gender reassignment surgery for minors

Putting numbers on the rise in children seeking gender care

By ROBIN RESPAUT and CHAD TERHUNE

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

Thousands of children in the United States now openly identify as a gender different from the one they were assigned at birth, their numbers surging amid growing recognition of transgender identity and rights even as they face persistent prejudice and discrimination.

As the number of transgender children has grown, so has their access to gender-affirming care, much of it provided at scores of clinics at major hospitals.

Reliable counts of adolescents receiving gender-affirming treatment have long been guesswork – until now. Reuters worked with health technology company Komodo Health Inc to identify how many youths have sought and received care. The data show that more and more families across the country are grappling with profound questions about what type of care to pursue for their children, placing them at the center of a vitriolic national political debate over what it means to protect youth who identify as transgender.

Diagnoses of youths with gender dysphoria surge

In 2021, about 42,000 children and teens across the United States received a diagnosis of gender dysphoria, nearly triple the number in 2017, according to data Komodo compiled for Reuters. Gender dysphoria is defined as the distress caused by a discrepancy between a person’s gender identity and the one assigned to them at birth.

Overall, the analysis found that at least 121,882 children ages 6 to 17 were diagnosed with gender dysphoria from 2017 through 2021. Reuters found similar trends when it requested state-level data on diagnoses among children covered by Medicaid, the public insurance program for lower-income families.

Gender-affirming care for youths takes several forms, from social recognition of a preferred name and pronouns to medical interventions such as hormone therapy and, sometimes, surgery. A small but increasing number of U.S. children diagnosed with gender dysphoria are choosing medical interventions to express their identity and help alleviate their distress.

These medical treatments don’t begin until the onset of puberty, typically around age 10 or 11.

For children at this age and stage of development, puberty-blocking medications are an option. These drugs, known as GnRH agonists, suppress the release of the sex hormones testosterone and estrogen. The U.S. Food and Drug Administration has approved the drugs to treat prostate cancer, endometriosis and central precocious puberty, but not gender dysphoria. Their off-label use in gender-affirming care, while legal, lacks the support of clinical trials to establish their safety for such treatment.

Over the last five years, there were at least 4,780 adolescents who started on puberty blockers and had a prior gender dysphoria diagnosis.

This tally and others in the Komodo analysis are likely an undercount because they didn’t include treatment that wasn’t covered by insurance and were limited to pediatric patients with a gender dysphoria diagnosis. Practitioners may not log this diagnosis when prescribing treatment.

By suppressing sex hormones, puberty-blocking medications stop the onset of secondary sex characteristics, such as breast development and menstruation in adolescents assigned female at birth. For those assigned male at birth, the drugs inhibit development of a deeper voice and an Adam’s apple and growth of facial and body hair. They also limit growth of genitalia.

Without puberty blockers, such physical changes can cause severe distress in many transgender children. If an adolescent stops the medication, puberty resumes.

The medications are administered as injections, typically every few months, or through an implant under the skin of the upper arm.

After suppressing puberty, a child may pursue hormone treatments to initiate a puberty that aligns with their gender identity. Those for whom the opportunity to block puberty has already passed or who declined the option may also pursue hormone therapy.

At least 14,726 minors started hormone treatment with a prior gender dysphoria diagnosis from 2017 through 2021, according to the Komodo analysis.

Hormones – testosterone for adolescents assigned female at birth and estrogen for those assigned male – promote development of secondary sex characteristics. Adolescents assigned female at birth who take testosterone may notice that fat is redistributed from the hips and thighs to the abdomen. Arms and legs may appear more muscular. The brow and jawline may become more pronounced. Body hair may coarsen and thicken. Teens assigned male at birth who take estrogen may notice the hair on their body softens and thins. Fat may be redistributed from the abdomen to the buttocks and thighs. Their testicles may shrink and sex drive diminish. Some changes from hormone treatment are permanent.

Hormones are taken in a variety of ways: injections, pills, patches and gels. Some minors will continue to take hormones for many years well into adulthood, or they may stop if they achieve the physical traits they want.

Hormone treatment may leave an adolescent infertile, especially if the child also took puberty blockers at an early age. That and other potential side effects are not well-studied, experts say.

The ultimate step in gender-affirming medical treatment is surgery, which is uncommon in patients under age 18. Some children’s hospitals and gender clinics don’t offer surgery to minors, requiring that they be adults before deciding on procedures that are irreversible and carry a heightened risk of complications.

The Komodo analysis of insurance claims found 56 genital surgeries among patients ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021. Among teens, “top surgery” to remove breasts is more common. In the three years ending in 2021, at least 776 mastectomies were performed in the United States on patients ages 13 to 17 with a gender dysphoria diagnosis, according to Komodo’s data analysis of insurance claims. This tally does not include procedures that were paid for out of pocket.

A note on the data

Komodo’s analysis draws on full or partial health insurance claims for about 330 million U.S. patients over the five years from 2017 to 2021, including patients covered by private health plans and public insurance like Medicaid. The data include roughly 40 million patients annually, ages 6 through 17, and comprise health insurance claims that document diagnoses and procedures administered by U.S. clinicians and facilities.

To determine the number of new patients who initiated puberty blockers or hormones, or who received an initial dysphoria diagnosis, Komodo looked back at least one year prior in each patient’s record. For the surgery data, Komodo counted multiple procedures on a single day as one procedure.

For the analysis of pediatric patients initiating puberty blockers or hormones, Komodo searched for patients with a prior gender dysphoria diagnosis. Patients with a diagnosis of central precocious puberty were removed. A total of 17,683 patients, ages 6 through 17, with a prior gender dysphoria diagnosis initiated either puberty blockers or hormones or both during the five-year period. Of these, 4,780 patients had initiated puberty blockers and 14,726 patients had initiated hormone treatment.

Youth in Transition

By Robin Respaut and Chad Terhune

Photo editing: Corrine Perkins

Art direction: John Emerson

Edited by Michele Gershberg and John Blanton

• Follow Reuters Investigates

Other Reuters investigations

• Election 2024
• Entertainment
• Newsletters
• Photography
• AP Buyline Personal Finance
• AP Buyline Shopping
• Press Releases
• Israel-Hamas War
• Russia-Ukraine War
• Global elections
• Asia Pacific
• Latin America
• Middle East
• Delegate Tracker
• AP & Elections
• 2024 Paris Olympic Games
• Auto Racing
• Movie reviews
• Book reviews
• Financial Markets
• Business Highlights
• Financial wellness
• Artificial Intelligence
• Social Media

Trans kids’ treatment can start younger, new guidelines say

This photo provided by Laura Short shows Eli Bundy on April 15, 2022 at Deception Pass in Washington. In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy hopes to get breast removal surgery next year before college. Bundy, 18, who identifies as nonbinary, supports updated guidance from an international transgender health group that recommends lower ages for some treatments. (Laura Short via AP)

FILE - Dr. David Klein, right, an Air Force Major and chief of adolescent medicine at Fort Belvoir Community Hospital, listens as Amanda Brewer, left, speaks with her daughter, Jenn Brewer, 13, as the teenager has blood drawn during a monthly appointment for monitoring her treatment at the hospital in Fort Belvoir, Va., on Sept. 7, 2016. Brewer is transitioning from male to female. (AP Photo/Jacquelyn Martin, File)

• Copy Link copied

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

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

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

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

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

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

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

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

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

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

Psychologist Erica Anderson resigned her post as a board member of the World Professional Association for Transgender Health last year after voicing concerns about “sloppy” treatment given to kids without adequate counseling.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The update also recommends:

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

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

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

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

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

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

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

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

Follow AP Medical Writer Lindsey Tanner at @LindseyTanner.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

Young Children Do Not Receive Medical Gender Transition Treatment

By Kate Yandell

Posted on May 22, 2023

SciCheck Digest

Families seeking information from a health care provider about a young child’s gender identity may have their questions answered or receive counseling. Some posts share a misleading claim that toddlers are being “transitioned.” To be clear, prepubescent children are not offered transition surgery or drugs.

Some children  identify  with a gender that does not match their sex assigned at birth. These children are referred to as transgender, gender-diverse or gender-expansive. Doctors will listen to children and their family members, offer information, and in some cases connect them with mental health care, if needed.

But for children who have not yet started puberty, there are  no recommended  drugs, surgeries or other gender-transition treatments.

Recent social media  posts   shared  the misleading  claim  that medical institutions in North Carolina are “transitioning toddlers,” which they called an “experimental treatment.” The posts referenced a  blog post  published by the Education First Alliance, a conservative nonprofit in North Carolina that says  many schools are engaging in “ideological indoctrination” of children and need to be reformed.

The group has advocated the passage of a North Carolina bill  to restrict medical gender-transition treatment before age 18. There are now  18 states  that have taken action to restrict  medical transition treatments  for  minors .

A widely shared  article  from the Epoch Times citing the blog post bore the false headline: “‘Transgender’ Toddlers as Young as 2 Undergoing Mutilation/Sterilization by NC Medical System, Journalist Alleges.” The Epoch Times has a history of publishing misleading or false claims. The article on transgender toddlers then disappeared from the website, and the Epoch Times published a new  article  clarifying that young children are not receiving hormone blockers, cross-sex hormones or surgery. 

Representatives from all three North Carolina institutions referenced in the social media posts told us via emailed statements that they do not offer surgeries or other transition treatments to toddlers.

East Carolina University, May 5: ECU Health does not offer gender affirming surgery to minors nor does the health system offer gender affirming transition care to toddlers.

