• Introduction
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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

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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

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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 .

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Dr. Aneesh Gupta

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Dr. Gupta is a triple board-certified cosmetic surgeon in Philadelphia who offers surgical solutions for people interested in gender-affirming Top Surgery and Breast Augmentation. A significant percentage of Dr. Gupta’s patients are transgender and he and the entire team at Jazzi Cosmetic Surgery are proud to provide the highest quality of care in a supportive and welcoming environment.

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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'

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  • Release Date: September 16, 2022

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Kristin Samuelson

  • (847) 491-4888
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  • 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.” 

What to Know About the Gender-Affirming-Care Bans Spreading Across the Country

People Gather To Rally For Abortion Rights On International Women's Day

O nly six states in the U.S. have not introduced a bill restricting LGBTQ rights during this legislative session, including Delaware and Illinois. Bathroom bills, measures that would limit the ability to update identity and gender information on records and IDs, sports bans, and bans on gender-affirming care are all up for consideration in states across America.

That last category of bills is growing. On Thursday, Iowa prohibited gender-reassignment procedures and prescriptions, and two of Florida’s State Senate committees passed Senate Bill 254, which would add onto the existing gender-affirming-care restrictions by prohibiting entities from using state funds to cover gender-affirming care, among other things.

Just this year, five states—Mississippi, Utah, South Dakota, Iowa, and Tennessee—have passed bans on gender-affirming care for minors, and nearly 90 other bills targeting access to gender-affirming health care, including Florida’s, are being considered in the U.S.

Proponents of these measures often claim these laws will protect young Americans from what they portray as risky medical experimentation. “We need to let kids be kids, and our laws need to set appropriate boundaries that respect the rights and responsibilities of parents, while protecting children from the serious health, safety, and welfare consequences of social agendas that are totally inconsistent with how the overwhelming majority of parents want to raise their children,” says Florida State Sen. Yarborough, the sponsor of a gender-affirming-care ban in the state, in a press release.

But every major medical organization—including the American Medical Association, American Academy of Pediatrics, American Psychiatric Association, and more— agrees that gender-affirming care for transgender patients , which can range from social interventions, to hormonal treatments, to surgery, is both safe and medically appropriate. For transgender people, who face unemployment at twice the rate of the general population and have a suicide rate nearly nine times that of the broader U.S. population, the prospect of losing access to such care is harrowing.

“Many adolescents with gender dysphoria have severe negative psychological reactions to their bodies developing in ways that do not align with who they are, and [hormonal treatments] can temporarily put these changes on pause,” Dr. Jack Turban, Assistant Professor of Child & Adolescent Psychiatry at The University of California, San Francisco, tells TIME.

Here’s what to know about some of the gender-affirming-care bans being considered across the U.S.

Where have bans been passed already?

Eight states already have gender-affirming-care bans in place for people under the age of 18, and states like Tennessee and Iowa, which both passed legislation this year, are part of the rise in anti-trans legislation being considered more broadly.

They join states like Arkansas, which passed similar legislation two years ago. (Ongoing lawsuits in Arkansas have delayed the program from rolling out, though legislators passed a measure that would criminalize medical practitioners for providing gender- affirming care for minors in March 2023.) Arizona and Alabama also passed gender-care bans in 2022, though the latter’s law is temporarily blocked by legal challenges.

Most laws in this category, like that of Tennessee, would ban puberty blockers and hormone treatment from being used to treat gender dysphoria. Patients would also be unable to undergo surgery.

Healthcare providers who violate the Tennessee law can be sued in civil court within 30 years of the violation. They could also face a fine of up to $25,000 and have their license restricted.

The Tennessee law, which could face lawsuits, is set to go into effect in the summer, though minors who are currently undergoing treatment have until March 31, 2024 to stop treatment.

Where are gender-affirming-care bans being considered?

While the many restrictions on gender-affirming care being considered in state houses across the country do share some similarities, state lawmakers are trying a range of tactics to control access to such medical treatment.

In Oklahoma, for example, state senators are advancing Senate Bill 613 , which would revoke doctors’, nurse practitioners’, or advanced practice nurses’ licenses if they offer gender-transition services to people under the age of 18. (Legislators did add a measure that says the bill would not prevent mental health counseling, depression and anxiety medication or “medications prescribed, dispensed, or administered specifically for the purpose of treating precocious puberty or delayed puberty in that patient.”)

Another bill being considered in the state, Senate Bill 129, adds onto the restrictions by banning transgender medical care at hospitals that indirectly receive public funding. This includes hospitals that are on land that is owned by a state or local government, according to the Oklahoman . House Bill 2177, meanwhile, would prohibit insurance from covering some gender-affirming care, including puberty blockers for minors, is also being considered.

“[People said] we need to protect sports…and then [legislators] didn’t and we knew it wasn’t going to stop there,” Eddie Hefner, a 22-year-old trans, nonbinary Oklahoma resident says. “That’s not what this is about. This is trans-affirming care across the board. And trans health care is essential for saving [lives] because, [for] a lot of the people that I know, to them it is just normal health care.”

Hefner, who plans on getting one gender-affirming surgery in the future, fears that legislators will make age restrictions increasingly strict—and, they say, 18 is already too late for some care. Under previous medical guidelines, UC San Francisco’s Turban tells TIME, most doctors did not allow patients to use gender-affirming hormones until age 16. (Doctors and mental health providers now work with parents to assess the best time frame for a patient to start estrogen or testosterone, which in some cases may be before 16.) But puberty blockers, which stop processes like voice changes or breast growth, are often used in the earlier stages of puberty.“Forcing [patients] to undergo a puberty that doesn’t align with who they are,” he says, “can be horrifying and traumatic.”

In Florida, a ban took effect on March 16 after the Florida Board of Medicine voted in favor of banning gender-affirming care including puberty blockers, cross-sex hormones, and surgery for minors in November.

Doctors who violate the law could face fines and the potential to have their licenses revoked. Legislators are attempting to make that ban law through Senate Bill 254, which would also mean that any healthcare paid for by the state, like Medicaid or state-employee plans, would not cover gender-affirming care.

Devon Ojeda, the Senior National Organizer at the National Center for Transgender Equality, notes that despite the rhetoric used to attack this form of healthcare, cisgender people could also be affected by these types of bans. “Cancer survivors who get breast implants, regardless if they’re cisgender or not, [are getting surgeries that are] affirming their gender,” Ojeda says. “Gender affirming care is for everyone.”

The bill would also allow Florida courts “to enter, modify, or stay a child custody determination relating to a child present in this state to the extent necessary to protect the child from being subjected to sex-reassignment prescriptions or procedures in another state.”

Two Senate committees have passed the bill. It will now head to the Senate floor for a vote.

In Missouri, the State Senate voted to advance their gender-affirming ban after a series of back-door negotiations in which Republican lawmakers agreed they would not prohibit people who are already transitioning from doing so, according to the Associated Press . (Florida’s medical rule has a similar provision.) Missouri’s Attorney General Andrew Bailey also announced on Monday that he would pass an emergency rule that would limit gender-affirming care for minors.

Bailey’s plan would require minors endure 15 hour-long therapy sessions and get a full psychiatric evaluation over the course of 18 months before accessing gender-affirming care.

“I am dedicated to using every legal tool at my disposal to stand in the gap and protect children from being subject to inhumane science experiments,” Bailey tweeted .

Organizations like the ACLU, however, contend that these bills will not protect kids, but are instead “harmful and exploitative.”

“There’s nothing extraordinary about this care except that it saves lives,” Harper Seldin, Staff Attorney for the ACLU’s LGBTQ and HIV Project, tells TIME. “I think it’s important to realize that this is not just an attack on this small group of people but is in fact, part of an ongoing attack on the bodily autonomy of people in every state.”

Correction, April 3

The original version of this story misstated when patients may start gender-affirming hormones. Previous medical guidelines instructed doctors not to begin these treatments before patients turned 16, but those guidelines have been updated.

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Americans’ complex views on gender identity and transgender issues, most favor protecting trans people from discrimination, but fewer support policies related to medical care for gender transitions; many are uneasy with the pace of change on trans issues.

Pew Research Center conducted this study to better understand Americans’ views about gender identity and people who are transgender or nonbinary. These findings are part of a larger project that includes findings from six focus groups on  the experiences and views of transgender and nonbinary adults  and estimates of the  share of U.S. adults who say their gender is different from the sex they were assigned at birth . 

This analysis is based on a survey of 10,188 U.S. adults. The data was collected as a part of a larger survey conducted May 16-22, 2022. Everyone who took part is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way, nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the  ATP’s methodology . See here to read more about the  questions used for this report and the report’s methodology .

References to White, Black and Asian adults include only those who are not Hispanic and identify as only one race. Hispanics are of any race.

All references to party affiliation include those who lean toward that party. Republicans include those who identify as Republicans and those who say they lean toward the Republican Party. Democrats include those who identify as Democrats and those who say they lean toward the Democratic Party.

References to college graduates or people with a college degree comprise those with a bachelor’s degree or more. “Some college” includes those with an associate degree and those who attended college but did not obtain a degree.

The terms “transgender” and “trans” are used interchangeably throughout this report to refer to people whose gender is different from the sex they were assigned at birth.

A chart showing Most favor protecting trans people from discrimination, even as growing share say gender is determined by sex at birth

As the United States addresses issues of transgender rights and the broader landscape around gender identity continues to shift, the American public holds a complex set of views around these issues, according to a new Pew Research Center survey.

Roughly eight-in-ten U.S. adults say there is at least some discrimination against transgender people in our society, and a majority favor laws that would protect transgender individuals from discrimination in jobs, housing and public spaces. At the same time, 60% say a person’s gender is determined by their sex assigned at birth, up from 56% in 2021 and 54% in 2017.

The public is divided over the extent to which our society has accepted people who are transgender: 38% say society has gone too far in accepting them, while a roughly equal share (36%) say society hasn’t gone far enough. About one-in-four say things have been about right. Underscoring the public’s ambivalence around these issues, even among those who see at least some discrimination against trans people, a majority (54%) say society has either gone too far or been about right in terms of acceptance.

The fundamental belief about whether gender can differ from sex assigned at birth is closely aligned with opinions on transgender issues. Americans who say a person’s gender  can  be different from their sex at birth are more likely than others to see discrimination against trans people and a lack of societal acceptance. They’re also more likely to say that our society hasn’t gone far enough in accepting people who are transgender. But even among those who say a person’s gender is determined by their sex at birth, there is a diversity of viewpoints. Half of this group say they would favor laws that protect trans people from discrimination in certain realms of life. And about one-in-four say forms and online profiles should include options other than “male” or “female” for people who don’t identify as either.   

Related:  The Experiences, Challenges and Hopes of Transgender and Nonbinary U.S. adults

Chart showing Young adults, Democrats more likely to say society hasn’t gone far enough in accepting people who are transgender

When it comes to issues surrounding gender identity, young adults are at the leading edge of change and acceptance. Half of adults ages 18 to 29 say someone can be a man or a woman even if that differs from the sex they were assigned at birth. This compares with about four-in-ten of those ages 30 to 49 and about a third of those 50 and older. Adults younger than 30 are also more likely than older adults to say society hasn’t gone far enough in accepting people who are transgender (47% vs. 39% of 30- to 49-year-olds and 31% of those 50 and older) 

These views differ even more sharply by partisanship. Democrats and those who lean to the Democratic Party are more than four times as likely as Republicans and Republican leaners to say that a person’s gender can be different from the sex they were assigned at birth (61% vs. 13%). Democrats are also much more likely than Republicans to say our society hasn’t gone far enough in accepting people who are transgender (59% vs. 10%). For their part, 66% of Republicans say society has gone  too far  in accepting people who are transgender.

Amid a national conversation over these issues, many states are considering or have put in place  laws or policies  that would directly affect the lives of transgender and nonbinary people – that is, those who don’t identify as a man or a woman. Some of these laws would limit protections for transgender and nonbinary people; others are aimed at safeguarding them. The survey finds that a majority of U.S. adults (64%) say they would favor laws that would protect transgender individuals from discrimination in jobs, housing and public spaces such as restaurants and stores. But there is also a fair amount of support for specific proposals that would limit how trans people can participate in certain activities and navigate their day-to-day lives. 

Roughly six-in-ten adults (58%) favor proposals that would require transgender athletes to compete on teams that match the sex they were assigned at birth (17% oppose this, 24% neither favor nor oppose). 1 And 46% favor making it illegal for health care professionals to provide someone younger than 18 with medical care for a gender transition (31% oppose). The public is more evenly split when it comes to making it illegal for public school districts to teach about gender identity in elementary schools (41% favor and 38% oppose) and investigating parents for child abuse if they help someone younger than 18 get medical care for a gender transition (37% favor and 36% oppose). Across the board, views on these policies are deeply divided by party. 

Views of laws and policies related to transgender issues differ widely by party

When asked what has influenced their views on gender identity – specifically, whether they believe a person can be a different gender than the sex they were assigned at birth – those who believe gender can be different from sex at birth and those who do not point to different factors. For the former group, the most influential factors shaping their views are what they’ve learned from science (40% say this has influenced their views a great deal or a fair amount) and knowing someone who is transgender (38%). Some 46% of those who say gender is determined by sex at birth also point to what they’ve learned from science, but this group is far more likely than those who say a person’s gender can be different from their sex at birth to say their religious beliefs have had at least a fair amount of influence on their opinion (41% vs. 9%).   

