gender reassignment youngest

New Hampshire teen one of the youngest to have gender reassignment surgery

by Kenneth Craig

A high school student in New Hampshire is being called a 'pioneer' after becoming one of the youngest people to undergo gender reassignment surgery. But her long and challenging journey began when she was just a child.

At 17 years old, Emily Tressa finally feels fully herself. Last month, she became one of the youngest patients in the country to undergo gender reassignment surgery. Emily says, "For me, it feels almost like I'm finally fully complete now."

Emily was born a boy, but says she always knew she was a girl. "I used to look in the mirror and be like, is it only me? Am I the only one that feels like this? That I'm trapped in the wrong body?"

As a young child, she changed her name and started dressing as a girl. First at home and later at school. With her parents support, and under the care of doctors and psychologists, Emily eventually started taking hormone blockers to prevent male puberty and then estrogen to develop a female body.

Dr. Jess Ting is director of surgery at Mount Sinai Center for Transgender Medicine and Surgery. He says, "Emily is a pioneer because she is at the forefront of this new generation of young kids, adolescents who are realizing what they are much earlier in life and are able to transition even before puberty."

Dr. Ting performed Emily’s reassignment surgery at Mount Sinai Hospital in New York. He created female anatomy that is fully functional.

His team has completed 12-hundred various operations. Dr. Ting considers it a life saving surgery, given the alarming rates of attempted suicide among transgender youth.

Emily's mother, Linda, says her only fear is what would happen if she tried to hold Emily back. “We saw the unhappy boy and we saw the happy girl. And we knew the statistics and we knew we'd much rather have an alive daughter than a dead son.”

Emily has become an activist and uses social media to let others know they're not alone. She says, "I don't want people to feel like that. It's OK to be who you are and just present to the world as yourself."

Experts say there are still many barriers for transgender people when it comes to accessing appropriate care and that contributes to long-term health problems. Recently, the American College of Physicians published new guidelines for doctors to help them better understand medical issues specific to this population.

Trans kids’ treatment can start younger, new guidelines say

• Show more sharing options
• Copy Link URL Copied!

A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Assn. for Transgender Health said hormones could be started at age 14, two years earlier than the group’s previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association, known as WPATH, provided an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn’t match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group’s standards of care and director of the University of Minnesota Medical School’s human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents’ consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

“Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision,” he said. “That is why we recommend a careful multidisciplinary assessment.”

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment , along with new efforts to prevent or restrict the treatment.

World & Nation

A transgender psychologist has helped hundreds of teens transition. But rising numbers have her concerned

Erica Anderson took more than half a century to come out as a woman. Now she works with teens in a rush to transition.

April 12, 2022

Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of WPATH last year after voicing concerns about “sloppy” treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn’t always happen.

“They tell me horror stories. They tell me, ‘Our child had 20 minutes with the doctor’” before being offered hormones, she said. “The parents leave with their hair on fire.”

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association’s new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8% in kids.

Anderson said she’s heard recent estimates suggesting the rate in kids is as high as 1 in 5 — which she strongly disputes. That number probably reflects gender-questioning kids who aren’t good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

“That’s just absolutely cruel,” she said.

Dr. Marci Bowers, the transgender health group’s president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been “forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis.”

Op-Ed: Denying trans youth gender-affirming care is an affront to science and medical ethics

States are pushing anti-trans policies that fly in the face of research and medical expertise.

June 13, 2022

Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, N.C., resident struggled miserably with gender discomfort before his treatment.

Poulos said he’s glad he was able to get treatment at a young age.

“Transitioning under the roof with your parents so they can go through it with you, that’s really beneficial,” he said. “I’m so much happier now.”

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

“Those decisions are best made by patients and patient families and medical professionals,” they said. “It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together.”

Science & Medicine

Early transgender identity in kids tends to endure, study suggests

Children who begin identifying as transgender at a young age tend to retain that identity for several years at least, a new study suggests.

May 4, 2022

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn’t strong evidence in favor of transgender medical treatment for kids.

“In medicine ... the treatment has to be proven safe and effective before we can start recommending it,” Mason said.

Experts say the most rigorous research — studies comparing treated kids with outcomes in untreated kids — would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That’s no change from the group’s previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

• Sex hormones — estrogen or testosterone — starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.

• Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum age wasn’t listed.

• Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Assn. support allowing kids to seek transgender medical treatment, but they don’t offer age-specific guidance.

Dr. Joel Frader , a Northwestern University pediatrician and medical ethicist who advises a gender treatment program at Chicago’s Lurie Children’s Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they’re prone to risk-taking and they take into account long-term consequences of their actions only when they’re much older.

Coleen Williams , a psychologist at Boston Children’s Hospital’s Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

“Medical intervention in any realm is not a one-size-fits-all option,” Williams said.

More to Read

Some states are trying to make sex binary. Transgender people see their existence denied

Feb. 28, 2024

Ohio is poised to become the 2nd state to restrict gender-affirming care for adults

Jan. 20, 2024

Editorial: Want to protect children? Don’t sign this trans-bashing petition

Dec. 10, 2023

More From the Los Angeles Times

Biden administration partners with 50 countries to stifle future pandemics

April 16, 2024

Opinion: The decline in American life expectancy harms more than our health

Too expensive, too slow: NASA asks for help with JPL’s Mars Sample Return mission

April 15, 2024

‘Miracle’ weight-loss drugs could have reduced health disparities. Instead they got worse

A Reuters Special Report

As more transgender children seek medical care, families confront many unknowns.

IN TREATMENT: Ryace Boyer, a 14-year-old high-school student, prepares to take the female hormone estrogen as part of her gender-affirming medical care. REUTERS/Megan Jelinger

USA-TRANSYOUTH/CARE

Across the United States, thousands of youths are lining up for gender-affirming care. But when families decide to take the medical route, they must make decisions about life-altering treatments that have little scientific evidence of their long-term safety and efficacy.

By CHAD TERHUNE , ROBIN RESPAUT , and MICHELLE CONLIN

Filed Oct. 6, 2022, 11 a.m. GMT

BELPRE, Ohio

On the two-hour drive back from the hospital, Danielle Boyer kept replaying the doctor’s questions in her mind. Was her then-12-year-old child, Ryace, hearing voices? Was she using illegal drugs? Had she ever been hospitalized for psychiatric treatment? Had she ever harmed herself?

Danielle was still shaken when she and Ryace arrived home in this small town nestled in a bend of the Ohio River. Dinner would have to wait. She had to talk to her husband. “They were asking us these sad, terrible questions,” she told Steve Boyer as the two sat in their garage that August 2020 evening. “Do you know kids have tried to kill themselves?”

“I had no idea,” he said.

Ryace (pronounced RYE-us) was assigned male at birth, but by the time she was 4, it was clear to her parents that she identified as a girl. She referred to herself as a girl. She wanted to dress as a girl. But her parents feared for her safety if they let her live openly as a girl in their tightly knit rural community. So they struck an uneasy compromise. At home, Ryace could be a girl, wearing makeup and dresses. At school, around town and in family photos, Ryace would remain a boy.

Ryace chafed at the restrictions. When she started middle school, she grew increasingly anxious about what puberty would bring: facial hair, an Adam’s apple, a deeper voice. That’s when Danielle sought help at Akron Children’s Hospital and its new gender clinic, where staff told her they could treat Ryace with puberty-blocking drugs and sex hormones to help her transition.

“This is what I’ve always wanted,” Ryace told her mother as they left the hospital. Afterward, the pair went on a celebratory shopping trip for girl’s clothes. Danielle was relieved. After years of struggling in isolation to do what they thought was best for Ryace, the Boyers were now getting expert help from people who understood their situation.

But the initial consultation brought troubling new questions. The doctor at the Akron clinic told Danielle and Ryace that puberty blockers could weaken Ryace’s bones. The effects on her brain development and fertility weren’t well-understood. The risk of inaction was even more alarming: Without treatment, the doctor said, Ryace would remain at increased risk of suicide.

Mention of suicide raised the stakes. “She’s been asking for how many years now to be a girl?” Danielle said to her husband as they sat talking in their garage that evening. “We just keep telling her no, and we’re crushing her. If they can help us, let’s do this.”

The United States has seen an explosion in recent years in the number of children who identify as a gender different from what they were designated at birth. Thousands of families like the Boyers are weighing profound choices in an emerging field of medicine as they pursue what is called gender-affirming care for their children.

Gender-affirming care covers a spectrum of interventions. It can entail adopting a child’s preferred name and pronouns and letting them dress in alignment with their gender identity – called social transitioning. It can incorporate therapy or other forms of psychological treatment. And, from around the start of adolescence, it can include medical interventions such as puberty blockers, hormones and, in some cases, surgery. In all of it, the aim is to support and affirm the child’s gender identity.

But families that go the medical route venture onto uncertain ground, where science has yet to catch up with practice. While the number of gender clinics treating children in the United States has grown from zero to more than 100 in the past 15 years – and waiting lists are long – strong evidence of the efficacy and possible long-term consequences of that treatment remains scant.

Puberty blockers and sex hormones do not have U.S. Food and Drug Administration (FDA) approval for children’s gender care. No clinical trials have established their safety for such off-label use. The drugs’ long-term effects on fertility and sexual function remain unclear. And in 2016, the FDA ordered makers of puberty blockers to add a warning about psychiatric problems to the drugs’ label after the agency received several reports of suicidal thoughts in children who were taking them.

More broadly, no large-scale studies have tracked people who received gender-related medical care as children to determine how many remained satisfied with their treatment as they aged and how many eventually regretted transitioning. The same lack of clarity holds true for the contentious issue of detransitioning, when a patient stops or reverses the transition process.

The National Institutes of Health, the U.S. government agency responsible for medical and public health research, told Reuters that “the evidence is limited on whether these treatments pose short- or long-term health risks for transgender and other gender-diverse adolescents.” The NIH has funded a comprehensive study to examine mental health and other outcomes for about 400 transgender youths treated at four U.S. children’s hospitals. However, long-term results are years away and may not address concerns such as fertility or cognitive development.

U.S. children ages 6 to 17 diagnosed with gender dysphoria from 2017 through 2021

U.S. children starting on puberty blockers or hormones over the five-year period

Reliable national data on how many children receive care for gender dysphoria – defined as a feeling of distress from identifying as a gender different from the one assigned at birth – have long been unavailable. To get some idea of the increasing prevalence of these cases, Reuters asked health technology company Komodo Health Inc to analyze its database of U.S. insurance claims and other medical records on about 330 million Americans. The analysis, the first of its kind, found that at least 121,882 children ages 6 to 17 were diagnosed with gender dysphoria in the five years to the end of 2021. More than 42,000 of those children were diagnosed just last year, up 70% from 2020.

Though smaller, the number of children receiving medical treatments like those the Akron clinic outlined for the Boyers is also growing fast. The number of children who started on puberty-blockers or hormones totaled 17,683 over the five-year period, rising from 2,394 in 2017 to 5,063 in 2021, according to the analysis. These numbers are probably a significant undercount since they don’t include children whose records did not specify a gender dysphoria diagnosis or whose treatment wasn’t covered by insurance.

Social acceptance

The surging numbers reflect in part the success of years of advocacy for transgender rights, which doctors say has made more children and their families comfortable about seeking help. Transgender children still live with discrimination, bullying and threats of violence. But as transgender identity has become more visible in popular culture, children with gender dysphoria have gained ready access on TV and social media to positive representations of young people who have received professional gender-affirming care.

Gender care for minors gained further legitimacy as medical groups endorsed the practice and began issuing treatment guidelines. Chief among them is the World Professional Association for Transgender Health, a 4,000-member organization that includes medical, legal, academic and other professionals from around the world. Over the past decade, its guidelines have been echoed by the likes of the American Academy of Pediatrics and the Endocrine Society, which represents specialists in hormones.

In its latest Standards of Care, released in September, WPATH notes the paucity of research supporting the long-term effectiveness of medical treatment for adolescents with gender dysphoria. As a result, the guidelines say, “a systematic review regarding outcomes of treatment in adolescents is not possible.” The Endocrine Society, in its own guidelines, acknowledges the “low” or “very low” certainty of evidence supporting its recommendations.

The federal government eased the path to treatment in 2016, when the administration of President Barack Obama prohibited health insurers and medical providers from limiting care because of a person’s gender identity. That prompted an expansion of public and private insurance coverage for gender-affirming care, including for children, which can cost tens of thousands of dollars a year for puberty blockers alone.

Today, more than half of states pay for gender-transition treatment through Medicaid, the government health insurance program for millions of low-income families. Nine states exclude youth gender care from Medicaid coverage. Florida, in its Medicaid prohibition, says treatments for gender dysphoria “do not meet the definition of medical necessity.”

That disparity among states is symptomatic of how gender-affirming care has become a flashpoint in the nation’s highly polarized politics.

Many conservatives decry it as a form of child abuse. “You don’t disfigure 10, 12, 13-year-old kids based on gender dysphoria,” Florida Governor Ron DeSantis, a Republican, said at an August news conference, just days before his state banned Medicaid coverage of gender care for children. Alabama, Arkansas and Texas have enacted laws or policies to broadly limit children’s access to care, all of them since blocked by courts. In more than a dozen other states, including Ohio, where the Boyers live, legislators have introduced bills that would ban care or penalize providers for treating children.

“Gender-affirming care for transgender youth is essential and can be life-saving.” Dr Rachel Levine, assistant secretary at the U.S. Department of Health and Human Services

At the same time, at least a dozen states, including New York, California and Massachusetts, have aligned with transgender advocates and many medical providers by ensuring that children are guaranteed access to care. And in July, the Biden administration proposed an expansion of the Obama-era protections.

“Gender-affirming care for transgender youth is essential and can be life-saving,” Dr Rachel Levine, an assistant secretary at the U.S. Department of Health and Human Services, said in an interview with Reuters.

Levine, a pediatrician and a transgender woman, drew outcry from conservative opponents of children’s gender care and some medical professionals earlier this year when she told National Public Radio: “There is no argument among medical professionals – pediatricians, pediatric endocrinologists, adolescent medicine physicians, adolescent psychiatrists, psychologists, et cetera – about the value and the importance of gender-affirming care.”

Levine was right, insofar as healthcare providers generally agree that anyone with gender dysphoria has a right to supportive care, whether that entails social transition, or counseling and therapy, or medical interventions. But her statement glossed over deep fissures that have opened within the gender-care community over the way treatment has evolved in the United States as new patients pour into clinics.

A growing number of gender-care professionals say that in the rush to meet surging demand, too many of their peers are pushing too many families to pursue treatment for their children before they undergo the comprehensive assessments recommended in professional guidelines.

Such assessments are crucial, these medical professionals say, because as the number of pediatric patients has surged, so has the number of those whose main source of distress may not be persistent gender dysphoria. Some could be gender fluid, with a gender identity that changes over time. Some may have mental health problems that complicate their cases. For these children, some practitioners say, medical treatment may pose unnecessary risks when counseling or other nonmedical interventions would be the better choice.

“I’m afraid what we’re getting are false positives and we’ve subjected them to irreversible physical changes,” said Dr Erica Anderson, a clinical psychologist who previously worked at the University of California San Francisco’s gender clinic. “These errors in judgment are fodder for the naysayers – the people who want to eradicate this care.” Anderson, a transgender woman who still treats children with gender dysphoria in her private practice, resigned as president of WPATH’s U.S. chapter last year after her public comments about “sloppy” care prompted the organization to issue a temporary moratorium on board members speaking to the press.

In Europe, concern that too many children might be unnecessarily put at risk has prompted countries like Finland and Sweden that were early to embrace gender care for children to now limit access to care. The United Kingdom is shutting down its main clinic for children’s gender care and overhauling the system after an independent review found that some staff felt “pressure to adopt an unquestioning affirmative approach.”

Ranged against those advising caution in the United States are members of the gender-care community who say that denying treatment to any child with gender dysphoria is unethical and dangerous. “You shouldn’t have to jump through hoops to prove your own trans-ness,” said Dallas Ducar, a psychiatric nurse practitioner and trans health provider in Massachusetts.

