviour. This possibility has been suggested in considering reasons for an increase in referrals of natal girls to a gender identity service between 2009 and 2016. 15 However, both these possibilities remain hypothetical at present and the reasons for the increase in referrals to transgender clinics is unknown.
Although one should not draw conclusions from a single case, it is of interest that one of the claimants in a judicial review brought about because they felt they had been inappropriately treated with puberty blocking drugs gives an account of her transgender development very much in accord with this second possibility. The claimant described a highly traumatic childhood in which she showed many gender-atypical behaviours: ‘ From the age of 14 she began actively to question her gender identity and started to look at YouTube videos and do research on the internet about gender identity disorder and the transition process’ (para. 78). 19
Although some cases of first presentation of transgender in the early teen years may arise from so-called adolescent identity problems or identity distress, it is likely that others do occur because the young person has been reluctant to come out as transgender beforehand, even though gender dysphoria has been present from the early years. Further, it is well established that such reluctance may persist well into adulthood, so that there are a number of recorded cases of people who have waited until their 30s or 40s to make this decision. 20
There is a need for both quantitative and qualitative research to investigate the early histories of girls referred with gender dysphoria for the first time in adolescence. Such research should include interviewing parents about their children's early years.
Life for children who are transgender from their early years can be challenging. At home, they have to try to communicate how they feel to potentially sceptical parents. At school, they are likely to experience disbelief, mockery and bullying. To cope they need resilient personalities as well as sensitive and understanding parents who are able to explore and talk openly about their children's feelings with acceptance and without trying to influence decisions one way or another. For, as we have seen, although some prepubertal children persist in their transgender identity, in the course of time many will, for reasons we do not understand, desist. 3 It is remarkable that most children who have been transgender from a young age reach adolescence without developing a higher-than-expected rate of significant mental health problems. 17
Many prepubertal children and their parents will benefit from having available a sympathetic counsellor, psychotherapist or other mental health professional. This will allow exploration of the reasons for the presence of gender dysphoria. Material from voluntary organisations such as Mermaids may be helpful, but parents of young children need to monitor this to ensure that their children are not being encouraged to persist, but are just accepted for what they are at the present time. Difficult decisions about changes of name and the use of toilets need to be negotiated with hopefully sympathetic, open-minded teachers.
As puberty approaches, difficult decisions have to be made. The Amsterdam group has been offering transgender adolescents puberty blockers for 30 years, their first case having been treated in 1991. 21 The group has pioneered an approach to assessment and management of gender dysphoria. It has produced a protocol for medical treatment of transgender children and adolescents that has been widely followed, 22 for example in Italy, Canada, the USA and the UK. The protocol is summarised below and in Box 1 :
- Psychological counselling for children and parents starts well before any medical treatment is considered and continues while such intervention is being administered.
- Once Tanner stage 2–3 is reached, and not before, gonadotropin-releasing hormone analogues (GnRHa) are prescribed where there is a clear indication that this is the appropriate course. This medication is given to block pubertal changes, so that the bodily changes rejected by the young person do not occur. Such treatment is only offered to children and young people aged 12 years and older who have intense gender dysphoria and no significant mental health problems. Informed consent by the young person and by the parents is required. The purpose of the use of puberty blockers is to ensure that young people with gender dysphoria do not live through pubertal bodily changes they find abhorrent. Further, the blocking of pubertal changes means that when, as is nearly always the case, transgender adults choose to have at least some degree of gender reassignment surgery, some procedures, particularly bilateral mastectomy for those assigned female gender at birth, will not be necessary.
- With careful assessment and selection, a very small minority of young people prescribed puberty blockers (between 1.4 and 3.5%) change their minds and do not wish to proceed further. 23 For the large majority who do wish to proceed, around the age of 16 years or older, cross-sex hormones are prescribed. For this treatment to be started, the young person must be living in the role of the preferred gender. Again, informed consent by the young person and, preferably, the parents is required.
- At the age of 18 years or older, those (again the great majority) who meet eligibility criteria can begin the process of gender reassignment surgery. Such surgery occurs variably according to the degree and at the pace desired by the individual concerned.
Management of gender dysphoria 22
- Make a full assessment as early as possible
- Follow with supportive counselling throughout childhood and adolescence
- Subsequent interventions should only take place with informed consent, first by parents and then by the young person, with reflection before each phase
- If intense gender dysphoria persists, consider using puberty blockers at Tanner stages 2–3
- Consider use of cross-sex hormones at age 16
- At age 18–19 and subsequently, consider gender reassignment surgery
Effectiveness of treatment
The aims of treatment are twofold:
- to explore with the child or young person with gender dysphoria the reasons for their discomfort with their gender assigned at birth and to consider alternative ways forward, including living in the role of their birth-assigned gender or pursuing medical intervention that will enable them to transition;
- in those who choose to live in their preferred transgender role, to start treatment, pausing for reflection before each step, first with puberty blockers, then with cross-sex hormones and finally with gender reassignment surgery to relieve gender dysphoria.