The nationally representative survey of 10,188 U.S. adults was conducted May 16-22, 2022.  Previously published findings from the survey  show that 1.6% of U.S. adults are trans or nonbinary, and the share is higher among adults younger than 30. More than four-in-ten U.S. adults know someone who is trans and 20% know someone who is nonbinary. Among the other key findings in this report:

Nearly half of U.S. adults (47%) say it’s extremely or very important to use a person’s new name if they transition to a gender that is different from the sex they were assigned at birth and change their name.  A smaller share (34%) say the same about using someone’s new pronouns (such as “he” instead of “she”). A majority of Democrats (64%) – compared with 28% of Republicans – say it’s at least very important to use someone’s new name if they go through a gender transition and change their name. And while 51% of Democrats say it’s extremely or very important to use someone’s new pronouns, just 14% of Republicans say the same.

Many Americans express discomfort with the pace of change around issues of gender identity.  Some 43% say views on issues related to people who are transgender or nonbinary are changing too quickly, while 26% say things aren’t changing quickly enough and 28% say the pace of change is about right. Adults ages 65 and older are the most likely to say views on these issues are changing too quickly; conversely, those younger than 30 are the most likely to say they’re not changing quickly enough. 

More than four-in-ten (44%) say forms and online profiles that ask about a person’s gender should include options other than “male” and “female” for people who don’t identify as either.  Some 38% say the same about government documents such as passports and driver’s licenses. Half of adults younger than 30 say government documents that ask about a person’s gender should provide more than two gender options, compared with about four-in-ten or fewer among those in older age groups. Views differ even more widely by party: While majorities of Democrats say forms and online profiles (64%) and government documents (58%) should offer options other than “male” and “female,” about eight-in-ten Republicans say they should  not  (79% say this about forms and online profiles and 83% say this about government documents). 

Democrats and Republicans who agree that a person’s gender is determined by their sex at birth often have different views on transgender issues.  A majority (61%) of Democrats – but just 31% of Republicans – who say a person’s gender is determined by the sex they were assigned at birth say there is at least a fair amount of discrimination against transgender people in our society today. And while 62% of Democrats who say gender is determined by sex at birth say they would favor policies that protect trans individuals against discrimination, fewer than half of their Republican counterparts say the same. 

Democrats’ views on some transgender issues vary by age.  Among Democrats younger than 30, about seven-in-ten (72%) say someone can be a man or a woman even if that’s different from the sex they were assigned at birth, and 66% say society hasn’t gone far enough in accepting people who are transgender. Smaller majorities of Democrats 30 and older express these views. Age is less of a factor among Republicans. In fact, similar shares of Republicans ages 18 to 29 and those 65 and older say a person’s gender is determined by their sex at birth (88% each) and that society has gone too far in accepting people who are transgender (67% of Republicans younger than 30 and 69% of those 65 and older).  

About three-in-ten parents of K-12 students (29%) say at least one of their children has learned about people who are transgender or nonbinary from a teacher or another adult at their school.  Similar shares across regions and in urban, suburban and rural areas say their children have learned about this in school, as do similar shares of Republican and Democratic parents. Views on whether it’s good or bad that their children have or haven’t learned about people who are trans or nonbinary at school vary by party and by children’s age. For example, among parents of children in elementary school, 45% say either that their children  have  learned about this and that’s a  bad  thing or that they  haven’t  learned about it and that’s a  good  thing. A smaller share of parents of middle and high schoolers (34%) say the same. Republican parents are much more likely than Democratic parents to say this, regardless of their child’s age.

A rising share say a person’s gender is determined by their sex at birth

Majority of U.S. adults say gender is determined by sex assigned at birth

Six-in-ten U.S. adults say that whether a person is a man or a woman is determined by their sex assigned at birth. This is up from 56%  one year ago  and 54% in  2017 . No single demographic group is driving this change, and patterns in who is more likely to say this are similar to what they were in past years.

Today, half or more in all age groups say that gender is determined by sex assigned at birth, but this is a less common view among younger adults. Half of adults younger than 30 say this, lower than the 60% of 30- to 49-year-olds who say the same. Even higher shares of those 50 to 64 (66%) and those 65 and older (64%) say a person’s gender is determined by their sex at birth.

The party gap on this issue remains wide. The vast majority of Republicans and those who lean toward the GOP say gender is determined by sex assigned at birth (86%), compared with 38% of Democrats and Democratic leaners. Most Democrats say that whether a person is a man or a woman can be different from their sex at birth (61% vs. just 13% of Republicans). Liberal Democrats are particularly likely to hold this view – 79% say a person’s gender can be different from sex at birth, compared with 45% of moderate or conservative Democrats. Meanwhile, 92% of conservative Republicans say gender is determined by sex at birth and 74% of moderate or liberal Republicans agree.

Democrats ages 18 to 29 are also substantially more likely than older Democrats to say that someone’s gender can be different from their sex assigned at birth, although majorities of Democrats across age groups share this view. About seven-in-ten Democrats younger than 30 say this (72%), compared with about six-in-ten or fewer in the older age groups. Among Republicans, there is no clear pattern by age. About eight-in-ten or more Republicans across age groups – including 88% each among those ages 18 to 29 and those 65 and older – say a person’s gender is determined by their sex at birth. 

The view that a person’s gender is determined by their sex assigned at birth is more common among those with lower levels of educational attainment and those living in rural areas or in the Midwest or South. This view is also more prevalent among men and Black Americans. 

A solid majority of those who do  not  know a transgender person say that whether a person is a man or a woman is determined by sex assigned at birth (68%), while those who  do  know a trans person are more evenly split. About half say gender is determined by sex assigned at birth (51%), while 48% say gender and sex assigned at birth can be different. 

Though Republicans who know a trans person are more likely than Republicans who don’t to say gender can be different from sex assigned at birth, more than eight-in-ten in both groups (83% and 88%, respectively) say gender is determined by sex at birth. Meanwhile, there are large differences between Democrats who do and do  not  know a transgender person. A majority of Democrats who  do  know a trans person (72%) say someone can be a man or a woman even if that differs from their sex assigned at birth, while those who don’t know anyone who is transgender are about evenly split (48% say gender is determined by sex assigned at birth while 51% say it can be different). 

Many Americans point to science when asked what has influenced their views on whether gender can differ from sex assigned at birth

When asked about factors that have influenced their views about whether someone’s gender can be different from the sex they were assigned at birth, 44% say what they’ve learned from science has had a great deal or a fair amount of influence. About three-in-ten (28%) point to their religious views and about two-in-ten (22%) say knowing someone who is transgender has influenced their views at least a fair amount. Smaller shares say what they’ve heard or read in the news (15%) or on social media (14%) has had a great deal or a fair amount of influence on their views.

Chart showing More than four-in-ten U.S. adults say science has influenced their views of gender and sex at least a fair amount

The factors people point to on this topic differ by whether or not they say gender is determined by sex at birth. Among those who say that whether someone is a man or a woman is determined by the sex they were assigned at birth, 46% say what they’ve learned from science has influenced their views on this at least a fair amount, while 41% say the same about their religious views. About one-in-ten point to what they’ve heard or read in the news (12%), what they’ve heard or read on social media (11%) or knowing someone who’s transgender (11%). 

Among those who say someone can be a man or a woman even if that’s different from the sex they were assigned at birth, 40% say their views on this topic have been influenced at least a fair amount by what they’ve learned from science. A similar share say the same about knowing a transgender person (38%). Smaller shares in this group say what they’ve heard or read in the news (19%) or on social media (18%) or their religious views (9%) have had a great deal or a fair amount of influence.

Among those who say gender is determined by sex assigned at birth, adults younger than 30 stand out as being more likely than their older counterparts to say their knowledge of science (60%), what they’ve heard or read on social media (22%) or knowing someone who is trans (17%) influenced this view a great deal or a fair amount. In turn, those ages 65 and older tend to be more likely than younger age groups to cite their religious views (51% in the older group say this has had at least a fair amount of influence). 

Republicans who say gender is determined by sex assigned at birth are more likely than Democrats with the same view to say their knowledge of science (52% vs. 40%) and their religious views (45% vs. 34%) have had at least a fair amount of influence, while Democrats are more likely than Republicans to say the news (17% vs. 10%), social media (16% vs. 10%) and knowing someone who is trans (15% vs. 9%) have influenced them – though the shares are still small among both groups.

U.S. adults with different viewpoints on gender and sex say their opinions have been influenced by different factors

On the flip side, among those who say someone’s gender can be  different  from the sex they were assigned at birth, adults younger than 30 are also more likely than older adults to say social media has contributed to this view at least a fair amount (33% vs. 15% or fewer among older age groups). Adults ages 65 and older are more likely than their younger counterparts to say what they’ve learned from science has influenced their view (46% vs. 40% or fewer). 

Democrats who say whether someone is a man or a woman can be different from their sex at birth are more likely than Republicans with the same view to say that what they’ve learned from science (43% vs. 26%) and knowing someone who is transgender (40% vs. 26%) has influenced their view a great deal or a fair amount.

Public sees discrimination against trans people and limited acceptance

Roughly eight-in-ten Americans say transgender people face at least some discrimination, and relatively few believe our society is extremely or very accepting of people who are trans. These views differ widely by partisanship and by beliefs about whether someone’s gender can differ from the sex they were assigned at birth.

Overall, 57% of adults say there is a great deal or a fair amount of discrimination against transgender people in our society today. An additional 21% say there is some discrimination against trans people, and 14% say there is a little or none at all. 

There are modest differences in views on this issue across demographic groups. Women (62%) are more likely than men (52%) to say there is a great deal or a fair amount of discrimination against transgender people, and college graduates (62%) are more likely than those with less education (55%) to say the same. 

Chart showing Most Americans say there is at least some discrimination against trans people in the U.S.

There is, however, a wide partisan divide in these views: While 76% of Democrats and those who lean to the Democratic Party say there is a great deal or a fair amount of discrimination against trans people, 35% of Republicans and Republican leaners share that assessment. One-in-four Republicans see little or no discrimination against this group, compared with 5% of Democrats. 

These views are also linked with underlying opinions about whether a person’s gender can be different from their sex assigned at birth. Among those who say someone can be a man or a woman even if that’s different from the sex they were assigned at birth, 83% say there is a great deal or a fair amount of discrimination against trans people. Even so, some 42% of those who hold the alternative point of view – that gender is determined by sex assigned at birth – also see at least a fair amount of discrimination. Among Democrats who say gender is determined by sex at birth, that share rises to 61%. 

Relatively few adults (14%) say society is extremely or very accepting, while about a third (35%) say it is somewhat accepting. A plurality (44%) says our society is a little or not at all accepting of trans people. 

Chart showing Plurality of Americans say there is little or no societal acceptance of transgender people

Again, these views are strongly linked with partisanship. Democrats have a much more negative view than Republicans, with 54% of Democrats saying society is a little accepting or not at all accepting of transgender people, compared with a third of Republicans. 

And, as with views of discrimination, assessments of societal acceptance are linked to underlying views about how gender is determined. Those who say one’s gender can be different from the sex they were assigned at birth see less acceptance: 56% say society is a little accepting or not accepting at all of people who are transgender. This compares with 37% among those who say gender is determined by sex at birth. Republicans who say gender is determined by sex at birth are more likely than Democrats who say the same to believe that society is at least somewhat accepting of people who are transgender (61% vs. 47%).

About four-in-ten say society has gone too far in accepting trans people

While a majority of Americans see at least a fair amount of discrimination against transgender people and relatively few see widespread acceptance, 38% say our society has gone too far in accepting them. Some 36% say society has not gone far enough in accepting people who are trans, and 23% say the level of acceptance has been about right.

These views differ along demographic and partisan lines. Young adults (ages 18 to 29) and those with a bachelor’s degree or more education are among the most likely to say society hasn’t gone far enough in accepting people who are trans. Men, White adults and those without a four-year college degree are among the most likely to say society has gone too far in this regard. 

Chart showing Public is divided over whether society has gone too far or not far enough in accepting transgender people

There is a wide partisan divide as well. Roughly six-in-ten Democrats (59%) say society hasn’t gone far enough in accepting people who are transgender, while 15% say it has gone too far (24% say it’s been about right). Republicans’ views are almost the inverse: 10% say society hasn’t gone far enough and 66% say it’s gone too far (22% say it’s been about right). 

Even among those who see at least some discrimination against trans people, a majority (54%) say society has either gone too far in accepting trans people or been about right; 44% say society hasn’t gone far enough.

Many say it’s important to use someone’s new name, pronouns when they’ve gone through a gender transition

Nearly half of adults say it’s important to use someone’s new name if they change their name  as part of a gender transition

Nearly half of adults (47%) say it’s extremely or very important that if a person who transitions to a gender that’s different from their sex assigned at birth changes their name, others refer to them by their new name. An additional 22% say this is somewhat important. Three-in-ten say this is a little or not at all important (18%) or that it shouldn’t be done (12%).

Smaller shares say that if a person transitions to a gender that’s different from their sex assigned at birth and starts going by different pronouns (such as “she” instead of “he”), it’s important that others refer to them by their new pronouns. About a third (34%) say this is extremely or very important, and 21% say this is somewhat important. More than four-in-ten say this is a little or not at all important (26%) or it should not be done (18%).

These views differ along many of the same dimensions as other topics asked about. While 80% of those who believe someone’s gender can be different from their sex assigned at birth also say it’s extremely or very important to use a person’s new name when they’ve gone through a gender transition, 27% of those who think gender is determined by one’s sex assigned at birth share this opinion. The pattern is similar when it comes to use of preferred pronouns. 

Democrats are much more likely than Republicans to say it’s extremely or very important to refer to a person using their new name or pronouns. When it comes to pronouns, a majority of Republicans (55%), compared with only 17% of Democrats, say using someone’s new pronouns when they’ve been through a gender transition is not at all important or should not be done.  