Ducar and officials at other clinics said the waiting lists at many facilities show that children already face significant barriers to treatment due to a shortage of providers and a persistent stigma in healthcare attached to transgender patients. “If you put unnecessary roadblocks in the way, we know the kid will still be trans and they will continue to experience deep psychological stress that increases the risk of suicide attempts or suicide itself,” Ducar said.

Dr Marci Bowers, a surgeon specializing in transgender procedures who became WPATH’s president in September, said in an interview that the organization is trying to find a middle ground between “those who basically would have hormones and surgeries available at a vending machine, let’s say, versus others who think that you need to go through all sorts of hoops and hurdles.”

In its new Standards of Care, WPATH retained its longstanding recommendation of comprehensive assessments to determine that adolescents are suitable for medical treatment. “There are no studies of the long-term outcomes of gender-related medical treatments for youth who have not undergone a comprehensive assessment,” the guidelines note. Without such evidence, the document adds, “the decision to start gender-affirming medical interventions may not be in the long-term best interest of the young person at that time.”

Levine, the U.S. assistant secretary for health, said that clinics are proceeding carefully and that no American children are receiving drugs or hormones for gender dysphoria who shouldn’t. “It’s not like anyone who arrives automatically gets medical treatment,” she said.

A good candidate

Belpre, Ohio, is in Washington County, a rural community of farmhouses, trailer homes and churches set among lush green hills. The area has been home to generations of Boyers. Danielle, 37, works in education. Steve Boyer, a 36-year-old plumber and pipefitter, has served on the board of a local fair, where Ryace and her older brother, Aiden, have shown ducks and lambs they tended. Weekends are spent camping or attending horse shows where Ryace, an accomplished equestrian, competes in barrel races and roping events. “Everybody knows the Boyers,” Steve said.

Steve and Danielle had no direct experience with transgender people when Ryace was born. By around age 4, she referred to herself as a girl, played with girls at friends’ houses and became fascinated with women’s clothing and jewelry. On Christmas morning 2011, shortly before her 4th birthday, Ryace was thrilled when she got much of what she had wanted from Santa: Barbie dolls, a dollhouse, and toys in pink and purple.

But Danielle feared Ryace wouldn’t be accepted as a transgender girl in their conservative community, and she wanted to protect her child from the stares, hateful comments and broken relationships that would inevitably come. “The agreement was, house only,” Danielle said.

Ryace constantly pushed back. From early on, when friends and neighbors complimented her as a cute little boy, she would correct them: She was a girl. Danielle then felt compelled to correct Ryace.

Danielle sought compromises. In elementary school, they often settled on outfits for Ryace of neutral black leggings and brightly colored T-shirts. She picked up dresses and hair pins at yard sales and let Ryace wear them at home. On trips into town, Danielle had Ryace take off the dresses she wore over her boy’s clothes and leave them in the car.

As middle school – and puberty – loomed, Ryace started sneaking bras and mascara to school. She repeatedly texted her mom, “Will you start calling me a girl?”

Television and the internet had opened Ryace’s eyes to new possibilities. She watched “I Am Jazz,” the reality TV show about Jazz Jennings, a transgender girl who socially transitioned at an early age and went on to take puberty blockers and hormones and have surgery. She watched young people on YouTube discuss gender dysphoria and their transitions and saw the before-and-after images they shared. On Instagram, she followed Nikita Dragun, a makeup artist and model who came out as transgender as a teenager and now has 9 million followers.

“This is actually a thing,” Ryace recalled thinking at the time. “I can actually do this.”

Ryace is the type of child that doctors in the Netherlands focused on in their pioneering work in the early 2000s on medical treatment for adolescents with gender dysphoria. Researchers at the Amsterdam University Medical Center methodically screened their subjects to ensure they met certain criteria before receiving treatment. Like Ryace, these adolescents exhibited persistent gender dysphoria from a very early age, lived in supportive environments, and had no serious psychiatric issues that could interfere with a diagnosis or treatment.

The assessments generally lasted about six months before treatment could start. The children filled out a series of questionnaires, and clinicians talked to them frequently to confirm that their gender dysphoria was persistent and to ensure that they understood the long-term implications of treatment. For patients who had psychiatric problems, the researchers extended the assessment phase to more than 18 months before considering medical treatment.

In 2011, the Dutch published detailed results of their work. In one study involving 70 adolescents, the group showed fewer behavioral and emotional problems and fewer symptoms of depression after nearly two years on puberty blockers. Feelings of anxiety and anger were relatively unchanged. All of the patients went on to take hormones.

European countries and the United States adopted the Dutch model for the newly emerging field of gender-affirming care for minors. WPATH and other professional groups issued guidelines recommending comprehensive psychological evaluations before referring any child for medical treatment.

More recently, though, many of the patients flooding into clinics wouldn’t meet Dutch researchers’ criteria. Some have significant psychiatric problems, including depression, anxiety and eating disorders. Some have expressed feelings of gender dysphoria relatively late, around the onset of puberty or after, according to published studies, gender specialists and clinic directors. Such cases require more extensive evaluation to rule out other possible causes of the patient’s distress.

And for reasons not understood, a disproportionate number are patients assigned female at birth. In the NIH study of children’s treatment outcomes now under way, minors designated female at birth made up 61% of enrollees. The gender clinic at Children’s Wisconsin hospital in Milwaukee said 65% of its patients were assigned female at birth. Some researchers and clinics say transgender females are less likely to seek treatment because they face greater social stigma for doing so. Critics of children’s gender care blame peer pressure, reinforced by social media, for boosting the number of transgender males seeking care.

Dr Annelou de Vries, a specialist in child and adolescent psychiatry, is one of the Dutch researchers whose early work established the importance of rigorous patient assessments before starting medical treatment. She said that while she worries about the growing number of children awaiting treatment, the graver sin is to move too fast when puberty blockers and hormones may not be appropriate.

“The existential ethical dilemma in transgender care is between on one hand the (child’s) right for self-determination,” de Vries said. “On the other hand, the do-not-harm principle of medical intervention. Aren’t we intervening medically in a developing body where we don’t know the results of those interventions?” In the United States, in particular, she said, “the transgender right or child’s right seems to be put forward more strongly.” De Vries helped write the section on adolescents in WPATH’s updated Standards of Care. She said she was gratified that language stressing the importance of rigorous patient assessments remained.

In interviews with Reuters, doctors and other staff at 18 gender clinics across the country described their processes for evaluating patients. None described anything like the months-long assessments de Vries and her colleagues adopted in their research.

At most of the clinics, a team of professionals – typically a social worker, a psychologist and a doctor specializing in adolescent medicine or endocrinology – initially meets with the parents and child for two hours or more to get to know the family, their medical history and their goals for treatment. They also discuss the benefits and risks of treatment options. Seven of the clinics said that if they don’t see any red flags and the child and parents are in agreement, they are comfortable prescribing puberty blockers or hormones based on the first visit, depending on the age of the child.

“For those kids, there’s not a value of stretching it out for six months to do assessments,” said Dr Eric Meininger, senior physician for the gender health program at Riley Hospital for Children in Indianapolis. “They’ve done their research, and they truly understand the risk.”

“We do not have enough therapists and psychologists who have had adequate training in this area to keep up with the pace of more gender-diverse patients who have come out recently.” Dr Michael Irwig, director of transgender medicine, Beth Israel Deaconess Medical Center

Many clinicians bristle at suggestions they may be moving too fast, treating children before adequately vetting them. Months-long assessments and counseling in lieu of medical treatment puts children at risk, pathologizes them and denies them their fundamental identity, they say. For minors with psychiatric problems, they say, medical treatment often alleviates the distress of gender dysphoria and allows professionals to then address those other conditions.

“Being trans is an identity, not a diagnosis, and transgender people just want the care that affirms who they are,” said Ducar, the trans health provider in Massachusetts.

Ducar and others were disappointed that in its updated Standards of Care, WPATH noted that “social influence” may impact some adolescents’ gender identity. They said the idea of a “social contagion” infecting children perpetuates an offensive misconception that being transgender is a fad spread among impressionable adolescents by friends and social media and fails to recognize the stigma, bullying and discrimination transgender people experience.

Dr Eli Coleman, director of the University of Minnesota Medical School’s Institute for Sexual and Gender Health who oversaw the update of WPATH’s Standards of Care, said: “A knowledgeable and competent clinician can discern between a person’s gender identity that is marked and sustained and an identity that might be socially influenced.”

The issue of assessments is complicated by a chronic shortage of mental-health professionals for children that has only worsened amid soaring rates of depression, anxiety, mood disorders and self harm nationwide.

“We do not have enough therapists and psychologists who have had adequate training in this area to keep up with the pace of more gender-diverse patients who have come out recently,” said Dr Michael Irwig, an associate professor at Harvard Medical School and director of transgender medicine at Beth Israel Deaconess Medical Center. “We are going to miss some people who haven’t been vetted appropriately or who haven’t gotten the mental health care that they need.” That, he said, may increase the number of people who later detransition.

Reuters interviewed parents of 39 minors who had sought gender-affirming care. Parents of 28 of those children said they felt pressured or rushed to proceed with treatment.

Kate, a 53-year-old mother in New Jersey, said she and her husband were shocked in November 2020 when their 13-year-old told them he was transgender. The child, assigned female at birth, had always played with other girls and had never expressly identified as a boy. They just thought their child was a “tomboy.” Now, they learned, he had chosen a male name and wanted to start puberty blockers and get breast-removal surgery.

After an initial one-on-one consultation of little more than an hour with the teen, a psychiatrist said he was a good candidate for puberty blockers, Kate said. An endocrinologist recommended the same after talking with the family for 15 minutes. Kate and her husband also attended a parents’ support group organized by a local gender therapist. Through it all, Kate said, “the message was, let your kid drive the bus. Wherever they lead you, that’s what you should do.”

Kate, who asked that only her first name be used to protect her child’s identity, had read up on puberty blockers. Concerned about their off-label use and possible side effects, she wouldn’t agree to treatment. She supports her son’s social transition, using his preferred pronouns and buying the tape he uses to bind his breasts. But she thinks he is too young to make decisions about life-altering medical treatments.

“Children, when they are 13 or 14, are sometimes totally different people from when they are 18 or 19,” she said. As a result of her decision, her relationship with her son has been “fractured,” Kate said. If he chooses to pursue medical transition after he turns 18, she said, she and her husband won’t be happy, but they won’t stand in the way, either.

Suicide Watch

The fragile truce between Ryace and her parents – girl at home, boy everywhere else – collapsed after Ryace started middle school.

In December 2019, Danielle let Ryace, 11 at the time, wear makeup and black bell-bottom pants to a basketball game at a nearby school. Danielle’s mother, Ruth Alden, was at the game, and afterward, she scolded Danielle. It was embarrassing to the family, Alden said, and other kids are “gonna beat the crap out of her.” Her granddaughter could be driven to suicide, she warned.

Danielle was incensed – and despondent. She felt trapped. She had long worried that she was pushing Ryace toward suicide by insisting that her identity remain a secret. That night, Danielle yelled at her own mother: “What do I do, Mom? Regardless of my decision, I could have a dead child.”

Early in the new year, Danielle, desperate for guidance, joined a Facebook group for Ohio parents of transgender children. That eventually led her to the children’s hospital a two-hour drive away in Akron, for the Aug. 6, 2020, meeting with Dr Crystal Cole and her team.

Dr Cole, an Akron native and specialist in adolescent medicine, founded the hospital’s Center for Gender Affirming Medicine in 2019. The clinic saw 25 patients that year. It now is treating more than 350 young people.

In their two-hour meeting, Cole started with general questions about Ryace, her family and their medical history. Then she sharpened the focus on Ryace’s mental health and readiness for treatment. Danielle exhaled with relief after Ryace responded that she wasn’t hearing voices, wasn’t using illegal drugs and had never tried to harm herself.

The doctor then laid out the treatment options. Ryace could socially transition. She could also opt to receive counseling and therapy to support her through transition. And she could receive treatment to medically transition. At age 12, Ryace was a candidate for puberty suppression to spare her the masculinizing features she feared, with known and unknown risks.

“Ryace is a very vibrant, well-adjusted young lady that just happened to be assigned male sex at birth.” Dr Crystal Cole, Akron Children’s Hospital’s Center for Gender Affirming Medicine

Cole then moved on to the danger of inaction. “The risk of people in the transgender population attempting suicide is over 40%,” she told Ryace and Danielle. “One of the things shown to lower that is affirming care and an affirming environment.”

The statistic Cole referred to came from the 2015 U.S. Transgender Survey, an anonymous online survey of nearly 28,000 transgender adults conducted by the National Center for Transgender Equality, a nonprofit advocacy group. Compared to the 40% of respondents who reported attempting suicide at some point their lives, the rate for the general U.S. population at the time was 4.6%, the authors of the 2015 survey said.

It’s one of several surveys that healthcare professionals cite when advising families with children seeking gender-affirming care. Another was by the Trevor Project, a nonprofit group that focuses on suicide prevention for LGBTQ youth. In that 2021 anonymous survey, 52% of transgender and nonbinary respondents ages 13 to 24 said they had seriously contemplated killing themselves. More than 13,000 survey respondents, or 38% of the overall sample, identified as transgender or nonbinary.

Dr Jonah DeChants, a Trevor Project research scientist, said the group’s survey data “tell a really important story about the mental health impact of being an LGBTQ person and living in a world that tells you that you’re wrong, that you’re an abomination and that you are not safe to be around other children.”

Such online surveys have become common in science, but researchers say they may not be fully representative of the larger population being studied. The authors of the 2015 U.S. Transgender Survey said: “It is not appropriate to generalize the findings in this study to all transgender people.”

Experts in gender care say more specific research is needed to determine whether medically transitioning as a minor reduces suicidal thoughts and suicides compared with those who socially transition or wait before starting treatment.

Some gender-care professionals complain that suicide risk is too often used to pressure and even frighten parents into consenting to treatment. “I think it’s irresponsible for clinicians to do that,” said Anderson, the former president of WPATH’s U.S. chapter. “As a clinical psychologist, I don’t do a suicide assessment by membership in a class. The level of risk varies tremendously across individuals.”

De Vries, the Dutch researcher, told Reuters there is no evidence that “providing care immediately leads to a decline in self harm or would prevent suicide.”

DeChants of the Trevor Project said he wouldn’t want the organization’s data to be used to pressure people on treatment decisions. “We would never say that gender-affirming healthcare is the only way to address suicide risk, but it is an important option for youth, their doctors, and their families to be able to consider,” he said.

After their two-hour evaluation of Ryace, Dr Cole and her team were confident that Ryace had gender dysphoria and was a strong candidate for medical treatment. “Ryace is a very vibrant, well-adjusted young lady that just happened to be assigned male sex at birth,” Cole said. Bringing up suicide on the first visit is scary for a lot of parents, she said, but “it’s a reality we have to ask about.”

A few weeks after visiting Akron, Danielle announced Ryace’s social transition in a Facebook message to family and friends. “I just wanted to let you know that Ryace started JH (junior high) as a female,” she wrote in a Sept. 19, 2020, post. “She can finally be who she feels she is. A girl. I wish this wasn’t our life sometimes but it is and it’s real and I have to let it be and be there to pick up the pieces when the world turns ugly. And it will, so we need all the love and support we can get.”

Many relatives and friends were supportive, including Alden, Danielle’s mother. Others stopped talking to the Boyers. Some parents complained to Ryace’s school about her using the girls’ bathroom. Previously, she had used a single-person bathroom. The principal backed Ryace.

Ryace was eager to begin treatment. “What are we waiting for?” she asked her mother. In November 2020, Danielle took Ryace to an appointment with the Akron clinic’s pediatric endocrinologist to learn more about puberty blockers. The endocrinologist scheduled Ryace for her first injection in March 2021.

Known unknowns

Endo International plc and AbbVie Inc dominate the U.S. market for puberty blockers. The only FDA-approved use for these drugs in children is for central precocious puberty, a condition in which children begin to sexually mature before age 8 or 9 because of pituitary gland dysfunction.

One side effect in children who take these drugs can be a decline in bone density, which is often treated with vitamin D or calcium supplements. Studies have shown that bone density can return to normal once therapy ends, but also that for some transgender girls, it may not.