ECU Health elaborated that it does not offer puberty blockers and only offers hormone therapy after puberty “in limited cases,” as recommended in national guidelines and with parental or guardian consent. It also said that it offers interdisciplinary gender-affirming primary care for LGBTQ+ patients, including access to services such as mental health care, nutrition and social work.

“These primary care services are available to any LGBTQ+ patient who needs care. ECU Health does not provide gender-related care to patients 2 to 4 years old or any toddler period,” ECU said.

University of North Carolina, May 12: To be clear: UNC Health does not offer any gender-transitioning care for toddlers. We do not perform any gender care surgical procedures or medical interventions on toddlers. Also, we are not conducting any gender care research or clinical trials involving children. If a toddler’s parent(s) has concerns or questions about their child’s gender, a primary care provider would certainly listen to them, but would never recommend gender treatment for a toddler. Gender surgery can be performed on anyone 18 years old or older .

Duke Health, May 12: Duke Health has provided high-quality, compassionate, and evidence-based gender care to both adolescents and adults for many years. Care decisions are made by patients, families and their providers and are both age-appropriate and adherent to national and international guidelines. Under these professional guidelines and in accordance with accepted medical standards, hormone therapies are explicitly not provided to children prior to puberty and gender-affirming surgeries are, except in exceedingly rare circumstances, only performed after age 18.

Duke and UNC both called the claims that they offer gender-transition care to toddlers false, and ECU referred to the “intentional spreading of dangerous misinformation online.”

Nor do other medical institutions offer gender-affirming drug treatment or surgery to toddlers, clinical psychologist  Christy Olezeski , director of the Yale Pediatric Gender Program, told us, although some may offer support to families of young children or connect them with mental health care. 

The Education First Alliance post also states that a doctor “can see a 2-year-old girl play with a toy truck, and then begin treatment for gender dysphoria.” But simply playing with a certain toy would not meet the criteria for a diagnosis of gender dysphoria, according to the medical diagnostic manual used by health professionals.

“With all kids, we want them to feel comfortable and confident in who they are. We want them to feel comfortable and confident in how they like to express themselves. We want them to be safe,” Olezeski said. “So all of these tenets are taken into consideration when providing care for children. There is no medical care that happens prior to puberty.”

Medical Transition Starts During Adolescence or Later 

The Education First Alliance blog post does not clearly state what it means when it says North Carolina institutions are “transitioning toddlers.” It refers to treatment and hormone therapy without clarifying the age at which it is offered. 

Only in the final section of the piece does it include a quote from a doctor correctly stating that children are not offered surgery or drugs before puberty.

To spell out the reality of the situation: The North Carolina institutions are not providing surgeries or hormone therapy to prepubescent children, nor is this standard practice in any part of the country.

Programs and physicians will have different policies, but widely referenced guidance from the  World Professional Association for Transgender Health  and the  Endocrine Society  lays out recommended care at different ages. 

Drugs that suppress puberty are the first medical treatment that may be offered to a transgender minor, the guidelines say. Children may be offered drugs to suppress puberty beginning when breast buds appear or testicles increase to a certain volume, typically happening between ages 8 to 13 or 9 to 14, respectively.

Generally, someone may start gender-affirming hormone therapy in early adolescence or later, the American Academy for Pediatrics  explains . The Endocrine Society says that adolescents typically have the mental capacity to participate in making an informed decision about gender-affirming hormone therapy by age 16.

Older adolescents who want flat chests may sometimes be able to get surgery to remove their breasts, also known as top surgery, Olezeski said. They sometimes desire to do this before college. Guidelines  do not offer  a  specific age  during adolescence when this type of surgery may be appropriate. Instead, they explain how a care team can assess adolescents on a case-by-case basis.

A previous  version  of the WPATH guidelines did not recommend genital surgery until adulthood, but the most recent version, published in September 2022, is  less specific  about an age limit. Rather, it explains various criteria to determine whether someone who desires surgery should be offered it, including a person’s emotional and cognitive maturity level and whether they have been on hormone therapy for at least a year.

The Endocrine Society similarly offers criteria for when someone might be ready for genital surgery, but specifies that surgeries involving removing the testicles, ovaries or uterus should not happen before age 18.

“Typically any sort of genital-affirming surgeries still are happening at 18 or later,” Olezeski said.

There are no comprehensive statistics on the number of gender-affirming surgeries performed in the U.S., but according to an insurance claims  analysis  from Reuters and Komodo Health Inc., 776 minors with a diagnosis of gender dysphoria had breast removal surgeries and 56 had genital surgeries from 2019 to 2021.

Research Shows Benefits of Affirming Gender Identity

Young children do not get medical transition treatment, but they do have feelings about their gender and can benefit from support from those around them. “Children start to have a sense of their own gender identity between the ages of 2 1/2 to 3 years old,” Olezeski said.

Programs vary in what age groups they serve, she said, but some do support families of preschool-aged children by answering questions or providing mental health care.

Transgender children are at increased risk of some mental health problems, including anxiety and depression. According to the WPATH guidelines, affirming a child’s gender through day-to-day changes — also known as social transition — may have a positive impact on a child’s mental health. Social transition “may look different for every individual,” Olezeski said. Changes could include going by a different name or pronouns or altering one’s attire or hair style.

Two studies of socially transitioned children — including one with kids as young as 3 — have found minimal or no difference in anxiety and depression compared with non-transgender siblings or other children of similar ages.

“Research substantiates that children who are prepubertal and assert an identity of [transgender and gender diverse] know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender and benefit from the same level of social acceptance,” the AAP  guidelines  say, adding that differences in how children identify and express their gender are normal.

Social transitions largely take place outside of medical institutions, led by the child and supported by their family members and others around them. However, a family with questions about their child’s gender or social transition may be able to get information from their pediatrician or another medical provider, Olezeski said.

Although not available everywhere, specialized programs may be particularly prepared to offer care to a gender-diverse child and their family, she said. A child may get a referral to one of these programs from a pediatrician, another specialty physician, a mental health care professional or their school, or a parent may seek out one of these programs.

“We have created a space where parents can come with their youth when they’re young to ask questions about how to best support their child: what to do if they have questions, how to get support, what do we know about the best research in terms of how to allow kids space to explore their identity, to explore how they like to express themselves, and then if they do identify as trans or nonbinary, how to support the parents and the youth in that,” Olezeski said of specialized programs. Parents benefit from the support, and then the children also benefit from support from their parents. 

WPATH  says  that the child should be the one to initiate a social transition by expressing a “strong desire or need” for it after consistently articulating an identity that does not match their sex assigned at birth. A health care provider can then help the family explore benefits and risks. A child simply playing with certain toys, dressing a certain way or enjoying certain activities is not a sign they would benefit from a social transition, the guidelines state.

Previously, assertions children made about their gender were seen as “possibly true” and support was often withheld until an age when identity was believed to become fixed, the AAP guidelines explain. But “more robust and current research suggests that, rather than focusing on who a child will become, valuing them for who they are, even at a young age, fosters secure attachment and resilience, not only for the child but also for the whole family,” the guidelines say.

Mental Health Care Benefits

A gender-diverse child or their family members may benefit from a referral to a psychologist or other mental health professional. However, being transgender or gender-diverse is not in itself a mental health disorder, according to the  American Psychological Association ,  WPATH and other expert groups . These organizations also note that people who are transgender or gender-diverse do not all experience mental health problems or distress about their gender. 

Psychological therapy is not meant to change a child’s gender identity, the WPATH guidelines  say . 

The form of therapy a child or a family might receive will depend on their particular needs, Olezeski said. For instance, a young child might receive play-based therapy, since play is how children “work out different things in their life,” she said. A parent might work on strategies to better support their child.

One mental health diagnosis that some gender-diverse people may receive is  gender dysphoria . There is  disagreement  about how useful such a diagnosis is, and receiving such a diagnosis does not necessarily mean someone will decide to undergo a transition, whether social or medical.

UNC Health told us in an email that a gender dysphoria diagnosis “is rarely used” for children.

Very few gender-expansive kids have dysphoria, the spokesperson said. “ Gender expansion in childhood is not Gender Dysphoria ,” UNC added, attributing the explanation to psychiatric staff (emphasis is UNC’s). “The psychiatric team’s goal is to provide good mental health care and manage safety—this means trying to protect against abuse and bullying and to support families.”

Social media posts incorrectly claim that toddlers are being diagnosed with gender dysphoria based on what toys they play with. One post  said : “Three medical schools in North Carolina are diagnosing TODDLERS who play with stereotypically opposite gender toys as having GENDER DYSPHORIA and are beginning to transition them!!”

There are separate criteria for diagnosing gender dysphoria in adults and adolescents versus children, according to the Diagnostic and Statistical Manual of Mental Disorders. For children to receive this diagnosis, they must meet six of eight criteria for a six-month period and experience “clinically significant distress” or impairment in functioning, according to the diagnostic manual. 

A “strong preference for the toys, games or activities stereotypically used or engaged in by the other gender” is one criterion, but children must also meet other criteria, and expressing a strong desire to be another gender or insisting that they are another gender is required.

“People liking to play with different things or liking to wear a diverse set of clothes does not mean that somebody has gender dysphoria,” Olezeski said. “That just means that kids have a breadth of things that they can play with and ways that they can act and things that they can wear . ”

Editor’s note: SciCheck’s articles providing accurate health information and correcting health misinformation are made possible by a grant from the Robert Wood Johnson Foundation. The foundation has no control over FactCheck.org’s editorial decisions, and the views expressed in our articles do not necessarily reflect the views of the foundation.

Rafferty, Jason. “ Gender-Diverse & Transgender Children .” HealthyChildren.org. Updated 8 Jun 2022.

