Katherine Imborek, MD, has seen the gender-affirming care provided at UI Health Care’s LGBTQ Clinic in Iowa City change the lives of transgender youths and adults. “It decreases depression, anxiety, and suicide attempts,” says Imborek, co-director of the clinic. To her, that care is “a medical necessity, like providing insulin to a person with diabetes.”
But a growing number of lawmakers, including in Iowa, view some gender-affirming care as medically unsound for youths and even a form of child abuse. Iowa is among 15 states that have enacted or are considering laws to prohibit certain gender-affirming treatments for youths and to impose penalties on health care professionals who provide it, according to the Williams Institute at the UCLA School of Law in California.
The state actions focus on specific therapies under the umbrella of gender-affirming care: hormone-related treatments that delay puberty or promote development of masculine or feminine sex characteristics. Alabama Gov. Kay Ivey signed a bill last week that prohibits doctors from providing those treatments, while an order declaring those procedures illegal in Texas was halted last month by a court injunction pending the intervention of the state Supreme Court. The AAMC joined other medical organizations in an amicus brief opposing the Texas order, arguing that extensive scientific evidence exists to support those therapies and that the law would force doctors to risk endangering their patients by not providing that care.
To put the controversy in context, several experts explain gender-affirming care. “It’s not just medication. It’s much deeper than that,” says Jason Rafferty, MD, MPH, a pediatrician and child psychiatrist who provides gender-affirming care at the Gender and Sexuality Clinic at Hasbro Children’s Hospital in Providence, Rhode Island.
What is gender-affirming care?
Gender-affirming care, as defined by the World Health Organization, encompasses a range of social, psychological, behavioral, and medical interventions “designed to support and affirm an individual’s gender identity” when it conflicts with the gender they were assigned at birth. The interventions help transgender people align various aspects of their lives — emotional, interpersonal, and biological — with their gender identity. As noted by the American Psychiatric Association (APA), that identity can run anywhere along a continuum that includes man, woman, a combination of those, neither of those, and fluid.
The interventions fall along a continuum as well, from counseling to changes in social expression to medications (such as hormone therapy). For children in particular, the timing of the interventions is based on several factors, including cognitive and physical development as well as parental consent. Surgery, including to reduce a person’s Adam’s Apple, or to align their chest or genitalia with their gender identity, is rarely provided to people under 18.
“The goal is not treatment, but to listen to the child and build understanding — to create an environment of safety in which emotions, questions, and concerns can be explored,” says Rafferty, lead author of a policy statement from the American Academy of Pediatrics (AAP) on gender-affirming care.
Why do youths seek gender-affirming care?
Some children sense a difference between their assigned gender and their gender identity at an early age, says Deanna Adkins, MD, director of the Duke Child and Adolescent Gender Care Clinic in Durham, North Carolina. By the time an adolescent or teenager comes to the clinic to talk about gender-affirming therapy, “they’ve typically been thinking about it for a long time,” says Adkins, whose clinic is part of Duke University Hospital.
Those who seek gender-affirming care are often experiencing gender dysphoria, which the APA cites as “psychological distress” stemming from the incongruence between gender assignment and identity. Although many transgender people feel this distress without being diagnosed by a doctor, gender dysphoria is a defined clinical condition in the APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM). The symptoms include “strong” desires to have the primary or secondary sex characteristics of another gender and to be treated as another gender, as well as “significant distress or impairment in social, occupational, or other important areas of functioning.”
Numerous studies have found that transgender youths, especially those experiencing gender dysphoria, are significantly more likely than other youths to suffer emotional distress and depression, to experience bullying and other forms of violence, and to harm themselves or attempt suicide. For example, a study led by the University of Minnesota of nearly 82,000 students in that state found that 61% of transgender youths reported suicidal ideation, more than three times the rate among cisgender youths.
In school, gender dysphoric youths often struggle to succeed socially and academically “due to pressure to dress in a way that’s associated with their sex assigned at birth or out of fear of being harassed or teased,” the Minnesota-based Mayo Clinic reports. When it comes to getting help, Mayo notes, “Accessing health services and mental health services can be difficult due to fear of stigma and a lack of experienced care providers.”
What types of emotional, social, and psychological care are available?
The fundamental thing that transgender people seek from health providers “is someone who’s culturally and medically competent to care for them in an environment where they feel safe,” says Imborek, whose LGBTQ Clinic is part of University of Iowa Hospitals and Clinics. “The primary care I provide is a gender-affirming environment.”
That environment allows for frank discussions about the patient’s gender identity and related stress, sexual activity, and potential transition toward a different gender identity. A young person’s stages of physical and psychological development are major factors in determining which interventions (if any) are most appropriate and when.
Most of the care — especially the more intensive care — is provided to youths during or after puberty. The World Professional Association for Transgender Health (WPATH) Standards of Care observes that “gender dysphoria during childhood does not inevitably continue into adulthood,” and “the persistence of gender dysphoria into adulthood appears to be much higher for adolescents.”