In September, the FDA published a study that found “no evidence for an increased risk of fracture” for precocious puberty patients who take leuprolide, the generic name for AbbVie’s Lupron and similar drugs. However, the FDA study didn’t review cases of children who took the drug for gender dysphoria.

In a 2018 study published in the medical journal Clinical Pediatrics, researchers at Yale University noted a sharp increase in the off-label use of puberty blockers and said these drugs “have not been thoroughly investigated in populations with normally timed puberty.”

In Texas earlier this year, bone scans indicated that a child, 15 years old at the time, had osteoporosis after 15 months on puberty blockers. The teen’s mother, who asked not to be identified because she works at the hospital where her child was treated, said she thought she had done everything right when her teen came out as a transgender girl. But after the bone scan results, reviewed by Reuters, she said she regretted putting her child on puberty blockers. She stopped the Lupron injections and wouldn’t agree to hormone therapy.

The child, who has socially transitioned, was at first furious with her and threatened to drop out of high school, she said. Their relationship is better now, she said, though “we don’t talk about gender.”

Another concern about puberty blockers emerged in 2016, when the FDA ordered drugmakers to add a warning about psychiatric problems to the drugs’ label as a treatment for children with precocious puberty. On its label for Lupron, AbbVie says: “Psychiatric events have been reported in patients” taking puberty blockers. Events include emotional symptoms “such as crying, irritability, impatience, anger and aggression.”

The FDA pursued the label change after receiving 10 reports through its adverse event reporting system of children who had suicidal thoughts, including one suicide attempt, according to a Dec. 5, 2016, agency report reviewed by Reuters. One of the cases involved a 14-year-old patient taking Lupron for gender dysphoria, the records show. In the report, the FDA said suicidal ideation and depression are “serious events,” and there is “enough evidence to warrant informing prescribers, even in the face of uncertainty about causality.”

The agency also asked drugmakers to closely monitor for these adverse events and file more detailed reports to the agency. “The FDA continues surveillance for psychiatric events associated with drugs indicated for the treatment of pediatric patients with central precocious puberty,” the agency said.

Adverse event reports from medical professionals, consumers and drugmakers help the FDA detect potential safety problems with a drug that may warrant investigation. However, the agency doesn’t receive reports for every adverse event, and there is no certainty that a reported event was caused by a drug. Reports may contain errors, partial data or duplicate information.

Reuters found 72 adverse event reports submitted to the FDA from 2013 through 2021 of children on puberty blockers who showed suicidal, self-injurious, or depressive behavior. The children were taking the drug for central precocious puberty or gender dysphoria or were simply identified as under 18.

A Dec. 17, 2020, adverse event report to the FDA describes a 15-year-old patient taking Lupron for gender therapy. The patient had a history of “major depressive disorder” and a family history of depression. The patient experienced “mental health deterioration” while on Lupron and attempted suicide twice. AbbVie wrote in the report to the FDA that “there is no reasonable possibility” that the adverse events were related to Lupron. The company did not elaborate.

Dr Brad Miller, division director of pediatric endocrinology at the University of Minnesota Medical School and M Health Masonic Children’s Hospital, expressed surprise at the number of adverse event reports Reuters found. He said he was particularly concerned because doctors prescribe puberty blockers for transgender children, who are already at higher risk of mental health problems.

Miller and several other doctors told Reuters they had repeatedly asked AbbVie, Endo and other makers of puberty blockers to seek FDA approval for the drugs in treating gender dysphoria in children and to conduct clinical trials to establish the drugs’ safety for such use. They said the companies always declined. “They would say it would cost a lot of money to get approval,” Miller said. “And they were not interested in going there because (transgender treatment) was a political hot potato.”

AbbVie declined to comment for this article. An Endo spokeswoman said the company has no plans to seek regulatory approval for the use of its drug for any new indications. The company did not respond to requests for further comment for this article.

As prescriptions of puberty blockers increase for off-label gender care, the drugmakers are making cheaper alternatives harder to get.

Endo’s puberty blocker is an implant in the upper arm that releases medication for as long as two years. About a year ago, the company told the FDA that it had discontinued an implant called Vantas that cost about $4,600. That left doctors and patients to use a similar Endo implant called Supprelin LA. It costs about $45,000, according to drug pricing data analyzed by Reuters. Some families with high-deductible insurance plans might have to pay several thousand dollars out of pocket.

AbbVie sells adult and pediatric formulations of Lupron, given by injection every few months. Doctors said that there is no meaningful difference between the two, but that they prefer to use the cheaper adult version, at about $4,700 for a three-month dose. They said insurers sometimes insist on the pediatric version, priced at more than $10,000, when the claim specifies that the patient is a child.

Some scientists and doctors also say they wonder about possible neurological effects of puberty blockers. The question: Hormones released during puberty play a major role in brain development, so when puberty is suppressed, can that result in reduced cognitive function, such as problem solving and decision making?

Dr John Strang, research director of the gender development program at Children’s National Hospital in Washington, D.C., and other researchers wrote in a 2020 paper that “pubertal suppression may prevent key aspects of development during a sensitive period of brain organization.”

Strang said at the time that “we need high-quality research to understand the impacts of this treatment – impacts which may be positive in some ways and potentially negative in others.” He declined to comment on whether he was pursuing such research or funding for it.

At their first meeting at the Akron clinic, Dr Cole was blunt with the Boyers about the unknowns related to puberty blockers and brain development. “We don’t know the long-term effects on cognitive function. It could make it better, worse. We have no idea,” Cole told them. But she said she wouldn’t recommend treatment “if I didn’t see the positive effect on patients.”

Back at the clinic seven months later, Ryace, 13 at the time, smiled in front of a whiteboard where the date, 3-4-21, was written in green marker. It was the day of her first Lupron injection. A photograph of Ryace from that day shows a small glittery bandage on her thigh peeking through her ripped jeans.

The family’s insurance is covering nearly all the cost.

As the months passed, Ryace complained of pain in her knees. She started taking vitamin D as a precaution, and her pain dissipated.

Questions about fertility

Early this year, the Akron clinic told the Boyers that it was time for Ryace to take the next step in her treatment: hormone therapy, to help her develop the feminine characteristics aligned with her gender identity.

Ryace was now 14. In its new guidelines, WPATH makes no age recommendation for hormones.

For decades, hormone therapy has been the central component of treatment to help adults transition – estrogen for transgender women and testosterone for transgender men.

But for children, the choice to take hormones is more complicated. As with much of transgender medicine, research on the impact of hormones on fertility consists of small observational studies or surveys of adults that have significant limitations, experts say.

Many doctors acknowledge that long-term hormone therapy may reduce fertility, and they say children who receive puberty blockers followed by hormones run the highest risk. But with no definitive science to rely on, doctors often leave the question open when talking to children and their parents.

One Tuesday earlier this year, 16-year-old Ethan S. and his mother were in an exam room in suburban Portland to talk about testosterone therapy with Dr Kara Connelly, director of Oregon Health & Science University’s Doernbecher Gender Clinic. After reviewing the family’s medical history, Connelly, an associate professor of pediatric endocrinology, asked Ethan what he wanted from testosterone. “My deepening of the voice definitely, and the, like, distribution of my fat and stuff. And hopefully facial hair,” he said.

Ethan could expect those and other masculinizing changes, Connelly said. A deeper voice and hair growth would be permanent.

Connelly then turned to fertility: Nearly all patients who stop taking testosterone start to have menstrual cycles again, she told them, and they can go on to carry a pregnancy or have their eggs used by someone else. “We can’t predict with 100% certainty that testosterone would not have any effect on your fertility potential,” Connelly said. “All we know is generally what happens in a population, and that it does seem from that evidence that it is not as harmful to fertility potential as we once thought.”

Connelly based her comments on a 2014 study published in the journal Obstetrics & Gynecology that analyzed survey responses from 41 transgender men who had a baby. Twenty-five of them reported using testosterone before becoming pregnant. However, the researchers acknowledged that the survey excluded transgender men “who attempt to get pregnant and cannot and those who do not carry to term.”

Ethan was unconcerned about possible side effects from taking testosterone. “When is the soonest that I can get it?” he asked.

In Oregon, teens can take hormones without parental consent starting at age 15. A social worker handed him a form, and Ethan eagerly signed it.

Ethan’s mother, Melissa, was supportive. She said Ethan had already socially transitioned when he started talking about medically transitioning two years ago. Then Melissa’s father, suffering from alcoholism and depression, committed suicide in February 2021. Ethan had been close with his grandfather, and with that family history, Melissa said she worried even more about her son. “There’s the fear of what happens if I let him transition and then the fear of what happens if I don’t,” Melissa said after the appointment.

Few children choose to have their eggs or sperm preserved before gender treatment as insurance in case they decide they want to try to have children later in life. In particular, harvesting eggs can be expensive and invasive. And for both genders, it can increase the discomfort they experience with their bodies.

Dr Angela Kade Goepferd, a pediatrician and medical director of the gender health program at Children’s Minnesota hospital, sometimes asks parents to write a letter to their future adult child about the decision to start medications that may affect their fertility. An adolescent’s views on starting a family may change over time, so the aim is for the child to remember conversations and choices made when they were younger, Goepferd said, adding: “I don’t think these are easy decisions for families.”

In Akron, Dr Cole tried a similar approach with Ryace. She suggests that her patients try imagining themselves as a 35-year-old and think about what that person might want. “Kids by design don’t tend to think about long-term consequences. That is not how their brains work,” Cole said.

At home, Danielle asked Ryace if she was comfortable with the possibility of being unable to have her own biological children. Ryace said she would adopt. Also, a friend had already offered to have a baby for her after they became adults. “It could be sad, but I’m OK with it,” Ryace told her mother.

By April this year, Ryace was taking estrogen pills along with regular shots of Lupron. The endocrinologist started her on low-dose estrogen, gradually increasing the amount while weaning Ryace from the puberty blocker. Ryace also regularly sees a counselor. The Akron clinic, like many that Reuters spoke to, requires that most teens taking hormones receive counseling to help them through what can be a physically and emotionally challenging time.

‘They’re trying their best’

Ryace lives much of her life as any teenager. But as her transition has progressed, she has continued to confront disapproval from other relatives and the community.

At the county fair last year, members of the crowd grumbled when Ryace was crowned Horse Princess. In town, she spots people rolling their eyes and hears their snide comments. During a field trip in May, she broke down in sobs when she saw students teasing a 16-year-old boy from another school who had flirted with her and had asked to message her online.

Some patients who receive treatments like Ryace’s eventually decide to undergo “bottom surgery.” For transgender girls, the procedure, called vaginoplasty with penile inversion, involves the creation of a vagina and vulva from the patient’s penis and scrotum. Sometimes, the testicles are removed, too. The surgery is irreversible, expensive, and can result in serious complications that require follow-up procedures.

The authors of WPATH’s new standards considered advising that genital surgery generally not be performed until at least age 17, but ultimately they made no age-related recommendations. The Endocrine Society puts it at 18. In its recent policy statement, the Biden administration said gender-affirming surgeries were “typically used in adulthood or case-by-case in adolescence.”

Genital surgeries performed on minors are rare, but surgeons say interest is growing. The Komodo analysis of insurance claims found 56 genital surgeries, including vaginoplasty and other procedures, among patients ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021. That doesn’t include surgeries not covered by insurance. In a 2017 research article that surveyed 20 WPATH-affiliated U.S. surgeons, the doctors said there had been “a definite increase in the number of minors” requesting information about vaginoplasty or being referred for surgery by their mental health providers.

Complications from genital surgeries are common. A California study found that a quarter of 869 vaginoplasty patients, with a mean age of 39, had a surgical complication so severe that they had to be hospitalized again. Among those patients, 44% needed additional surgery to address the complication, which included bleeding and bowel injuries.

For adolescents transitioning to female, puberty blockers and hormones can complicate eventual genital surgery. That’s because the medications can stunt development of the male genitalia from which a vagina and vulva are constructed. In 2020, de Vries and other Dutch researchers urged clinicians to inform transgender youth and their parents about this risk when starting puberty blockers.

Bowers, the new WPATH president and a transgender woman, said she has worried that some patients who begin puberty blockers at a young age won’t ever be able to have an orgasm because they never experienced one prior to pausing puberty, regardless of whether they have surgery. She said ongoing research has allayed many of her concerns, and “it seems not only probable but likely there is retention of orgasmic function.” She said she has encouraged doctors to talk about this risk with adolescents before they start medication.

The Akron clinic hasn’t discussed genital surgery with the Boyers yet. Akron Children’s Hospital doesn’t provide gender-affirming surgeries.

Overall, Ryace appears unfazed by the long-term implications of treatment. “I just go along with it pretty much,” she said.

In hindsight, she forgives her mother for making her conceal her identity for so long. “Sometimes she really wasn’t protecting me. She was just hurting me. And I know she didn’t mean it,” Ryace said. “I know a lot of parents probably do that, and they think they’re trying their best.”

Do you have an experience with gender-affirming care to share as a patient, family member or medical provider? Share it with Reuters .

Youth in Transition

By Chad Terhune, Robin Respaut and Michelle Conlin

Photography: Megan Jelinger and Lindsey Wasson

Photo editing: Corrine Perkins

Video editing: Christine Kiernan, Francesca Lynagh and Lucy Ha

Art direction: John Emerson

Edited by Michele Gershberg and John Blanton

• Follow Reuters Investigates

Other Reuters investigations

• Skip to main content
• Keyboard shortcuts for audio player

Medical Treatments

Most teens who start puberty suppression continue gender-affirming care, study finds.

Laurel Wamsley

Demonstrators gather on the steps to the Texas State Capitol in Austin to speak against transgender-related bills being considered in the state legislature in May 2021. Eric Gay/AP hide caption

Demonstrators gather on the steps to the Texas State Capitol in Austin to speak against transgender-related bills being considered in the state legislature in May 2021.

A large majority of transgender adolescents who received puberty suppression treatment went on to continue gender-affirming treatment, a new study from the Netherlands has found.

The study, published in The Lancet , used data that included people who visited the gender identity clinic of Amsterdam UMC, a leading medical center in the Dutch capital, for gender dysphoria. (Gender dysphoria refers to psychological distress that results from an incongruence between one's sex assigned at birth and one's gender identity.)

Researchers found that a whopping 98% of people who had started gender-affirming medical treatment in adolescence continued to use gender-affirming hormones at follow-up. The finding is significant because of ongoing political debates over whether young people should receive gender-affirming treatment, with some opponents arguing that many transgender children and teens will realize later in life that they aren't really trans.

The paper's data included people who started medical treatment in adolescence with puberty blockers before the age of 18 for a minimum duration of three months, before adding gender-affirming hormones. Researchers then linked that data to a nationwide prescription registry in the Netherlands to look for a prescription for gender-affirming hormones at follow-up.

'It's Hurtful': Trans Youth Speaks Out As Alabama Debates Banning Medical Treatment

The study, thought to be the largest of its kind, provides a new data point in the highly charged political debate over the prescribing of puberty blockers or providing gender-affirming medical care to trans youth. Young people seeking transition-related treatment are sometimes told that they are simply going through "a phase" that they'll grow out of.

Marianne van der Loos, a physician at Amsterdam UMC's Center for Expertise on Gender Dysphoria, is the paper's lead author.

"I think it's an important finding because we see that most of these people continue to use gender-affirming hormones," van der Loos tells NPR.

The debate over whether youths should be able to access gender-affirming care is largely a political one. Major medical organizations in the U.S. have published guidelines for providing appropriate gender-affirming care.

For example, the American Academy of Child and Adolescent Psychiatry has stated that it "supports the use of current evidence-based clinical care with minors. ... Blocking access to timely care has been shown to increase youths' risk for suicidal ideation and other negative mental health outcomes."

The subject of medical treatment for trans adolescents is a hot topic not only in the U.S., but in the Netherlands as well, says van der Loos: "There's just a lot of people having an opinion on this."

Pride Month

A guide to gender identity terms.

The cohort study included 720 people, of whom 31% were assigned male at birth, and 69% were assigned female at birth. The presence of more people assigned female at birth is a reflection of the population who sought gender-affirming treatment at this clinic.

For the 2% of people in the cohort who did not appear to continue treatment with gender-affirming hormones, the researchers were not able to identify the cause.