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

Rachmuth, Sloan. “ Transgender Toddlers Treated at Duke, UNC, and ECU .” Education First Alliance. 1 May 2023.

North Carolina General Assembly. “ Senate Bill 639, Youth Health Protection Act .” (as introduced 5 Apr 2023).

Putka, Sophie et al. “ These States Have Banned Youth Gender-Affirming Care .” Medpage Today. Updated 17 May 2023.

Davis, Elliott Jr. “ States That Have Restricted Gender-Affirming Care for Trans Youth in 2023 .” U.S. News & World Report. Updated 17 May 2023.

Montgomery, David and Goodman, J. David. “ Texas Legislature Bans Transgender Medical Care for Children .” New York Times. 17 May 2023.

Ji, Sayer. ‘ Transgender’ Toddlers as Young as 2 Undergoing Mutilation/Sterilization by NC Medical System, Journalist Alleges .” Epoch Times. Internet Archive, Wayback Machine. Archived 6 May 2023.

McDonald, Jessica. “ COVID-19 Vaccines Reduce, Not Increase, Risk of Stillbirth .” FactCheck.org. 9 Nov 2022.

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

Spencer, Saranac Hale. “ Social Media Posts Misrepresent FDA’s COVID-19 Vaccine Safety Research .” FactCheck.org. 23 Dec 2022.

Jaramillo, Catalina. “ WHO ‘Pandemic Treaty’ Draft Reaffirms Nations’ Sovereignty to Dictate Health Policy .” FactCheck.org. 2 Mar 2023.

McCormick Sanchez, Darlene. “ IN-DEPTH: North Carolina Medical Schools See Children as Young as Toddlers for Gender Dysphoria .” The Epoch Times. 8 May 2023.

ECU health spokesperson. Emails with FactCheck.org. 12 May 2023 and 19 May 2023.

UNC Health spokesperson. Emails with FactCheck.org. 12 May 2023 and 19 May 2023.

Duke Health spokesperson. Email with FactCheck.org. 12 May 2023.

Olezeski, Christy. Interview with FactCheck.org. 16 May 2023.

Hembree, Wylie C. et al. “ Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline .” The Journal of Clinical Endocrinology and Metabolism. 1 Nov 2017.

Emmanuel, Mickey and Bokor, Brooke R. “ Tanner Stages .” StatPearls. Updated 11 Dec 2022.

Rafferty, Jason et al. “ Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents .” Pediatrics. 17 Sep 2018.

Coleman, E. et al. “ Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7 .” International Journal of Transgenderism. 27 Aug 2012.

Durwood, Lily et al. “ Mental Health and Self-Worth in Socially Transitioned Transgender Youth .” Journal of the American Academy of Child and Adolescent Psychiatry. 27 Nov 2016.

Olson, Kristina R. et al. “ Mental Health of Transgender Children Who Are Supported in Their Identities .” Pediatrics. 26 Feb 2016.

“ Answers to Your Questions about Transgender People, Gender Identity, and Gender Expression .” American Psychological Association website. 9 Mar 2023.

“ What is Gender Dysphoria ?” American Psychiatric Association website. Updated Aug 2022.

Vanessa Marie | Truth Seeker (indivisible.mama). “ Three medical schools in North Carolina are diagnosing TODDLERS who play with stereotypically opposite gender toys as having GENDER DYSPHORIA and are beginning to transition them!! … ” Instagram. 7 May 2023.

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

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

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

Media Information

• Release Date: September 16, 2022

Media Contacts

Kristin Samuelson

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

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

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

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

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

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

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

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

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

Transgender individuals’ right to bodily autonomy

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

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

• Sexual Health
• Feature Stories

What Trans Health Care for Minors Really Means

As of April 2022, two states have passed bills banning gender-affirming care – health care related to a transgender person’s medical transition – for transgender youth, and 20 states are considering laws that would do so. If passed in all these states, more than a third of transgender teens aged 13 to 17 would live in a state that prohibits them from accessing trans health care. But the meaning of gender-affirming care for young people, and what it looks like on the ground, isn’t always clear. The cloud of politics surrounding these bills has obscured the medical reality of how and when trans youth can get the treatments they seek.

Gender-affirming care encompasses nonsurgical treatments like mental health care, puberty blockers, hormone therapy, and reproductive counseling, as well as surgical options like “top” or “bottom” surgery. These treatments can be years-long, incremental processes that may only begin with the approval of parents and health care providers.

The bills banning this kind of care have caused confusion about what gender-affirming care for trans youth actually involves. Some have characterized care like puberty blockers and hormone therapy as child abuse despite the fact that a range of medical associations, including the American Academy of Pediatrics and the American Medical Association, supports them. Some of the bills also present incorrect medical information, like falsely stating that puberty blockers cause infertility (they do not).

In fact, gender-affirming care looks quite different for youth of different ages. Young children – those who have not yet gone through puberty – can’t medically transition. Instead, their transition is entirely social; a gender-expansive child can choose a new name and pronouns, cut their hair, or dress in a different style.

The next step of a child’s transition, if they and their family choose, is to take puberty blockers: medications that essentially press pause on puberty. Puberty blockers have long been given to cisgender children for precocious puberty, a phenomenon which can cause puberty to begin at an unusually young age, such as 7 or 8. As gender-affirming care, puberty blockers are only prescribed to a child once they have begun puberty, which for those assigned female at birth can begin around age 8, or slightly earlier for those who are Black or Hispanic; children assigned male at birth usually hit puberty about 2 years later, according to the Cleveland Clinic .

Physical development in children is measured on what’s called the Tanner Scale, which tracks the progress of puberty from Tanner Stage 1 (prepubescence) to Tanner Stage 5 (sexual maturity). The start of puberty, or Tanner Stage 2, is signaled by breast budding for those assigned female at birth and testicular enlargement for those assigned male at birth, says David Inwards-Breland, MD, MPH, co-director of the Center for Gender Affirming Care at Rady Children's Hospital-San Diego. Some clinics will not offer puberty blockers until a child has reached Tanner Stage 3 or 4, meaning they are only one or two stages away from the end of puberty, according to the Standards of Care (SOC) published by the World Professional Organization for Transgender Health.

To be eligible for puberty blockers, a child should have a “long-lasting and intense pattern of gender nonconformity or gender dysphoria,” according to the SOC. (The latest version of the SOC was released in 2012, and an updated edition is expected this spring .) Gender dysphoria is often evaluated by a mental health professional, who may want to see the child and their family for a number of sessions before making a diagnosis.

After taking puberty blockers, which are fully reversible, a child can still undergo their natural puberty, or they may begin to medically transition and eventually undergo gender-affirming hormone treatment with parental consent. The Endocrine Society recommends waiting to prescribe hormones until an adolescent can give informed consent, which is generally recognized as age 16, though it is widely accepted that starting before age 16 is appropriate in many cases. For those assigned female at birth, this would mean taking testosterone, and for those assigned male at birth, estrogen with or without a progestin and an anti-androgen. Hormone treatment is considered “partially reversible” by the SOC because some changes it causes, such as body fat redistribution, are reversible, and others, such as deeping of the voice from testosterone, are permanent.

To receive hormone treatment, a trans child should have “persistent, well-documented gender dysphoria,” according to the SOC, often as determined by a mental health care provider, who will then write a letter of recommendation for the treatment. And although the Endocrine Society recommends waiting until age 16 to start hormones, it recognizes that there may be compelling reasons to begin treatment earlier. In practice, many do receive it before this age. And a draft of the new version of the SOC drops the minimum recommended age for starting hormones to 14.

“It's not totally around age because we tend to do peer-congruent transition,” Inwards-Breland says. In other words, he wants his trans patients to be able to fit in with their peers when they’re going through puberty – and ideally, not be going through puberty late in high school, long after their peers. “Probably the youngest would be around 13,” he says of when he would start a teenager on hormones.

Deciding when an adolescent should begin hormones is a process that should involve the child, their family, and a multidisciplinary team, says Stephanie Roberts, MD, a pediatric endocrinologist at the Gender Multispeciality Service at Boston Children’s Hospital. “We really try to keep it extremely flexible and individualized, and to work with the young person and their family over time to help them meet their [transition] goals.”

The third step sometimes taken as part of gender-affirming treatment is surgery. Some surgeries are options for trans adolescents while others are not. The Endocrine Society recommends that surgery involving the genitals be delayed until a person reaches the age of consent, which is 18 in the United States.

For adolescents who are assigned female at birth, top surgery can be performed to create a flat chest. The Endocrine Society states that there is not enough evidence to set a minimum age for this type of gender-affirming surgery, and the draft of the updated SOC recommends a minimum age of 15. “Usually, for a [person] assigned female at birth, the chest tissue continues to mature until around 14 or 15,” Inwards-Breland says. “What I've seen surgeons do is after 14, they feel more comfortable.” If, though, a person is started on puberty blockers followed by hormone therapy from a relatively early age – around 13 – they will never develop breast tissue and wouldn’t need surgery to remove it.

Although trans youth are technically allowed to receive certain forms of gender-affirming care, in practice, it’s often difficult.

One common barrier is family approval. For minors, parental consent is needed for any form of gender-affirming care, and not all parents are willing to give it. Some parents never give consent; for others, it can take a while to learn about transgender health and get comfortable with letting their child medically transition.

Even parents who want to be supportive can slow things down. When Rose, a transgender girl in California’s Bay Area, came out to her mom, Jessie, around age 15, she became a patient at the gender clinic at Stanford Children’s Health and soon began taking puberty blockers (Jessie asked that their first names only be used due to privacy concerns). Rose wanted to begin hormone therapy shortly thereafter, but Jessie was hesitant. She wanted to make sure she was doing the right thing for her daughter.