The transition supports might start with cosmetic changes and move toward more intensive interventions, drawing on an array of physicians, mental health counselors, and non-medical caregivers. That care includes:
- Counseling about coming out as transgender to family, peers, and others (such as teachers).
- Resources to assist with changing outward appearances and gender presentation. For example, IU Health Care’s LGBTQ Clinic refers interested patients to the hair salon at the university hospital for hair and makeup lessons, Imborek says.
- Speech therapy to help match vocal characteristics (such as pitch and phrasing patterns) with gender identity.
- Hair removal through electrolysis, laser treatment, or waxing.
- Breast binding or padding, genital tucking, and padding of the hips or buttocks.
Specialists who provide this care stress that these interventions are reversible. Young people sometimes stop a process to reassess their identity or because they’ve transitioned to a point that feels right.
What hormone-related therapies are available?
Puberty blockers: Transgender youths who have not started or completed puberty can receive “puberty blocker” medication, which suppresses the release of sex hormones, including testosterone and estrogen. The Mayo Clinic explains that for those identified as male at birth, “the blockers decrease the growth of facial and body hair, prevent voice deepening, and limit the growth of genitalia.” For those identified as female at birth, “the treatment limits or stops breast development and stops menstruation.”
One purpose of puberty blockers is to allow a young person time to fully determine their gender identity and how far they wish to transition before the onset of permanent sex characteristics.
“They’re usually used in early puberty to slow things down,” Rafferty says. “They [the youths] haven’t had much of an option to explore who they are. They’re coming in and saying, ‘Something doesn’t feel right’” about their assigned gender.
If puberty blockers are stopped during puberty, hormone development resumes until the end of that child’s puberty, Rafferty says. Blockers are typically not initiated after a child finishes puberty, he explains, because they are not necessary and some of the blocked hormones are necessary for healthy adult development (such as estrogen for bone strength).
Hormone therapy: Older youths (usually in mid-adolescence) and adults can receive hormone therapy to increase their levels of estrogen or testosterone so that they develop sex characteristics more closely aligned with their gender identity. These include more hair growth and increased muscle mass for those transitioning to a more masculine presentation, and breast development and testicular atrophy for those transitioning to a more feminine presentation.
The changes occur slowly, and Rafferty notes that it’s not unusual for patients to stop hormone therapy before the secondary sex characteristics fully develop, deciding that they have biologically transitioned as far as they wish. He adds that depending on when the treatments stop, some of the effects partially or completely reverse, such as broadening of the shoulders for those taking male hormones and early breast development for those taking female hormones.
How is it determined that someone needs and is eligible for these procedures?
Criteria for gender-affirming care and therapy are provided in guidelines from several organizations, including the WPATH, the AAP, and the Endocrine Society. The WPATH Standards of Care caution that “before any physical interventions are considered for adolescents, extensive exploration of psychological, family, and social issues should be undertaken.”
“Some people come in in a questioning phase, and we just take our time and they work with the therapist,” says Imborek at the Iowa clinic. “They lean into trying to figure out where their gender dysphoria lies and whether or not hormones would make that better.”
Among the criteria that are typical for providing hormone-related therapies for youths are:
- A finding that the youth has experienced several symptoms of gender dysphoria listed in the DSM for at least six consecutive months.
- A letter of support from the youth’s licensed therapist and written concurrence from a mental health professional for the provider.
- Parental consent for those under 18.
- Ongoing psychotherapy.
For youths in particular, providers must ensure that the patients understand the permanent nature of some of the changes and potential harmful side effects that might affect their lives years into adulthood (such as infertility). In supporting Gov. Abbot’s order in Texas, Attorney General Ken Paxton issued an opinion citing the potential risks — including infertility, cardiovascular disease, and elevated blood pressure — as reasons that the therapies violate child abuse laws.
What is the impact of the therapies?
Studies have linked gender-affirming care at various levels to a decrease in depression and harmful behaviors. For example, a study from the Stanford University School of Medicine in California, published in January, concluded that those who began hormone therapy in adolescence experienced less suicidal ideation, fewer mental health disorders, and less substance abuse than those who began such therapy later.
The WPATH says there is insufficient evidence about the long-term outcomes among younger children who receive those therapies.
The Texas attorney general’s opinion contends all the evidence is insufficient, stating, “There is no evidence that long-term mental health outcomes are improved or that rates of suicide are reduced by hormonal or surgical intervention.”
Providers attest to seeing positive changes in their patients from gender-affirming care. “Most of them are happier, less depressed, and less anxious,” says Adkins at the Duke Child and Adolescent Gender Care Clinic. “Their schoolwork often improves, their safety often improves.”
“Saving their lives is a big deal.”
Regardless of state government efforts against some treatments, Rafferty urges doctors to focus on all types of gender affirmation as essential health care:
“It’s important for providers to know that what they do, even if it’s just affirming someone’s [asserted] name, can have a positive influence on the health and development of that child. This support has to take place within a clinic. It’s not something that can be legislated.”