Chart showing People who know a trans person place more importance on using a person’s new name, pronouns if they transition

There are some demographic differences as well, with women more likely than men and those with a four-year college degree more likely than those with less education to say it’s extremely or very important to use a person’s new name or pronouns when referring to them.

In addition, people who say they know someone who is trans are more likely than those who do not to say this is extremely or very important. Even so, substantial shares of those who don’t know a trans person view this as important. For example, 39% of those who don’t know someone who is transgender say it’s extremely or very important to refer to a person who goes through a gender transition and changes their name by their new name. 

Plurality of adults say views on gender identity issues are changing too quickly

Many Americans are not comfortable with the pace of change that’s occurring around issues involving gender identity. Some 43% say views on issues related to people who are transgender and nonbinary are changing too quickly. About one-in-four (26%) say things are not changing quickly enough, and 28% say they are changing at about the right speed.

Women (30%) are more likely than men (21%) to say views on these issues are not changing quickly enough, and adults younger than 30 are more likely than their older counterparts to say the same. Among those ages 18 to 29, 37% say views on these issues are not changing quickly enough; this compares with 26% of those ages 30 to 49, 22% of those ages 50 to 64 and 19% of those 65 and older. At the same time, White adults (46%) are more likely than Black (34%), Hispanic (39%) or Asian (31%) adults to say views are changing  too quickly .

Chart showing More than four-in-ten Americans say societal views on gender identity are changing too quickly

Opinions also differ sharply by partisanship. Among Democrats, a plurality (42%) say views on issues involving transgender and nonbinary people are not changing fast enough, and 21% say they are changing too quickly. About a third (35%) say the speed is about right. By contrast, 70% of Republicans say views on these issues are changing too quickly, while only 7% say views aren’t changing fast enough. About one-in-five Republicans (21%) say they’re changing at about the right speed. 

Respondents were asked in an open-ended format why they think views are changing too quickly or not quickly enough, when it comes to issues surrounding transgender and nonbinary people. For those who say things are changing too quickly, responses fell into several different categories. Some indicated that new ways of thinking about gender were inconsistent with their religious beliefs. Others expressed concern that the long-term consequences of medical gender transitions are not well-known, or that changing views on gender identity are merely a fad that’s being pushed by the media. Still others said they worry that there’s too much discussion of these issues in schools these days.

In their own words: Why do some people think views on issues related to transgender people and those who don’t identify as a man or a woman are changing  too quickly ?

General concerns about the pace of change

“The issue is so new to me I can’t keep up. I don’t know what to think about all of this new information. I’m baffled by so many changes.”

“It takes quite a bit of time for society to accept changes. I have not been aware of this issue for very long. I am relatively conservative and feel that changes need time to be accepted.”

Religious reasons

“People now believe everyone should just forget about their birth identity and just go along with what they think they are. God made us all for a reason and if He intended us to pick our gender then there would be no reason to be born with specific male or female parts .”

“I have a personal religious belief that sex is an essential part of our eternal identity and that identifying as something other than you are … just doesn’t make a lot of sense.”

“I believe GOD created a man and a woman. We have overstepped our bounds in messing with the miracle of life. I side with my creator.”

Concerns about long-term medical consequences

“We do not know the long-term health problems of hormone therapy, especially in young children.”

“More time needs to pass to study mental, physical, emotional ramifications of medications & surgeries, especially when done before puberty and/or adulthood.”

“Accepting gender fluidity, especially for younger children, seems quick. Also, medical treatments related to gender for people under 18 seems to be being accepted without longer term studies.”

It’s a fad/Driven by the media

“I respect people’s views about themselves, and I will refer to them in the way they want to be referred to, but I believe it’s become trendy because it’s being pushed so much in culture, especially for children.”

“News media, social media and entertainment media companies are trying to change, and it seems they have been succeeding in changing public opinion on this issue for many people.”

“It is encouraging kids who are easily influenced to participate in the ‘in’ fad when their brains are not fully developed.”

Concerns about schools

“Elementary school students should not be subjected to instruction on sex identity, any questions the child asks should be referred to a parent.”

“I think that young people are exposed to these issues at too early an age. I believe that it is up to the parents, and I oppose schools that want to include it in the ‘curriculum.’”

“It’s being pushed on society and especially on younger children, confusing them all the more. This is not something that should be taught in schools.”

In their own words: Why do some people think views on issues related to transgender people and those who don’t identify as a man or a woman are changing  too slowly ?

Discrimination

“There is far too much discrimination, hate, and violence directed toward people who are brave enough to stand up for who they truly are. We, as a country and as a society, need to respect how people want to identify themselves and be kind toward one another, end of story.”

“Protections for basic rights to self-determination in identity, health care choices, privacy, and consensual relationships should be a bare minimum that our society can provide for everyone – transgender people included . ”

“There’s too much discrimination. People need to quit controlling other people’s private lives. I consider them very brave for having the courage to be who they identify with . ”

“Equal protection has not kept up with trans issues, including trans youth and the right to gender-affirming care.”

Legislative efforts

“Acceptance is not changing quick enough. There remains discrimination and elected officials are passing laws that make it more difficult for transgender individuals in society to live, work and exist.”

“We are going backwards with all the anti-gay & -trans legislation that is being passed.”

“For every step forward, it feels like there are two steps back with reactive conservative laws.”

“These laws are working to restrict the rights of trans and nonbinary people, and also discrimination is still very high which results in elevated rates of suicide, poverty, violence and homelessness especially for people of color.”

“The spate of laws being proposed that would take away the rights of transgender people is evidence that we’re a long way from treating them right.”

Society is not open to change

“Too many people are simply stuck in the binary. We, as a society, need to just accept that someone else’s gender identity is whatever they say it is and it rarely has any bearing on the lives of others.”

“These are people. Who they say they are is all that matters. Society, mostly conservatives, doesn’t understand change in any form. So, they fight it. And they hinder the ability for others to learn about themselves and others, which slows growing as a society to a crawl.” 

“It’s an issue that has been in the closet for centuries. It’s time to acknowledge and accept that gender identity is a spectrum and not binary.” 

“We are not accepting the changes. We refuse to see what is in front of us. We care too much about not changing the status quo as we know it.” 

“Society often views this as a phase or a period of uncertainty in their life. Instead, it’s about a person bringing their gender identity in line with what they have experienced internally all their life.”

Most say they’re not paying close attention to news about bills related to transgender people 

Chart showing Liberal Democrats are more likely than other groups to be following news about bills related to trans people closely

Only about one-in-ten or less across age, racial and ethnic groups, and across levels of educational attainment, say they are following news about bills related to people who are transgender extremely or very closely. Six-in-ten or more across demographic groups say they’re following news about these bills a little closely or not closely at all. 

Liberal Democrats and Democratic-leaning independents (46%) are more likely than moderate and conservative Democrats (29%) to say they are following news about state bills related to people who are transgender at least somewhat closely. Conservative Republicans and Republican leaners (31%) are more likely than their moderate and liberal counterparts (24%) – but less likely than liberal Democrats – to be following news about these bills at least somewhat closely. Still, half or more among each of these groups say they have been following news about this a little or not at all closely. 

About six-in-ten would favor requiring that transgender athletes compete on teams that match their sex at birth

The survey asked respondents how they feel about some current laws and policies that are either in place or being considered across the U.S. related to transgender issues. Only two of seven items are either endorsed or rejected by a majority: 64% say they would favor policies that protect transgender individuals from discrimination in jobs, housing, and public spaces such as restaurants and stores, and 58% say they would favor policies that require that transgender athletes compete on teams that match the sex they were assigned at birth rather than the gender they identify with. 

Chart showing Most Americans say they would favor laws that would protect transgender people from discrimination in jobs, housing and public spaces

Even though there is not a majority consensus on most of these laws or policies, there are gaps of at least 10 percentage points on three items. Some 46% say they would favor making it illegal for health care professionals to provide someone younger than 18 with medical care for gender transitions, and 41% would favor requiring transgender individuals to use public bathrooms that match the sex they were assigned at birth rather than the gender they identify with; 31% say they would oppose each of these. Meanwhile, more say they would  oppose  (44%) than say they would favor (27%) requiring health insurance companies to cover medical care for gender transitions. 

Views are more divided when it comes to laws and policies that would make it illegal for public school districts to teach about gender identity in elementary schools (41% favor and 38% oppose) or that would investigate parents for child abuse if they helped someone younger than 18 get medical care for a gender transition (37% favor and 36% oppose). Some 21% and 27%, respectively, say they’d neither favor nor oppose these policies. 

Views on many policies related to transgender issues vary by age, party, and race and ethnicity 

Majorities of U.S. adults across age groups express support for laws and policies that would protect transgender individuals from discrimination in jobs, housing, and public spaces such as restaurants and stores. About seven-in-ten adults ages 18 to 29 (70%) and 30 to 49 (68%) say they favor such protections, as do about six-in-ten adults ages 50 to 64 (60%) and 65 and older (59%). 

But adults younger than 30 are more likely than those in each of the older age groups to say they favor laws or policies that would require health insurance companies to cover medical care for gender transitions (37% among those younger than 30 vs. about a quarter among each of the older age groups). They’re also less likely than older adults to express support for bills and policies that would restrict the rights of people who are transgender or limit what schools teach about gender identity. On most items, those ages 50 to 64 and those 65 and older express similar views. 

Chart showing Views of laws and policies related to transgender issues differ by age

Views differ even more widely along party lines. For example, eight-in-ten Democrats say they favor laws or policies that would protect trans individuals from discrimination, compared with 48% of Republicans. Conversely, by margins of about 40 percentage points or more, Republicans are more likely than Democrats to express support for laws or policies that would do each of the following: require trans athletes to compete on teams that match the sex they were assigned at birth (85% of Republicans vs. 37% of Democrats favor); make it illegal for health care professionals to provide someone younger than 18 with medical care for a gender transition (72% vs. 26%); make it illegal for public school districts to teach about gender identity in elementary schools (69% vs. 18%); require transgender individuals to use public bathrooms that match the sex they were assigned at birth (67% vs. 20%); and investigate parents for child abuse if they help someone younger than 18 get medical care for a gender transition (59% vs. 17%). 

Overall, White adults tend to be more likely than Black, Hispanic and Asian adults to express support for laws and policies that would restrict the rights of transgender people or limit what schools can teach about gender identity. But among Democrats, White adults are often  less  likely than other groups to favor such laws and policies, particularly compared with their Black and Hispanic counterparts. And White Democrats are more likely than Black, Hispanic and Asian Democrats to say they favor protecting trans individuals from discrimination and requiring health insurance companies to cover medical care for gender transitions. 

Sizable shares say forms and government documents should include options other than ‘male’ and ‘female’

Chart showing About four-in-ten or more say forms and government documents should offer options other than ‘male’ and ‘female’

About four-in-ten Americans (38%) say government documents such as passports and driver’s licenses that ask about a person’s gender should include options other than “male” and “female” for people who don’t identify as either; a larger share (44%) say the same about forms and online profiles that ask about a person’s gender.

Half of adults younger than 30 say government documents that ask about gender should include options other than “male” and “female,” compared with 39% of those ages 30 to 49, 35% of those 50 to 64 and 33% of adults 65 and older. When it comes to forms and online profiles, 54% of adults younger than 30 and 47% of those ages 30 to 49 say these forms should include more than two gender options; smaller shares of adults ages 50 to 64 and 65 and older (37% each) say the same. 

Views on this vary considerably by party. A majority of Democrats and Democratic-leaning independents say forms and online profiles (64%) and government documents (58%) that ask about a person’s gender should include options other than “male” and “female.” In contrast, about eight-in-ten or more Republicans and Republican leaners say forms and online profiles (79%) and government documents (83%) should  not  include more than these two gender options. 

Those who say they know someone who is nonbinary are more likely than those who don’t know anyone who’s nonbinary to say forms and government documents should include gender options other than “male” and “female.” Still, 39% of those who don’t know anyone who’s nonbinary say forms and online profiles shouldinclude other gender options, and 33% say the same about government documents that ask about a person’s gender. Conversely, 31% of those who say they know someone who’s nonbinary say forms and online profiles should  not  include options other than “male” and “female,” and 41% say this about government documents. 

About three-in-ten parents of K-12 students say their children have learned about people who are trans or nonbinary at school 

In recent months, lawmakers in several states have introduced legislation that would  prohibit or limit instruction on sexual orientation or gender identity  in schools. The survey asked parents of K-12 students whether any of their children have learned about people who are transgender or who don’t identify as a boy or a girl from a teacher or another adult at their school and how they feel about the fact that their children have or have not learned about this.

Some 37% of parents with children in middle or high school say their middle or high schoolers have learned about people who are transgender or who don’t identify as a boy or a girl from a teacher or another adult at their school; a much smaller share of parents of elementary school students (16%) say the same. Overall, 29% of parents with children in elementary, middle or high school say at least one of their K-12 children have learned about this at school. 

Similar shares of parents of K-12 students in urban (31%), suburban (27%) and rural (32%) areas – and in the Northeast (34%), Midwest (33%), South (26%) and West (28%) – say their school-age children have learned about people who are transgender or who don’t identify as a boy or a girl. And Republican (27%) and Democratic (31%) parents are also about equally likely to say their children have learned about this in school. None of these differences are statistically significant.