“I didn’t know too much about the impact of hormone therapy, and to be frank, I even questioned will she be regretting her choices later and decide this is not what she wanted,” Jessie says. “As a parent, we ask all sorts of questions and try to look at all angles, try to figure out what should we do as a parent to be responsible?”

After receiving education at the clinic and having some tough conversations, Jessie gave her consent and Rose started on hormones about a year later. “The weight of responsibility for the parent, making that decision for their kid, it’s very daunting.”

Another major issue is the availability of pediatric gender clinics. Comprehensive multidisciplinary clinics are rare outside urban areas, Inwards-Breland says. Primary care providers can offer trans health care, but many aren’t experienced in it, particularly for trans youth.

“We still have these deserts where we don't have high-quality transgender health care programs available,” Roberts says. “Now we have more than 50 pediatric transgender health care programs available across the country, but there's still areas where patients and their families may need to travel long distances to access care.”

If a family is able to find a program, they often face long wait times before they can get a foot in the door. Rose’s original wait time was 6 months, and she was lucky to get in after 3, Jessie says. “That’s how she feels: She’s lucky. She’s one of the few lucky ones,” Jessie says.

For those who don’t have access to in-person care, there are telemedicine options. Organizations like Queermed provide remote care to adolescents, including puberty blockers and hormone therapy, in 14 states in the Southeast, where regular care is limited.

Once they’re in, families must navigate insurance coverage, which is inconsistent across public and private plans. “Even if a patient is insured, they may still be underinsured with respect to accessing transgender-related health care,” Roberts says. And insurance appeals can add further delays.

Distrust of the medical system, including fear of discrimination and being misgendered, can also lead trans youth to delay seeking care.

These obstacles are in states where gender-affirming care for trans youth is legal. The barriers introduced by the recent wave of anti-trans legislation in some states make it illegal in some cases for a child to access gender-affirming care. And this onslaught of bills doesn’t seem to be stopping anytime soon.

Top doctors in ,

Find more top doctors on, related links.

• Sexual Health News
• Sexual Health Reference
• Sexual Health Slideshows
• Sexual Health Quizzes
• Sexual Health Videos
• Birth Control
• Erectile Dysfunction
• FDA Drug Trials Snapshot
• HPV/Genital Warts
• Low Testosterone
• Sex & Relationships
• Sex Headaches
• Sex Problems in Men
• Sexual Conditions

Cookies in use

Get the facts on gender-affirming care.

Everyone deserves to be treated with dignity and respect. But across the country, politicians desperate to gain power and their allies in the media are attacking LGBTQ+ people and making it impossible, particularly for transgender and non-binary youth, to be their authentic selves.

State legislatures, governors and administrative agencies across the country are taking steps to eliminate access to gender-affirming care — medically necessary, safe health care backed by decades of research and supported by every major medical association representing over 1.3 million U.S. doctors. Some are even going as far as to accuse parents who support their transgender children of child abuse. Those backing these bills are also seeking to ban this care for adults.

A concerted disinformation campaign is not only behind discriminatory laws but is fueling threats and violence against providers of gender-affirming care , preventing them from supporting the communities they are meant to serve.

As attacks on the LGBTQ+ community continue to gain steam, it is important to get the facts about gender-affirming care.

What exactly is gender-affirming care?

Gender-affirming care, sometimes referred to as transition-related care, is life-saving healthcare for transgender people of all ages. It is not a single category of services but instead is a range of services, including mental health care, medical care, and social services. At all ages, clear, well-established, evidence-based standards of care exist for who can access what form of gender affirming care, and when they are eligible to receive it.

Many transgender and non-binary people experience symptoms of gender dysphoria, or distress that results from having one’s gender identity not match their sex assigned at birth. Gender-affirming care helps transgender and non-binary people live openly and authentically as their true selves. Just like any other form of healthcare, it also helps transgender and non-binary people live safe and healthy lives.

Gender affirming care is always delivered in age-appropriate, evidence-based ways, and decisions to provide care are made in consultation with doctors and parents. Collectively representing more than 1.3 million doctors across the United States, every major medical and mental health organization — including the American Medical Association, the American Academy of Pediatrics, and the American Psychological Association — recognizes that it is medically necessary to support people in affirming their gender identity.

What does it mean for someone to transition?

Gender transition is the process through which a transgender or non-binary person takes steps to live authentically in their true gender identity. It is a personal process that looks different for every transgender and non-binary person, and individual paths do not always follow the same order. Some people take medication, and some do not; some adults have surgeries, and others do not. For some people, it can include steps as simple as changing clothes, names and hairstyles to fit their gender identity. Regardless of the age at which a person transitions, how they do so is their choice to be made with their family and doctors.

What does it mean for children to transition? Aren’t they too young to do so?

Transgender and non-binary people who begin transitioning during childhood or adolescence work closely with parents and health care providers — including mental health providers — to determine which changes to make at a given time that are age-appropriate and in the best interest of the child. At all stages, parents, young people and medical professionals make decisions together, and no permanent medical interventions happen until a transgender person is old enough to give truly informed consent.

Prior to puberty, transition is entirely social, and may involve changing names, pronouns, clothing, and hairstyles. During and after puberty, some medical treatments may be available, but only after significant consideration and consultation between the youth, their families and their health care providers.

What is “social transitioning”?

Social transitioning is when someone takes non-medical and fully reversible steps to begin living and presenting publicly as their gender . This can include changes such as:

Using a new name and pronouns

Adopting a new hairstyle

Wearing different clothing

Disclosing gender identity to others in their lives

For those who begin transitioning prior to puberty, transition is entirely social. But for many transgender and non-binary people, social transition is the first step in their gender transition journey, regardless of the age they begin transitioning. This is because it offers the opportunity to easily and quickly take small steps to begin living authentically, before involving medical interventions.

What are puberty blockers? Why are they used? Are they safe?

"Puberty blockers” (or simply “blockers”) are a type of medication which can temporarily pause puberty and are fully reversible.

For transgender and non-binary youth who are aware of their gender at a young age, going through puberty can cause intense distress and dysphoria , as it leads their body to develop into a gender that is not theirs —including in ways that are irreversible, or only reversible with surgery. For example, teenage transgender boys who do not have access to blockers will have to go through a puberty that includes growing breasts and later in life will require surgery.

In these instances, puberty blockers may be prescribed by doctors early in puberty, in consultation with the child, their parents and therapists, in order to temporarily stop the body from going through the unwanted physical and developmental changes of puberty. They are used to give youth time to continue exploring their gender identity before potentially moving on to more permanent transition-related care when they are older.

Puberty blockers are safe . They were approved by the FDA to treat precocious puberty in cisgender youth in 1993, citing minimal side effects and high efficacy; 30 years later, puberty blockers remain the gold standard treatment for precocious puberty in cisgender youth. All youth who are taking puberty blockers — cisgender or transgender — are monitored by their care team for any side effects or complications.

Puberty blockers are fully reversible . If a person stops taking puberty blockers, normal puberty will resume , with minimal long-term effects, if any. While there may be some loss of bone mineral density, this can be easily addressed with calcium and vitamin D supplements . Previous research has also shown that cisgender youth who take puberty blockers for precocious puberty have normal fertility and reproductive function .

Puberty blockers can also be life-saving: Previous studies have found that transgender and non-binary youth who are able to receive puberty blockers report positive psychosocial impacts , including increased well-being and decreased depression. Other recent studies have found that receipt of puberty blockers can dramatically reduce risk of suicidality — in some cases by over 70% — among transgender youth, compared to those who were unable to access desired treatment.

What are cross-sex hormones or gender-affirming hormones? Why are they used? Are they safe?

Gender-affirming hormones are a type of prescription medicine transgender and non-binary people can take to cause their body to begin physically developing into the gender they identify as. These medications allow transgender and non-binary people to live more fully as their identified gender, significantly reducing negative psychological outcomes such as gender dysphoria, depression, anxiety and suicidality.

Gender-affirming hormone medications are synthetic versions of testosterone or estrogen, the same hormones that naturally develop at various levels in both cisgender men and cisgender women. These same medications are used safely every day by millions of cisgender men and women worldwide.

Gender affirming hormones are typically not prescribed until a person is at least 18 years old. Though adolescents may receive gender-affirming hormones starting in their late teens, this is only done with physician approval, parental consent and informed consent from the adolescent in question, and is typically reserved for those adolescents who have been on puberty blockers and/or socially transitioned for some time.

Gender affirming hormones are safe in both youth and adults with provider supervision and appropriate management. Depending how long a person has been taking gender-affirming hormones, the effects may be fully or partially reversible as wel l. The informed consent process involves discussions about side effects and benefits–as with any informed consent process for medication or treatments–including discussions about fertility.

Gender-affirming hormones are life-saving for transgender youth and adults . A recent study from the Trevor Project shows that transgender youth with access to gender-affirming hormones have lower rates of depression and are at a lower risk for suicide. A study by Stanford University School of Medicine found that positive mental health outcomes were higher for transgender people who accessed gender-affirming hormones as teenagers versus those who accessed it as adults. A third study, published in the New England Journal of Medicine , found that, two years after initiating gender-affirming hormones, transgender youth reported higher levels of life satisfaction and positive affect, and lower levels of gender dysphoria, depression and anxiety.

What is gender-affirming surgery? Can minors have “the” surgery?

There is no single gender-affirming surgery — nor does a person have to have any surgery, or a specific surgery, to be transgender. Gender-affirming surgery includes a wide range of procedures such as plastic surgery to change features in the face to be more typically masculine or feminine, “top surgery” to make changes to the chest or torso or “bottom surgery” to make changes to genitals.