"We aren't sure that they really quit treatment. We couldn't find a prescription for gender-affirming hormones for those people. So it seems that they don't have one anymore in the Netherlands. And we can't really tell from this data as to why they would have quit," says van der Loos, adding that it's an important question to answer in further research, along with the long-term effects of the treatment protocol on bone health.

Trans inmates need access to gender-affirming care. Often they have to sue to get it

Van der Loos emphasizes that mental health support is a key part of the treatment at Amsterdam UMC, with a diagnostic evaluation prior to a patient starting puberty suppression, and continued mental health care during treatment. As a result, van der Loos wasn't surprised to find that most of those who began treatment chose to continue it.

"These were people that were supported by a mental health professional before start of treatment, [and] also after start of treatment. So based on that and our clinical experience, it's not really surprising that so many people continue to treatment later on," she says.

And, van der Loos notes, mental health support may not be a part of treatment everywhere.

• gender-affirming care

• For Journalists
• News Releases
• Latest Releases
• News Release

Age restriction lifted for gender-affirming surgery in new international guidelines

'Will result in the need for parental consent before doctors would likely perform surgeries'

Media Information

• Release Date: September 16, 2022

Media Contacts

Kristin Samuelson

• (847) 491-4888
• Email Kristin
• Expert can speak to transgender peoples’ right to bodily autonomy, how guidelines affect insurance coverage, how the U.S. gender regulations compare to other countries, more

CHICAGO --- The World Professional Association for Transgender Health (WPATH) today today announced  its updated Standards of Care and Ethical Guidelines for health professionals. Among the updates is a new suggestion to lift the age restriction for youth seeking gender-affirming surgical treatment, in comparison to previous suggestion of surgery at 17 or older. 

Alithia Zamantakis (she/her), a member of the Institute of Sexual & Gender Minority Health at Northwestern University Feinberg School of Medicine, is available to speak to media about the new guidelines. Contact Kristin Samuelson at [email protected] to schedule an interview.

“Lifting the age restriction will greatly increase access to care for transgender adolescents, but will also result in the need for parental consent for surgeries before doctors would likely perform them,” said Zamantakis, a postdoctoral fellow at Northwestern, who has researched trans youth and resilience. “Additionally, changes in age restriction are not likely to change much in practice in states like Alabama, Arkansas, Texas and Arizona, where gender-affirming care for youth is currently banned.”

Zamantakis also can speak about transgender peoples’ right to bodily autonomy, how guidelines affect insurance coverage and how U.S. gender regulations compare to other countries.

Guidelines are thorough but WPATH ‘still has work to do’

“The systematic reviews conducted as part of the development of the standards of care are fantastic syntheses of the literature on gender-affirming care that should inform doctors' work,” Zamantakis said. “They are used by numerous providers and insurance companies to determine who gets access to care and who does not.

“However, WPATH still has work to do to ensure its standards of care are representative of the needs and experiences of all non-cisgender people and that the standards of care are used to ensure that individuals receive adequate care rather than to gatekeep who gets access to care. WPATH largely has been run by white and/or cisgender individuals. It has only had three transgender presidents thus far, with Marci Bower soon to be the second trans woman president.

“Future iterations of the standards of care must include more stakeholders per committee, greater representation of transgender experts and stakeholders of color, and greater representation of experts and stakeholders outside the U.S.”

Transgender individuals’ right to bodily autonomy

“WPATH does not recommend prior hormone replacement therapy or ‘presenting’ as one's gender for a certain period of time for surgery for nonbinary people, yet it still does for transgender women and men,” Zamantakis said. “The reality is that neither should be requirements for accessing care for people of any gender.

“The recommendation of requiring documentation of persistent gender incongruence is meant to prevent regret. However, it's important to ask who ultimately has the authority to determine whether individuals have the right to make decisions about their bodily autonomy that they may or may not regret? Cisgender women undergo breast augmentation regularly, which is not an entirely reversible procedure, yet they are not required to have proof of documented incongruence. It is assumed that if they regret the surgery, they will learn to cope with the regret or will have an additional surgery. Transgender individuals also deserve the right to bodily autonomy and ultimately to regret the decisions they make if they later do not align with how they experience themselves.” 

May 12, 2022

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

As attacks against transgender kids increase in the U.S., Minnesotans hold a rally at the state’s capitol in Saint Paul in March 2022 to support trans kids in Minnesota and Texas and around the country.

Michael Siluk/UCG/Universal Images Group via Getty Images

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.

On supporting science journalism

If you're enjoying this article, consider supporting our award-winning journalism by subscribing . By purchasing a subscription you are helping to ensure the future of impactful stories about the discoveries and ideas shaping our world today.

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.

Young Children Do Not Receive Medical Gender Transition Treatment

By Kate Yandell

Posted on May 22, 2023

SciCheck Digest

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.

Coleman, E. et al. “ Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 .” International Journal of Transgender Health. 15 Sep 2022.

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.

Jaramillo, Catalina. “ Posts Distort Questionable Study on COVID-19 Vaccination and EMS Calls .” FactCheck.org. 15 June 2022.

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.

• Follow us on Facebook
• Follow us on Twitter
• Criminal Justice
• Environment
• Politics & Government
• Race & Gender

Expert Commentary

What the research says about hormones and surgery for transgender youth

Researchers and physicians point to a growing body of peer-reviewed academic scholarship in support of gender-affirming medical treatment for transgender youth.

Republish this article

This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License .

by Chloe Reichel, The Journalist's Resource August 7, 2019

This <a target="_blank" href="https://journalistsresource.org/politics-and-government/gender-confirmation-surgery-transgender-youth-research/">article</a> first appeared on <a target="_blank" href="https://journalistsresource.org">The Journalist's Resource</a> and is republished here under a Creative Commons license.<img src="https://journalistsresource.org/wp-content/uploads/2020/11/cropped-jr-favicon-150x150.png" style="width:1em;height:1em;margin-left:10px;">

In the interest of examining this important news topic through a research lens, Journalist’s Resource collaborated on this story with The Burlington Free Press,  where it first appeared .  This piece is part of the newspaper’s series of stories about transgender youth  in the state.

As Vermont regulators consider changes to Medicaid that would expand access to gender confirmation surgery for transgender youth, researchers and physicians point to a growing body of peer-reviewed academic scholarship in support of the new proposal.

Among other changes,  the proposed rules would eliminate the requirement that transgender individuals on Medicaid must wait until the age of 21  to receive surgery. Individuals over the age of 18 and minors — with informed parental consent — would be eligible.

Such changes are in line with current thinking among academics and physicians in the field. It’s still a fledgling field, as Marci Bowers, a California-based gynecologist and surgeon who specializes in gender confirmation and serves as a professorial lecturer at the Icahn School of Medicine at Mount Sinai points out.

“Kids are coming out very young. A generation ago, they were driven into the closet,” Bowers said. “It’s only these last 20 years or so where instead of that happening, people are getting professional help.”

How common are gender confirmation surgeries in the U.S.?

Estimates suggest that in the U.S., between 2000 and 2014, 10.9% of inpatient visits for transgender people involved gender confirmation surgery. This figure comes from  an analysis of inpatient visits for a nationally representative sample that includes, but is not limited to, transgender patients, which was published in 2018 in the medical journal JAMA Surgery . Over the study period, the number of patients who sought gender confirmation surgery increased annually.

Further, the percentage of gender confirmation surgeries that are “genital surgeries” — commonly referred to as bottom surgeries — has increased over time. Between 2000 and 2005, 72% of gender confirmation surgeries were bottom surgeries; from 2006 to 2011, that number increased to 84%. And the number of patients insured by Medicare or Medicaid seeking these procedures increased threefold between 2012-2013 and 2014.

As societal acceptance of gender diversity has grown, medical thinking has changed, too, Bowers notes.

“At least in the academic circles, in the medical circles, we realize that yes, it’s valid, that yes, kids do better after treatment, yes, surgery is appropriate, and why wait till 21?” Bowers said. “That’s really completely arbitrary. In fact, it’s probably cruel.”

“Most of the research is on older patients,” Elizabeth Boskey, a social worker at the Center for Gender Surgery at Boston Children’s Hospital and co-author of several research papers on gender confirmation gender-affirming surgery in youth, notes. “But there is evidence in the literature about just overall improved health, reduced anxiety, increased ability to function, for individuals after they have these gender-affirming surgeries.”

What does research say about treatment of transgender youth?

A  review of the latest research on gender-affirming hormones and surgery in transgender youth , published in a June 2019 edition of The Lancet Diabetes & Endocrinology , supports Bowers’ assertions that gender confirmation surgery benefits adolescents, though it does not go as far as to recommend specific age guidelines.

“Several preliminary studies have shown benefits of gender-affirming surgery in adolescents, particularly regarding bilateral mastectomy in transgender adolescent males, but there is a scarcity of literature to guide clinical practice for surgical vaginoplasty in transgender adolescent females,” the authors write. “The optimal age and developmental stage for initiating [cross sex hormones] and performing gender-affirming surgeries remains to be clarified.”

The  World Professional Association for Transgender Health  (WPATH), a leading organization for transgender health worldwide whose membership consists of physicians and educators, publishes Standards of Care and Ethical Guidelines for the treatment of transgender patients.

Though WPATH’s Standards of Care was last updated in 2011 and is under revision, even the current standards suggest that individuals at the age of majority in a given country (for the United States, that’s 18) who have lived for at least 12 months in accordance with their gender identity should be eligible for genital surgery, and that chest surgeries can be done earlier.

“I think it’s important to recognize for all of these standards of care, these are flexible guidelines,” says Loren Schechter, director of the  Center for Gender Confirmation Surgery  at  Weiss Memorial Hospital , clinical professor of surgery at the University of Illinois at Chicago, and co-lead for the revision of the WPATH standards of care surgery chapter for adolescents and adults. “It is not necessarily uncommon that we will currently perform bottom surgeries under the legal age of majority now.”

Schechter also indicated that the revision of the standards will likely include lowered age guidelines.

One reason to give transgender youth access to surgery

Schechter maintains that there are many reasons why minors should be eligible to receive gender confirmation surgery.

“One of them is that post-operative care in a supportive environment is very important,” Schechter said. “So, for example, for those individuals going off to college, the ability to recuperate while at home in a supportive environment and parents during that post-operative period is quite important. Trying to have your post-operative care in a dorm room after surgery is it is not necessarily an ideal scenario.”

This reasoning was echoed in a  paper published in the Journal of Sexual Medicine in April 2017 . For the study, researchers asked 20 WPATH-affiliated surgeons practicing in the U.S. about whether and why they performed genital surgery on transgender female minors.

Respondents noted the beneficial recovery environment some minor patients may have.

“Some surgeons viewed timing the procedure before college attendance as a harm reduction measure: Younger patients who have the support of their families, support of their parents, and can have the operation while they are still at home, as opposed to being alone at school or at work, anecdotally tend to do much better than someone who is alone and doesn’t have appropriate support.”

Others suggest that receiving surgery as a minor might allow the patient to “fully socially transition” in their next phase, such as in college.

Who is ready for surgery? Considerations beyond age

Physicians involved in the study also noted that while the number of minors requesting information about genital surgery had increased, psychological maturity is their main criteria for approval.

As one interviewed surgeon put it, “Age is arbitrary. The true measures of how well a patient will do are based on maturity, discipline and support.”

Eleven of the 20 surgeons interviewed had performed such surgeries. Minors ranged in age from 15 to “a day before 18.” About two-thirds of surgeons interviewed believe that such decisions should be made on a case-by-case basis rather than in strict adherence with current WPATH guidelines, which advises to wait until 18 in the U.S.

Boskey, who works for the Center for Gender Surgery at Boston Children’s Hospital, notes: “Just setting the age guidelines in place doesn’t remove the need to appropriately assess whether the surgery is something that should be happening,” she said.

“They’re going to need to make certain that the patient is appropriate for that surgery, that they are being diagnosed with gender dysphoria, that they are taking hormones as appropriate, that they are living in their affirmed gender, that they are aware of all of the life-changing nature of these surgeries,” she said. “These are surgeries that require pretty intense assessment to make certain that they’re appropriate. But that needs to come from the clinical side, rather than the insurance side.”

Will trans youth regret surgery? What the research says

Research supports the benefits of early interventions.

A 2018 study published in JAMA Pediatrics of 136 transmasculine youth and young adults between the ages of 13 and 25 receiving care at Children’s Hospital of Los Angeles finds that, on average,  chest dysphoria, or distress caused by one’s chest, was significantly higher among participants who had not received chest reconstruction surgery as compared with those who did .

Serious complications among the surgery group were rare, and only one of the 68 patients who received surgery reported experiencing regret sometimes, with the other 67 reporting no regret over the procedure. The time that had elapsed between surgery and the survey ranged from less than 1 year to 5 years.

“Given these findings,” the authors conclude, “professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age.”

Those who study the impact of early access to gender confirming surgeries often point to research from the Netherlands, home to one of the earliest comprehensive gender clinics.

“[T]hey’ve probably got the most data on transgender, gender non-conforming adolescents, who have been followed longitudinally, prospectively in the most rigorous way — that data indicates that people do well with early access and early interventions,” Schechter says. “By early, I mean late adolescence — we’re not, of course, talking about operating on children.”

Adolescents who were the first 22 people to receive gender confirming surgery at the clinic in the Netherlands  showed after surgery that they no longer experienced distress over their gender, according to a 1997 publication in the Journal of the American Academy of Child & Adolescent Psychiatry .

The study also showed that the 22 adolescents scored within the normal range for a number of psychological measures.

Further, the authors note, “Not a single subject expressed feelings of regret concerning the decision to undergo sex reassignment.”

A follow-up study, published four years later, of another group of 20 adolescents receiving surgery after the first group of 22  confirmed the initial findings .

Another, later study in the Netherlands focused on the outcomes of  55 transgender young adults  who received gender confirmation surgery between 2004 and 2011. The participants all “were generally satisfied with their physical appearance and none regretted treatment.”

Moreover, gender dysphoria was alleviated, mental health improved, and well-being among those studied was similar to or better than their peers in the general population.

About The Author

Chloe Reichel

• Election 2024
• Entertainment
• Newsletters
• Photography
• Personal Finance
• AP Investigations
• AP Buyline Personal Finance
• Press Releases
• Israel-Hamas War
• Russia-Ukraine War
• Global elections
• Asia Pacific
• Latin America
• Middle East
• Election Results
• Delegate Tracker
• AP & Elections
• March Madness
• AP Top 25 Poll
• Movie reviews
• Book reviews
• Personal finance
• Financial Markets
• Business Highlights
• Financial wellness
• Artificial Intelligence
• Social Media

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)

• Copy Link copied

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 .

The independent source for health policy research, polling, and news.

Youth Access to Gender Affirming Care: The Federal and State Policy Landscape

Lindsey Dawson , Jennifer Kates , and MaryBeth Musumeci Published: Jun 01, 2022

This analysis reflects the policy environment as of June 2020. Our newer tracker , provides a regularly updated overview of state policy restrictions on youth access to gender affirming care.

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.

Looking forward

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.

← Return to text

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

Watch CBS News

Sex-change treatment for kids on the rise

February 20, 2012 / 8:12 AM EST / AP

CHICAGO - A small but growing number of teens and even younger children who think they were born the wrong sex are getting support from parents and from doctors who give them sex-changing treatments, according to reports in the medical journal Pediatrics.

It's an issue that raises ethical questions, and some experts urge caution in treating children with puberty-blocking drugs and hormones.

An 8-year-old second-grader in Los Angeles is a typical patient. Born a girl, the child announced at 18 months, "I a boy" and has stuck with that belief. The family was shocked but now refers to the child as a boy and is watching for the first signs of puberty to begin treatment, his mother told The Associated Press.

Pediatricians need to know these kids exist and deserve treatment, said Dr. Norman Spack, author of one of three reports published Monday and director of one of the nation's first gender identity medical clinics, at Children's Hospital Boston.

"If you open the doors, these are the kids who come. They're out there. They're in your practices," Spack said in an interview.

Switching gender roles and occasionally pretending to be the opposite sex is common in young children. But these kids are different. They feel certain they were born with the wrong bodies.