Chart showing Views on children learning about people who are trans or nonbinary at school differ by party, children’s age

Many parents of K-12 students don’t think it’s good for their children to learn about people who are transgender or nonbinary from their teachers or other adults at school. Among parents of elementary school students, 45% either say their children have learned about people who are trans or nonbinary at school and see this is a  bad  thing or say their children have  not  learned about this and say this is a  good  thing. A far smaller share (13%) say it’s a good thing that their elementary school children have learned about people who are trans or nonbinary or that it’s a bad thing that they  haven’t  learned about this. And about four-in-ten (41%) say it’s neither good nor bad that their elementary school children have or haven’t learned about people who are transgender or nonbinary. 

Among parents with children in middle or high school, 34% say it’s a bad thing that their children have learned about people who are trans or nonbinary at school  or  that it’s a good thing that they haven’t; 14% say it’s good that their middle or high schoolers have learned about this  or  that it’s bad that they haven’t; and 51% say it’s neither good nor bad that their children have or haven’t learned about this in school. 

Republican and Republican-leaning parents with children in elementary, middle and high school are more likely than their Democratic and Democratic-leaning counterparts to say it’s a bad thing that their children have learned about people who are trans or nonbinary at school or that it’s a good thing that they haven’t. In turn, Democratic parents are more likely to say it’s  good  that their children  have  learned about this or  bad  that they  haven’t . They are also more likely to say it’s neither good nor bad that their children have or haven’t learned about people who are trans or nonbinary at school. 

  • For each policy item, respondents were also given the option of answering “neither favor nor oppose.”  ↩
  • Open-ended responses (quotations) have been lightly edited for clarity and length. ↩
  • The shares who say they are following news about this a little or not at all closely do not add up to the combined share shown in the chart due to rounding.  ↩

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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.

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These states include California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Carolina, Oregon, Rhode Island, Vermont, and Washington.

Also of Interest

  • LGBT+ People’s Health and Experiences Accessing Care
  • The Health System Appears To Be Selling LGBT+ People Short
  • The Impact of the COVID-19 Pandemic on LGBT+ People’s Mental Health

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National Trends in Gender-Affirming Surgical Procedures: A Google Trends Analysis

Emily merrick.

1 Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA

Joshua P Weissman

Sumanas w jordan, marco ellis.

Background: There has been a significant increase in the volume of gender-affirming surgical (GAS) procedures over the past decade. The objective of this paper is to use online search data from Google Trends (GT) to describe national search trends for GAS procedures.

Methods: GT was queried for search terms relating to GAS from January 2004 to February 2021. The 19 selected keywords covered a broad range of GAS topics. United States (US) search interest was collected as relative search volumes (RSVs) and then analyzed by geographic region. The number of plastic surgery providers offering GAS and academic surgery centers was collected from the World Professional Association for Transgender Health (WPATH) and Trans- health.com . RSVs were analyzed by metro area to determine the relationship between search demand and personal income. State Medicaid policies for transgender health services were also collected.

Results: All search terms demonstrated a positive increase in RSVs over time except “sex reassignment surgery” and “penectomy”. The Mountain/Pacific and East South Central/West South Central had the greatest search volume for GAS and most providers offering care. The East South Central/West South Central region​​ ranked last for providers offering care, despite the relatively high search interest. This region also had no states with explicit Medicaid policies covering gender-affirming care. Metro areas in the top five for RSV but bottom quartile for per capita personal income were identified.

Conclusions: Online search interest for GAS-related terms has increased. Search interest for GAS has regional variation and did not show a specific pattern with provider availability.

Introduction

Approximately 1.4 million transgender and non-binary (TGNB) adults and 150,000 TGNB adolescents and young adults live in the United States (US) [ 1 ]. Gender-affirming surgery (GAS) has become increasingly performed over the past five years for this growing patient population [ 2 ]. GAS has been shown to improve quality of life among TGNB patients experiencing gender dysphoria [ 3 - 6 ]. Many patients consult internet forums and social media for information regarding GAS [ 7 , 8 ]. El-Hadi et al. found that websites targeted at TGNB patients were the primary source of information for GAS. Furthermore, the authors found that the majority of TGNB individuals had difficulty finding a physician and reported having a lack of access to information [ 3 ]. 

Search engines such as Google can provide valuable information about healthcare-related search trends. The largest keyword search engine, Google Trends (GT), is a free, accessible tool that allows individuals to analyze geographic and temporal trends as relative search volumes (RSVs) for search terms [ 9 ]. GT is gaining popularity in healthcare-related research [ 10 - 14 ]. As has been done in prior studies, these RSVs can be used as a proxy for both search demand and interest [ 14 - 19 ]. Prior plastic surgery research has utilized GT to predict public interest in various surgical procedures, understand demand for marketing purposes, perceive celebrity influences on procedure interest, and conduct geographical analysis of provider demand [ 14 - 19 ]. A recent study utilizing GT reported increased searches for GAS-related search terms globally [ 19 ]. 

GT has not been utilized to analyze US interest in GAS. The purpose of this study is to describe US trends in internet searches for GAS-related keywords by region and over time. We hypothesize that there will be discrepancies across various national regions between GT search demand for GAS such that areas with more surgical providers and gender centers will generate higher search interest. 

Materials and methods

Data source

GT was used to assess search volumes and trends over time [ 9 , 20 ]. GT evaluates the interest of a specific search term and generates an indicator known as an RSV, which is a score that calculates the relative popularity of a term as a proportion of all Google search terms for a specific geographic region or time frame [ 9 , 20 ]. GT analyses can be customized by search term, geographic location, time period, category (e.g. “Arts and Entertainment”, “Books and Literature”), and type of Google search (e.g. “web search”, “image search”, “news search”). This method provides anonymous, open-source data that controls population size and internet usage. Each data point is divided by the total number of searches of the geography and time point it represents. The resultant numbers are scaled on a range of 0 to 100 based on a topic’s proportion to all searches on all topics within that region or time [ 9 ]. A score of 100 represents the geographic area or time period with the greatest interest for that search term. All other geographic areas and times are assigned numbers that quantify interest relative to the maximum. For example, if area or time X had a search volume of 550 searches and area or time Y had an RSV of 495 searches, GT would record area or time X as having an RSV of 100 (550/550) and area or time Y would have an RSV of 90 (495/550).

Data acquisition

GT search parameters were set to Geographic Location: “United States,” Time Period: “1/1/2004-2/18/2021,” Category: “All Categories,” and Type of Search: “Web Search” to capture all US queries for the designated terms. Specific dates were used to ensure the replicability of the study. The terms used in this analysis were among the core procedure types defined by the World Professional Association for Transgender Health (WPATH) [ 21 ]. The aim was to capture a broad scope of demand for GAS. Researcher and clinical consensus were used for final term selection as determined by the two senior authors who regularly perform GAS. Of note, the authors acknowledge that terminology such as male-to-female (“MTF”), “FTM”, and “gender confirmation surgery” may be considered outdated and/or stigmatizing to some. These terms were included in order to reflect and analyze language that shifts within a wide time frame. The search terms included in this study can be found in Table ​ Table1. 1 . “Male to female/female to male surgery” was counted as one search term as GT does not consider word order and generates the same data for both searches. Terms that did not generate any RSV values from GT were excluded from the analysis. These terms were as follows: “peritoneal flap vaginoplasty”, “Adam’s apple reduction”, “facial masculinization”, “MTF vaginoplasty”, “transmasculine bottom surgery”, and “transfeminine bottom surgery”. Surgical terms that were not specific to gender-affirming procedures such as “vaginoplasty”, “breast augmentation”, and “mastectomy” were excluded. All terms were individually queried via GT and the RSVs were determined for each search term from January 1, 2004 to February 18, 2021.

Terms were selected through the World Professional Association for Transgender Health and clinical consensus between the two senior authors who frequently perform gender affirming procedures. The authors acknowledge that some terms are outdated and stigmatizing but were utilized to reflect the changing language of this wide time frame.

Temporal data

Microsoft Excel (Redmond, WA) was used to conduct a trend line analysis for each search term’s RSV. 

Regional data

RSV values were recorded by state for each of the 19 search terms. States were categorized according to regions designated by the American Society of Plastic Surgeons (ASPS) Annual Reports [ 2 ]. Figure ​ Figure1 1 displays the five regions used in the analysis. The top 10 RSVs were recorded for all search terms. The total number of times each region appeared in the top ten RSVs was recorded to compare regional interest in GAS.

An external file that holds a picture, illustration, etc.
Object name is cureus-0014-00000025906-i01.jpg

To determine the specific region in which each search term was most popular, the top 10 RSVs were examined. The region composed the largest percentage of RSVs for each search term’s top 10 RSVs was deemed to have the greatest regional interest for that term. For search terms where there was insufficient data to report on 10 states, the RSV for all available states was reported. In the event that multiple regions made up equal percentages (e.g., five RSVs were from Region 1 and five RSVs were from Region 2), the region with the larger average RSV for that search term was determined to have the greatest interest. 

Metropolitan area based on income data

A metropolitan analysis of RSV for each of our search terms was also conducted for all of our search terms. GT search parameters were set to Geographic Location: “United States,” Time Period: “1/1/2004-2/18/2021,” Categories: “All categories,” and Type of Search: “Web Search.” For each of our search terms, we analyzed any metro area that was in the top five for RSV but bottom quartile according to the US Bureau of Economic Analysis [ 22 ]. Metro areas were then recorded to determine demand trends in low-income areas where care may be less accessible.

Providers and academic medical centers offering GAS data

To quantify the number of plastic surgeon providers in the US offering GAS as of February 2021, the World Professional Association of Transgender Health’s (WPATH) website was utilized. The website lists plastic surgery providers in each state, and the search was subsequently filtered for these providers [ 21 ]. The number of providers listed on this website for each state were determined and the number of providers in each region were calculated. The Trans-Health website was queried for the number of academic medical centers with TGNB surgery programs [ 23 ]. Additional centers were manually added if they were known to have TGNB programs but were not listed on the website. All 154 websites of US medical schools were evaluated for access to a dedicated TGNB surgical program or dedicated GAS section, and fifteen academic medical centers were added to the original list. The number of centers were counted for each state and region. 

Medicaid coverage data

As of February 2021, the states that have an explicit policy stating that TGNB health-related services are covered under Medicaid were determined [ 24 ]. We also examined which states had a policy excluding coverage and which states did not have a specific stance. We then calculated the number of states within each region that had each of the aforementioned policies. This was done to determine whether there are associations between a state’s Medicaid status for GAS and its overall search demand for GAS-specific terms. 

Trends in interest in the United States from 2004 to 2021

Overall, national trends in search terms for gender affirming surgery revealed “transgender surgery,” “gender reassignment surgery,” “gender affirming surgery,” “gender confirming surgery” “top surgery,” “bottom surgery,” “upper surgery,” “lower surgery,” “male to female/female to male surgery,” “MTF bottom surgery,” “FTM bottom surgery,” “facial feminization surgery,” “metoidioplasty,” “FTM phalloplasty,” “tracheal shave,” “vulvoplasty,”, and “penile skin inversion.” all showed positive increases in RSV from 2004 to 2021. The two terms that showed a decrease in RSV overtime were “sex reassignment surgery” and “penectomy.” 

Interest in GAS by region

Based on GT data for all selected search term to identify interest by state and region, 41/159 (25.8%) of the top ten RSV values fell into Region 5 (Mountain/Pacific), 38/159 (23.4%) RSVs fell into Region 4 (East South Central/West South Central), 34/159 (21.4%) of RSVs fell into Region 1 (New England/Middle Atlantic), 25/159 (15.7%) fell into Region 2 (East North Central/West North Central), and 21/159 (13.2%) RSVs fell into Region 3 (South Atlantic) (Figure ​ (Figure2 2 ). 

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Object name is cureus-0014-00000025906-i02.jpg

For all 19 search terms, the states with the top ten relative search volumes were listed. The number of times each state was included in the top 10 was noted and added into one of the five regions described by the America Society of Plastic Surgeons.

Based on RSV data for all nineteen search terms, Region 5 (Mountain/Pacific) had the greatest interest for the search terms: “sex reassignment surgery,” “gender reassignment surgery,” “tracheal shave,” “penectomy,” “facial feminization surgery,” “metoidioplasty,” and “penile skin inversion.” Region 4 (East South Central/West South Central) had the greatest interest for the search terms “bottom surgery,” “male to female/female to male surgery,” “vulvoplasty,” “lower surgery.” Region 1 (New England/Middle Atlantic) had the greatest interest for “transgender surgery,” “top surgery,” “FTM phalloplasty.” Region 3 (South Atlantic) had the greatest search interest for “MTF bottom surgery,” “FTM bottom surgery,” and “upper surgery.” Region 2 (East North Central/West North Central) had the greatest interest for the search terms “gender affirming surgery” and “gender confirming surgery.”

Metropolitan data based on income

Metro areas in the top five for RSV but bottom quartile for per capita personal income included: Richmond, Virginia, Las vegas, Nevada, Spartansburg, South Carolina, Grand rapids-Kalamazoo-Battle Creek, MI, Jacksonville, Florida, Columbus, Ohio, Hartford, Connecticut, and Bowling Green Kentucky.

The WPATH website provided 101 plastic surgery providers across the US. A national distribution of these providers can be seen in Figure ​ Figure3. 3 . Region 5 (Mountain/Pacific) has the most providers with 33% of the total. Region 1 (New England/Middle Atlantic) has 26%, Region 2 (East North Central/West North Central) has 19%, Region 3 (South Atlantic) has 14% of the providers. Region 4 (East South Central/West South Central) has the fewest number of providers with nine percent.

An external file that holds a picture, illustration, etc.
Object name is cureus-0014-00000025906-i03.jpg

Plastic surgeon providers across the United States as listed on the World Professional Association for Transgender Health (WPATH) website.

