As of April 2022, two states have passed bills banning gender-affirming care (health care related to the medical transition of transgender people) for transgender youth, and 20 states are considering laws. If the bill passes in all these states, more than one-third of transgender youth ages 13 to 17 will live in states that prohibit them from receiving transgender health care. But what gender-affirming care for young people means and what it actually looks like isn’t always clear. The political cloud surrounding these bills obscures the medical realities of how and when transgender youth can receive the treatment they seek.
Gender-affirming care includes non-surgical treatments, such as mental health care, puberty blockers, hormonal therapy, and reproductive counseling, as well as surgical options, such as “top” or “bottom” surgery. These treatments can be a gradual process over several years and can only be started with the approval of parents and health care providers.
The bill banning such care has caused confusion about what gender-affirming care for transgender youth actually involves. Some still view treatments like puberty blockers and hormonal therapy as child abuse, although a range of medical societies, including the American Academy of Pediatrics and the American Medical Association, support these treatments. Some bills also provide incorrect medical information, such as falsely stating that puberty blockers cause infertility (which is not the case).
In fact, gender-affirming care looks very different for teens of different ages. Young children—those who have not yet gone through puberty—cannot medically transition. Instead, their transition is entirely social; gender-expanding children may choose new names and pronouns, cut their hair, or wear different styles of clothing.
The next step in a child’s transition, if they and their family choose, is to take puberty blockers: drugs that essentially pause puberty. Puberty blockers have long been used to treat cisgender children with precocious puberty, a phenomenon that can cause puberty to begin at an unusually young age, such as 7 or 8 years old. Puberty can begin around age 8 in people, and a little earlier in black or Hispanic people; children assigned male at birth usually enter puberty about two years later, according to the Cleveland Clinic.
Children’s physical development is measured through the so-called Tanner Scale, which tracks the progression of puberty from Tanner Stage 1 (prepuberty) to Tanner Stage 5 (sexual maturity). David Inwards-Breland, MD, MPH, co-director of the Gender Affirmation Center, says the beginning of puberty, or Tanner Stage 2, is marked by breast budding at birth in women and enlarged testicles at birth in men. Hospital for care. According to the Standards of Care (SOC) published by the World Trans Professional Organization, some clinics will not provide puberty blockers until a child reaches Tanner Stage 3 or 4, meaning they are just one or two stages away from the end of puberty.
To qualify for puberty blockers, a child should have a “long-standing and strong pattern of gender nonconformity or gender dysphoria,” the SOC said. (The most recent version of the SOC was released in 2012, with an updated version expected this spring.) Gender dysphoria is typically evaluated by a mental health professional, who may want to have multiple sessions with the child and their family before making a decision.
Children may still experience natural puberty while taking fully reversible puberty blockers, or they may begin a medical transition and eventually undergo gender-affirming hormone therapy with parental consent. The Endocrine Society recommends waiting to prescribe hormones until adolescents are able to give informed consent, which is generally considered to be 16 years of age, but it is generally accepted that starting hormones before age 16 is appropriate in many circumstances. For those assigned female at birth, this means taking testosterone, while for those assigned male at birth, this means taking estrogen, with or without progestins and anti-androgens. The SOC considers hormone therapy “partially reversible” because some of the changes it causes (such as body fat redistribution) are reversible, while others (such as testosterone-induced deepening of the voice) are permanent.
According to SOC, to receive hormone therapy, a transgender child should have “persistent, well-documented gender dysphoria,” which is typically determined by a mental health care provider, who then writes a recommendation letter for treatment . Although the Endocrine Society recommends waiting until age 16 to start hormones, it also recognizes that there may be compelling reasons to start treatment earlier. In fact, many people do take it before this age. The new draft SOC lowers the minimum recommended age for starting hormone use to 14 years.