Among those who opt for medical treatment, the degree of success of intervention is measured by the absence of gender dysphoria and mental health problems and by the presence of psychological well-being. Ideally it would be possible to quote findings from a number of controlled trials of each of the interventions. Given the impracticability of obtaining agreement from children and young people with intense gender dysphoria to participate in controlled trials, the findings from uncontrolled but carefully conducted studies provide the main evidence for effectiveness.
There have now been a number of such uncontrolled studies, in which patients have been followed up to see whether their physical and psychological states have improved or deteriorated after the use of puberty blockers alone 24 – 26 and puberty blockers followed by cross-sex hormones followed by surgery. 27 – 29 The most recently published study of the effects of puberty blockers was reported from the Portman Clinic, London. 30 This study reported on the short-term outcome over 2 years of 44 children and young people aged 12 to 15 years when they started treatment with puberty blockers. Overall, the patient experience was positive. Although there were some children who showed some negative outcomes in mood and quality of relationships with family and friends, the majority showed positive change. There was no change in the rate of parent- or child-rated behaviour problems or risk of self-harm. All adverse effects, when they occurred, were mild. In line with other studies, only 1 of the 44 children and young people treated with puberty blockers did not go on to request cross-sex hormone treatment.
All the studies quoted above have provided valuable information. In all cases, there has been benefit from the interventions for the majority and an absence of significant harm. The most recent critical review of the use of puberty blockers has concluded: ‘Although large long-term studies with diverse and multicultural populations have not been done, the evidence to date supports the finding of few serious adverse outcomes and several potential positive outcomes. This literature suggests the need for transgender youth to be cared for in a manner that not only affirms their gender identities but that also minimises the negative physical and psychological outcomes that could be associated with pubertal development’. 31 In all published cases, the majority has reported benefit from the interventions and an absence of significant harm. Where it has been measured, an improvement in psychological well-being has always been found. It is well established that adults who transition ‘experience fewer psychological problems and interpersonal difficulties as well as a strongly increased life satisfaction’ than before the transition and show no wish to revert to their gender assigned at birth. 32
It should be added that the use of puberty blockers in early adolescence has been strongly criticised. 33 , 34 It has been claimed that there has been undue reliance on an affirmative approach (self-identification) in making a transgender diagnosis, that the complexity of the underlying problems of young people presenting as transgender has been inadequately assessed, that a high proportion of those who are treated with puberty blockers regret that they have received this treatment and that the young people who have been treated have not been capable of giving informed consent to treatment that has such profound implications for their future.
Adverse effects of medical interventions
The effect of puberty blockers is generally, though not universally, regarded as reversible. Their use has been associated with apparently reversible stunting effects on height velocity and bone maturation. 29 , 35 General cautions that have been expressed by clinicians about the possibility of irreversibility, such as those by Professor Butler and Dr de Vries quoted in a judicial review, 19 are no more than one might expect in relation to a large number of interventions in routine use. Caution about possible harm is always an appropriate clinical stance. It should not be taken to mean that the intervention in question should not be used where it is indicated.
There is one undeniable loss that occurs as a result of the use of puberty blockers. The individual does not go through the experience of the ‘normal’ adolescence he or she would have had without their use. However, most transgender young people do not consider this to be a loss or in any way regrettable.
The use of cross-sex hormones exposes the individual to the risk of a metabolic abnormality in about 15% of cases, but the significance of this finding is not clear and it does not seem a contraindication to their use. 36 Further research is required on the nature of possible metabolic abnormalities arising from the use of cross-sex hormones.
The competence of young people to give informed consent to the use of puberty blockers and cross-sex hormones is currently a matter of great relevance to clinical management. In UK law, 16 years is regarded as the youngest age at which it can be assumed, on the basis of chronological age, that a young person can give informed consent to a medical procedure. Below that age, it is widely accepted that, in considering whether a young person is capable of giving informed consent, the so-called Gillick principle should be applied. This principle, expressed by Lord Scarman in a 1985 House of Lords judgment and repeated in the above-mentioned judicial review, 19 is that ‘as a matter of law the parental right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to […] understand fully what is proposed’. There is a controversy as to whether, because of the unusually complicated issues involved, children under the age of 16 could ever have the cognitive competence to give consent to puberty blockers or cross-sex hormones. This matter was considered in great detail in the judicial review whose judgment was published in December 2020. 19 This court decided that young people under 16 years could not give informed consent to the use of puberty blockers. Further, the court ruled that, even in cases where parents give their informed consent and clinicians are in agreement, an application should be made to the courts for authorisation before a child under 16 years can be administered puberty blockers. However, on appeal, this decision was reversed. The Appeal Court decided that the initial judgment had placed an improper restriction on the Gillick test and that it would not be appropriate for an application to the courts to be required before a child could be administered puberty blockers. 37
There is a need for systematic psychological investigation into the capacity of children and young people to make decisions in this area. Although there is some evidence on the capacity of young people aged 14–16 years to understand medical procedures, there is no evidence relating to the specific question of their understanding of the use of puberty blockers and cross-sex hormones, for example, in comparison with that of older people. Such evidence should be obtained. In the meantime, it would seem reasonable to rely on the findings of Weithorn & Campbell, whose study provides the most relevant data. 38 These investigators looked at 24 individuals in each of four age groups: 9, 14, 18 and 21 years. They tested their competence to make informed treatment decisions in a series of medical dilemmas, involving conditions such as epilepsy, diabetes and psychological problems. The children, adolescents and young adults were given the nature of the problem, treatments options, expected benefits, possible risks and consequences of failure, and then assessed on how much they understood. The 14-year-olds did as well as the 21-year-olds. The 9-year-olds did distinctly less well. Although it is many years since this study was carried out, until more relevant evidence is produced, there is no reason why its findings should not be regarded as highly pertinent.