A total of 46 academic medical centers with TGNB surgery programs or dedicated TGNB surgery sections on their websites were found. A national distribution of these institutions can be seen in Figure ​ Figure4. 4 . Region 1 (New England/Middle Atlantic) had the most institutions with 14 (30%). Region 2 (East North Central/West North Central) followed with 12 institutions (26%). Regions 3 (South Atlantic) and 5 (Mountain/Pacific) had nine (20%) and eight (17%) institutions, respectively. Region 4 (East South Central/West South Central) had the fewest number of institutions with three (7%).

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Object name is cureus-0014-00000025906-i04.jpg

States with academic medical centers with a dedicated transgender and non-binary surgery program or faculty dedicated to providing this type of care - World Professional Association for Transgender Health (WPATH) website.

Of the 22 states and Washington D.C. in which Medicaid programs cover gender affirming care, Region 1 (New England/Middle Atlantic) has the most states with this policy (nine states). Region 5 (Mountain/Pacific) follows with seven states, Region 2 (East North Central/West North Central) has four states, Region 3 (South Atlantic) has three states. Region 4 (East South Central/West South Central) has no states with this explicit policy. Figure ​ Figure5 5 illustrates a national distribution of state policy.

An external file that holds a picture, illustration, etc.
Object name is cureus-0014-00000025906-i05.jpg

We used GT to describe US search trends for various GAS procedures according to geographic region. As past studies have done, we aimed to use GT search data as a proxy for national interest in GAS [ 14 , 16 - 19 ]. Given the greater number of individuals identifying as TGNB, GAS is becoming an increasingly important component of health care in the US [ 25 - 27 ]. Prior studies have highlighted the rapid increase in demand for GAS [ 25 ]. We found that national search interest related to GAS has increased over time while demonstrating regional variation.

Our results highlight growing US search interest in GAS, as 17 of 19 included search terms had positive increases in RSVs from 2004 to 2021. The only terms that decreased in popularity were “sex reassignment surgery” and “penectomy.” This may be due to a shift in language used by TGNB individuals [ 4 - 7 , 25 - 27 ]. 

TGNB patients report that the lack of knowledgeable TGNB providers is a large barrier to care [ 27 ]. Using GT to identify areas that lack available providers may be a helpful step in addressing this barrier. Our GT analysis demonstrates that search interest for GAS does not align with areas containing providers or gender centers. This highlights a geographic barrier to accessing care. Our GT regional analysis shows that Region 5 (Mountain/Pacific) and Region 4 (East South Central/West South Central) have higher search demand volume relative to the other three regions. Despite generating relatively high search interest, Region 4 (East and West South Central) ranked last for both the number of providers and academic medical centers offering care. GT can be used to identify high interest, low availability areas where increasing providers may want to be prioritized.

Each region had certain search terms that were more widely used. For example, Region 5 (Mountain/Pacific) had the highest demand for terms such as “tracheal shave”, “penectomy”, and “facial feminization surgery” whereas Region 4 (East South Central/West South Central) had the highest demand for “vulvoplasty”. Variation in search interest for specific terms may indicate potentially popular procedures in certain regions and/or regional differences in language. Providers in these areas can use this knowledge to include popular searches in their internet presence or increase awareness about other available procedures that patients might appreciate but not be exposed to in their region.

Additionally, certain states (Wyoming, Wisconsin, Virginia, Delaware, South Dakota, and Hawaii) did not have top 10 search volumes for any of the selected terms. Of the states that did not appear in the top 10 for RSV volumes, only Wisconsin and Virginia had available providers to perform GAS. These can be targeted as areas where increasing awareness of potential procedures may be of significant value to TGNB individuals. GT can be used to track increased interest, and providers can be recruited to practice in areas of increasing interest. 

We identified eight low-income metro areas with significant search interest for GAS procedures. To ensure equitable access to care, providers can be incentivized to practice in these areas. Our results demonstrate that Region 4 (East South Central/West South Central) had the lowest rates of Medicaid coverage and the fewest providers. Increasing coverage may be another means to draw providers to certain areas. Ultimately, regional variations of demand for gender-affirming care are complex and are often the result of local and state legislation, Medicaid coverage, and culture [ 28 ].

There are several limitations to this study. Search volume values can be skewed by population size. A state with a larger population may have a higher absolute search volume but a lower proportion of total search results compared to a state with a smaller population. This limitation is minimized as numbers are taken in the context of RSVs and there are no comparisons made between absolute search volumes. In addition, only search terms with sufficient interest to generate an RSV value were included. The authors also recognize that not every term relating to GAS may have been included in this analysis. Patients may also be searching terms not specifically analyzed in this study or search terms in another language. Additionally, this study is limited in not providing information or outcomes for those actually undergoing GAS: not differentiating between the number of insured versus uninsured patients undergoing GAS, complication rates, or the types of surgeries people are getting. This offers the future-direction of questionnaire-based studies to elucidate this information. The GT algorithm generates RSV values based on a random sample of Google searches, meaning that reproducibility of our exact search is not guaranteed. It is also important to acknowledge that not all patients have internet access. Our sample only represents patients who can search online. Nevertheless, the 2018 United States Census shows that 92% of households in the US own a computer and 85% had an internet subscription [ 29 ]. ​​ Although Google has the largest search engine market share (93%), the results of this study are only representative of the demographic that uses the Google search engine users and those who use the internet for healthcare-related information [ 30 ]. 

Conclusions

This paper reports on the utility of GT in relation to transgender health and GAS. We describe national trends in online search interest based on region, city, and metropolitan area. Our results highlight a strong, growing national interest in GAS. Search interest for GAS has regional variation and did not show a specific pattern with provider availability. By improving our understanding of temporal and geographical search interest, we can identify areas where patients may seek GAS. 

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained or waived by all participants in this study

Animal Ethics

Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

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States Passed a Record Number of Transgender Laws. Here’s What They Say.

Many of the bills denied certain medical care to transgender people, while others targeted bathroom use and preferred personal pronouns.

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A large crowd of people, many holding signs, stands outside near the Kentucky Capitol building.

By Adeel Hassan

Adeel Hassan read through dozens of state laws and spoke with law professors about the implications of the new legislation.

Statehouses around the country this year have been consumed by fights over laws governing transgender people.

Seventeen states during their most recent legislative sessions passed restrictions on medical care for transgender people, joining just three other states that passed similar bans in the last two years. A series of other laws passed regulate which bathrooms transgender people can use and whether schools can affirm transgender children’s identities.

Already many of these laws are being challenged in court, and judges are scrutinizing their precise wording. A federal judge in Arkansas last week struck down that state’s law forbidding medical treatments for children and teenagers seeking gender transitions. Earlier this month, a Florida judge sided with families seeking to block the state’s law banning gender transition care for minors, saying that the ban is likely to be found to be unconstitutional.

Amid the fighting, it’s easy to overlook the text of the laws themselves, which can get clinical very quickly.

So what’s actually in these bills? Here is a closer look at the language.

Many states have banned medical treatments and various surgical procedures for minors.

Laws banning gender-transition care for minors have been enacted in 20 states; Alabama, Arkansas, Tennessee and Arizona enacted bans before 2023, though Arkansas’s was recently struck down. Arizona’s law focuses on surgical procedures, but the rest extend the ban to other treatments, including puberty blockers and hormones.

Out of an estimated 1.6 million Americans who are transgender, about 300,000 are under 18. A small number get surgery as part of their transition, but it is much more common for children to transition socially — changing their name, clothing, haircut or other parts of their appearance and identity — and through the use of puberty-delaying medications or hormones.

Often these laws lay out a broad list of procedures. Indiana’s law, for example, includes mastectomies but also mentions procedures like liposuction and hair reconstruction. The legislation specifies that these procedures are banned for minors only if they are for the specific purpose of gender transition.

Sec. 8. As used in this chapter, “non genital gender reassignment surgery” means medical procedures knowingly performed for the purpose of assisting an individual with a gender transition , including the following: (1) Surgical procedures for a male sex patient, including augmentation mammoplasty, facial feminization surgery, liposuction, lipofilling, voice surgery, thyroid cartilage reduction, gluteal augmentation, hair reconstruction, or associated aesthetic procedures. (2) Surgical procedures for a female sex patient, including subcutaneous mastectomy, voice surgery, liposuction, lipofilling, pectoral implants, or associated aesthetic procedures.

Indiana SEA 480

Genital surgery for minors is extremely rare. Top surgery — breast augmentation or removal — for minors is performed more often but is still very uncommon.

Proponents of the bans argue that these operations can be harmful and that children are not mature enough to make decisions about such procedures.

Leading medical organizations oppose bans on transition care, citing extensive evidence that such treatment leads to better mental health outcomes, and associating a lack of treatment with higher rates depression.

A few states passed laws that will also affect adults.

While most of these laws focus on treatments for minors, some states included provisions that will also create obstacles for transgender adults seeking transition treatments.

Florida’s law includes several restrictions, including requiring that medication like puberty blockers be prescribed in person by a physician. Many transgender people receive their prescriptions via telehealth and from nurse practitioners.

(3) Sex-reassignment prescriptions or procedures may not be prescribed, administered, or performed except by a physician . For the purposes of this section, the term “physician” is defined as a physician licensed under chapter 458 or chapter 459 or a physician practicing medicine or osteopathic medicine in the employment of the Federal Government.

Florida SB 254

Laws in both Florida and Missouri prevent Medicaid from covering transition care, which could make it harder for transgender adults to afford treatments and surgeries.

Some states have created strict penalties for providers who break the law.

Many states have defined the act of providing surgeries and medical care to transgender minors as “unprofessional conduct,” which could jeopardize a doctor’s ability to practice medicine.

Some states added potential penalties for people beyond doctors. For example, Indiana and Mississippi outline legal consequences for doctors and others who “aid or abet” in administering care. This language is similar to abortion bans that include legal penalties for providers or others who “aid or abet” someone receiving an abortion.

SECTION 3. (1) A person shall not knowingly provide gender transition procedures to any person under eighteen (18) years of age. (2) A person shall not knowingly engage in conduct that aids or abets the performance or inducement of gender transition procedures to any person under eighteen (18) years of age. This subsection may not be construed to impose liability on any speech protected by federal or state law.

Mississippi HB 1125

“In some states, such as Mississippi, the ‘aid or abet’ language is very broad,” said Elana Redfield, the federal policy director of the Williams Institute at the law school of the University of California, Los Angeles, “and could conceivably subject parents or allies to liability.”

And Montana’s ban allows people who receive care to sue their provider for up to 25 years after the procedure if they claim they were harmed by it.

While most of the laws passed this year do not include criminal liability, last month Florida joined at least four other states that make providing such care a felony. Florida’s law penalizes doctors who violate the law with up to five years in prison. It also changes child custody rules to treat transition care as equivalent to child abuse.

“It is wrong to be sexualizing these kids,” Gov. Ron DeSantis said at the signing. “It’s wrong to have gender ideology and telling kids that they may have been born in the wrong body.”

To enforce these laws, states are defining “male” and “female.”

Both as part of the medical bans and sometimes as separate laws, states are strictly defining “male” and “female.” This could prevent transgender people from receiving identification that matches their identity and appearance.

Tennessee’s law defining sex goes into effect on July 1, and would prevent anyone from changing the sex on their birth certificate and driver’s license. This can create challenges for transgender people when they need to, say, vote or apply for a library card.

(c) As used in this code, "sex" means a person's immutable biological sex as determined by anatomy and genetics existing at the time of birth and evidence of a person's biological sex . As used in this subsection (c), "evidence of a person's biological sex" includes, but is not limited to, a government-issued identification document that accurately reflects a person's sex listed on the person's original birth certificate.

Tennessee SB 1440

Research points to other consequences, including higher levels of anxiety and depression for transgender people who have an inconsistency between their documents and their gender identity.

There is some acknowledgment in the laws, though, that sex is not always binary. Most of the bans or restrictions include exceptions for intersex people who need or opt for medical treatments and surgery. Roughly 0.5 to 2 percent of the population has some intersex condition , meaning a person is born with chromosomes, hormones or sexual anatomy that differs from what is considered typical for males and females.

Nearly half of all states enacted laws banning transgender women and girls from playing on female teams.

At least 21 states, including North Dakota, specifically exclude transgender women and girls from participating in sports consistent with their gender identity. Five of those states extend the bans to transgender boys. All of the bans apply to high schools, and most states include colleges in their bans.

2. An athletic team or sport designated for “females”, “women”, or “girls” may not be open to students of the male sex. 3. This section may not be construed to restrict the eligibility of a student to participate in interscholastic or intramural athletic teams or sports designated as “males”, “men”, or “boys” or designated as “coed” or “mixed”.

North Dakota HB 1249

In Ohio last year, early drafts of the state’s athletic ban , which is still being debated by the legislature, included language requiring a physical examination by a doctor when the sex of an athlete is disputed. That language has since been removed. But it’s unclear in many of the laws how schools and organizations should enforce the bans.

Bathroom laws return, with a focus on school facilities.

In 2016, North Carolina became the first state to pass a bill barring transgender people from using public bathrooms consistent with their gender identity. The law drew nationwide outrage, and companies canceled planned expansions in the state, while the N.B.A. and N.C.A.A. moved events elsewhere. It was repealed in 2017.

But so-called bathroom bills have recently made a comeback in state legislatures. Tennessee passed one in 2021, while Alabama and Oklahoma followed in 2022. At least six states this year enacted laws regulating the use of bathrooms.

Idaho’s law, like many of these laws, targets school restrooms. The law says facilities that can be used by multiple people at once must be designated male or female and may be used only by members of that sex. The reason, it says, is to limit the shame and embarrassment students may feel sharing a restroom with someone of the opposite sex.