Some are labeled with "gender identity disorder," a psychiatric diagnosis. But Spack is among doctors who think that's a misnomer. Emerging research suggests they may have brain differences more similar to the opposite sex.

Spack said by some estimates, 1 in 10,000 children have the condition.

Offering sex-changing treatment to kids younger than 18 raises ethical concerns, and their parents' motives need to be closely examined, said Dr. Margaret Moon, a member of the American Academy of Pediatrics' bioethics committee. She was not involved in any of the reports.

Some kids may get a psychiatric diagnosis when they are just hugely uncomfortable with narrowly defined gender roles; or some may be gay and are coerced into treatment by parents more comfortable with a sex change than having a homosexual child, said Moon, who teaches at the Johns Hopkins Berman Institute of Bioethics.

It's harmful "to have an irreversible treatment too early," Moon said.

Doctors who provide the treatment say withholding it would be more harmful.

These children sometimes resort to self-mutilation to try to change their anatomy; the other two journal reports note that some face verbal and physical abuse and are prone to stress, depression and suicide attempts. Spack said those problems typically disappear in kids who've had treatment and are allowed to live as the opposite sex.

Guidelines from the Endocrine Society endorse transgender hormone treatment but say it should not be given before puberty begins. At that point, the guidelines recommend puberty-blocking drugs until age 16, then lifelong sex-changing hormones with monitoring for potential health risks. Mental health professionals should be involved in the process, the guidelines say. The group's members are doctors who treat hormonal conditions.

Those guidelines, along with YouTube videos by sex-changing teens and other media attention, have helped raise awareness about treatment and led more families to seek help, Spack said.

His report details a fourfold increase in patients at the Boston hospital. His Gender Management Service clinic, which opened at the hospital in 2007, averages about 19 patients each year, compared with about four per year treated for gender issues at the hospital in the late 1990s.

The report details 97 girls and boys treated between 1998 and 2010; the youngest was 4 years old. Kids that young and their families get psychological counseling and are monitored until the first signs of puberty emerge, usually around age 11 or 12. Then children are given puberty-blocking drugs, in monthly $1,000 injections or implants imbedded in the arm.

In another Pediatrics report, a Texas doctor says he's also provided sex-changing treatment to an increasing number of children; so has a clinic at Children's Hospital Los Angeles where the 8-year-old is a patient.

The drugs used by the clinics are approved for delaying puberty in kids who start maturing too soon. The drugs' effects are reversible, and Spack said they've caused no complications in his patients. The idea is to give these children time to mature emotionally and make sure they want to proceed with a permanent sex change. Only 1 of the 97 opted out of permanent treatment, Spack said.

Kids will more easily pass as the opposite gender, and require less drastic treatment later, if drug treatment starts early, Spack said. For example, boys switching to girls will develop breasts and girls transitioning to boys will be flat-chested if puberty is blocked and sex-hormones started soon enough, Spack said.

Sex hormones, especially in high doses when used long-term, can have serious side effects, including blood clots and cancer. Spack said he uses low, safer doses but that patients should be monitored.

Gender-reassignment surgery, which may include removing or creating penises, is only done by a handful of U.S. doctors, on patients at least 18 years old, Spack said. His clinic has worked with local surgeons who've done breast removal surgery on girls at age 16, but that surgery can be relatively minor, or avoided, if puberty is halted in time, he said.

The mother of the Los Angeles 8-year-old says he's eager to begin treatment.

When the child was told he could get shots to block breast development, "he was so excited," the mother said.

He also knows he'll eventually be taking testosterone shots for life but surgery right now is uncertain.

The child attends a public school where classmates don't know he is biologically a girl. For that reason, his mother requested anonymity.

She said she explained about having a girl's anatomy but he rejected that, refused to wear dresses, and has insisted on using a boy's name since preschool.

The mother first thought it was a phase, then that her child might be a lesbian, and sought a therapist's help to confirm her suspicion. That's when she first heard the term "gender identity disorder" and learned it's often not something kids outgrow.

Accepting his identity has been difficult for both parents, the woman said. Private schools refused to enroll him as a boy, and the family's pediatrician refused to go along with their request to treat him like a boy. They found a physician who would, Dr. Jo Olson, medical director of a transgender clinic at Children's Hospital Los Angeles.

Olson said the journal reports should help persuade more doctors to offer these kids sex-changing treatment or refer them to specialists who will.

"It would be so nice to move this out of the world of mental health, and into the medical world," Olson said.

More from CBS News

• Introduction
• Conclusions
• Article Information

Error bars represent 95% CIs. GAS indicates gender-affirming surgery.

Percentages are based on the number of procedures divided by number of patients; thus, as some patients underwent multiple procedures the total may be greater than 100%. Error bars represent 95% CIs.

eTable.  ICD-10 and CPT Codes of Gender-Affirming Surgery

eFigure. Percentage of Patients With Codes for Gender Identity Disorder Who Underwent GAS

Data Sharing Statement

See More About

Sign up for emails based on your interests, select your interests.

Customize your JAMA Network experience by selecting one or more topics from the list below.

• Academic Medicine
• Acid Base, Electrolytes, Fluids
• Allergy and Clinical Immunology
• American Indian or Alaska Natives
• Anesthesiology
• Anticoagulation
• Art and Images in Psychiatry
• Artificial Intelligence
• Assisted Reproduction
• Bleeding and Transfusion
• Caring for the Critically Ill Patient
• Challenges in Clinical Electrocardiography
• Climate and Health
• Climate Change
• Clinical Challenge
• Clinical Decision Support
• Clinical Implications of Basic Neuroscience
• Clinical Pharmacy and Pharmacology
• Complementary and Alternative Medicine
• Consensus Statements
• Coronavirus (COVID-19)
• Critical Care Medicine
• Cultural Competency
• Dental Medicine
• Dermatology
• Diabetes and Endocrinology
• Diagnostic Test Interpretation
• Drug Development
• Electronic Health Records
• Emergency Medicine
• End of Life, Hospice, Palliative Care
• Environmental Health
• Equity, Diversity, and Inclusion
• Facial Plastic Surgery
• Gastroenterology and Hepatology
• Genetics and Genomics
• Genomics and Precision Health
• Global Health
• Guide to Statistics and Methods
• Hair Disorders
• Health Care Delivery Models
• Health Care Economics, Insurance, Payment
• Health Care Quality
• Health Care Reform
• Health Care Safety
• Health Care Workforce
• Health Disparities
• Health Inequities
• Health Policy
• Health Systems Science
• History of Medicine
• Hypertension
• Images in Neurology
• Implementation Science
• Infectious Diseases
• Innovations in Health Care Delivery
• JAMA Infographic
• Law and Medicine
• Leading Change
• Less is More
• LGBTQIA Medicine
• Lifestyle Behaviors
• Medical Coding
• Medical Devices and Equipment
• Medical Education
• Medical Education and Training
• Medical Journals and Publishing
• Mobile Health and Telemedicine
• Narrative Medicine
• Neuroscience and Psychiatry
• Notable Notes
• Nutrition, Obesity, Exercise
• Obstetrics and Gynecology
• Occupational Health
• Ophthalmology
• Orthopedics
• Otolaryngology
• Pain Medicine
• Palliative Care
• Pathology and Laboratory Medicine
• Patient Care
• Patient Information
• Performance Improvement
• Performance Measures
• Perioperative Care and Consultation
• Pharmacoeconomics
• Pharmacoepidemiology
• Pharmacogenetics
• Pharmacy and Clinical Pharmacology
• Physical Medicine and Rehabilitation
• Physical Therapy
• Physician Leadership
• Population Health
• Primary Care
• Professional Well-being
• Professionalism
• Psychiatry and Behavioral Health
• Public Health
• Pulmonary Medicine
• Regulatory Agencies
• Reproductive Health
• Research, Methods, Statistics
• Resuscitation
• Rheumatology
• Risk Management
• Scientific Discovery and the Future of Medicine
• Shared Decision Making and Communication
• Sleep Medicine
• Sports Medicine
• Stem Cell Transplantation
• Substance Use and Addiction Medicine
• Surgical Innovation
• Surgical Pearls
• Teachable Moment
• Technology and Finance
• The Art of JAMA
• The Arts and Medicine
• The Rational Clinical Examination
• Tobacco and e-Cigarettes
• Translational Medicine
• Trauma and Injury
• Treatment Adherence
• Ultrasonography
• Users' Guide to the Medical Literature
• Vaccination
• Venous Thromboembolism
• Veterans Health
• Women's Health
• Workflow and Process
• Wound Care, Infection, Healing

Get the latest research based on your areas of interest.

Others also liked.

• Download PDF
• X Facebook More LinkedIn

Wright JD , Chen L , Suzuki Y , Matsuo K , Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348

Manage citations:

© 2024

• Permissions

National Estimates of Gender-Affirming Surgery in the US

• 1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
• 2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

Question   What are the temporal trends in gender-affirming surgery (GAS) in the US?

Findings   In this cohort study of 48 019 patients, GAS increased significantly, nearly tripling from 2016 to 2019. Breast and chest surgery was the most common class of procedures performed overall; genital reconstructive procedures were more common among older individuals.

Meaning   These findings suggest that there will be a greater need for clinicians knowledgeable in the care of transgender individuals with the requisite expertise to perform gender-affirming procedures.

Importance   While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

Objective   To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants   This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures   Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

Results   A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance   Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Gender dysphoria is characterized as an incongruence between an individual’s experienced or expressed gender and the gender that was assigned at birth. 1 Transgender individuals may pursue multiple treatments, including behavioral therapy, hormonal therapy, and gender-affirming surgery (GAS). 2 GAS encompasses a variety of procedures that align an individual patient’s gender identity with their physical appearance. 2 - 4

While numerous surgical interventions can be considered GAS, the procedures have been broadly classified as breast and chest surgical procedures, facial and cosmetic interventions, and genital reconstructive surgery. 2 , 4 Prior studies 2 - 7 have shown that GAS is associated with improved quality of life, high rates of satisfaction, and a reduction in gender dysphoria. Furthermore, some studies have reported that GAS is associated with decreased depression and anxiety. 8 Lastly, the procedures appear to be associated with acceptable morbidity and reasonable rates of perioperative complications. 2 , 4

Given the benefits of GAS, the performance of GAS in the US has increased over time. 9 The increase in GAS is likely due in part to federal and state laws requiring coverage of transition-related care, although actual insurance coverage of specific procedures is variable. 10 , 11 While prior work has shown that the use of inpatient GAS has increased, national estimates of inpatient and outpatient GAS are lacking. 9 This is important as many GAS procedures occur in ambulatory settings. We performed a population-based analysis to examine trends in GAS in the US and explored the temporal trends in the types of GAS performed across age groups.

To capture both inpatient and outpatient surgical procedures, we used data from the Nationwide Ambulatory Surgery Sample (NASS) and the National Inpatient Sample (NIS). NASS is an ambulatory surgery database and captures major ambulatory surgical procedures at nearly 2800 hospital-owned facilities from up to 35 states, approximating a 63% to 67% stratified sample of hospital-owned facilities. NIS comprehensively captures approximately 20% of inpatient hospital encounters from all community hospitals across 48 states participating in the Healthcare Cost and Utilization Project (HCUP), covering more than 97% of the US population. Both NIS and NASS contain weights that can be used to produce US population estimates. 12 , 13 Informed consent was waived because data sources contain deidentified data, and the study was deemed exempt by the Columbia University institutional review board. This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We selected patients of all ages with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) diagnosis codes for gender identity disorder or transsexualism ( ICD-10 F64) or a personal history of sex reassignment ( ICD-10 Z87.890) from 2016 to 2020 (eTable in Supplement 1 ). We first examined all hospital (NIS) and ambulatory surgical (NASS) encounters for patients with these codes and then analyzed encounters for GAS within this cohort. GAS was identified using ICD-10 procedure codes and Common Procedural Terminology codes and classified as breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures. 2 , 4 Breast and chest surgical procedures encompassed breast reconstruction, mammoplasty and mastopexy, or nipple reconstruction. Genital reconstructive procedures included any surgical intervention of the male or female genital tract. Other facial and cosmetic procedures included cosmetic facial procedures and other cosmetic procedures including hair removal or transplantation, liposuction, and collagen injections (eTable in Supplement 1 ). Patients might have undergone procedures from multiple different surgical groups. We measured the total number of procedures and the distribution of procedures within each procedural group.

Within the data sets, sex was based on patient self-report. The sex of patients in NIS who underwent inpatient surgery was classified as either male, female, missing, or inconsistent. The inconsistent classification denoted patients who underwent a procedure that was not consistent with the sex recorded on their medical record. Similar to prior analyses, patients in NIS with a sex variable not compatible with the procedure performed were classified as having undergone genital reconstructive surgery (GAS not otherwise specified). 9

Clinical variables in the analysis included patient clinical and demographic factors and hospital characteristics. Demographic characteristics included age at the time of surgery (12 to 18 years, 19 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, 61 to 70 years, and older than 70 years), year of the procedure (2016-2020), and primary insurance coverage (private, Medicare, Medicaid, self-pay, and other). Race and ethnicity were only reported in NIS and were classified as White, Black, Hispanic and other. Race and ethnicity were considered in this study because prior studies have shown an association between race and GAS. The income status captured national quartiles of median household income based of a patient’s zip code and was recorded as less than 25% (low), 26% to 50% (medium-low), 51% to 75% (medium-high), and 76% or more (high). The Elixhauser Comorbidity Index was estimated for each patient based on the codes for common medical comorbidities and weighted for a final score. 14 Patients were classified as 0, 1, 2, or 3 or more. We separately reported coding for HIV and AIDS; substance abuse, including alcohol and drug abuse; and recorded mental health diagnoses, including depression and psychoses. Hospital characteristics included a composite of teaching status and location (rural, urban teaching, and urban nonteaching) and hospital region (Northeast, Midwest, South, and West). Hospital bed sizes were classified as small, medium, and large. The cutoffs were less than 100 (small), 100 to 299 (medium), and 300 or more (large) short-term acute care beds of the facilities from NASS and were varied based on region, urban-rural designation, and teaching status of the hospital from NIS. 8 Patients with missing data were classified as the unknown group and were included in the analysis.

National estimates of the number of GAS procedures among all hospital encounters for patients with gender identity disorder were derived using discharge or encounter weight provided by the databases. 15 The clinical and demographic characteristics of the patients undergoing GAS were reported descriptively. The number of encounters for gender identity disorder, the percentage of GAS procedures among those encounters, and the absolute number of each procedure performed over time were estimated. The difference by age group was examined and tested using Rao-Scott χ 2 test. All hypothesis tests were 2-sided, and P  < .05 was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc).

A total of 48 019 patients who underwent GAS were identified ( Table 1 ). Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged 12 to 18 years. Private insurance coverage was most common in 29 064 patients (60.5%), while 12 127 (25.3%) were Medicaid recipients. Depression was reported in 7192 patients (15.0%). Most patients (42 467 [88.4%]) were treated at urban, teaching hospitals, and there was a disproportionate number of patients in the West (22 037 [45.9%]) and Northeast (12 396 [25.8%]). Within the cohort, 31 668 patients (65.9%) underwent 1 procedure while 13 415 (27.9%) underwent 2 procedures, and the remainder underwent multiple procedures concurrently ( Table 1 ).

The overall number of health system encounters for gender identity disorder rose from 13 855 in 2016 to 38 470 in 2020. Among encounters with a billing code for gender identity disorder, there was a consistent rise in the percentage that were for GAS from 4552 (32.9%) in 2016 to 13 011 (37.1%) in 2019, followed by a decline to 12 818 (33.3%) in 2020 ( Figure 1 and eFigure in Supplement 1 ). Among patients undergoing ambulatory surgical procedures, 37 394 (80.3%) of the surgical procedures included gender-affirming surgical procedures. For those with hospital admissions with gender identity disorder, 10 625 (11.8%) of admissions were for GAS.

Breast and chest procedures were most common and were performed for 27 187 patients (56.6%). Genital reconstruction was performed for 16 872 patients (35.1%), and other facial and cosmetic procedures for 6669 patients (13.9%) ( Table 2 ). The most common individual procedure was breast reconstruction in 21 244 (44.2%), while the most common genital reconstructive procedure was hysterectomy (4489 [9.3%]), followed by orchiectomy (3425 [7.1%]), and vaginoplasty (3381 [7.0%]). Among patients who underwent other facial and cosmetic procedures, liposuction (2945 [6.1%]) was most common, followed by rhinoplasty (2446 [5.1%]) and facial feminizing surgery and chin augmentation (1874 [3.9%]).