One can conclude from the evidence that gender dysphoria is a relatively rare but well-defined condition, characterised by a strong desire to be of the gender opposite to that assigned at birth and by an insistence that one is, indeed, of the other gender. Affected transgender individuals are usually aware of its existence by the age of 5 years. Gender dysphoria needs to be distinguished from gender-atypical behaviour, where those assigned male gender at birth showed an interest in activities generally preferred by girls and vice versa . Marked gender-atypical behaviour occurs in around 2–3% of the population, most of whom are not transgender. Further, many children who show gender dysphoria before puberty do not continue to do so during and after pubertal changes occur. However, if gender dysphoria does persist into adolescence, its intensity tends to increase at this time.
From about 2005 until the present, there has been a considerable, perhaps tenfold, increase in the number of children and young people referred to gender identity clinics. This change has been observed not just in the UK, but in Canada, the USA and Finland. These more recent referrals have differed from previous cases in three ways. More recent referrals have been older, often not presenting until the early teen years. Whereas previously referrals were relatively evenly balanced between those assigned male and female gender at birth, there is now a considerable preponderance of those assigned female gender at birth. Further, whereas previously children and young people with transgender did not show high rates of behavioural and emotional disturbance, this is not the case for recent referrals.
The assessment and management of gender dysphoria has been pioneered by a Dutch group based in Amsterdam. This group has laid down a number of principles of management, which have been widely adopted by gender identity clinics in other countries. The effectiveness of this sequence of interventions is now reasonably well established, with good evidence that it relieves gender dysphoria and usually improves psychological well-being. Physical side-effects may occur but as far as can be ascertained at present, not to a degree where possible harm outweighs benefit. There are, however, unresolved issues concerning the capacity of young people with gender dysphoria to give informed consent to the use of puberty blockers.
There are a number of gaps in knowledge requiring urgent attention. First, it is unclear whether the considerable increase in referrals to gender identity clinics in the past 15 years is due to greater willingness of early affected individuals to come out at this age or whether clinics are dealing with a different population with different needs. There is clearly a need for both quantitative and qualitative research to investigate the early histories of those assigned female gender at birth referred with gender dysphoria for the first time in adolescence. Such research should include interviewing parents about their children's early years. Second, although it is reasonably well established that the use of puberty blockers is not accompanied by serious adverse effects, further research is required on the nature of possible metabolic abnormalities arising from the use of cross-sex hormones. Finally, there is a need for research into the capacity of children and young people, compared with older people, to understand the implications of the use of puberty blockers and cross-sex hormones.
About the author
Philip Graham is Emeritus Professor of Child Psychiatry in the Institute of Child Health, University College, London, UK.
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
Young Children Do Not Receive Medical Gender Transition Treatment
By Kate Yandell
Posted on May 22, 2023
Families seeking information from a health care provider about a young child’s gender identity may have their questions answered or receive counseling. Some posts share a misleading claim that toddlers are being “transitioned.” To be clear, prepubescent children are not offered transition surgery or drugs.
Some children identify with a gender that does not match their sex assigned at birth. These children are referred to as transgender, gender-diverse or gender-expansive. Doctors will listen to children and their family members, offer information, and in some cases connect them with mental health care, if needed.
But for children who have not yet started puberty, there are no recommended drugs, surgeries or other gender-transition treatments.
Recent social media posts shared the misleading claim that medical institutions in North Carolina are “transitioning toddlers,” which they called an “experimental treatment.” The posts referenced a blog post published by the Education First Alliance, a conservative nonprofit in North Carolina that says many schools are engaging in “ideological indoctrination” of children and need to be reformed.
The group has advocated the passage of a North Carolina bill to restrict medical gender-transition treatment before age 18. There are now 18 states that have taken action to restrict medical transition treatments for minors .
A widely shared article from the Epoch Times citing the blog post bore the false headline: “‘Transgender’ Toddlers as Young as 2 Undergoing Mutilation/Sterilization by NC Medical System, Journalist Alleges.” The Epoch Times has a history of publishing misleading or false claims. The article on transgender toddlers then disappeared from the website, and the Epoch Times published a new article clarifying that young children are not receiving hormone blockers, cross-sex hormones or surgery.
Representatives from all three North Carolina institutions referenced in the social media posts told us via emailed statements that they do not offer surgeries or other transition treatments to toddlers.
East Carolina University, May 5: ECU Health does not offer gender affirming surgery to minors nor does the health system offer gender affirming transition care to toddlers.