(2) Every person has a natural right to privacy and safety in restrooms and changing facilities where such person might be in a partial or full state of undress in the presence of others; (3) This natural right especially applies to students using public school restrooms and changing facilities where student privacy and safety is essential to providing a safe learning environment for all students; (4) Requiring students to share restrooms and changing facilities with members of the opposite biological sex generates potential embarrassment, shame, and psychological injury to students, as well as increasing the likelihood of sexual assault, molestation, rape, voyeurism, and exhibitionism;

Idaho SB 1100

Lawmakers who back such bills say that every child must feel safe in the bathroom and that the laws can help prevent abuse. Multiple studies , however, have shown that transgender people are much more likely to be victims of violence than cisgender people.

“We’ve had a natural experiment going in colleges, universities and high schools for some time” with coed bathrooms, said Katherine Franke, a professor at Columbia University Law School. After all these years, she added, “we haven’t seen any incidence of increased risks to personal security.”

Federal appeals courts have so far been split on the issue. At least two courts have upheld transgender students’ rights to use the bathroom corresponding with their gender identity, and in January one court ruled that a transgender boy was not entitled to use the boys’ bathroom in a public high school in Florida.

Some states extended their laws to include school field trips

Since many of the bathroom bans specifically apply to school facilities, they also often include accommodations on school field trips.

Kansas passed a law specifically targeting school overnight trips, stating that students must have overnight lodging that is separated by sex.

Be it enacted by the Legislature of the State of Kansas: New Section 1. (a) The board of education of each school district shall adopt a policy requiring that separate overnight accommodations be provided for students of each biological sex during school district sponsored travel that requires overnight stays by students. Such policy shall be provided to parents prior to a student’s participation in an activity or travel that requires overnight stays by students.

Kansas HB 2138

Republican legislators passed the law off a report that a female student was assigned to share a room with a transgender student during an overnight trip, and overruled a veto by Gov. Laura Kelly, a Democrat.

“Conservatives who were worried about education were always committed to local school control,” Ms. Franke said. Now they’re “relying on state legislatures, which are taking away that discretion from local school boards.”

A handful of laws directed at schools restrict the discussion of personal pronouns.

At least nine states this year have passed laws regarding how pronouns are handled in school. Florida’s law explicitly prohibits teachers and students from discussing their preferred pronouns.

Kentucky has a law saying teachers can’t be required to use pronouns for students that differ from their sex.

(b) The Kentucky Board of Education or the Kentucky Department of Education shall not require or recommend policies or procedures for the use of pronouns that do not conform to a student's biological sex as indicated on the student's original, unedited birth certificate issued at the time of birth pursuant to KRS 156.070(2)(g)2. (c) A local school district shall not require school personnel or students to use pronouns for students that do not conform to that particular student's biological sex as referenced in paragraph (b) of this subsection.

Kentucky SB 150

Other states, like Indiana, outline “parental rights” policies, requiring that parents be notified when their children request to use a different name or want to be called pronouns that don’t match their sex.

Overall, the many new laws governing transgender children and adults have yet to be tested in everyday life. But already, many are facing lawsuits seeking to stop them.

Nearly half of all the medical bans that have passed are already being challenged in court. A Florida judge issued a limited injunction this month, saying that the state’s medical ban would most likely be found unconstitutional. The judge took issue with the state’s prohibiting treatments “even when medically appropriate.” Texas’ law, which was enacted this month , is also expected to face legal challenges before going into effect in September.

Maggie Astor contributed reporting.

Adeel Hassan is a reporter and editor on the National Desk. He is a founding member of Race/Related , and much of his work focuses on identity and discrimination. He started the Morning Briefing for NYT Now and was its inaugural writer. He also served as an editor on the International Desk.  More about Adeel Hassan

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Gender Confirmation Surgery (GCS)

What is Gender Confirmation Surgery?

  • Transfeminine Tr

Transmasculine Transition

  • Traveling Abroad

Choosing a Surgeon

Gender confirmation surgery (GCS), known clinically as genitoplasty, are procedures that surgically confirm a person's gender by altering the genitalia and other physical features to align with their desired physical characteristics. Gender confirmation surgeries are also called gender affirmation procedures. These are both respectful terms.

Gender dysphoria , an experience of misalignment between gender and sex, is becoming more widely diagnosed.  People diagnosed with gender dysphoria are often referred to as "transgender," though one does not necessarily need to experience gender dysphoria to be a member of the transgender community. It is important to note there is controversy around the gender dysphoria diagnosis. Many disapprove of it, noting that the diagnosis suggests that being transgender is an illness.

Ellen Lindner / Verywell

Transfeminine Transition

Transfeminine is a term inclusive of trans women and non-binary trans people assigned male at birth.

Gender confirmation procedures that a transfeminine person may undergo include:

  • Penectomy is the surgical removal of external male genitalia.
  • Orchiectomy is the surgical removal of the testes.
  • Vaginoplasty is the surgical creation of a vagina.
  • Feminizing genitoplasty creates internal female genitalia.
  • Breast implants create breasts.
  • Gluteoplasty increases buttock volume.
  • Chondrolaryngoplasty is a procedure on the throat that can minimize the appearance of Adam's apple .

Feminizing hormones are commonly used for at least 12 months prior to breast augmentation to maximize breast growth and achieve a better surgical outcome. They are also often used for approximately 12 months prior to feminizing genital surgeries.

Facial feminization surgery (FFS) is often done to soften the lines of the face. FFS can include softening the brow line, rhinoplasty (nose job), smoothing the jaw and forehead, and altering the cheekbones. Each person is unique and the procedures that are done are based on the individual's need and budget,

Transmasculine is a term inclusive of trans men and non-binary trans people assigned female at birth.

Gender confirmation procedures that a transmasculine person may undergo include:

  • Masculinizing genitoplasty is the surgical creation of external genitalia. This procedure uses the tissue of the labia to create a penis.
  • Phalloplasty is the surgical construction of a penis using a skin graft from the forearm, thigh, or upper back.
  • Metoidioplasty is the creation of a penis from the hormonally enlarged clitoris.
  • Scrotoplasty is the creation of a scrotum.

Procedures that change the genitalia are performed with other procedures, which may be extensive.

The change to a masculine appearance may also include hormone therapy with testosterone, a mastectomy (surgical removal of the breasts), hysterectomy (surgical removal of the uterus), and perhaps additional cosmetic procedures intended to masculinize the appearance.

Paying For Gender Confirmation Surgery

Medicare and some health insurance providers in the United States may cover a portion of the cost of gender confirmation surgery.

It is unlawful to discriminate or withhold healthcare based on sex or gender. However, many plans do have exclusions.

For most transgender individuals, the burden of financing the procedure(s) is the main difficulty in obtaining treatment. The cost of transitioning can often exceed $100,000 in the United States, depending upon the procedures needed.

A typical genitoplasty alone averages about $18,000. Rhinoplasty, or a nose job, averaged $5,409 in 2019.  

Traveling Abroad for GCS

Some patients seek gender confirmation surgery overseas, as the procedures can be less expensive in some other countries. It is important to remember that traveling to a foreign country for surgery, also known as surgery tourism, can be very risky.

Regardless of where the surgery will be performed, it is essential that your surgeon is skilled in the procedure being performed and that your surgery will be performed in a reputable facility that offers high-quality care.

When choosing a surgeon , it is important to do your research, whether the surgery is performed in the U.S. or elsewhere. Talk to people who have already had the procedure and ask about their experience and their surgeon.

Before and after photos don't tell the whole story, and can easily be altered, so consider asking for a patient reference with whom you can speak.

It is important to remember that surgeons have specialties and to stick with your surgeon's specialty. For example, you may choose to have one surgeon perform a genitoplasty, but another to perform facial surgeries. This may result in more expenses, but it can result in a better outcome.

A Word From Verywell

Gender confirmation surgery is very complex, and the procedures that one person needs to achieve their desired result can be very different from what another person wants.

Each individual's goals for their appearance will be different. For example, one individual may feel strongly that breast implants are essential to having a desirable and feminine appearance, while a different person may not feel that breast size is a concern. A personalized approach is essential to satisfaction because personal appearance is so highly individualized.

Davy Z, Toze M. What is gender dysphoria? A critical systematic narrative review . Transgend Health . 2018;3(1):159-169. doi:10.1089/trgh.2018.0014

Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization: Systematic Review of the Literature . Plast Reconstr Surg. 2016;137(6):1759-70. doi:10.1097/PRS.0000000000002171

Hadj-moussa M, Agarwal S, Ohl DA, Kuzon WM. Masculinizing Genital Gender Confirmation Surgery . Sex Med Rev . 2019;7(1):141-155. doi:10.1016/j.sxmr.2018.06.004

Dowshen NL, Christensen J, Gruschow SM. Health Insurance Coverage of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information . Transgend Health . 2019;4(1):131-135. doi:10.1089/trgh.2018.0055

American Society of Plastic Surgeons. Rhinoplasty nose surgery .

Rights Group: More U.S. Companies Covering Cost of Gender Reassignment Surgery. CNS News. http://cnsnews.com/news/article/rights-group-more-us-companies-covering-cost-gender-reassignment-surgery

The Sex Change Capital of the US. CBS News. http://www.cbsnews.com/2100-3445_162-4423154.html

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

U.S. Gender-Affirming Surgeries Nearly Tripled in 3 Years

By Alan Mozes HealthDay Reporter

gender reassignment usa

WEDNESDAY, Aug. 23, 2023 (HealthDay News) -- The number of Americans undergoing gender-affirming surgery is on the rise, new research reveals, almost tripling between 2016 and 2019 alone.

During that period, more than 48,000 patients -- about half of them between 19 and 30 years of age -- underwent some form of gender-affirming (GAS) surgery, researchers found.

About 4,500 of those procedures were performed in 2016. By 2019, that figure rose to a high of 13,000, a number that dipped only slightly in 2020.

“A lot of scare pieces are being written about how many trans people there seem to be all of a sudden, but this is not about a skyrocketing number of people who all of a sudden are trans and all of a sudden are seeking these procedures,” said Kellan Baker , a transgender health care policy expert. "This is about the fact that before 2016 it was just not possible for many of these patients to get the medical care they needed because of discriminatory exclusions."

U.S. Cities With the Most Homelessness

gender reassignment usa

The study's lead author, Dr. Jason Wright , pointed to several possible reasons for the rapid increase. One, he said, is a greater awareness of the procedures among patients and health care providers.

“And there is a growing body of literature that the procedures are generally safe and associated with high satisfaction,” said Wright, chief of gynecologic oncology at Columbia University College of Physicians and Surgeons in New York City.

“There have also been a number of initiatives to improve insurance coverage for these operations, which likely make them more accessible to patients,” he added.

Gender-affirming surgery is one of the treatments -- alongside behavioral therapy and hormonal therapy -- available to patients struggling with gender dysphoria.

Gender dysphoria occurs when the gender a person is assigned at birth doesn't match the gender with which one identifies.

Certain breast, chest, cosmetic, facial and genital reconstruction surgeries are intended to help.

Researchers cite previous studies that found such procedures can alleviate the depression and anxiety that accompany gender dysphoria. They also boost quality of life and overall satisfaction levels, those studies have found.

To learn how many Americans are now embracing gender-affirming surgery, Wright's team reviewed a national database of surgical procedures in almost 2,800 hospitals in 35 states. The researchers also combed a second database that covers a large swath of inpatient admissions in community hospitals across 48 states.

Between 2016 and 2020, just over 48,000 gender-affirming procedures were performed.

They included breast reconstruction, repositioning and size adjustments; nipple reconstruction; male or female genital reconstruction; cosmetic facial procedures; hair removal or transplantation; liposuction and/or collagen injections.

Broken down year by year, the patient pool rose from 4,552 in 2016 to a peak of 13,011 in 2019. In all, 12,818 patients had gender-affirming surgery in 2020, the final year of the study.

Over the entire period, just over half (52%) of the patients were between 19 and 30 years of age, while about 22% were between 31 and 40. Fewer than 8% were between the ages of 12 and 18.

Most lived in the West (46%) or the Northeast (26%). About two-thirds underwent a single GAS procedure. More than a quarter of patients had two.

While all forms of gender-affirming surgery rose, breast and chest surgeries were most common. About 57% of patients had that type of surgery, with breast reconstruction being the most popular option.

About one-third (35%) of patients underwent genital reconstruction, with older patients more likely to choose this option. About 14% underwent cosmetic or facial operations.

Characterizing the spike in GAS surgeries as "remarkable," Wright said more study is needed.

“There is clearly a need to further explore the very rapid rise in the number of procedures performed each year,” he said, in order to get a better handle on exactly what’s behind it.

Meanwhile, Baker, executive director of the Whitman-Walker Institute, a health policy think tank in Washington, D.C., had a straightforward explanation for the trend.

In the past, insurers often refused to cover gender-affirming surgery. That changed dramatically in 2016, when the Obama administration clarified in regulation that the Affordable Care Act bars discrimination in insurance coverage and health care against transgender people.

“But when you remove that exclusion," Baker said, "it then makes it possible for providers to provide care. And it makes that care much more accessible and affordable to patients."

In other words, he said, the trend is no mystery.

"Trans people have always been here," Baker said. "The numbers we’re seeing now just reflect the fact that people have finally gotten some legal recognition, social visibility and the ability to be open about who they are and to get the medical care they need."

He is concerned, however, about ongoing efforts in many states to legislatively restrict access to transgender care.

“That would not be a positive thing," Baker said. "It would reflect going back to a state of unmet need. Gender dysphoria is a real and serious condition. And not treating it is not an option."