Transgender and non-binary people typically do not have gender-affirming surgeries before the age of 18. In some rare exceptions, 16 or 17 year-olds have received gender-affirming surgeries in order to reduce the impacts of significant gender dysphoria, including anxiety, depression, and suicidality. However, this is limited to those for whom the surgery is deemed clinically necessary after discussions with both their parents and doctors, and who have been consistent and persistent in their gender identity for years, have been taking gender-affirming hormones for some time, who have undergone informed consent discussions and have approvals from both their parents and doctors, and who otherwise meet standards of care criteria (such as those laid out by WPATH ).

In all cases, regardless of the age of the patient, gender-affirming surgeries are only performed after multiple discussions with both mental health providers and physicians (including endocrinologists and/or surgeons) to determine if surgery is the appropriate course of action.

None of these surgical procedures are unique to transgender people. They are the same procedures that have safely and effectively been given to cisgender and intersex people for decades, for a host of cosmetic and medical reasons. Prior research shows that post-surgical complication rates are similarly low among transgender and cisgender people receiving the same type of surgery — if not lower among transgender people .

What is the impact of parental support — or lack of support — on transgender young people?

The single most important thing anyone can do to support the transgender and non-binary people in their lives, regardless of their age, is to support and affirm them and their journey. A simple first step is committing to use their chosen name and pronouns — and, if you make a mistake, to simply apologize, correct yourself and move on.

For transgender youth, this can be particularly important.

When parents, caregivers and teachers support a transgender youth’s journey in transitioning, they are helping them to live authentically and grow into the person they are meant to be — just like all other children and adolescents their ages do. Adolescence is typically the time when all youth begin to develop autonomy and independence and learn about themselves and their identity , as they prepare for adulthood. When parents and families support their children through actions such as respecting their opinions, showing interest in their activities and interests and providing a loving, affirming, and trusting home , it can go a long way towards ensuring they will successfully develop into happy and healthy adolescents and adults.

And parental support can save lives. Previous research has found that transgender youth who are able to socially transition and simply have their gender identity, name and pronouns affirmed report higher levels of resilience and positive well-being and lower levels of depression , anxiety, gender dysphoria , and suicidality , relative to transgender youth who are not affirmed.

What do doctors have to say about gender-affirming care? Do they think it’s necessary?

Every single major medical organization , including the American Academy of Pediatrics, the American Medical Association and the American Psychiatric Association , supports the provision of age-appropriate, gender-affirming care for transgender and non-binary people. These organizations represent millions of doctors, researchers and mental health professionals in the United States. Gender-affirming care has always existed and isn’t a new phenomenon — it’s just that in recent years, extremist politicians have made it into an issue for their own self-gain.

What is the process to begin receiving gender-affirming care from health providers?

Clear, well-established, evidence-based standards of care exist for who can get gender-affirming care and when — and these standards have existed for decades. In 2022, for example, the World Professional Association of Transgender Health (WPATH) released their 8th Standards of Care for treating transgender patients. Both the Endocrine Society and the American Academy of Pediatrics have issued guidelines as well.

The process to access gender-affirming care can differ from state to state, and hospital to hospital, due to differences in state laws around who can access gender-affirming care, and when. But, in general, transgender patients (along with their families, if they are minors under the age of 18), will start by visiting a health care provider or clinic that specializes in gender-affirming care. Some may be referred to this clinic after first disclosing their gender dysphoria to a primary care provider or therapist, and others may start with a gender clinic.

For patients seeking out gender-affirming medical care, they often receive counseling for extended periods of time. If medications or surgery are part of their gender journey, they are only prescribed after further assessments to ensure they meet prescribing criteria. This can include but is not limited to documentation and referral letters, parental consent and ongoing mental health support. At all stages, gender-affirming care is only delivered after patients and their families have been counseled, and informed consent has been given.

Are people transitioning because it’s trendy? It feels like everyone is transgender all of sudden?

Being transgender is not new . Transgender people have always existed and will continue to exist regardless of harmful laws that pass.

One thing that has changed is that people are more willing to be out about their gender identity (and sexual orientation) and live openly as LGBTQ+ in all facets of their lives. This is happening because transgender people feel safer about coming out. Public support for LGBTQ+ rights , and acceptance of LGBTQ+ people, are the highest they’ve ever been .

Another thing that has changed is people’s awareness of transgender people and gender identity. As transgender people become more visible, and willing to live openly as their authentic selves, people are simply seeing more depictions of transgender people — and encountering more transgender people in their lives.

It is also true that people are openly identifying as LGBTQ+ at younger ages . But this is because, in addition to rising national support for pro-equality policies overall, on average, younger age groups hold more pro-equality, LGBTQ+ affirming attitudes and beliefs than older generations. This shift creates a cycle where:

Higher acceptance leads more people to come out

More people coming out increases visibility of LGBTQ+ people

Increased visibility leads to increased acceptance

Increased acceptance leads more people to feel safe coming out

Are kids transitioning because of social media, or because their friends are also transitioning?

This is a right-wing theory known as “rapid onset gender dysphoria” or “social contagion” — and it has been thoroughly debunked. The American Psychological Association, the American Psychiatric Association and over 120 other medical associations issued a position statement calling for eliminating the use of this term as a diagnosis, based on a “lack of rigorous empirical support for its existence ” and "its likelihood of contributing to harm and mental health burden.” The statement also specifically calls out laws which use this debunked theory to justify anti-trans legislation.

What if someone transitions and then they change their mind about it? Don’t a lot of people de-transition?

Previous studies have found that de-transitioning is quite rare —with some studies finding levels of de-transition and regret as low as 1% or 2% . Transgender youth who meet criteria for gender dysphoria and who undergo social or medical transition are actually the least likely to de-transition — and those vast majority of transgender youth remain consistent and persistent in their gender identity over time: One recent study, published in the academic journal Pediatrics, followed over 300 transgender youth after first initiating social transition, and found that over 92% remained consistent and persistent in their gender identity 5 years later.

However, evidence-based standards of care exist to ensure that no one, regardless of their age, undergoes any permanent, irreversible changes without informed consent and careful consultation with medical and mental health care providers.

But what about legislators who say they’re protecting kids with laws about gender-affirming care?

When legislation attempts to regulate who can access gender-affirming care, they are inserting political battles into private and personal conversations between parents and their children, and patients and their doctors. These laws are not about safety — as the safety, efficacy and life-saving nature of gender-affirming care for transgender and non-binary youth and adults is clear. Instead, in ignoring a wealth of scientific evidence and overwhelming support from the medical community, these legislators are attempting to enshrine discrimination into law. Rather than protecting kids, these laws are preventing parents and young people from making informed medical decisions, and doctors and health care providers from providing best-practice care to their patients.

Last updated: 7/25/23

What is gender-affirming care? HRC staff break down what it is, what it’s not and why it’s life-saving.

Related Resources

Laws & Legislation

Congressional Scorecard

Transgender

HRC’s Brief Guide to Reporting on Transgender Individuals

Health & Aging, Laws & Legislation

Get Insured - Affordable Care Act Resources for the LGBTQ+ Community

Love conquers hate., wear your pride this year..

100% of every HRC merchandise purchase fuels the fight for equality.

Choose a Location

• Connecticut
• District of Columbia
• Massachusetts
• Mississippi
• New Hampshire
• North Carolina
• North Dakota
• Pennsylvania
• Puerto Rico
• Rhode Island
• South Carolina
• South Dakota
• West Virginia

Video Modal

Hrc explains gender-affirming care, leaving site, you are leaving hrc.org.

By clicking "GO" below, you will be directed to a website operated by the Human Rights Campaign Foundation, an independent 501(c)(3) entity.

May 12, 2022

What the Science on Gender-Affirming Care for Transgender Kids Really Shows

Laws that ban gender-affirming treatment ignore the wealth of research demonstrating its benefits for trans people’s health

By Heather Boerner

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

Michael Siluk/UCG/Universal Images Group via Getty Images

Editor’s Note (3/30/23): This article from May 2022 is being republished to highlight the ways that ongoing anti-trans legislation is harmful and unscientific.

For the first 40 years of their life, Texas resident Kelly Fleming spent a portion of most years in a deep depression. As an adult, Fleming—who uses they/them pronouns and who asked to use a pseudonym to protect their safety—would shave their face in the shower with the lights off so neither they nor their wife would have to confront the reality of their body.

What Fleming was experiencing, although they did not know it at the time, was gender dysphoria : the acute and chronic distress of living in a body that does not reflect one’s gender and the desire to have bodily characteristics of that gender. While in therapy, Fleming discovered research linking access to gender-affirming hormone therapy with reduced depression in transgender people. They started a very low dose of estradiol, and the depression episodes became shorter, less frequent and less intense. Now they look at their body with joy.

On supporting science journalism

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

So when Fleming sees what authorities in Texas , Alabama , Florida and other states are doing to bar transgender teens and children from receiving gender-affirming medical care, it infuriates them. And they are worried for their children, ages 12 and 14, both of whom are agender—a identity on the transgender spectrum that is neither masculine nor feminine.

“I’m just so excited to see them being able to present themselves in a way that makes them happy,” Fleming says. “They are living their best life regardless of what others think, and that’s a privilege that I did not get to have as a younger person.”