The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020 ( Figure 1 ). Similar trends were noted for breast and chest surgical procedures as well as genital surgery, while the rate of other facial and cosmetic procedures increased consistently from 2016 to 2020. The distribution of the individual procedures performed in each class were largely similar across the years of analysis ( Table 3 ).

When stratified by age, patients 19 to 30 years had the greatest number of procedures, 25 099 ( Figure 2 ). There were 10 476 procedures performed in those aged 31 to 40 years and 4359 in those aged 41 to 50 years. Among patients younger than 19 years, 3678 GAS procedures were performed. GAS was less common in those cohorts older than 50 years. Overall, the greatest number of breast and chest surgical procedures, genital surgical procedures, and facial and other cosmetic surgical procedures were performed in patients aged 19 to 30 years.

When stratified by the type of procedure performed, breast and chest procedures made up the greatest percentage of the surgical interventions in younger patients while genital surgical procedures were greater in older patients ( Figure 2 ). Additionally, 3215 patients (87.4%) aged 12 to 18 years underwent GAS and had breast or chest procedures. This decreased to 16 067 patients (64.0%) in those aged 19 to 30 years, 4918 (46.9%) in those aged 31 to 40 years, and 1650 (37.9%) in patients aged 41 to 50 years ( P  < .001). In contrast, 405 patients (11.0%) aged 12 to 18 years underwent genital surgery. The percentage of patients who underwent genital surgery rose sequentially to 4423 (42.2%) in those aged 31 to 40 years, 1546 (52.3%) in those aged 51 to 60 years, and 742 (58.4%) in those aged 61 to 70 years ( P  < .001). The percentage of patients who underwent facial and other cosmetic surgical procedures rose with age from 9.5% in those aged 12 to 18 years to 20.6% in those aged 51 to 60 years, then gradually declined ( P  < .001). Figure 2 displays the absolute number of procedure classes performed by year stratified by age. The greatest magnitude of the decline in 2020 was in younger patients and for breast and chest procedures.

These findings suggest that the number of GAS procedures performed in the US has increased dramatically, nearly tripling from 2016 to 2019. Breast and chest surgery is the most common class of procedure performed while patients are most likely to undergo surgery between the ages of 19 and 30 years. The number of genital surgical procedures performed increased with increasing age.

Consistent with prior studies, we identified a remarkable increase in the number of GAS procedures performed over time. 9 , 16 A prior study examining national estimates of inpatient GAS procedures noted that the absolute number of procedures performed nearly doubled between 2000 to 2005 and from 2006 to 2011. In our analysis, the number of GAS procedures nearly tripled from 2016 to 2020. 9 , 17 Not unexpectedly, a large number of the procedures we captured were performed in the ambulatory setting, highlighting the need to capture both inpatient and outpatient procedures when analyzing data on trends. Like many prior studies, we noted a decrease in the number of procedures performed in 2020, likely reflective of the COVID-19 pandemic. 18 However, the decline in the number of procedures performed between 2019 and 2020 was relatively modest, particularly as these procedures are largely elective.

Analysis of procedure-specific trends by age revealed a number of important findings. First, GAS procedures were most common in patients aged 19 to 30 years. This is in line with prior work that demonstrated that most patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age 7 years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. 19 Our findings were also notable that GAS procedures were relatively uncommon in patients aged 18 years or younger. In our cohort, fewer than 1200 patients in this age group underwent GAS, even in the highest volume years. GAS in adolescents has been the focus of intense debate and led to legislative initiatives to limit access to these procedures in adolescents in several states. 20 , 21

Second, there was a marked difference in the distribution of procedures in the different age groups. Breast and chest procedures were more common in younger patients, while genital surgery was more frequent in older individuals. In our cohort of individuals aged 19 to 30 years, breast and chest procedures were twice as common as genital procedures. Genital surgery gradually increased with advancing age, and these procedures became the most common in patients older than 40 years. A prior study of patients with commercial insurance who underwent GAS noted that the mean age for mastectomy was 28 years, significantly lower than for hysterectomy at age 31 years, vaginoplasty at age 40 years, and orchiectomy at age 37 years. 16 These trends likely reflect the increased complexity of genital surgery compared with breast and chest surgery as well as the definitive nature of removal of the reproductive organs.

This study has limitations. First, there may be under-capture of both transgender individuals and GAS procedures. In both data sets analyzed, gender is based on self-report. NIS specifically makes notation of procedures that are considered inconsistent with a patient’s reported gender (eg, a male patient who underwent oophorectomy). Similar to prior work, we assumed that patients with a code for gender identity disorder or transsexualism along with a surgical procedure classified as inconsistent underwent GAS. 9 Second, we captured procedures commonly reported as GAS procedures; however, it is possible that some of these procedures were performed for other underlying indications or diseases rather than solely for gender affirmation. Third, our trends showed a significant increase in procedures through 2019, with a decline in 2020. The decline in services in 2020 is likely related to COVID-19 service alterations. Additionally, while we comprehensively captured inpatient and ambulatory surgical procedures in large, nationwide data sets, undoubtedly, a small number of procedures were performed in other settings; thus, our estimates may underrepresent the actual number of procedures performed each year in the US.

These data have important implications in providing an understanding of the use of services that can help inform care for transgender populations. The rapid rise in the performance of GAS suggests that there will be a greater need for clinicians knowledgeable in the care of transgender individuals and with the requisite expertise to perform GAS procedures. However, numerous reports have described the political considerations and challenges in the delivery of transgender care. 22 Despite many medical societies recognizing the necessity of gender-affirming care, several states have enacted legislation or policies that restrict gender-affirming care and services, particularly in adolescence. 20 , 21 These regulations are barriers for patients who seek gender-affirming care and provide legal and ethical challenges for clinicians. As the use of GAS increases, delivering equitable gender-affirming care in this complex landscape will remain a public health challenge.

Accepted for Publication: July 15, 2023.

Published: August 23, 2023. doi:10.1001/jamanetworkopen.2023.30348

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Wright JD et al. JAMA Network Open .

Corresponding Author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 4th Floor, New York, NY 10032 ( [email protected] ).

Author Contributions: Dr Wright had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wright, Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wright.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Wright, Chen.

Administrative, technical, or material support: Wright, Suzuki.

Conflict of Interest Disclosures: Dr Wright reported receiving grants from Merck and personal fees from UpToDate outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

• Register for email alerts with links to free full-text articles
• Access PDFs of free articles
• Manage your interests
• Save searches and receive search alerts

Gender Transitioning in Minors

How young is too young.

Posted May 2, 2023 | Reviewed by Michelle Quirk

• Find a counsellor who understands gender identity
• While increased awareness of an issue is beneficial, too much emphasis on it when it has become part of the zeitgeist may be harmful.
• Creating blanket laws permitting youth transitioning gives rise to opposing laws meant to prevent gender transitioning.
• Before an attempt is made to come to a legal solution, we need to understand the underlying facts.

When discussing transgender issues in minors, “harm” is understood in precisely opposite ways by those on either side of the debate. Where there are calls for children under the age of 18—the age of legal majority in most U.S. states—to be able to transition, one side argues that “harm” would be preventing minors from doing so, and the other side argues that “harm” would be allowing minors to do so.

Arguments For and Against

One argument for preventing minors from gender transitioning is that they are too young to make that kind of permanent, life-changing decision, and they therefore must wait until they have reached the age of legal majority to make such a decision, with the assumption being that by age 18 they will be prepared and mature enough to make permanent, life-changing decisions.

One counterargument deals with the concept of maturity in an alternative fashion, such that if children don’t transition before puberty , they will in fact develop into biologically mature males or females, which later transitioning will not be able to reverse even with the use of hormones . Another argument is that 18 is an arbitrary age and that decision-making capacity is not significantly less developed in 17-year-olds or 16-year-olds.

A Psychology, Rather Than Legal, Perspective

Instead of immediately brandishing picket signs and legislative pens, we must think about how to approach the issue as it applies to minors. If we consider the question from a psychology perspective rather than a legal perspective, we will be able to evaluate how many individuals actually suffer from gender dysphoria , the age at which decision-making capacity ripens, at what age allowing children to transition might be abusive (the analysis may be different for a 17-year-old and a 7-year-old, for instance), the long-term harms of youth transitioning, and whether something like this emerges in waves in society.

That is, for example, does zeitgeist play a part in the emergence and disappearance of certain disorders simply by virtue of it being widely in the public consciousness? If this is true, how many children are we harming by—to a degree—normalizing gender dysphoria when it’s actually a minority of people who suffer from it?

While increased awareness of an issue is beneficial, too much emphasis on it when it has become part of the zeitgeist may be harmful, such that it may become more difficult for those suffering from gender dysphoria to be taken seriously and get the treatment they need—which may indeed include medical intervention, such as gender reassignment surgery (also referred to as “gender affirmation surgery”).

The Least Harm for the Greatest Number

Assume that the goal is to find a solution that results in the least harm for the greatest number of individuals. If the status quo is that only those who have reached the age of legal majority can make the decisions necessary to facilitate gender transitioning (for reasons that would need to be delineated, such as brain development with regard to decision-making capacity and the percentage of the minor population actually affected by gender dysphoria), the correct immediate step to take in finding the solution that will result in the least harm for the greatest number of individuals may not be reevaluating what laws should exist about preventing or permitting transgender “treatments” for minors—whether that is gender reassignment surgery or otherwise—but what exceptions to the laws should be available to minors.

Perhaps individuals under the age of 18 (the youngest age to which this could apply would need to be discussed) who actually suffer from gender dysphoria rather than experience standard, minor confusion or dissatisfaction with their body would be able to transition sooner—assuming that transitioning is the recommended clinical “treatment” for such a psychological disorder (gender dysphoria is in the Diagnostic and Statistical Manual of Mental Disorders )—if the laws allowed for exceptions in particular cases. Exceptions would be granted, for example, based on the recommendation of trusted psychologists after evaluating the minor, and of doctors after evaluating the child’s medical fitness for a particular course of treatment.

Questions about whether exceptions should be granted for the minor without the consent of the parents would need to be answered. The parents’ involvement would need to be a part of the psychological evaluation of the minor as well: Are the parents unreasonably unsupportive? Supportive but hesitant? Irrational? How does their behavior affect the child’s self-image and perspective on the issue? In addition, there would need to be an evaluation of the long-term effects of transitioning: Aside from long-term physical effects, would the child be mentally capable of thriving in society as a transgender individual? Do the risks outweigh the benefits in this particular case?

Creating blanket laws permitting youth transitioning that do not necessarily apply to the greater population gives rise to opposing laws meant to prevent gender transitioning for all minors, including the small percentage that might actually benefit from such an early transition as determined by medical professionals. This is because lawmakers of the latter persuasion see the harm that is potentially done by large-scale encouragement of youth transitioning where no gender dysphoria exists on a large scale.

Before an attempt is made to come to a legal solution about what path allows for the least harm for the greatest number of individuals, if that is indeed the agreed-upon goal, we need to understand the underlying facts about child psychology, the prevalence of gender dysphoria in minors, and the long-term risks and benefits of transitioning at an early age—and how early is too early from a developmental rather than legal perspective is a key question.

This article draws from ideas discussed in Episodes 6 and 7: “Transitioning Minors” of my Grey Matter video podcast series on Spotify.

Copyright © 2023 Kaitlin Puccio

Kaitlin Puccio, Esq., M.S. , is a lawyer, bioethicist, producer, and host of the "Grey Matter" video podcast. Her work explores and magnifies cultural topics buried at the intersection of philosophy, psychology, politics, bioethics, and law.

• Find a Therapist
• Find a Treatment Center
• Find a Support Group
• International
• New Zealand
• South Africa
• Switzerland
• Asperger's
• Bipolar Disorder
• Chronic Pain
• Eating Disorders
• Passive Aggression
• Personality
• Goal Setting
• Positive Psychology
• Stopping Smoking
• Low Sexual Desire
• Relationships
• Child Development
• Therapy Center NEW
• Diagnosis Dictionary
• Types of Therapy

Understanding what emotional intelligence looks like and the steps needed to improve it could light a path to a more emotionally adept world.

• Coronavirus Disease 2019
• Affective Forecasting
• Neuroscience

What the trans care recommendations from the NHS England report mean

The report calls for more research on puberty blockers and hormone therapies.

A new report commissioned by the National Health Service England advocates for further research on gender-affirming care for transgender youth and young adults.

Dr. Hillary Cass, a former president of the Royal College of Paediatrics and Child Health, was appointed by NHS England and NHS Improvement to chair the Independent Review of Gender Identity Services in 2020 amid a rise in referrals to NHS' gender services. Upon review, she advises "extreme caution" for the use of hormone therapies.

"It is absolutely right that children and young people, who may be dealing with a complex range of issues around their gender identity, get the best possible support and expertise throughout their care," Cass states in the report.

Around 2022, about 5,000 adolescents and children were referred to the NHS' gender services. The report estimated that roughly 20% of children and young people seen by the Gender Identity Development Service (GIDS) enter a hormone pathway -- roughly 1,000 people under 18 in England.

Following four years of data analysis, Cass concluded that "while a considerable amount of research has been published in this field, systematic evidence reviews demonstrated the poor quality of the published studies, meaning there is not a reliable evidence base upon which to make clinical decisions, or for children and their families to make informed choices."

Cass continued: "The strengths and weaknesses of the evidence base on the care of children and young people are often misrepresented and overstated, both in scientific publications and social debate," read the report.

Among her recommendations, she urged the NHS to increase the available workforce in this field, to work on setting up more regional outlets for care, increase investment in research on this care, and improve the quality of care to meet international guidelines.

Cass' review comes as the NHS continues to expand its children and young people's gender identity services across the country. The NHS has recently opened new children and young people's gender services based in London and the Northwest.

NHS England, the country's universal healthcare system, said the report is expected to guide and shape its use of gender affirming care in children and potentially impact youth patients in England accessing gender-affirming care.

MORE: Lawsuit filed by families against Ohio trans care ban legislation

The debate over transgender youth care.

In an interview with The Guardian , Cass stated that her findings are not intended to undermine the validity of trans identities or challenge young people's right to transition but to improve the care they are receiving.

"We've let them down because the research isn't good enough and we haven't got good data," Cass told the news outlet. "The toxicity of the debate is perpetuated by adults, and that itself is unfair to the children who are caught in the middle of it. The children are being used as a football and this is a group that we should be showing more compassion to."

In the report, Cass argued that the knowledge and expertise of "experienced clinicians who have reached different conclusions about the best approach to care" has been "dismissed and invalidated" amid arguments concerning transgender care in youth.

Cass did not immediately respond to ABC News' request for comment.

Recommendations for trans youth care

Cass is calling for more thorough research that looks at the "characteristics, interventions and outcomes" of NHS gender service patients concerning puberty blockers and hormone therapy, particularly among children and adolescents.

The report's recommendations also urge caregivers to take an approach to care that considers young patients "holistically and not solely in terms of their gender-related distress."

The report notes that identity exploration is "a completely natural process during childhood and adolescence."

Related Stories

Ukrainian president signs controversial law to boost conscription to fend off Russia's aggression

• Apr 16, 10:42 AM

Soldiers desert Putin's war but no hero’s welcome

• Apr 12, 2:07 AM

State sends bill to ban 1st-cousin marriages

• Apr 11, 5:37 PM

Cass recommends that pre-pubertal children and their families have early discussions about how parents can best support their child "in a balanced and non-judgemental way," which may include "psychological and psychopharmacological treatments" to manage distress associated with gender incongruence and co-occurring conditions.

In past interviews, U.S. physicians told ABC News , that patients, their physicians and their families often engage in a lengthy process of building a customized and individualized approach to care, meaning not every patient will receive any or every type of gender-affirming medical care option.

Cass' report states that evidence particularly for puberty blockers in children and adolescents is "weak" regarding the impact on "gender dysphoria, mental or psychosocial health. The effect on cognitive and psychosexual development remains unknown."