The findings were published Aug. 23 in JAMA Network Open .

More information

There's more about gender-affirming surgery at the Cleveland Clinic .

SOURCES: Jason Wright, MD, chief, gynecologic oncology, Columbia University College of Physicians and Surgeons, New York City; Kellan Baker, PhD, MPH, transgender health care policy expert, Whitman-Walker Institute, Washington, D.C.; JAMA Network Open , Aug. 23, 2023

Copyright © 2023 HealthDay . All rights reserved.

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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.

gender reassignment usa

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.

gender reassignment usa

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.”

gender reassignment usa

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.”

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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.

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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.

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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.”

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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.

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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.

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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

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Photography: Megan Jelinger and Lindsey Wasson

Photo editing: Corrine Perkins

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Fact Sheet: National Strategy on Gender Equity and   Equality

The Biden-Harris Administration issues first-ever national gender strategy to advance the full participation of all people – including women and girls – in the United States and around the world.

[Click here to read the Gender Strategy Report] President Biden and Vice President Harris believe that advancing gender equity and equality is fundamental to every individual’s economic security, safety, health, and ability to exercise their most basic rights.  It is also essential to economic growth and development, democracy and political stability, and the security of nations across the globe.  Ensuring that all people, regardless of gender, have the opportunity to realize their full potential is, therefore, both a moral and strategic imperative. Yet no country in the world has achieved gender equality—and we are at an inflection point.  The COVID-19 pandemic has fueled a health crisis, an economic crisis, and a caregiving crisis that have magnified the challenges that women and girls, especially women and girls of color, have long faced.  It has also exacerbated a “shadow pandemic” of gender-based violence in the United States and around the world.  These overlapping crises have underscored that, for far too long, the status quo has left too many behind. This moment demands that we build back better.  It requires that we acknowledge and address longstanding gender discrimination and the systemic barriers to full participation that have held back women and girls.  And it requires that we bring the talent and potential of all people to bear to face the challenges of our time.  That’s why the Biden-Harris Administration established the White House Gender Policy Council, charged with leading the development of the first-ever National Strategy on Gender Equity and Equality, which sets forth an aspirational vision and a comprehensive agenda to advance gender equity and equality in domestic and foreign policy—and demonstrates that families, communities, and nations around the world stand to benefit.

The strategy identifies ten interconnected priorities: 1) economic security; 2) gender-based violence; 3) health; 4) education; 5) justice and immigration; 6) human rights and equality under the law; 7) security and humanitarian relief; 8) climate change; 9) science and technology; and 10) democracy, participation, and leadership.  These priorities are inherently linked and must be tackled in concert. The strategy also adopts an intersectional approach that considers the barriers and challenges faced by those who experience intersecting and compounding forms of discrimination and bias related to gender, race, and other factors, including sexual orientation, ethnicity, religion, disability, age, and socioeconomic status.  This includes addressing discrimination and bias faced by Black, Latino, and Indigenous and Native American people, Asian Americans, Native Hawaiians, and Pacific Islanders, and other people of color.   Strategic priorities include:   Improving economic security. As we recover from the pandemic, we have the opportunity to build an economy that works for women and their families.  To build back better, we will:

  • Ensure that people have equal access to good jobs, including by addressing persistent gender discrimination and systemic barriers to full workforce participation. 
  • Invest in care infrastructure and care workers to help rebuild the economy and lower costs for working families. 
  • Dismantle the barriers to equal opportunity in education that undermine the ability to compete on a level playing field, recognizing that education affects future economy security.

Preventing and responding to gender-based violence.  Gender-based violence is endemic in homes, schools, workplaces, the military, communities, and online—and far too often a hallmark of conflict and humanitarian crises.  It exacts tremendous costs on the safety, health and economic security of survivors and their families.  To prevent and response to gender-based violence, we will:

  • Work to eliminate gender-based violence wherever it occurs by developing and strengthening national and global laws and policies, investing in comprehensive services for survivors, and increasing prevention efforts. 
  • Address sexual violence in conflict settings; the elevated risk of violence facing women human rights defenders, activists, and politicians; human trafficking both at home and abroad; and the crisis of missing and murdered Indigenous people. 
  • Promote the safety and fair treatment of all people in the justice and immigration systems.

Increasing access to health care.  Health care is a right—not a privilege.  All people deserve access to high-quality, affordable health care, regardless of their zip code, income, ethnicity, race, or any other factor.  To protect, improve, and expand access to health care, we will:

  • Build on the historic work of the Affordable Care Act and continue to expand and improve health care globally. 
  • Defend the constitutional right to safe and legal abortion in the United States, established in Roe v. Wade, and promote access to sexual and reproductive health and rights both at home and abroad. 
  • Address the pernicious effects of health inequity, including by addressing the maternal mortality crisis in the United States, which has a disproportionate impact on Black and Native American women, and by reducing maternal mortality and morbidity abroad.

Advancing democracy, rights and full participation.  Supporting women’s and girls’ full participation in social, economic, civic, and political life—and ensuring they are represented at the tables where decisions are made—is essential to progress in every other area and a precondition to advancing strong and sustainable democracies.  To advance democracy, rights, and full participation, we will:

  • Work to advance gender equity and equality in the law and ensure that rights on paper are fully implemented in practice.  
  • Work towards gender parity and diversity in leadership roles, including in peace processes, national security and defense, global health and humanitarian efforts, and in the private sector. 
  • Promote the leadership of women and girls in addressing the challenge of climate change and seek to close gender gaps in STEM fields so that women and girls can shape the workforce of the future. 

Realizing this bold vision is a government-wide responsibility that cuts across the work of the Biden-Harris Administration in both domestic and foreign affairs.  Implementing this strategy will require the leadership of every White House office and executive agency.  This strategy is not just words on paper; it is a roadmap to deliver results for the American people and our partners around the world. And it builds on the work the Biden-Harris Administration has already done to advance gender equity and equality at home and abroad.  Through the American Rescue Plan, we have provided immediate relief to women and families, fully vaccinating over two-thirds of eligible Americans, reopening schools, providing direct payments to individuals, investing in domestic violence and sexual assault prevention and services, and helping child care providers keep their doors open.  The American Rescue Plan also expanded the Child Tax Credit, distributing monthly payments to tens of millions of American families covering over 60 million children.  Building on the American Rescue Plan, the President’s Bipartisan Infrastructure Deal and Build Back Better Agenda are once-in-a-generation investments to support America’s working families to rebuild the economy and support women and families.  Among its many transformative investments, the budget framework calls for: cutting taxes for middle class families with children, investing in the care economy and the care workforce, and lowering health care costs.  To advance economic security for women and girls globally, we have established a Gender Equity and Equality Action Fund, which supports efforts to address the impact that COVID-19, climate change, conflict, and crisis have on the economic security of women and their families.  And we have restored America’s leadership on the rights of women and girls on the world stage. We have also taken action to prevent and respond to gender-based violence, including through the Independent Review Commission on Sexual Assault and Sexual Harassment in the Military and by directing the Department of Education to review Title IX regulations, guidance, and policies to ensure students receive an education free from sexual violence.  We continue working with Congress on meaningful legislative action, including through championing the landmark Violence Against Women Act, which passed the House in March with bipartisan support, and signing into law the Amendments to the Victims of Crime Act. And we have committed to updating and strengthening our strategy to combat gender-based violence around the world. To advance women’s health around the world, the Biden-Harris Administration has revoked the Global Gag Rule and reinstated funding to the UNFPA.  In the United States, the Administration has called for historic investments to respond to the maternal mortality crisis.  The President also launched a whole-of-government effort to respond to the recent Texas law which blatantly violates women’s constitutional right to a safe and legal abortion under Roe v. Wade .  

To inform our ongoing and future efforts to advance gender equity and equality at home and abroad, the strategy calls for continued accountability, consultation, and engagement as we work towards our collective vision for gender equity and equality at home and abroad.  Its implementation will guide strategic planning and budgeting, policy and program development, measurement and data, and management and training.  We look forward to partnering with Congress, local, state, Tribal, and territorial governments, civil society, the private sector, foreign governments, and multilateral institutions to drive progress towards the objectives outlined in this strategy.  In doing so, we will advance economic growth, health and safety, and the security of our nation and the world.

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Why the largest transgender survey ever could be a powerful rebuke to myths, misinformation

gender reassignment usa

When Ashton Holmes saw the results of the largest-ever transgender survey in the U.S ., the data elicited ripples of joy: “It made my heart happy.”

The survey by the National Center for Transgender Equality of over 92,000 binary and nonbinary transgender people offers a window into a world often clouded by misconceptions. Nearly all respondents – 94% − said they were satisfied with their lives after transitioning.  

Holmes, 39, a Black transgender man who navigates life with a “let’s love on each other” philosophy, says the statistics give powerful proof “that people are satisfied when they are seen, when they are affirmed.”

Transgender advocates are hoping the data not only shows that validation − but also cuts through a tornado of misinformation about transgender people that has swirled in the past few years.

“This survey is tremendously significant for the quality, the quantity and frankly the timing,” says Cathy Renna, communications director for the National LGBTQ Task Force. “We could not need this more than we do right now.”

Rights of transgender people are in the crosshairs

The survey, released earlier this month. lands as the rights of transgender people continue to be in the crosshairs: About 130 bills targeting the community have been filed in 2024 in statehouses, according to the Human Rights Campaign. Last year saw 225 bills.

As the community, particular youths, “face increased attacks on our ability to access health care, public facilities and other fundamental aspects of life, these findings serve as a critical resource,” said Rodrigo Heng-Lehtinen, executive director of the National Center for Transgender Equality, which conducted the U.S. Trans Survey in partnership with other groups. The NCTE is a national organization that advocates for understanding and acceptance of transgender people.

The survey also showed that nearly all respondents, or 98%, reported that receiving hormone treatments for their transition resulted in greater satisfaction with their lives.

And nearly half – 47% − said they have considered moving to another state because their state passed or was weighing legislation that targeted transgender people for unequal treatment.    

Renna said the data is going to be a “101 for allies” – those who have transgender people in their lives and have questions. “Instead of having them find a sea of misinformation, myths and stereotypes, they are going to find the lived realities of trans people.”

Real-world data to help support families

Laura Hoge, a clinical social worker in New Jersey who works with transgender people and their families, said the survey results underscore what she sees in her daily practice: that lives improve when access to something as basic as gender-affirming care is not restricted.

“I see children who come here sometimes not able to go to school or are completely distanced from their friends,” she said. “And when they have access to care they can go from not going to school to trying out for their school play.”

Every time misinformation about transgender people surfaces, Hoge says she is flooded with phone calls.

The survey now gives real-world data to lived experiences of transgender people and how their lives are flourishing, she said. “I can tell you that when I talk to families I am able to say to them: This what other people in your child’s situation or in your situation are saying.”

Gender-affirming care has been a target of state bills

Gender-affirming care , which can involve everything from talk sessions to hormone therapy, in many ways has been ground zero in recent legislative debates over the rights of transgender people.  

A poll by the Trevor Project, which provides crisis and suicide prevention services to LGBTQ people under 25, found that 85% of trans and nonbinary youths say even the debates about these laws have negatively impacted their mental health.

In January, the Ohio Senate overrode the governor’s veto of legislation that restricted medical care for transgender young people.

The bill prohibits doctors from prescribing hormones, puberty blockers or gender reassignment surgery before patients turn 18 and requires mental health providers to get parental permission to diagnose and treat gender dysphoria.

Backers of the bill said it was needed to protect the state’s children. One lawmaker, state Sen. Kristina Roegner, disputed whether transgender people even exist : “There is no such thing as gender-affirming care. You can’t affirm something that doesn’t exist," she said. 

Florida Gov. Ron DeSantis, whose state restricts gender-affirming care , also has said “ a lot of the dysphoria resolves itself by the time” young people become adults.

Transgender advocates say not only are those kinds of statements false, but they make the case for the urgency of the national survey.

“It is astounding that people can say things like that,” Renna said. ”That’s why you need this, why you need data − especially when what you are dealing with is not just ignorance: It is a concerted effort to erase transgender and nonbinary people.”

A 'coordinated campaign that is good at confusing people'

Heng-Lehtinen says many of the anti-transgender policies in states are based on “fearmongering” to “exploit the public’s relative unfamiliarity with transgender people.”

Some organizations use names that appear to be legitimate and can mislead the public, Hoge said, citing one such example: The American College of Pediatricians (ACPeds), which has a name similar to the American Academy of Pediatrics (AAP).

AAP, which was founded in 1930 and has about 67,000 members, is a major medical association and one that supports gender-affirming care .

ACPeds, which was founded in 2002 and says it has about 600 members, has been designated an anti-LGBTQ hate group by the Southern Poverty Law Center. The group links gender incongruence on its website with mental illness.

When asked to comment on whether the national transgender survey refutes claims made by ACPeds, past president Quentin Van Meter said the group supports the belief that “realigning the personal identity and physical body to accommodate an incongruent gender identity” in youths can cause harm.

Other major medical groups – from the American Medical Association to the American Psychiatric Association – disagree and have lined up in support of gender-affirming care and against bills that criminalize it in recent years.

Hoge says it is a pivotal time to call out entities that push debunked science. “There is a very coordinated and strategic campaign that is good at confusing people. You have these very confusing named organizations that sound reputable,” she said. “But it’s connected to a larger movement that has strong ties to anti-LGBTQ sentiments.”

Misinformation 'dehumanizes' transgender people

Holmes left his South Carolina roots for Ohio in 2020. The Dayton resident says he has been fortunate to find resources to help with his transition, from medical to legal.  