ECU Health elaborated that it does not offer puberty blockers and only offers hormone therapy after puberty “in limited cases,” as recommended in national guidelines and with parental or guardian consent. It also said that it offers interdisciplinary gender-affirming primary care for LGBTQ+ patients, including access to services such as mental health care, nutrition and social work.
“These primary care services are available to any LGBTQ+ patient who needs care. ECU Health does not provide gender-related care to patients 2 to 4 years old or any toddler period,” ECU said.
University of North Carolina, May 12: To be clear: UNC Health does not offer any gender-transitioning care for toddlers. We do not perform any gender care surgical procedures or medical interventions on toddlers. Also, we are not conducting any gender care research or clinical trials involving children. If a toddler’s parent(s) has concerns or questions about their child’s gender, a primary care provider would certainly listen to them, but would never recommend gender treatment for a toddler. Gender surgery can be performed on anyone 18 years old or older .
Duke Health, May 12: Duke Health has provided high-quality, compassionate, and evidence-based gender care to both adolescents and adults for many years. Care decisions are made by patients, families and their providers and are both age-appropriate and adherent to national and international guidelines. Under these professional guidelines and in accordance with accepted medical standards, hormone therapies are explicitly not provided to children prior to puberty and gender-affirming surgeries are, except in exceedingly rare circumstances, only performed after age 18.
Duke and UNC both called the claims that they offer gender-transition care to toddlers false, and ECU referred to the “intentional spreading of dangerous misinformation online.”
Nor do other medical institutions offer gender-affirming drug treatment or surgery to toddlers, clinical psychologist Christy Olezeski , director of the Yale Pediatric Gender Program, told us, although some may offer support to families of young children or connect them with mental health care.
The Education First Alliance post also states that a doctor “can see a 2-year-old girl play with a toy truck, and then begin treatment for gender dysphoria.” But simply playing with a certain toy would not meet the criteria for a diagnosis of gender dysphoria, according to the medical diagnostic manual used by health professionals.
“With all kids, we want them to feel comfortable and confident in who they are. We want them to feel comfortable and confident in how they like to express themselves. We want them to be safe,” Olezeski said. “So all of these tenets are taken into consideration when providing care for children. There is no medical care that happens prior to puberty.”
Medical Transition Starts During Adolescence or Later
The Education First Alliance blog post does not clearly state what it means when it says North Carolina institutions are “transitioning toddlers.” It refers to treatment and hormone therapy without clarifying the age at which it is offered.
Only in the final section of the piece does it include a quote from a doctor correctly stating that children are not offered surgery or drugs before puberty.
To spell out the reality of the situation: The North Carolina institutions are not providing surgeries or hormone therapy to prepubescent children, nor is this standard practice in any part of the country.
Programs and physicians will have different policies, but widely referenced guidance from the World Professional Association for Transgender Health and the Endocrine Society lays out recommended care at different ages.
Drugs that suppress puberty are the first medical treatment that may be offered to a transgender minor, the guidelines say. Children may be offered drugs to suppress puberty beginning when breast buds appear or testicles increase to a certain volume, typically happening between ages 8 to 13 or 9 to 14, respectively.
Generally, someone may start gender-affirming hormone therapy in early adolescence or later, the American Academy for Pediatrics explains . The Endocrine Society says that adolescents typically have the mental capacity to participate in making an informed decision about gender-affirming hormone therapy by age 16.
Older adolescents who want flat chests may sometimes be able to get surgery to remove their breasts, also known as top surgery, Olezeski said. They sometimes desire to do this before college. Guidelines do not offer a specific age during adolescence when this type of surgery may be appropriate. Instead, they explain how a care team can assess adolescents on a case-by-case basis.
A previous version of the WPATH guidelines did not recommend genital surgery until adulthood, but the most recent version, published in September 2022, is less specific about an age limit. Rather, it explains various criteria to determine whether someone who desires surgery should be offered it, including a person’s emotional and cognitive maturity level and whether they have been on hormone therapy for at least a year.
The Endocrine Society similarly offers criteria for when someone might be ready for genital surgery, but specifies that surgeries involving removing the testicles, ovaries or uterus should not happen before age 18.
“Typically any sort of genital-affirming surgeries still are happening at 18 or later,” Olezeski said.
There are no comprehensive statistics on the number of gender-affirming surgeries performed in the U.S., but according to an insurance claims analysis from Reuters and Komodo Health Inc., 776 minors with a diagnosis of gender dysphoria had breast removal surgeries and 56 had genital surgeries from 2019 to 2021.
Research Shows Benefits of Affirming Gender Identity
Young children do not get medical transition treatment, but they do have feelings about their gender and can benefit from support from those around them. “Children start to have a sense of their own gender identity between the ages of 2 1/2 to 3 years old,” Olezeski said.
Programs vary in what age groups they serve, she said, but some do support families of preschool-aged children by answering questions or providing mental health care.