The NHS has said it will halt routine use of puberty blockers as it prepares for a study into the practice later this year.

MORE: Amid anti-LGBTQ efforts, transgender community finds joy in 'chosen families'

According to the Endocrine Society puberty blockers, as opposed to hormone therapy, temporarily pause puberty so patients have more time to explore their gender identity.

The report also recommends "extreme caution" for transgender youth from age 16 who take more permanent hormone therapies.

"There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18," the report's recommendations state.

Hormone therapy, according to the Endocrine Society , triggers physical changes like hair growth, muscle development, body fat and more, that can help better align the body with a person's gender identity. It's not unusual for patients to stop hormone therapy and decide that they have transitioned as far as they wish, physicians have told ABC News.

Cass' report asserts that there are many unknowns about the use of both puberty blockers and hormones for minors, "despite their longstanding use in the adult transgender population."

"The lack of long-term follow-up data on those commencing treatment at an earlier age means we have inadequate information about the range of outcomes for this group," the report states.

Cass recommends that NHS England facilities have procedures in place to follow up with 17 to 25-year-old patients "to ensure continuity of care and support at a potentially vulnerable stage in their journey," as well as allow for further data and research on transgender minors through the years.

Several British medical organizations, including British Psychological Society and the Royal College of Paediatrics and Child Health, commended the report's recommendations to expand the workforce and invest in further research to allow young people to make better informed decisions.

“Dr Cass and her team have produced a thought-provoking, detailed and wide-ranging list of recommendations, which will have implications for all professionals working with gender-questioning children and young people," said Dr Roman Raczka, of the British Psychological Society. "It will take time to carefully review and respond to the whole report, but I am sure that psychology, as a profession, will reflect and learn lessons from the review, its findings and recommendations."

Some groups expressed fears that the report will be misused by anti-transgender groups.

"All children have the right to access specialist effective care on time and must be afforded the privacy to make decisions that are appropriate for them in consultation with a specialist," said human rights group Amnesty International. "This review is being weaponised by people who revel in spreading disinformation and myths about healthcare for trans young people."

Transgender care for people under 18 has been a source of contention in both the United States and the United Kingdom. Legislation is being pushed across the U.S. by many Republican legislators focused on banning all medical care options like puberty blockers and hormone therapies for minors. Some argue that gender-affirming care is unsafe for youth, or that they should wait until they're older.

Gender-affirming medical does come with risks, according to the Endocrine Society , including impacts to bone mineral density, cholesterol levels, and blood clot risks. However, physicians have told ABC News that all medications, surgeries or vaccines come with some kind of risk.

Major national medical associations in the U.S., including the American Academy of Pediatrics, the American Medical Association, the American Academy of Child and Adolescent Psychiatry, and more than 20 others have argued that gender-affirming care is safe, effective, beneficial, and medically necessary.

The first-of-its-kind gender care clinic at Johns Hopkins Hospital in Maryland opened in the 1960s, using similar procedures still used today.

Some studies have shown that some gender-affirming options can have positive impacts on the mental health of transgender patients, who may experience gender-related stress.

Related Topics

• United Kingdom

Supreme Court allows Idaho to enforce its ban on gender-affirming care for transgender youth, reversing lower courts

• Apr 15, 5:10 PM

Tori Spelling posts '90210' reunion photo

• Apr 15, 2:12 PM

ABC News Live

24/7 coverage of breaking news and live events

• International edition
• Australia edition
• Europe edition

Thousands of children unsure of gender identity ‘let down by NHS’, report finds

Leading consultant paediatrician says unproven treatments and ‘toxicity’ of trans debate damaging outcomes

• Key findings

Thousands of vulnerable children questioning their gender identity have been let down by the NHS providing unproven treatments and by the “toxicity” of the trans debate, a landmark report has found.

The UK’s only NHS gender identity development service used puberty blockers and cross-sex hormones, which masculinise or feminise people’s appearances, despite “remarkably weak evidence” that they improve the wellbeing of young people and concern they may harm health, Dr Hilary Cass said.

Cass, a leading consultant paediatrician, stressed that her findings were not intended to undermine the validity of trans identities or challenge people’s right to transition, but rather to improve the care of the fast-growing number of children and young people with gender-related distress.

But she said this care was made even more difficult to provide by the polarised public debate, and the way in which opposing sides had “pointed to research to justify a position, regardless of the quality of the studies”.

“There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop.”

NHS England commissioned her inquiry in 2020 amid rising concern over the care provided by the Tavistock and Portman NHS mental health trust’s gender identity development services (Gids). It treated about 9,000 children and young people, with an average age at referral of 14, during 2009-2020.

Her inquiry has already led to NHS England shutting Gids, banning puberty blockers and switching to a new “holistic” model of care in which under-18s experiencing confusion about their gender identity will routinely receive psychological support rather than medical intervention.

“For most young people, a medical pathway will not be the best way to manage their gender-related distress. For those young people for whom a medical pathway is clinically indicated, it is not enough to provide this without also addressing wider mental health and/or psychosocially challenging problems,” said Cass, an ex-president of the Royal College of Paediatrics and Child Health .

The report recommends that all such young people should be screened to detect neurodevelopmental conditions, such as autism spectrum disorder or ADHD, and there should be an assessment of their mental health, because many who seek help with their gender identity also have anxiety or depression, for example.

Some transgender adults “are leading positive and successful lives, and feeling empowered by having made the decision to transition”, Cass said. However, “I have spoken to people who have detransitioned, some of whom deeply regret their earlier decisions”, she added.

“While some young people may feel an urgency to transition, young adults looking at their younger selves would often advise slowing down,” the report says.

“Some of the young adults said to us they wished they’d known when they were younger that there were more ways of being trans than just a binary medical transition,” Cass told the Guardian.

In her report, she outlines how the Tavistock trust began prescribing puberty blockers much more widely in 2014, despite a lack of evidence that they helped.

In an interview with the Guardian, Cass said that gender-questioning children have been “let down” by the NHS, health professionals and a “woeful” lack of evidence about what treatment works.

“One of the things that has let them down is that the toxicity of the debate has been so great that people have become afraid to work in this area.

“A majority of people have been so afraid, because of the lack of guidance, lack of research, and how polarised this is that they’ve passed [patients] straight on to Gids.”

after newsletter promotion

Wes Streeting, the shadow health secretary, said: “Today’s report must provide a watershed moment for the NHS’s gender identity services. Children’s healthcare should always be led by evidence and children’s welfare, free from culture wars. Clinicians and parents alike want the best for children at this crucial developmental stage. This report provides an evidence-led framework to deliver that.”

Sallie Baxendale, a professor of clinical neuropsychology at University College London, said that Cass’s report “has laid bare the worrying lack of evidence to support the treatments that were prescribed by NHS clinicians to children with gender distress for over a decade.

“These treatments inflicted significant harm on some of the most vulnerable children in our society.

“Exceptionalism often lies at the heart of medical scandals when services go rogue and start to operate outside the normal parameters of clinical practice.”

However, Dr Aidan Kelly, a clinical psychologist specialising in gender who left the Tavistock in 2021, said the NHS was struggling to recruit skilled and experienced people to run the planned eight clinics that will provide the new, broader model of care.

“Although Gids wasn’t perfect, we had a service with a history and expertise. There were things that needed to change but at least holding on to the knowledge that was accrued over time would have made sense to me,” he said.

Disputing many of Cass’s findings he said that a recent German review had found that puberty blockers were safe and effective. NHS England’s switch to a wholly different way of treating young people confused about their gender identity has left England “out of step with the rest of the world”, he added.

Cass disclosed in the report that six of the NHS’s seven specialist gender services in England for adults had “thwarted” an attempt by the University of York, at her request, to obtain and analyse the health outcomes of people who had been treated by Gids in order to improve future care.

This refusal to cooperate “was coordinated”, she told the Guardian. “It seemed to me to be ideologically-driven.”. Clinicians caring for those with gender-related distress are very divided on how best to do that, she acknowledges in the report.

It also documents how Gids experienced both an explosion in demand for its service from 2010, and also a huge increase in the number of birth-registered females, in a reversal of the pattern of referrals.

Cass said that “online influencers” had played a key role in fuelling confusion among young people about their gender identity and what they needed to do to change it.

“We haven’t done a comprehensive search but certainly when we were told about particular influencers I followed some of those up. Some of them give them very unbalanced information.

“And some of them [young people] were told that parents would not understand so that they had to actively separate from their parents or distance their parents. All the evidence shows that family support is really key to people’s well being. So there was really some dangerous influencing going on,” she said.

Rishi Sunak said: “We simply do not know the long-term impacts of medical treatment or social transitioning on them, and we should therefore exercise extreme caution.

“We acted swiftly on Dr Cass’s interim report to make changes in schools and our NHS, providing comprehensive guidance for schools and stopping the routine use of puberty blockers, and we will continue to ensure we take the right steps to protect young people.”

This article was amended on 10 April 2024 to refer to ADHD as a neurodevelopmental condition.

• Transgender

More on this story

No case for closing Scotland’s only NHS gender services clinic, says first minister

Veteran trans campaigner: ‘Cass review has potential for positive change’

Cass review must be used as ‘watershed moment’ for NHS gender services, says Streeting

‘This isn’t how good scientific debate happens’: academics on culture of fear in gender medicine research

Five thousand children with gender-related distress awaiting NHS care in England

Ban on children’s puberty blockers to be enforced in private sector in England

What Cass review says about surge in children seeking gender services

Adult transgender clinics in England face inquiry into patient care

‘Children are being used as a football’: Hilary Cass on her review of gender identity services

Most viewed.

• Share full article

Advertisement

Supported by

Youth Gender Medications Limited in England, Part of Big Shift in Europe

Five European countries have recently restricted hormone treatments for adolescents with gender distress. They have not banned the care, unlike many U.S. states.

By Azeen Ghorayshi

Azeen Ghorayshi reports on transgender health and visited the world’s first youth gender clinic in Amsterdam this fall.

The National Health Service in England started restricting gender treatments for children this month, making it the fifth European country to limit the medications because of a lack of evidence of their benefits and concern about long-term harms.

England’s change resulted from a four-year review released Tuesday evening by Dr. Hilary Cass, an independent pediatrician. “For most young people, a medical pathway will not be the best way to manage their gender-related distress,” the report concluded. In a related editorial published in a medical journal, Dr. Cass said the evidence that youth gender treatments were beneficial was “built on shaky foundations.”

The N.H.S. will no longer offer drugs that block puberty , except for patients enrolled in clinical research. And the report recommended that hormones like testosterone and estrogen, which spur permanent physical changes, be prescribed to minors with “extreme caution.” (The guidelines do not apply to doctors in private practice, who serve a small fraction of the population.)

England’s move is part of a broader shift in northern Europe, where health officials have been concerned by soaring demand for adolescent gender treatments in recent years. Many patients also have mental health conditions that make it difficult to pinpoint the root cause of their distress, known as dysphoria.

In 2020, Finland’s health agency restricted the care by recommending psychotherapy as the primary treatment for adolescents with gender dysphoria. Two years later, Sweden restricted hormone treatments to “exceptional cases.”

In December, regional health authorities in Norway designated youth gender medicine as a “treatment under trial,” meaning hormones will be prescribed only to adolescents in clinical trials. And in Denmark, new guidelines being finalized this year will limit hormone treatments to transgender adolescents who have experienced dysphoria since early childhood.

Several transgender advocacy groups in Europe have condemned the changes , saying that they infringe on civil rights and exacerbate the problems of overstretched health systems. In England, around 5,800 children were on the waiting list for gender services at the end of 2023, according to the N.H.S.

“The waiting list is known to be hell,” said N., a 17-year-old transgender boy in southern England who requested to withhold his full name for privacy. He has been on the waiting list for five years, during which time he was diagnosed with autism and depression. “On top of the trans panic our own government is pushing, we feel forgotten and left behind,” he said.

In the United States, Republican politicians have cited the pullback in Europe to justify laws against youth gender medicine. But the European policies are notably different from the outright bans for adolescents passed in 22 U.S. states, some of which threaten doctors with prison time or investigate parents for child abuse. The European countries will still allow gender treatments for certain adolescents and are requiring new clinical trials to study and better understand their effects.

“We haven’t banned the treatment,” said Dr. Mette Ewers Haahr, a psychiatrist who leads Denmark’s sole youth gender clinic, in Copenhagen. Effective treatments must consider human rights and patient safety, she said. “You have to weigh both.”

In February, the European Academy of Paediatrics acknowledged the concerns about youth gender medicine. “The fundamental question of whether biomedical treatments (including hormone therapy) for gender dysphoria are effective remains contested,” the group wrote. In contrast, the American Academy of Pediatrics last summer reaffirmed its endorsement of the care, stating that hormonal treatments are essential and should be covered by health insurers, while also commissioning a systematic review of evidence.

Europeans pioneered the use of gender treatments for young people. In the 1990s, a clinic in Amsterdam began giving puberty-suppressing drugs to adolescents who had felt they were a different gender since early childhood.

The Dutch doctors reasoned that puberty blockers could give young patients with gender dysphoria time to explore their identity and decide whether to proceed with hormones to ultimately transition. For patients facing male puberty, the drugs would stave off the physical changes — such as a deeper voice and facial hair — that could make it more difficult for them to live as women in adulthood. The Dutch team’s research, which was first published in 2011 and tracked a carefully selected group of 70 adolescents, found that puberty blockers, in conjunction with therapy, improved psychological functioning.

That study was hugely influential, inspiring clinics around the world to follow the Dutch protocol. Referrals to these clinics began to surge around 2014, though the numbers remain small. At Sweden’s clinic, for example, referrals grew to 350 adolescents in 2022 from around 50 in 2014. In England, those numbers grew to 3,600 referrals in 2022 from 470 in 2014.

Clinics worldwide reported that the increase was largely driven by patients raised as girls. And unlike the participants in the original Dutch study, many of the new patients did not experience gender distress until puberty and had other mental health conditions, including depression and autism.

Given these changes, some clinicians are questioning the relevance of the original Dutch findings for today’s patients.

“The whole world is giving the treatment, to thousands, tens of thousands of young people, based on one study,” said Dr. Riittakerttu Kaltiala, a psychiatrist who has led the youth gender program in Finland since 2011 and has become a vocal critic of the care.

Dr. Kaltiala’s own research found that about 80 percent of patients at the Finnish clinic were born female and began experiencing gender distress later in adolescence. Many patients also had psychological issues and were not helped by hormonal treatments, she found. In 2020, Finland severely limited use of the drugs.

Around the same time, the Swedish government commissioned a rigorous research review that found “insufficient” evidence for hormone therapies for youth. In 2022, Sweden recommended hormones only for “exceptional cases,” citing in part the uncertainty around how many young people may choose to stop or reverse their medical transitions down the line, known as detransitioning.

Even the original Dutch clinic is facing pressure to limit patients receiving the care. In December, a public documentary series in the Netherlands questioned the basis of the treatments. And in February, months after a far-right political party swept an election in a country long known as socially liberal , the Dutch Parliament passed a resolution to conduct research comparing the current Dutch approach with that of other European countries.

“I would have liked that the Netherlands was an island,” said Dr. Annelou de Vries, a psychiatrist who led the original Dutch research and still heads the Amsterdam clinic. “But of course, we are not — we are also part of the global world. So in a way, if everybody is starting to be concerned, of course, these concerns come also to our country.”

In England, brewing concerns about the surge of new patients reached a boiling point in 2018, when 10 clinicians at the N.H.S.’s sole youth gender clinic, known as the Tavistock Gender Identity Development Service, formally complained that they felt pressure to quickly approve children, including those with serious mental health problems, for puberty blockers.

In 2021, Tavistock clinicians published a study of 44 children who took puberty blockers that showed a different result from the Dutch: The patients given the drugs, on average, saw no impact on psychological function.

Although the drugs did not lessen thoughts of self-harm or the severity of dysphoria, the adolescents were “resoundingly thrilled to be on the blocker,” Dr. Polly Carmichael, the head of the clinic, said at a 2016 conference . And 43 of the 44 study participants later chose to start testosterone or estrogen, raising questions about whether the drug was serving its intended purpose of giving adolescents time to consider whether a medical transition was right for them.