“It’s not all about age, because we tend to make peer-consistent transitions,” Inwards-Breland said. In other words, he wants his transgender patients to blend in with their peers by the time they reach puberty—ideally, not in late high school, much later than their peers. “The youngest is probably around 13,” he said of when teenagers should start taking hormones.
Determining when to start a teen taking hormones is a process that involves the child, their family and a multidisciplinary team, said Roberts, MD, a pediatric endocrinologist at the Gender Multispecialty Service at Boston Children’s Hospital. “We really try to be extremely flexible and personalized and work with young people and their families over time to help them meet their needs. [transition] Target.
Sometimes the third step as part of gender-affirming treatment is surgery. Some surgeries are options for transgender teens, and some are not. The Endocrine Society recommends delaying surgery involving the genitals until the patient reaches the age of consent (18 years in the United States).
For teenagers who were assigned female at birth, top surgery can be performed to create flatter breasts. The Endocrine Society says there is insufficient evidence to set a minimum age for such gender-affirming surgery, and the updated draft SOC recommends a minimum age of 15 years. [person] If assigned female at birth, breast tissue continues to mature until around age 14 or 15,” Inwards-Breland said. “I’ve seen surgeons do things after age 14, and they feel more comfortable.” However, if a person starts taking puberty blockers at a relatively early age (around 13) and then undergoes hormone therapy, they Breast tissue will never develop and surgery will not be needed to remove it.
Although technically trans teens can receive some forms of gender-affirming care, in practice, this is often difficult.
A common barrier is family approval. For minors, any form of gender-affirming care requires parental consent, but not all parents are willing to give it. Some parents never agree; some don’t. For others, it may take some time to understand transgender health and adjust to having a child medically transition.
Even parents who want to be supportive slow down. After Rose, a transgender girl in California’s Bay Area, came out to her mom, Jesse, around age 15, she became a patient at the Gender Clinic at Stanford Children’s Health and soon began taking puberty blockers (Jesse requested their Names may only be used for privacy reasons). Shortly thereafter, Rose wanted to start hormone treatments, but Jesse was hesitant. She wanted to make sure she did the right thing for her daughter.
“I don’t know much about the impact of hormone therapy, and frankly, I wonder if she will regret her choice later and think it’s not what she wanted,” Jesse said. “As parents, we ask all kinds of questions, try to look at it from every angle, try to figure out what should we be responsible for as parents?”
After education at the clinic and some tough conversations, Jesse agreed, and about a year later Rose started taking hormones. “Parents have a huge responsibility and it’s very daunting to make decisions for their children.”
Another major issue is the availability of pediatric gender clinics. Comprehensive multidisciplinary clinics are rare outside urban areas, Inwards-Breland said. Primary care providers can provide transgender health care, but many do not have experience with it, especially for transgender youth.
“We’re still facing these deserts where there are no high-quality transgender health care programs,” Roberts said. “We now offer more than 50 pediatric transgender health care programs across the country, but there are still areas where patients and their families may have to travel great distances to receive care.”
If a family is able to find a program, they often face a long wait to get a foot in the door. Jessie said Rose’s initial wait time was 6 months and she was lucky to get in after 3 months. “That’s how she feels: She’s lucky. She’s one of the lucky few,” Jesse said.
For those who don’t have access to in-person care, there are options for telemedicine. Organizations like Queermed provide remote care, including puberty blockers and hormone treatments, to teens in 14 southeastern states where routine care is limited.
Once enrolled, families must understand coverage, which is inconsistent across public and private plans. “Even if patients have insurance, they may still be underinsured when it comes to accessing transgender-related health care,” Roberts said. Insurance appeals may cause further delays.
Mistrust of the medical system, including concerns about discrimination and misgendering, may also lead to delays in seeking treatment among transgender youth.
These barriers occur in states where gender-affirming care for transgender youth is legal. The recent wave of anti-trans legislation in some states has created barriers that make it illegal for children to receive gender-affirming care in some cases. And this bill onslaught doesn’t seem to be stopping anytime soon.