Transgender children are at increased risk of some mental health problems, including anxiety and depression. According to the WPATH guidelines, affirming a child’s gender through day-to-day changes — also known as social transition — may have a positive impact on a child’s mental health. Social transition “may look different for every individual,” Olezeski said. Changes could include going by a different name or pronouns or altering one’s attire or hair style.
Two studies of socially transitioned children — including one with kids as young as 3 — have found minimal or no difference in anxiety and depression compared with non-transgender siblings or other children of similar ages.
“Research substantiates that children who are prepubertal and assert an identity of [transgender and gender diverse] know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender and benefit from the same level of social acceptance,” the AAP guidelines say, adding that differences in how children identify and express their gender are normal.
Social transitions largely take place outside of medical institutions, led by the child and supported by their family members and others around them. However, a family with questions about their child’s gender or social transition may be able to get information from their pediatrician or another medical provider, Olezeski said.
Although not available everywhere, specialized programs may be particularly prepared to offer care to a gender-diverse child and their family, she said. A child may get a referral to one of these programs from a pediatrician, another specialty physician, a mental health care professional or their school, or a parent may seek out one of these programs.
“We have created a space where parents can come with their youth when they’re young to ask questions about how to best support their child: what to do if they have questions, how to get support, what do we know about the best research in terms of how to allow kids space to explore their identity, to explore how they like to express themselves, and then if they do identify as trans or nonbinary, how to support the parents and the youth in that,” Olezeski said of specialized programs. Parents benefit from the support, and then the children also benefit from support from their parents.
WPATH says that the child should be the one to initiate a social transition by expressing a “strong desire or need” for it after consistently articulating an identity that does not match their sex assigned at birth. A health care provider can then help the family explore benefits and risks. A child simply playing with certain toys, dressing a certain way or enjoying certain activities is not a sign they would benefit from a social transition, the guidelines state.
Previously, assertions children made about their gender were seen as “possibly true” and support was often withheld until an age when identity was believed to become fixed, the AAP guidelines explain. But “more robust and current research suggests 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,” the guidelines say.
Mental Health Care Benefits
A gender-diverse child or their family members may benefit from a referral to a psychologist or other mental health professional. However, being transgender or gender-diverse is not in itself a mental health disorder, according to the American Psychological Association , WPATH and other expert groups . These organizations also note that people who are transgender or gender-diverse do not all experience mental health problems or distress about their gender.
Psychological therapy is not meant to change a child’s gender identity, the WPATH guidelines say .
The form of therapy a child or a family might receive will depend on their particular needs, Olezeski said. For instance, a young child might receive play-based therapy, since play is how children “work out different things in their life,” she said. A parent might work on strategies to better support their child.
One mental health diagnosis that some gender-diverse people may receive is gender dysphoria . There is disagreement about how useful such a diagnosis is, and receiving such a diagnosis does not necessarily mean someone will decide to undergo a transition, whether social or medical.
UNC Health told us in an email that a gender dysphoria diagnosis “is rarely used” for children.
Very few gender-expansive kids have dysphoria, the spokesperson said. “ Gender expansion in childhood is not Gender Dysphoria ,” UNC added, attributing the explanation to psychiatric staff (emphasis is UNC’s). “The psychiatric team’s goal is to provide good mental health care and manage safety—this means trying to protect against abuse and bullying and to support families.”
Social media posts incorrectly claim that toddlers are being diagnosed with gender dysphoria based on what toys they play with. One post said : “Three medical schools in North Carolina are diagnosing TODDLERS who play with stereotypically opposite gender toys as having GENDER DYSPHORIA and are beginning to transition them!!”
There are separate criteria for diagnosing gender dysphoria in adults and adolescents versus children, according to the Diagnostic and Statistical Manual of Mental Disorders. For children to receive this diagnosis, they must meet six of eight criteria for a six-month period and experience “clinically significant distress” or impairment in functioning, according to the diagnostic manual.
A “strong preference for the toys, games or activities stereotypically used or engaged in by the other gender” is one criterion, but children must also meet other criteria, and expressing a strong desire to be another gender or insisting that they are another gender is required.
“People liking to play with different things or liking to wear a diverse set of clothes does not mean that somebody has gender dysphoria,” Olezeski said. “That just means that kids have a breadth of things that they can play with and ways that they can act and things that they can wear . ”
Editor’s note: SciCheck’s articles providing accurate health information and correcting health misinformation are made possible by a grant from the Robert Wood Johnson Foundation. The foundation has no control over FactCheck.org’s editorial decisions, and the views expressed in our articles do not necessarily reflect the views of the foundation.
Rafferty, Jason. “ Gender-Diverse & Transgender Children .” HealthyChildren.org. Updated 8 Jun 2022.
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Rachmuth, Sloan. “ Transgender Toddlers Treated at Duke, UNC, and ECU .” Education First Alliance. 1 May 2023.
North Carolina General Assembly. “ Senate Bill 639, Youth Health Protection Act .” (as introduced 5 Apr 2023).
Putka, Sophie et al. “ These States Have Banned Youth Gender-Affirming Care .” Medpage Today. Updated 17 May 2023.
