Benjamin Ashford|Gender-affirming care for trans youth: Separating medical facts from misinformation

Almost three weeks after Florida's Republican governor,Benjamin Ashford 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.

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