Believing people’s stories is crucial, Holmes says. He recalls his first meeting with an endocrinologist who told him to “just talk” – which he did for almost an hour. The doctor then told him: “I believe you, and I’m going to help you.”

He also points to “misconceptions” about what it means to be transgender. “We aren’t a monolith. Who I am as a person is not the same as some of my other trans siblings.” 

Holmes says he knows there are times when he is the first transgender person someone has met, and his motto is just to “be human to them.” He will hear a familiar response of “well I didn’t know.” His answer: “You aren’t supposed to know.”

That is why the national transgender survey is so significant, he said. Misinformation “dehumanizes us,” he said. “When we can come together and respect and value each other, this is what this does: We have people that are happy. If can make this path, this road a little bit easier for this person, let’s do it. Let people have experiences they thought they could never have.”

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The US Census Bureau will test new questions for its American Community Survey.

US Census Bureau to trial questions on gender identity and sexual orientation

Test questions will be sent to 480,000 households for possible inclusion in the American Community Survey

The US Census Bureau this year plans to test questions about sexual orientation and gender identity for its most comprehensive survey of American life.

The test questions will be sent to 480,000 households, with the statistical agency expecting just over half to respond.

If the questions are approved, it will be the first time sexual orientation and gender identity questions are asked on the American Community Survey, which already asks questions about commuting times, internet access, family life, income, education levels, disabilities and military service, among other topics.

During the test, people will be able to respond to the questions online, by mail, over the phone or through in-person interviews. People who fill out the American Community Survey form typically answer the questions for the other members of their household in what is called a proxy response.

Given privacy concerns, the agency is proposing using flash cards for in-person interviews and using numbered response categories for people who don’t want others in their household to know their responses.

A look at the the proposed test questions:

For everyone:

Gender question one: What sex was Name assigned at birth?

Possible answers: Male; female.

For people age 15 and older:

Gender question two: What is Name’s current gender?

Possible answers: Male; Female; Transgender; Nonbinary; and “This person uses a different term” (with a space to write in a response).

The second gender question will be tested in two different ways to determine whether to give respondents the opportunity to select multiple answers.

Responses to the questions that allow people to select multiple categories will be compared with responses allowing only one answer.

The agency also plans to add what it describes as a “verification” question for anyone whose responses on the two gender questions don’t match.

Sexual orientation question: Which of the following best represents how Name thinks of themselves?

Possible answers: Gay or lesbian; Straight – that is not gay or lesbian; Bisexual; and This person uses a different term (with space to write-in a response).

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Proposed questions on sexual orientation and gender identity for the Census Bureau’s biggest survey

FILE - Pride flags are held at the Tennessee Capitol, Jan. 22, 2024, in Nashville, Tenn. Dozens of health officials, civil rights groups, individuals and businesses have weighed in about how the U.S. Census Bureau should ask about sexual orientation and gender identity for the first time on its most comprehensive survey of American life. An Associated Press review of the 91 written public comments posted in January 2024 shows them to be largely supportive of the proposed additions, though not without constructive criticism. (AP Photo/George Walker IV, File)

FILE - Pride flags are held at the Tennessee Capitol, Jan. 22, 2024, in Nashville, Tenn. Dozens of health officials, civil rights groups, individuals and businesses have weighed in about how the U.S. Census Bureau should ask about sexual orientation and gender identity for the first time on its most comprehensive survey of American life. An Associated Press review of the 91 written public comments posted in January 2024 shows them to be largely supportive of the proposed additions, though not without constructive criticism. (AP Photo/George Walker IV, File)

gender reassignment usa

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The U.S. Census Bureau this year plans to test questions about sexual orientation and gender identity for its most comprehensive survey of American life.

The test questions will be sent to 480,000 households, with the statistical agency expecting just over half to respond.

If the questions are approved, it will be the first time sexual orientation and gender identity questions are asked on the American Community Survey , which already asks questions about commuting times, internet access, family life, income, education levels, disabilities and military service, among other topics.

During the test, people will be able to respond to the questions online, by mail, over the phone or through in-person interviews. People who fill out the American Community Survey form typically answer the questions for the other members of their household in what is called a proxy response.

In combo of undated selfie images provided courtesy of the Dime Doe family, show Dime Doe, a Black transgender woman. Doe's August 2019 death is now the subject of a first-of-its-kind federal hate crimes trial that began this week in Columbia, S.C. (Courtesy Dime Doe Family via AP)

Given privacy concerns, the agency is proposing using flash cards for in-person interviews and using numbered response categories for people who don’t want others in their household to know their responses.

A look at the the proposed test questions:

For everyone:

Gender question one: What sex was Name assigned at birth?

Possible answers: Male; female.

For people age 15 and older:

Gender question two: What is Name’s current gender?

Possible answers: Male; Female; Transgender; Nonbinary; and “This person uses a different term” (with a space to write in a response).

The second gender question will be tested in two different ways to determine whether to give respondents the opportunity to select multiple answers.

Responses to the questions that allow people to select multiple categories will be compared with responses allowing only one answer.

The agency also plans to add what it describes as a “verification” question for anyone whose responses on the two gender questions don’t match.

Sexual orientation question: Which of the following best represents how Name thinks of themselves?

Possible answers: Gay or lesbian; Straight — that is not gay or lesbian; Bisexual; and This person uses a different term (with space to write-in a response).

Follow Mike Schneider on X: @MikeSchneiderAP .

MIKE SCHNEIDER

KUTV Salt Lake City

Utah representative proposes gender reassignment surgery benefits for state employees

U tah State Rep. Sahara Hayes (D- Salt Lake) has introduced a joint resolution aimed at providing gender reassignment surgery health benefits to the state of Utah's 22,000 employees.

Hayes's proposal highlights the need for Utah to match the benefits offered in the private sector and other states to prevent the loss of valuable talent.

MORE: Vested-interest Utahns provide closer look at ban on gender-affirming care for trans youth

The resolution proposed by Hayes outlines specific criteria for eligibility: state employees and adult beneficiaries who have presented as their desired gender for at least 12 months, been diagnosed with gender dysphoria, undergone hormone treatment, and legally changed their name would qualify for the gender reassignment surgery benefits.

"I think, at the end of the day, it's not necessarily about values; it's about who people are and getting the care that they need," Hayes said.

Sorry, we couldn't load this embedded content

Hayes said she is concerned about retaining talented state employees who might leave for jobs elsewhere that offer the care they need.

"These are the people who are on the ground and making our state run, and I want them to have the best experience possible and the care that they need," Hayes added.

The Movement Advancement Project reports that 26 states are currently offer gender-affirming care benefits to state employees. The proposed policy in Utah is estimated to cost the state about $384,000 a year.

MORE: Sen. Mike Lee proposes bill to ban federal funding for youth gender transition research

"Even if it doesn't apply to people, even if they don't personally understand it, that doesn't make it less important," Hayes said.

Sue Robbins of Equality Utah said the negative impact of laws impacts the transgender community.

"If you have laws that go against the transgender community, then you start to say you're not welcome," she said.

A spokesperson for the House Majority Caucus said they have yet to review the legislation. The legislative session starts on Jan. 16.

Utah representative proposes gender reassignment surgery benefits for state employees

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COMMENTS

  1. National Estimates of Gender-Affirming Surgery in the US

    Oles N, Darrach H, Landford W, et al. Gender affirming surgery: a comprehensive, systematic review of all peer-reviewed literature and methods of assessing patient-centered outcomes (part 1: breast/chest, face, and voice).  . 2022;275 (1):e52-e66. doi: 10.1097/SLA.0000000000004728 PubMed Google Scholar Crossref 3.

  2. Gender Surgeons In the United States

    Learn about Surgeons in the U.S. who offer Male to Female (MTF) and Female to Male (FTM) procedures, also known as Gender Confirmation Surgery (GCS), Sex Reassignment Surgery (SRS) or Gender Reassignment Surgery (GRS). Dr. Gabriel Del Corral

  3. Age restriction lifted for gender-affirming surgery in new

    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.

  4. What Is Gender-Affirming Care, and Which States Have Restricted it

    Republican Gov. Jim Pillen signed into law on May 22 a bill that prohibits gender-affirming medical care for minors, which covers people under the age of 19 in Nebraska. The law, which also bans ...

  5. Center for Transgender and Gender Expansive Health

    The Johns Hopkins Center for Transgender and Gender Expansive Health offers comprehensive, evidence-based and affirming care for transgender youth and adults that is in line with the standards of care set by the World Professional Association for Transgender Health (WPATH). We offer services for children and adolescents, dermatology, facial ...

  6. Gender-Affirming-Care Bans Are Spreading Across the U.S

    Eight states already have gender-affirming-care bans in place for people under the age of 18, ... Iowa prohibited gender-reassignment procedures and prescriptions, and two of Florida's State ...

  7. Americans' Complex Views on Gender Identity and Transgender Issues

    The public is divided over the extent to which our society has accepted people who are transgender: 38% say society has gone too far in accepting them, while a roughly equal share (36%) say society hasn't gone far enough. About one-in-four say things have been about right.

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

    KFF Headquarters: 185 Berry St., Suite 2000, San Francisco, CA 94107 | Phone 650-854-9400 Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone ...

  9. The story of the nation's first clinic for gender-affirming surgery

    Nicolas AsfouriAFP/Getty Images. N early 60 years ago, Johns Hopkins Hospital opened a first-of-its-kind clinic to provide gender-affirming surgery. The Gender Identity Clinic blazed a new trail ...

  10. National Trends in Gender-Affirming Surgical Procedures: A Google

    Approximately 1.4 million transgender and non-binary (TGNB) adults and 150,000 TGNB adolescents and young adults live in the United States (US) [ 1 ]. Gender-affirming surgery (GAS) has become increasingly performed over the past five years for this growing patient population [ 2 ].

  11. The Transgender Laws States Passed This Year

    June 27, 2023 Statehouses around the country this year have been consumed by fights over laws governing transgender people. Seventeen states during their most recent legislative sessions passed...

  12. Transgender rights in the United States

    The ban on Medicare coverage for gender reassignment surgery was repealed by the US Department of Health and Human Services in 2014. Insurance companies, however, still hold the authority to decide whether the procedures are a medical necessity. Thus, insurance companies can decide whether they will provide Medicare coverage for the surgeries.

  13. Gender Confirmation Surgery

    Gender confirmation surgery (GCS), known clinically as genitoplasty, are procedures that surgically confirm a person's gender by altering the genitalia and other physical features to align with their desired physical characteristics. Gender confirmation surgeries are also called gender affirmation procedures. These are both respectful terms.

  14. U.S. Gender-Affirming Surgeries Nearly Tripled in 3 Years

    WEDNESDAY, Aug. 23, 2023 (HealthDay News) -- The number of Americans undergoing gender-affirming surgery is on the rise, new research reveals, almost tripling between 2016 and 2019 alone. During ...

  15. Gender-affirming surgeries in US nearly tripled from 2016 to 2019 ...

    LGBTQ Rights Milestones Fast Facts. The number of gender-affirming surgeries rose from 4,552 in 2016 to 13,011 in 2019, declining only slightly to 12,818 during the first year of the Covid-19 ...

  16. Here are the states where you can (and cannot) change your gender

    Maine Maryland Massachusetts Michigan Minnesota Nevada New Hampshire New Jersey New Mexico New York Oregon Pennsylvania Rhode Island Vermont

  17. Putting numbers on the rise in children seeking gender care

    About 42,000 U.S. children ages 6 to 17 were diagnosed with gender dysphoria in 2021, nearly triple the number in 2017, a unique data analysis for Reuters found.

  18. Guidelines lower minimum age for gender transition treatment and

    Published 6:00 AM PST, June 15, 2022 A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

  19. Gender-affirming surgery

    Gender-affirming surgery is a surgical procedure, or series of procedures, that alters a person's physical appearance and sexual characteristics to resemble those associated with their identified gender.

  20. As children line up at gender clinics, families confront many unknowns

    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 ...

  21. Gender-affirming surgeries nearly triple as states enact restrictions

    Louisiana, Texas, Missouri, Florida and Nebraska are among states that passed legislation restricting gender-reassignment operations among minors or limiting other gender-affirming care. In all ...

  22. Fact Sheet: National Strategy on Gender Equity and Equality

    Statements and Releases The Biden-Harris Administration issues first-ever national gender strategy to advance the full participation of all people - including women and girls - in the United...

  23. 19 states have laws restricting gender-affirming care, some with the

    This year has been record shattering for anti-LGBTQ legislation, with particular scrutiny on gender-affirming health care access for transgender children and teenagers.Nineteen states have passed ...

  24. Transgender survey: Can the largest ever rebuke myths ...

    When Ashton Holmes saw the results of the largest-ever transgender survey in the U.S., the data elicited ripples of joy: "It made my heart happy." The survey by the National Center for ...

  25. US Census Bureau to trial questions on gender identity and sexual

    The US Census Bureau this year plans to test questions about sexual orientation and gender identity for its most comprehensive survey of American life.. The test questions will be sent to 480,000 ...

  26. Proposed questions on sexual orientation and gender identity for the

    The U.S. Census Bureau this year plans to test questions about sexual orientation and gender identity for its most comprehensive survey of American life.. The test questions will be sent to 480,000 households, with the statistical agency expecting just over half to respond. If the questions are approved, it will be the first time sexual orientation and gender identity questions are asked on ...

  27. Utah representative proposes gender reassignment surgery benefits ...

    U tah State Rep. Sahara Hayes (D- Salt Lake) has introduced a joint resolution aimed at providing gender reassignment surgery health benefits to the state of Utah's 22,000 employees.. Hayes's ...