Laws Based on “Completely Wrong” Information

Currently more than a dozen state legislatures  or administrations are considering—or have already passed—laws banning health care for transgender young people. On April 20 the Florida Department of Health issued guidance to withhold such gender-affirming care. This includes social gender transitioning—acknowledging that a young person is trans, using their correct pronouns and name, and supporting their desire to live publicly as the gender of their experience rather than their sex assigned at birth. This comes nearly two months after Texas Governor Greg Abbott issued an order for the Texas Department of Family and Protective Services to investigate for child abuse parents who allow their transgender preteens and teenagers to receive medical care. Alabama recently passed SB 184 , which would make it a felony to provide gender-affirming medical care to transgender minors. In Alabama, a “minor” is defined as anyone 19 or younger.

If such laws go ahead, 58,200 teens in the U.S. could lose access to or never receive gender-affirming care, according to the Williams Institute at the University of California, Los Angeles. A decade of research shows such treatment reduces depression, suicidality and other devastating consequences of trans preteens and teens being forced to undergo puberty in the sex they were assigned at birth).

The bills are based on “information that’s completely wrong,” says Michelle Forcier, a pediatrician and professor of pediatrics at Brown University. Forcier literally helped write the book on how to provide evidence-based gender care to young people. She is also an assistant dean of admissions at the Warren Alpert Medical School of Brown University. Those laws “are absolutely, absolutely incorrect” about the science of gender-affirming care for young people, she says. “[Inaccurate information] is there to create drama. It’s there to make people take a side.”

The truth is that data from more than a dozen studies of more than 30,000 transgender and gender-diverse young people consistently show that access to gender-affirming care is associated with better mental health outcomes—and that lack of access to such care is associated with higher rates of suicidality, depression and self-harming behavior. (Gender diversity refers to the extent to which a person’s gendered behaviors, appearance and identities are culturally incongruent with the sex they were assigned at birth. Gender-diverse people can identify along the transgender spectrum, but not all do.) Major medical organizations, including the American Academy of Pediatrics (AAP) , the American Academy of Child and Adolescent Psychiatry , the Endocrine Society , the American Medical Association , the American Psychological Association and the American Psychiatric Association , have published policy statements and guidelines on how to provide age-appropriate gender-affirming care. All of those medical societies find such care to be evidence-based and medically necessary.

AAP and Endocrine Society guidelines call for developmentally appropriate care, and that means no puberty blockers or hormones until young people are already undergoing puberty for their sex assigned at birth. For one thing, “there are no hormonal differences among prepubertal children,” says Joshua Safer, executive director of the Mount Sinai Center for Transgender Medicine and Surgery in New York City and co-author of the Endocrine Society’s guidelines. Those guidelines provide the option of gonadotropin-releasing hormone analogues (GnRHas), which block the release of sex hormones, once young people are already into the second of five puberty stages—marked by breast budding and pubic hair. These are offered only if a teen is not ready to make decisions about puberty. Access to gender-affirming hormones and potential access to gender-affirming surgery is available at age 16—and then, in the case of transmasculine youth, only mastectomy, also known as top surgery. The Endocrine Society does not recommend genital surgery for minors.

Before puberty, gender-affirming care is about supporting the process of gender development rather than directing children through a specific course of gender transition or maintenance of cisgender presentation, says Jason Rafferty, co-author of AAP’s policy statement on gender-affirming care and a pediatrician and psychiatrist at Hasbro Children’s Hospital in Rhode Island. “The current research suggests that, rather than predicting or preventing who a child might become, it’s better to value them for who they are now—even at a young age,” Rafferty says.

A Safe Environment to Explore Gender

A 2021 systematic review of 44 peer-reviewed studies found that parent connectedness, measured by a six-question scale asking about such things as how safe young people feel confiding in their guardians or how cared for they feel in the family, is associated with greater resilience among teens and young adults who are transgender or gender-diverse. Rafferty says he sees his role with regard to prepubertal children as offering a safe environment for the child to explore their gender and for parents to ask questions. “The gender-affirming approach is not some railroad of people to hormones and surgery,” Safer says. “It is talking and watching and being conservative.”

Only once children are older, and if the incongruence between the sex assigned to them at birth and their experienced gender has persisted, does discussion of medical transition occur. First a gender therapist has to diagnose the young person with gender dysphoria .

After a gender dysphoria diagnosis—and only if earlier conversations suggest that hormones are indicated—guidelines call for discussion of fertility, puberty suppression and hormones. Puberty-suppressing medications have been used for decades for cisgender children who start puberty early, but they are not meant to be used indefinitely. The Endocrine Society guidelines recommend a maximum of two years on GnRHa therapy to allow more time for children to form their gender identity before undergoing puberty for their sex assigned at birth, the effects of which are irreversible.

“[Puberty blockers] are part of the process of ‘do no harm,’” Forcier says, referencing a popular phrase that describes the Hippocratic Oath, which many physicians recite a version of before they begin to practice.

Hormone blocker treatment may have side effects. A 2015 longitudinal observational cohort study of 34 transgender young people found that, by the time the participants were 22 years old, trans women experienced a decrease in bone mineral density. A 2020 study of puberty suppression in gender-diverse and transgender young people found that those who started puberty blockers in early puberty had lower bone mineral density before the start of treatment than the public at large. This suggests, the authors wrote, that GnRHa use may not be the cause of low bone mineral density for these young people. Instead they found that lack of exercise was a primary factor in low bone-mineral density, especially among transgender girls.

Other side effects of GnRHa therapy include weight gain, hot flashes and mood swings. But studies have found that these side effects—and puberty delay itself—are reversible , Safer says.

Gender-affirming hormone therapy often involves taking an androgen blocker (a chemical that blocks the release of testosterone and other androgenic hormones) and estrogen in transfeminine teens, and testosterone supplementation in transmasculine teens. Such hormones may be associated with some physiological changes for adult transgender people. For instance, transfeminine people taking estrogen see their so-called “good” cholesterol increase. By contrast, transmasculine people taking testosterone see their good cholesterol decrease. Some studies have hinted at effects on bone mineral density, but these are complicated and also depend on personal, family history, exercise, and many other factors in addition to hormones.”

And while some critics point to decade-old study and older studies suggesting very few young people persist in transgender identity into late adolescence and adulthood, Forcier says the data are “misleading and not accurate.” A recent review detailed methodological problems with some of these studies . New research in 17,151 people who had ever socially transitioned found that 86.9 percent persisted in their gender identity. Of the 2,242 people who reported that they reverted to living as the gender associated with the sex they were assigned at birth, just 15.9 percent said they did so because of internal factors such as questioning their experienced gender but also because of fear, mental health issues and suicide attempts. The rest reported the cause was social, economic and familial stigma and discrimination. A third reported that they ceased living openly as a trans person because doing so was “just too hard for me.”

The Harms of Denying Care

Data suggest the effects of denying that care are worse than whatever side effects result from delaying sex-assigned-at-birth puberty. And medical society guidelines conclude that the benefits of gender-affirming care outweigh the risks. Without gender-affirming hormone therapy, cisgender hormones take over, forcing body changes that can be permanent and distressing.

A 2020 study of 300 gender-incongruent young people found that mental distress—including self-harm, suicidal thoughts and depression— increased as the children were made to proceed with puberty according to their assigned sex. By the time 184 older teens (with a median age of 16) reached the stage in which transgender boys began their periods and grew breasts and transgender girls’ voice dropped and facial hair began to appear, 46 percent had been diagnosed with depression, 40 percent had self-harmed, 52 percent had considered suicide, and 17 percent had attempted it—rates significantly higher than those of gender-incongruent children who were a median of 13.9 years old or of cisgender kids their own age.

Conversely, access to gender-affirming hormones in adolescence appears to have a protective effect. In one study, researchers followed 104 teens and young adults for a year and asked them about their depression, anxiety and suicidality at the time they started receiving hormones or puberty blockers and again at the three-month, six-month and one-year mark. At the beginning of the study, which was published in JAMA Network Open in February 2022, more than half of the respondents reported moderate to severe depression, half reported moderate to severe anxiety, and 43.3 percent reported thoughts of self-harm or suicide in the past two weeks.

But when the researchers analyzed the results based on the kind of gender-affirming care the teens had received, they found that those who had access to puberty blockers or gender-affirming hormones were 60 percent less likely to experience moderate to severe depression. And those with access to the medical treatments were 73 percent less likely to contemplate self-harm or suicide.

“Delays in prescribing puberty blockers and hormones may in fact worsen mental health symptoms for trans youth,” says Diana Tordoff, an epidemiology graduate student at the University of Washington and co-author of the study.

That effect may be lifelong. A 2022 study of more than 21,000 transgender adults showed that just 41 percent of adults who wanted hormone therapy received it, and just 2.3 percent had access to it in adolescence. When researchers looked at rates of suicidal thinking over the past year in these same adults, they found that access to hormone therapy in early adolescence was associated with a 60 percent reduction in suicidality in the past year and that access in late adolescence was associated with a 50 percent reduction.

For Fleming’s kids in Texas, gender-affirming hormones are not currently part of the discussion; not all trans people desire hormones or surgery to feel affirmed in their gender. But Fleming is already looking at jobs in other states to protect their children’s access to such care, should they change their mind. “Getting your body closer to the gender [you] identify with—that is what helps the dysphoria,” Fleming says. “And not giving people the opportunity to do that, making it harder for them to do that, is what has made the suicide rate among transgender people so high. We just—trans people are just trying to survive.”

IF YOU NEED HELP If you or someone you know is struggling or having thoughts of suicide, help is available. Call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK), use the online Lifeline Chat or contact the Crisis Text Line by texting TALK to 741741.