Davis, Elliott Jr. “ States That Have Restricted Gender-Affirming Care for Trans Youth in 2023 .” U.S. News & World Report. Updated 17 May 2023.
Montgomery, David and Goodman, J. David. “ Texas Legislature Bans Transgender Medical Care for Children .” New York Times. 17 May 2023.
Ji, Sayer. ‘ Transgender’ Toddlers as Young as 2 Undergoing Mutilation/Sterilization by NC Medical System, Journalist Alleges .” Epoch Times. Internet Archive, Wayback Machine. Archived 6 May 2023.
McDonald, Jessica. “ COVID-19 Vaccines Reduce, Not Increase, Risk of Stillbirth .” FactCheck.org. 9 Nov 2022.
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Spencer, Saranac Hale. “ Social Media Posts Misrepresent FDA’s COVID-19 Vaccine Safety Research .” FactCheck.org. 23 Dec 2022.
Jaramillo, Catalina. “ WHO ‘Pandemic Treaty’ Draft Reaffirms Nations’ Sovereignty to Dictate Health Policy .” FactCheck.org. 2 Mar 2023.
McCormick Sanchez, Darlene. “ IN-DEPTH: North Carolina Medical Schools See Children as Young as Toddlers for Gender Dysphoria .” The Epoch Times. 8 May 2023.
ECU health spokesperson. Emails with FactCheck.org. 12 May 2023 and 19 May 2023.
UNC Health spokesperson. Emails with FactCheck.org. 12 May 2023 and 19 May 2023.
Duke Health spokesperson. Email with FactCheck.org. 12 May 2023.
Olezeski, Christy. Interview with FactCheck.org. 16 May 2023.
Hembree, Wylie C. et al. “ Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline .” The Journal of Clinical Endocrinology and Metabolism. 1 Nov 2017.
Emmanuel, Mickey and Bokor, Brooke R. “ Tanner Stages .” StatPearls. Updated 11 Dec 2022.
Rafferty, Jason et al. “ Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents .” Pediatrics. 17 Sep 2018.
Coleman, E. et al. “ Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7 .” International Journal of Transgenderism. 27 Aug 2012.
Durwood, Lily et al. “ Mental Health and Self-Worth in Socially Transitioned Transgender Youth .” Journal of the American Academy of Child and Adolescent Psychiatry. 27 Nov 2016.
Olson, Kristina R. et al. “ Mental Health of Transgender Children Who Are Supported in Their Identities .” Pediatrics. 26 Feb 2016.
“ Answers to Your Questions about Transgender People, Gender Identity, and Gender Expression .” American Psychological Association website. 9 Mar 2023.
“ What is Gender Dysphoria ?” American Psychiatric Association website. Updated Aug 2022.
Vanessa Marie | Truth Seeker (indivisible.mama). “ Three medical schools in North Carolina are diagnosing TODDLERS who play with stereotypically opposite gender toys as having GENDER DYSPHORIA and are beginning to transition them!! … ” Instagram. 7 May 2023.
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Get the Facts: The Truth About Transition-Related Care for Transgender Youth
As extremist lawmakers in state after state try to attack our transgender community’s basic health care, the misinformation is rampant. Serious misconceptions about transgender people are fueling legislation from Florida to Missouri to Mississippi – and they all aim to stop young people and their parents from accessing essential mental and physical health care. Some even go farther, with some bills attempting to ban transition-related care until the age of 21 or even beyond. These bans attack our most basic values of privacy and control over our own bodies, and they’re based on misleading or even outright false ideas. Here are the real facts everyone should know.
Being trans is beautiful.
The reality is that trans people of all ages are leading joyous, full, normal lives. Transition-related care helps make those lives possible. All too often, media narratives portray transgender people as if our lives are just pain and suffering, but nothing could be further from the truth. Age-appropriate medical care helps so many people to live their best lives. Trans people deserve to live joyfully and authentically – and so many of us are doing just that!
Trans kids know who they are.
The overwhelming majority of transgender and nonbinary youth who receive transition-related health care continue to identify as transgender or nonbinary after reaching adulthood.
Those who argue that being transgender is a “phase” often rely on deeply flawed studies that conflate gender dysphoria with gender non-conforming behavior. That means that these flawed studies lumped children who don't conform to gendered expectations in with transgender children, regardless of how they describe themselves or whether they experience gender dysphoria at all.
Studies which solely examine patients experiencing gender dysphoria show extremely low rates of desistance. This recent study found that 98% of youths prescribed puberty blockers went on to be prescribed hormone replacement therapy after turning 18. This means that the overwhelming majority of young people who take medications that delay the onset of puberty are indeed transgender - and continue to be so as adults. Those medications helped them get through puberty without unwanted physical changes that would have otherwise caused them distress.
Transition-related care is safe.
Expert health care providers have been studying and providing transition-related health care for more than four decades. Decades of clinical research and experience show that transgender people who have access to the care they need see a positive impact on their mental and physical health.