In 2020, the N.H.S. commissioned Dr. Cass to carry out an independent review of the treatments. She commissioned scientific reviews and considered international guidelines of the care. She also met with young people and their families, trans adults, people who had detransitioned, advocacy groups and clinicians.

The review concluded that the N.H.S.’s standard of care was inadequate, with long waiting lists for access to drug treatments and few routes to address the mental health concerns that may be contributing to gender distress. The N.H.S. shuttered the Tavistock center last month and opened two new youth gender clinics, which Dr. Cass said should have a “holistic” approach, with more support for those with autism, depression and eating disorders, as well as psychotherapy to help adolescents explore their identities.

“Children and young people have just been really poorly served,” Dr. Cass said in an interview with the editor of The British Medical Journal, released Tuesday. She added, “I can’t think of another area of pediatric care where we give young people potentially irreversible treatments and have no idea what happens to them in adulthood.”

The changes enacted by the N.H.S. this month are “an acknowledgment that our concerns were, in fact, valid,” said Anna Hutchinson, a clinical psychologist in London who was one of the Tavistock staff members who raised concerns in 2018. “It’s reassuring that we’re going to return to a more robust, evidence-based pathway for decisions relating to these children.”

Some critics said that Europe, like the United States, had also been influenced by a growing backlash against transgender people.

In Britain, for example, a yearslong fight over a proposed law that would have made it easier for transgender people to change the gender on their identification documents galvanized a political movement to try to exclude transgender women from women’s sports, prisons and domestic violence shelters.

“The intention with the Cass review is to be neutral, but I think that neutral has maybe moved,” said Laurence Webb, a representative from Mermaids, a trans youth advocacy organization in Britain. “Extremist views have become much more normalized.”

Other countries have seen more overt attacks on transgender rights and health care. In 2020, Hungary’s Parliament passed a law banning gender identity changes on legal documents. Last year, Russia banned legal gender changes as well as gender-related medical care, with one lawmaker describing gender surgeries as the “path to the degeneration of the nation.”

In France this year, a group of conservative legislators introduced a bill to ban doctors from prescribing puberty blockers and hormones, with punishments of two years’ imprisonment and a fine of 30,000 euros, or about $32,600. And on Monday, the Vatican condemned gender transitions as threats to human dignity.

Azeen Ghorayshi covers the intersection of sex, gender and science for The Times. More about Azeen Ghorayshi

Ohio judge temporarily blocks ban on gender-affirming care for transgender minors

A Franklin County judge on Tuesday temporarily blocked an impending law that would restrict medical care for transgender minors in Ohio.

The decision came weeks after the American Civil Liberties Union filed a lawsuit challenging House Bill 68 on behalf of two transgender girls and their families. The measure prevents doctors from prescribing hormones, puberty blockers or gender reassignment surgery before patients turn 18.

Attorneys contend the law violates the state Constitution , which gives Ohioans the right to choose their health care.

"Today's ruling is a victory for transgender Ohioans and their families," said Harper Seldin, staff attorney for the ACLU. "Ohio's ban is an openly discriminatory breach of the rights of transgender youth and their parents alike and presents a real danger to the same young people it claims to protect."

House Bill 68 was set to take effect April 24 after House and Senate Republicans  voted to override  Gov. Mike DeWine's veto. Proponents of the bill contend it will protect children, but critics say decisions about transition care should be left to families and their medical providers.

The suit in Ohio mirrors efforts in other states to challenge laws that restrict gender-affirming care for minors. A federal judge struck down a  similar policy in Arkansas , arguing it violates the constitutional rights of transgender youth and their families. The state is appealing that decision.

"We protect children with various restrictions that do not apply to adults − from signing legal contracts to buying alcohol and tobacco and more," Attorney General Dave Yost posted on X after the lawsuit was filed. "As I promised during the veto override, my office will defend this constitutional statute."

What does House Bill 68 do?

House Bill 68 allows Ohioans younger than 18 who already receiving hormones or puberty blockers to continue, as long as doctors determine stopping the prescription would cause harm. Critics say that's not enough to protect current patients because health care providers could be wary of legal consequences.

The legislation does not ban talk therapy, but it requires mental health providers to get permission from at least one parent or guardian to diagnose and treat gender dysphoria.

The bill also bans transgender girls and women from playing on female sports teams in high school and college. It doesn't specify how schools would verify an athlete's gender if it's called into question. Players and their families can sue if they believe they lost an opportunity because of a transgender athlete.

The lawsuit doesn't specifically challenge the athlete ban. But it argues that House Bill 68 flouts the constitution's single-subject rule, which requires legislation to address only one topic. House Republicans introduced separate bills on gender-affirming care and transgender athletes before  combining them into one .

In Tuesday's decision, Franklin County Judge Michael Holbrook indicated that the law could be tossed out because of a single-subject violation.

"It is not lost upon this Court that the General Assembly was unable to pass the (Saving Ohio Adolescents from Experimentation) portion of the Act separately, and it was only upon logrolling in the Saving Women’s Sports provisions that it was able to pass," Holbrook wrote.

Panel clears ban on gender reassignment surgery for minors

Tuesday's decision came one day after a legislative panel cleared the way for an administrative rule that will ban gender reassignment surgery for minors. Ohio health care providers say they do not perform that procedure on patients under 18.

The rule will take effect May 3.

The measure was among several that DeWine proposed to regulate gender-affirming care after he vetoed House Bill 68. In testimony for Monday's meeting, opponents argued that the rules overstep the administration's authority and conflict with federal law.

"The proposed administrative rule changes are based on biased definitions, ignore well-established best practices and restrict countless patients’ access to gender-affirming care," said Mallory Golski, civic engagement and advocacy manager for Kaleidoscope Youth Center.

DeWine's other proposals are still working their way through the rulemaking process. That includes a requirement for transgender minors to undergo at least six months of counseling before further treatment occurs. Another rule would require providers to report non-identifying data on gender dysphoria diagnoses and treatment.

Haley BeMiller is a reporter for the USA TODAY Network Ohio Bureau, which serves the Columbus Dispatch, Cincinnati Enquirer, Akron Beacon Journal and 18 other affiliated news organizations across Ohio.

Evidence around youth gender care 'remarkably weak', major English review says

LONDON — Medical evidence underlying gender care for adolescents is “remarkably weak” and provides little clarity on long-term outcomes, according to an in-depth review of care commissioned by England’s state-funded National Health Service.

Gender care can include anything from counselling to medications related to gender issues, including drugs that can pause puberty.

The final report of the Cass Review, led by prominent pediatrician Dr. Hilary Cass and which includes research from independent academics at the University of York as well as input from families and clinicians was released on Wednesday.

The report concludes that young people with gender dysphoria — the distress of identifying as a gender different from the one assigned at birth — deserve better care but stresses that there is a lack of good evidence about how best to provide that.

The review was commissioned by the National Health Service in 2020, after the service — in line with other countries in Europe as well as the United States — saw increasing numbers of young people seeking gender care and differing  opinions  among experts about how best to help them.

The NHS has already announced that, in future, puberty-blocking drugs in England will only be available for young people experiencing gender distress in the context of a clinical trial. It acted after the Cass Review published interim recommendations in 2022. There is little detail yet on how this trial may work.

As part of plans to widen access to gender care and broaden the professionals involved, the NHS has also closed the previous provider of gender care for young people and replaced it with two new services in London and northwest England.

However, there is a huge backlog of cases after delays in getting services operational, and several thousand young people remain stuck in  limbo  on years-long waiting lists.

Prime Minister Rishi Sunak said he welcomed the “care and compassion” of the review.

“We simply do not know the long-term impacts of medical treatment or social transitioning… and we should therefore exercise extreme caution,” he said.

The Cass Review urges extreme caution around providing masculinizing or feminizing hormones before the age of 18.

But on social transition — changing names or pronouns — it concludes there is a lack of good evidence on the impact. It recommends professionals are consulted early on for pre-pubertal children, but for adolescents, “exploration is a normal process and rigid binary gender stereotypes can be unhelpful.”

Kansas governor vetoes a ban on gender-affirming care; GOP vows override

The Democratic governor of Kansas vetoed a bill Friday that would have banned gender-affirming care for minors, setting up a confrontation with the state’s Republican supermajority as it tries to join more than a dozen states restricting transgender care.

The Republican-led legislature is widely expected to attempt an override of the veto. The measure that Kansas Gov. Laura Kelly (D) quashed, Senate Bill 233, would ban hormone therapy, puberty blockers and gender reassignment surgery for people younger than 18.

Carrie Rahfaldt, a spokeswoman for Kansas House Speaker Dan Hawkins (R), told The Washington Post that she expects the Senate to begin voting sometime after a veto session begins April 29.

If two-thirds of the Senate votes to pass the bill, the measure would be kicked to the House, which also requires a two-thirds majority for an override. Hawkins said in a statement Friday that “House Republicans stand ready to override [the] veto to protect vulnerable Kansas kids.”

Kansas has 40 Democrats and 85 Republicans in its House and 11 Democrats and 29 Republicans in its Senate. The bill passed the House 82-39, and the Senate 27-13, largely along party lines. To override the veto, the House would need to add two yes votes and the Senate would not be able to lose any.

The success of the vote in the part-time legislature largely depends on attendance.

“Absences will change the number that they need to reach,” said Don Haider-Markel, a political science professor at the University of Kansas. “People have to leave and go home or some work-related or family-related issue. So, it very well could be that they don’t have enough votes in both chambers to override the veto.”

Kelly wrote in her veto message that she rejected the bill because it “tramples parental rights,” a phrase often used by conservatives to defend book restrictions at public libraries and schools.

“This divisive legislation targets a small group of Kansans by placing government mandates on them and dictating to parents how to best raise and care for their children,” Kelly said. “The last place that I would want to be as a politician is between a parent and a child who needed medical care of any kind. And, yet, that is exactly what this legislation does.”

House Republican leadership decried the veto.

“As we watch other states, nations, and organizations reverse course on these experimental procedures on children, Laura Kelly will most surely find herself on the wrong side of history with her reckless veto of this common-sense protection for Kansas minors,” Hawkins said in the Friday statement.

Last year, Kelly vetoed four bills that would have created restrictions on transgender people, including measures barring transgender girls and women from joining female K-12 and college sports teams, and ending the state’s legal recognition of transgender people’s gender identities. Republicans overrode vetoes on three of those measures, according to the Kansas City Star .

A record number of bills targeting transgender people have made their way through state legislatures in recent years. Lawmakers have introduced nearly 500 anti-LGBTQ+ bills during the 2024 legislative session, according to data compiled by the American Civil Liberties Union. By May 2023, legislators had introduced more than 400 such bills, compared with about 150 in 2022, according to The Washington Post.

Many of these bills target gender-affirming care for minors, the use of restrooms and other facilities such as locker rooms, pronouns and drag shows, according to the ACLU. Oklahoma, Missouri, Iowa and Tennessee have introduced the highest share of anti-LGBTQ+ bills this year, according to the ACLU.

In January, Ohio’s Republican supermajority banned gender-affirming care for minors, overriding Republican Gov. Mike DeWine’s December veto of the bill. The law prohibits hormone therapy, puberty blockers and gender reassignment surgery for people younger than 18. The measure also bans transgender girls from playing on sports teams designated for girls and women in high school and college.

Like Ohio’s bill, Kansas’s S.B. 233 would ban gender-affirming care for transgender youths. The bill also would restrict the use of state funds for gender-affirming care; ban the use of state property, including the University of Kansas Medical Center, on such care; and bar state employees who work with children from promoting or advocating for gender-affirming care. Under the measure, any health care provider who violates the ban would have their license revoked.

Major medical organizations such as the American Medical Association , the American Academy of Pediatrics , the American Psychological Association and the Endocrine Society oppose restrictions on gender-affirming care. The American Medical Association and the American Academy of Pediatrics have said gender-affirming care for transgender children is “medically necessary.”

Advocacy organizations warned state legislators that the “the bill’s extreme reach could have unintended consequences.”

“We cannot overstate the harm this bill will cause to some of our most vulnerable Kansas children and their families,” D.C. Hiegert, LGBTQ+ fellow of the ACLU of Kansas, said in a statement after the veto. “This bill attacks parents’ rights to access life-saving healthcare for their kids and threatens Kansas medical providers. And it is written so broadly, it could impact spaces like schools, therapist offices, or state agencies like the Kansas Department of Children and Families — and possibly every person who provides any kind of support or services to children in those places, as well as the youth who need them.”

Haider-Markel, who has written books about transgender rights and politics, predicts that the bill would prompt parents of transgender children to move out of the state to seek medical care.

The legislation would upend “the lives of young people and their families and really, I think, encourages many families with trans members to think about leaving the state because of the way in which they’ve targeted their families,” he said.

Danielle Laidley among advocates to welcome bid to scrap WA Gender Reassignment Board

Western Australians will no longer have to undergo medical or surgical reassignment in order to change their sex or gender, under the state government's proposed law reforms.

The state's Gender Reassignment Board, which manages applications to legally change a person's gender, would be abolished under the new laws.

Attorney-General John Quigley said the legislation would bring WA in line with the rest of Australia.

"This is not radical legislation … we're only bringing Western Australia out of the dark ages, up to a level of social reform that the rest of the country already respects and enjoys," he said.

Reforms will save lives, advocate says

Danielle Laidley is an AFL premiership winner, and one of the youngest senior coaches in the sport's history.

Laidley was outed as a trans woman by police, had her family turn their back on her, and survived the drugs she turned to as her life spiralled out of control.

"Today I can finally stand here, as a proud Western Australian and transgender woman," she said.

Laidley said the abolition of the Gender Reassignment Board was a step forward for WA.

"It was wrong for someone to sit there and tell me who I was. They haven't walked a mile in my shoes, they don't know how I feel," she said.

Transfolk of WA deputy chairperson Dylan Green said the reform was a significant step to creating a pathway for transgender and gender-diverse people to align legal documentation with their gender identity.

"This will improve the lives, and save the lives, of many trans and gender diverse people in Western Australia," he said.

However, Mr Green noted the state government's proposal did not meet all of the recommendations made by the state's Law Reform Commission in 2018.

"We will be making further recommendations to the government regarding the regulations for this proposed bill, and advocating for further law reform," he said.

"We've seen in other states … certain requirements for clinical evidence have been removed for adults over the age of 18, so they use the self-determination model.

"That is what is widely considered best practice."

More change to come

Under the new laws, adults who have received counselling would be able to apply for a sex-change through the Registry of Births, Deaths and Marriages.

Teenagers between 12 and 18-years-old would need the consent of both parents, and children under 12 would need approval from the WA Family Court.

The legislation also includes clauses prohibiting certain types of offenders from applying to change their gender.

"You don't want someone who, for example, has been convicted of a nasty, aggravated sexual offence, then changing gender so they can access women-only areas," Mr Quigley said.

The proposed bill would also make the sex descriptors "non-binary" and "indeterminate/intersex" available, alongside "male" and "female".

The reforms would not change the existing procedure for registering the sex of a newborn. It also contains a requirement for the legislation to be reviewed after three years.

Mr Quigley has flagged the proposed legislation is only the first tranche of a multitude of changes to remove barriers for, and improve the lives of, the LGBTQIA+ community.

The WA government is chasing further reforms, including the development of a new Equal Opportunity Act and banning conversion therapy practices, which the attorney-general said would have to wait until after the 2025 state election.

"The federal government has announced the Australian Law Reform Commission findings, and the Prime Minister has come out and said on some contentious areas he is hopeful of getting bipartisan support," Mr Quigley said.

"I don't want to come in from left field and upset the applecart."

Reform follows landmark UK review

The proposed law reform comes after a landmark investigation into gender-affirming care in England, known as the Cass Review.

It recommended significantly limiting the prescription of medications, known as puberty blockers, for people aged under 18.

Federal health minister Mark Butler described the review's findings as "significant" but said the clinical treatment of transgender children in Australia was very different than in the UK.

• X (formerly Twitter)

Related Stories

A review into how children with gender dysphoria are treated in england has been released. here's what it means for australia.

Former AFL star Danielle Laidley tells her story — 'nothing more, nothing less'

• Gender Identity
• Government Policy
• State and Territory Government