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

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

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

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

Numerous states have implemented or considered actions aimed at limiting LGBTQ+ youth access to gender affirming health care. Four states (Alabama, Arkansas, Texas, and Arizona) have recently enacted such restrictions (though the AL, AR, and TX laws all have been temporarily blocked by court rulings) and in 2022, 15 states are considering 25 similar pieces of legislation. At the same time, other states have adopted broad nondiscrimination health protections based on gender identity and sexual orientation. Separately, the Biden administration, which has been working to eliminate barriers and expand access to health care for LGBTQ+ people more generally, has come out against restrictive state policies. This analysis explores the current state and federal policy landscape regarding gender affirming services for youth and the implications of restrictive state laws.

What is the status of state policy restrictions aimed at limiting youth access to gender affirming care?

Four states (Alabama, Arkansas, Texas, and Arizona) recently enacted laws or policies restricting youth access to gender affirming care and, in some cases, imposing penalties on adults facilitating access. Alabama, Arkansas, and Texas have been temporarily blocked from enforcing these laws and policies by court order.

• Alabama. In April 2022, the Alabama governor signed a bill into law that prevents transgender minors from receiving gender affirming care, including puberty blockers, hormone therapy, and surgical intervention. The bill makes it a felony for any person to “engage in or cause” a transgender minor to receive any of these treatments, punishable by up to 10 years in prison or a fine up to $15,000. The bill additionally states that nurses, counselors, teachers, principals, and other administrative school officials shall not withhold from a minor’s parents or guardian that their child’s “perception of his or her gender or sex is inconsistent with the minor’s sex” assigned at birth and shall not encourage a minor to do so. Shortly after enactment, a federal lawsuit challenging the law was filed by four Alabama families with transgender children, two healthcare providers, and a clergy member. Subsequently, the U.S. Department of Justice (DOJ) joined the case as an additional plaintiff challenging the law. This case has been consolidated with another lawsuit filed by two other Alabama families with transgender children, which raises similar challenges. In May 2022, a federal district court entered a preliminary injunction, blocking enforcement of several sections of the Alabama law while the litigation is pending. Specifically, the preliminary injunction applies to the sections of the law that prohibit puberty blockers and hormone therapy. Other sections of the law remain in effect, including the prohibition on surgical intervention and the prohibition on school officials keeping secret or encouraging or compelling children to keep secret certain gender-identity information from children’s parents. When deciding to grant the preliminary injunction, the district court found that the plaintiffs were substantially likely to succeed on their claim that the sections of the law that prohibit puberty blockers and hormone therapy unconstitutionally violate parents’ fundamental right to autonomy under the 14 th Amendment’s due process clause by prohibiting parents from obtaining medical treatment for their children subject to medically accepted standards. The court also fond that the plaintiffs were substantially likely to succeed on their claim that these sections of the law are unconstitutional sex discrimination in violation of the 14 th Amendment’s equal protection clause because the law denies medically necessary services only to transgender minors, while allowing those services for cisgender minors. Additionally, the court found that the plaintiffs were likely to suffer irreparable harm, in the form of “severe physical and/or psychological harm” and “significant deterioration in their familial relationships and educational performance,” if the law was not blocked. The state has appealed the district court’s decision to the 11 th Circuit.
• Arkansas . In 2021, on override of Governor Hutchinson’s veto, Arkansas lawmakers passed legislation prohibiting gender-affirming treatment for minors, including puberty blockers, hormone therapy, and gender affirming surgery. The law also prohibits medical providers from making referrals to other providers for minors seeking these procedures. Under the law, medical providers offering gender affirming care or providing referrals for such care to minors may be subject to discipline by relevant licensing entities. The legislation additionally includes a prohibition on private insurance coverage of gender affirming services for minors and a prohibition on the use of public funds, including through Medicaid, for coverage of these services for minors. In May 2021, four families of transgender youth and two physicians challenged the Arkansas law in federal court, arguing that the law is illegal sex discrimination under the 14 th Amendment’s equal protection clause. They also argue that the law violates parents’ right to autonomy protected by the 14 th Amendment’s due process clause and violates the families and physicians’ right to free speech under the 1 st Amendment. The U.S. Department of Justice (DOJ) filed a statement of interest in support of the plaintiffs’ motion for a preliminary injunction in the Arkansas case. DOJ  argued that the Arkansas law  violates the Equal Protection Clause of the 14 th Amendment because the state law “singles out transgender minors. . . specifically and discriminatorily den[ies] their access to medically necessary care based solely on their sex assigned at birth.” A preliminary injunction was granted in July 2021, temporarily blocking the state from enforcing the law while the case is pending. The court found that the plaintiffs were likely to succeed on all three of their Constitutional claims, and that the law was not substantially related to the state’s interest in protecting children or regulating physicians’ ethics because the law allows the same medical treatments for cisgender minors. The court also found that the plaintiffs will suffer irreparable physical and psychological harm if the law is not blocked. The court also denied the state’s motion to dismiss the case. The state has appealed both of those decisions to the 8 th Circuit, where a decision is currently pending. A group of 19 states filed an amicus brief in support of the state’s appeal. 1 They argue that states have “broad authority” to regulate gender affirming services, because they allege this area is “fraught with medical uncertainties,” contrary to the evidence from the American Academy of Pediatrics and the American Medical Association on which the lower court relied. Another group of 20 states and the District of Columbia filed an amicus brief in support of the plaintiffs. 2 They argue that they and their residents are economically, physically, and mentally harmed by discrimination against transgender people. They also argue that their states “protect access to gender-affirming healthcare based on well-accepted medical standards” and that Arkansas’ law is unconstitutional sex discrimination and “ignores medical consensus as well as decisions made between doctors and their patients.” Litigation in the case continues in the district court, where the case is scheduled for trial during the week of July 25, 2022.
• Texas . In February 2022, Governor Abbott of Texas issued a directive defining certain gender affirming services for youth as child abuse, and calling for investigation of and penalties for parents who support their children in taking certain medications or undertaking certain procedures, which could include the removal of their children. In addition, under the directive, health care professionals who facilitate access to these services could also face penalties and a range of professionals in the state would be mandated to report known use of the specified gender affirming services. While other states with proposed policies to limit youth access to gender affirming care include penalties for parents who facilitate access to these services (see below), no implemented policy ties the parental role to child abuse as the Texas directive does. In the wake of litigation , a state court entered a temporary injunction preventing the state from enforcing the directive while the case is pending. The court found that the governor acted outside his statutory legal authority in issuing the directive, and the plaintiffs will suffer immediate and irreparable injuries, including loss of employment, deprivation of constitutional rights, and loss of medically necessary care. However, the Texas Supreme Court subsequently modified the temporary injunction, finding that the courts lack authority to prevent enforcement of the directive statewide. Instead, the state is prohibited from enforcing the directive only against the plaintiffs involved in the lawsuit while the case is pending. The case is scheduled for trial on July 11, 2022.
• Arizona . In March 2022, Arizona Governor Ducey signed legislation into law that bans physicians from providing gender-affirming surgical treatment to minors. The legislation does not address hormone therapy or puberty blockers.

In addition, since January 2022 15 states introduced a total of 25 bills that would restrict access to gender-affirming care for youth. Provisions in these bills varied considerably and include those that would:

• criminalize or impose/permit professional disciplinary action (e.g. revoking or suspending licensure) on health professionals providing gender-affirming care to minors, in some cases labeling such services as child abuse
• penalize parents aiding in youth accessing gender-affirming care
• permit individuals to file for damages against providers who violate such laws
• limit insurance coverage or payment for gender affirming services or prohibit the use of state funds for such services

Beyond these policies, states have also passed or considered other policies restricting access, including so called “bathroom bills” which restrict access to bathrooms or locker rooms based on sex assigned at birth, the recent Florida “don’t say gay” bill that would prohibit classroom discussion on sexual orientation or gender identity, and laws that limit transgender students’ access to sports. While these policies are not directly tied to health or health care access, their attempts to limit access to social spaces and services and present non-affirming sentiments could negatively impact LGBTQ+ people’s mental health and well-being. For instance, one recent study found that state laws permitting the denial of services to same-sex couples “are associated with increases in mental distress among sexual minority adults.” In addition, and directly related to health care, Florida recently released non-biding guidance recommending against gender affirming care for youth.

What states have introduced protections related to sexual orientation and gender identity in health care?

Though not specific to youth access to gender affirming care, some states have adopted policies that provide health care protections to LGBTQ+ people, including:

• prohibitions on health insurance discrimination based on sexual orientation and/or
• requirements that state Medicaid programs explicitly cover health services related to gender transition

What is federal policy regarding gender-affirming services?

The Biden administration has taken multiple steps to promote access to health care for LGBTQ+ people and to prohibit discrimination on the basis of sexual orientation and gender identity, including:

• On his first day in office, President Biden signed an executive order directing federal agencies to review existing regulations and policies in order to “prevent and combat discrimination” based on gender identity and sexual orientation. The order states that “people should be able to access healthcare…without being subjected to sex discrimination” and views sex nondiscrimination protections as encompassing sexual orientation and gender identity, following the Supreme Court’s Bostock
• On May 10, 2021, also in light of the Bostock ruling, the Biden Administration announced that the Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) would include gender identity and sexual orientation in its interpretation and enforcement of Section 1557’s prohibition against sex discrimination. Section 1557 of the Affordable Care Act (ACA) contains the law’s primary nondiscrimination provisions, including a prohibition on discrimination on the basis of sex by a range of health care entities and programs that receive federal funding. The May 2021 announcement marked both a reversal of Trump Administration policy, which eliminated gender identity and sex stereotyping from the regulations, and an expansion of Obama Administration policy, which included gender identity and sex stereotyping in the definition of sex discrimination but omitted sexual orientation. Following the  Bostock  ruling, two federal district courts issued nationwide preliminary injunctions, blocking implementation of several provisions of the Trump Administration’s regulations related to Section 1557. Biden Administration implementing regulations on Section 1557 are expected to expand on the May announcement.