Young people seeking transition-related medical care first receive significant counseling and a psychological assessment. The World Professional Association for Transgender Health (WPATH), which sets global best practices for transition care , recommends “extensive exploration of psychological, family, and social issues” prior to any physical interventions for young people. Puberty-blocking medications and hormone therapy for trans youth and adults have been prescribed and studied by experts for over 40 years. When needed, cisgender (meaning non-transgender) children also safely receive these medications for other health conditions. In addition, puberty-blocking medications simply delay puberty. If the medications are stopped, puberty will continue.
Like all medical interventions, surgical care is highly individual, and only undertaken after significant consultations with experts. It’s important to know that very young children do not receive surgeries or medications . For young children, gender transition is a social transition, which often involves a haircut, a new name, and new clothes that match their gender identity. For adolescents, any medical transition care such as hormone therapy or puberty blockers are only prescribed based on an individual young person’s needs.
Any surgical care for teenagers under 18 is rare and individualized. It is carefully examined under the supervision of medical professionals using standardized, evidence-based guidelines. Like everyone, those teenagers deserve the best possible medical care for their well-being. Importantly, young people deserve privacy as they make their own decisions with the support of parents, mental health professionals, and doctors.
Transition-related care is lifesaving care.
A large body of research demonstrates that trans youth who receive transition-related health care to treat their dysphoria show decreased anxiety, depression, suicidal behavior, and psychological distress, and increased quality of life.
Acceptance and support for LGBTQ youth quite literally saves lives . According to the Trevor Project’s 2022 Report , young people who felt highly supported by their family reported attempting suicide at less than half the rate of those who did not receive support.
Trans children who are allowed to socially transition before puberty have normal rates of depression and anxiety, “in striking contrast” with trans children who could not socially transition. There is an extremely strong scientific and medical consensus that transgender people exist and that transition-related care is clinically appropriate and medically necessary. Transition-related health care is acknowledged as medically necessary by the American Medical Association , the American Academy of Pediatrics , and many more.
"Regret" about transition is extremely rare.
Feigned concerns about “regret” around medical transition completely fail to see the reality of trans people’s lives. The vast majority of trans people cannot even access the transition-related care they need! The truth is that trans people deserve competent and compassionate health care as they seek to live their best lives – and that very, very few ever regret receiving this care. One Dutch study of nearly 7,000 transgender people found that the rate of regret was less than 1% among those who received treatment as adults – and there were no cases of regret among those who received care before the age of 18.
It’s helpful to put this fearmongering about “regret” into context. Up to 30% of knee replacement patients regret getting surgery – but no one’s trying to ban those!
Research tells us that the overwhelming majority of people who transition medically are satisfied with their decision to do so. Of the very few people who have detransitioned, over 82% did so because of external pressures such as rejection from family, and discrimination in education or employment. Most people also only detransitioned temporarily – likely due to those same pressures from others - before resuming their lives as trans people.
Gender identity is personal.
As trans theorist and biologist Julia Serano writes , “Transitioning is a matter of personal exploration, of finding what works for you on the individual level.” Everyone deserves the freedom to explore and express their identity – and that includes, if they decide they need it, receiving compassionate transition-related care. These are deeply personal and individual decisions, and it’s simply wrong for politicians to attack our health care and violate our basic privacy.
Click here for a printable PDF of this fact sheet.
[ A note on terminology: While "gender-affirming care" is a commonly used term with a broad definition, we use the term "transition-related care" in this article to specifically refer to the type of health care involved in medical transition for transgender people, such as hormone treatment and transition-related surgeries .]
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Gender-affirming care for trans youth: Separating medical facts from misinformation
By Helen Santoro
Updated on: June 28, 2023 / 6:09 PM / KFF Health News
Almost three weeks after Florida's Republican governor, Ron DeSantis, signed a bill making it a felony for doctors to provide gender-affirming care to transgender minors , a judge issued a preliminary injunction preventing enforcement of the law for three children whose parents are part of an ongoing lawsuit.
Florida is one of at least 20 states that have limited gender-affirming treatment for minors . The legislators sponsoring some of these bills say their intent is to protect children and families from pressure "to receive harmful, experimental puberty blockers and cross-sex hormones and to undergo irreversible, life-altering surgical procedures," as a new Montana law puts it.
"Gender transitions involving major surgeries not only result in sterility, but other irreversible negative biological effects," said Montana state Sen. John Fuller, the Republican who introduced the bill.
Such laws and policies, and statements — such as Fuller's — used to justify them, reflect misconceptions and misinformation that conflate treatments and strip trans youth of essential care .
What is gender-affirming care?
Gender-affirming care is a broad term for many distinct treatments provided to children, teens, and adults. Puberty blockers, for example, are medications that inhibit puberty by suppressing the body's production of sex hormones, while hormone therapy is the administration of testosterone or estrogen to alter secondary sex characteristics.
One common misbelief heard when legislation is discussed is that gender-affirming medical interventions are provided immediately to any trans or nonbinary kid who walks into a gender clinic.
The reality is that the process informing these treatments is a long and intensive one. Before any medical or surgical interventions, kids must first be diagnosed with gender dysphoria , which, for prepubescent youth, involves experiencing significant distress for at least six months from at least six of a set of causes, including a strong desire to be of the other gender and a strong dislike of one's sexual anatomy. Youth who have gone through puberty must meet two of the criteria for a diagnosis.
Providers also abide by the standards of care set by the World Professional Association for Transgender Health. These standards encourage health care professionals to perform a comprehensive assessment of a child's or teen's "strengths, vulnerabilities, diagnostic profile, and unique needs" before providing any medical or surgical interventions. Without this assessment, other mental health issues "that need to be prioritized and treated may not be detected."
The time it takes to perform this assessment varies from patient to patient, said Jack Turban, an assistant professor of child and adolescent psychiatry at the University of California-San Francisco. Turban may see someone who is 12 years old and asking for puberty blockers. This hypothetical patient has known they are trans since they were 5 years old and has already adopted a new name and pronouns that match their gender identity.
"That's going to be a much shorter assessment to know that they are ready for treatment when compared to somebody who has only understood their trans identity for six months" and has other complex mental health conditions like schizophrenia, Turban said.
Puberty blockers, hormone therapy and surgical options
To receive puberty blockers, kids must also have experienced the onset of puberty, or Stage 2 on the Tanner scale of developmental change. This is marked by physical changes like the development of breast buds or testicle growth and tends to happen between the ages of 9 and 14 in kids with testes and 8 and 13 in those with ovaries. By pausing puberty, these drugs buy children more time to explore their gender identity before undergoing permanent and potentially unwanted pubertal changes.
The age at which trans minors receive gender-affirming hormone therapy depends on the patient's ability to provide informed consent for the treatment, which can happen when they're as young as 12 or 13 years old. The Endocrine Society notes that most adolescents have "sufficient mental capacity" to consent by the time they're 16.
"We offer hormones to patients who are experiencing gender incongruence when patients and families are ready. This may be at an earlier age so that patients can go through puberty alongside their cisgender peers, or later, if they choose to," said Mandy Coles, co-director of the Child and Adolescent Transgender Center for Health at Boston Medical Center. "If someone says, 'I'm interested in estrogen,' I say, 'Great. What are the things that you are hoping to get out of that?' Because it's incredibly important to speak to patients and families about what medications can do, and what they can't do."
Coles said she also makes sure to talk continuously about consent with both the child and parents throughout the treatment process and lets her patients know they can stop taking hormones at any time.
Some physical changes brought about by gender-affirming hormone therapy are reversible. For example, decreased muscle strength and body fat redistribution caused by estrogen can reverse once a person stops taking the hormone — though these changes become more fixed the longer someone stays on the hormone. However, breast growth from estrogen or a deepening of the voice caused by testosterone are not reversible.
If a trans person decides to receive gender-affirming surgery, clinics require that the individual receive letters from one or more providers stating they have persistent and well-documented gender dysphoria, any significant mental health concerns they have are sufficiently controlled, and they can consent to the surgery. For genital, or "bottom," surgery, the letter may also need to state that the individual has been living full time in their "identified gender" for at least 12 months.
Most medical centers require individuals to be at least 18 years old for bottom surgery and chest, or "top," surgery, though some do perform top surgery on younger teens if the patient, their parents, and health care providers agree the procedure is appropriate.
Much of the confusion is over puberty blockers, drugs that have been used for decades for children who enter puberty too early. A common assertion anti-trans groups and legislators make is that puberty blockers are dangerous and lead to infertility. This is not the case, said Coles. "Puberty blockers are fully reversible medications. They work like a pause button on puberty."
Fertility may be impaired, however, in those who go straight from puberty blockers to hormone therapy, which is why the current medical guidelines require fertility counseling prior to any gender-affirming medical care, said Turban.
The FDA has not approved the use of puberty blockers for gender-affirming care. However, 10 to 20% of prescriptions across all medications are for "off-label," or unapproved, use — and the rate is even higher for prescriptions to children.
"We know that taking away the decision to use blockers from parents and providers leads to poor health outcomes for patients," said Coles.
Mental health benefits
A study by Turban and colleagues found that trans adults who received puberty blockers during adolescence were less likely to have suicidal thoughts than those who wanted puberty blockers but did not receive them.
The same benefits have been found with gender-affirming hormone therapy.
In a study of data from nearly 28,000 trans adults who responded to the 2015 U.S. Transgender Survey , Turban and fellow researchers found that people who received gender-affirming hormone therapy during adolescence had more favorable mental health outcomes than those who didn't take hormones until they were adults.
Additionally, a study of 104 young trans and nonbinary patients at the Gender Clinic of Seattle Children's Hospital found those who had started on puberty blockers or hormone therapy had 60% lower odds of depression and 73% lower odds of self-harm or suicidal thoughts than peers who hadn't received those treatments.
There is so much misinformation claiming that providers of gender-affirming care are permanently harming vulnerable children, said Coles. "Denying access to care harms transgender and gender-diverse kids," she said. "Gender-affirming care is not new. It's the attacks on care that are new."
Editor's note: This article was revised to clarify that youth who have gone through puberty must meet two criteria for a gender dysphoria diagnosis, whereas younger children must meet at least six.
KFF Health News , formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
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