In addition to establishing a foundation of nondiscrimination policies for LGBTQ+ people, and participating in the Alabama and Arkansas cases as noted above, the administration has responded specifically to the Texas directive, denouncing it as discriminatory and stating that gender affirming care for youth should be supported as follows:

• Statement from President Biden: The statement from the president states that the administration is “putting the state of Texas on notice that their discriminatory actions put children’s lives at risk. These announcements make clear that rather than weaponizing child protective services against loving families, child welfare agencies should instead expand access to gender-affirming care for transgender children.”
• Statement from Dept. of Health and Human Services (HHS) Sec. Becerra : Becerra’s statement reaffirms “HHS’s commitment to supporting and protecting transgender youth and their parents, caretakers and families” and details action items the administration is taking in response to the Texas directive including those that follow below.
• Following the actions in Texas, HHS’s Administration on Children, Youth and Families issued an Information Memorandum to state child welfare agencies writing that child welfare systems should advance safety and support for LGBTQI+ youth, including though access to gender affirming care.
• Specifically, the guidance states that categorically refusing treatment based on gender identity is prohibited discrimination under Section 1557. The guidance also states that Section 1557’s prohibition against sex-based discrimination is likely violated if a provider reports parents seeking medically necessary gender affirming care for their child to state authorities, if the provider or facility is receiving federal funding. The guidance further states that restricting a provider from providing gender affirming care may violate Section 1557.
• The guidance states that in cases where gender dysphoria qualifies as a disability, restrictions that prevent individuals from receiving medically necessary care based on a diagnosis or perception of gender dysphoria may also violate Section 504 and the ADA.
• It also articulates requirements under the Health Insurance Portability and Accountability Act (HIPAA) that prohibit health plans and providers from disclosing protected health information, such as use of gender affirming physical or mental health care without patient consent, except in limited circumstances.

OCR enforces each of these federal laws, and the guidance states that parents or caregivers who believe their child has been denied health care, including gender affirming care, and health care providers who believe they have been unlawfully restricted from providing such care, may file an administrative complaint for OCR to investigate.

What do major medical societies say about gender affirming services?

Most major U.S. medical associations, including those in the fields of pediatrics, endocrinology, psychiatry, and psychology, have issued statements recognizing the medical necessity and appropriateness of gender affirming care for youth, typically noting harmful effects of denying access to these services. These include statements from the American Medical Association , American Academy of Pediatrics , the Endocrine Society , American Psychological Association , American Psychiatric Association , and the World Professional Association for Transgender Health , among others , which in some cases were specifically issued in response to the Arkansas legislation and Texas directive. Further, 23 medical associations or societies, including those named above, together filed an amicus brief in the case filed against Texas Gov. Abbott opposing the state directive. The brief states that denying gender affirming treatment to adolescents who need them would irreparably harm their health and that enforcing the directive would irreparably harm providers who are forced to choose between potentially facing civil and criminal penalties or endangering their patients. A similar amicus brief was filed in the Arkansas case.

Additionally, the Endocrine Society supports gender affirming care for young people in their clinical practice guidelines , as does the World Professional Association for Transgender Health’s standards of care . Together these guidelines form the standard of care for treatment of gender dysphoria.

What are the implications of access restrictions?

State policies restricting youth access to gender affirming care could have significant health and other implications for LGBTQ+ youth, their parents, health care providers, and, in some cases, other community members:

LGBTQ+ youth : LGBTQ+ youth experience higher rates of depression, anxiety, and suicidality than their non-LGBTQ+ peers. In one CDC study of youth in 10 states and 9 urban school districts, a higher share of transgender students reported suicide risk outcomes across a range of metrics than cisgender students. These include, in the past 12 months: having felt sad or hopeless, considered attempting suicide, made a suicide plan, attempted suicide, or had a suicide attempt treated by a doctor or nurse. Inability to access gender affirming care, such as puberty suppressors and hormone therapy , has been linked to worse mental health outcomes for transgender youth, including with respect to suicidal ideation, potentially exacerbating the already existing disparities. Conversely, access to this care is associated with improved outcomes in these domains. Policies that aim to prohibit or interrupt access to gender affirming care for youth can therefore have negative implications for health in potentially life-threatening ways.

In addition, LGBTQ people report higher rates of negative experiences with medical providers, so creating barriers to gender affirming care could further challenge transgender people’s relationship with the healthcare system.

Finally, with the Texas directive specifically, and in several other states with bills under consideration, youth are vulnerable to secondary trauma, knowing that if they seek such care, their families and providers could be subject to penalties, and, in the case of Texas, children could be separated from their parents.

Parents : In several states with bills under consideration, parents who facilitate access to evidence-based and potentially lifesaving gender affirming services for their children could face penalties. Under the Texas directive, because it is defined as child abuse, parents who facilitate access to gender affirming care for their children, could be subject to penalties, including losing custody of their children. This may place parents in the position of either supporting their children in accessing care supported by medical evidence and facing penalties or denying their children access in an effort not to make their family vulnerable to investigation and potential separation. Each option for parents in this scenario has the potential to be traumatic for the family, and for youth in particular.

Providers: Like parents, providers may be torn between what the medical literature supports is in the best interest of their patients or facing potential sanctions, including violating professional ethics around confidentiality, as in the case of Texas. The American Psychological Association said in a statement that a requirement such as the Texas directive is a violation of both patient confidentiality and professional ethics. Under such circumstances, providers may be forced to decide whether they will provide the highest standard of care for their patients and potentially face sanctions, or obey the state directive but withhold care and potentially violate patient confidentiality and professional ethics. Further, as noted above, the Biden Admiration has stated that HIPAA requirements prohibit providers from disclosing use of gender affirming care without patient consent, except as in narrow circumstances. However, following HIPPA requirements in this case may make providers vulnerable to state sanction under the directive.

Teachers and others : In Texas, in addition to health care providers, other mandated reporters, such as teachers, could also face penalties for failure to report youth known to be accessing gender affirming care. The directive also states that ”there are similar reporting requirements and criminal penalties for members of the general public,” extending the policy’s reach to practically anyone with knowledge of youth accessing these services.

Looking forward

The legal and policy landscape regarding youth access to gender affirming care is shifting across the country, with an increasing number of states seeking to limit such access and impose penalties. Such policies may have significant, negative implications for the health of young people. At the same time, these states are at odds with federal law and policy, and in two recent cases courts have temporarily blocked enforcement of such restrictions. Moving ahead, it will be important to watch how state bills still under consideration unfold and the final outcome of cases in Alabama, Arkansas, and Texas. Decisions in these cases could determine how such policies intersect with existing federal policies — including Section 1557’s prohibition on sex based discrimination in health care, federal disability non-discrimination protections, and HIPAA patient privacy protections — as well as providers’ professional ethics standards.

These states include Alabama, Alaska, Arizona, Georgia, Idaho, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, South Carolina, South Dakota, Tennessee, Texas, Utah, and West Virginia.

← Return to text

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

Also of Interest

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

The Evidence for Trans Youth Gender-Affirming Medical Care

Research suggests gender-affirming medical care results in better mental health..

Posted January 24, 2022 | Reviewed by Abigail Fagan

• Sixteen studies to date have examined the impact of gender-affirming medical care for transgender youth.
• Existing evidence suggests that gender-affirming medical care results in favorable mental health outcomes.
• All major medical organizations oppose legislation that would ban gender-affirming medical care for transgender adolescents.

NOTE: This post was updated on October 11, 2022. In discussions of studies 5, 7, 8 and 10, the final sentence was appended to include further information about the study.

I'm a physician-scientist who studies the mental health of transgender and gender diverse youth. I also spend a lot of time on Twitter . And yes I know, that's my first mistake. I've noticed there seem to be hundreds if not thousands of Twitter accounts that will repeatedly post that there is no evidence that gender-affirming medical care results in good mental health outcomes for transgender youth.

Since several U.S. states are introducing legislation to outlaw gender-affirming medical care this year (despite opposition from just about every major medical organization including The American Medical Association, The American Academy of Pediatrics, and The American Psychiatric Association), I thought this was a good time to review the relevant research for you all. So buckle up — here we go. The studies are in chronological order. I'll provide a brief summary of each and provide the citation for people who want to read more. I'll plan on updating this post as new studies become available. As you read, please keep in mind that all studies have methodological strengths and weaknesses and conclusions must be drawn from all of these studies together.

The Studies

Study 1: De Vries, A. L., Steensma, T. D., Doreleijers, T. A., & Cohen‐Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow‐up study. The Journal of Sexual Medicine, 8(8), 2276-2283.

This study from the Netherlands followed 70 transgender adolescents and measured their mental health before and after pubertal suppression. Study participants had improvements in depression and global functioning following treatment. However, feelings of anxiety and anger , gender dysphoria , and body satisfaction did not change.

Study 2: De Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696-704.

Another study from the Netherlands. This one followed 55 transgender adolescents through pubertal suppression, gender-affirming hormone treatment ( estrogen or testosterone ), and gender-affirming genital surgery (as adults). Of note, many of these participants were also participants in study 1 (this study followed them for longer). The researchers found that psychological functioning steadily improved over the course of the study and by adulthood these now young adults had global functioning scores similar to or better than age-matched peers in the general population. Of note, one patient in this study died from a surgical complication of vaginoplasty (necrotizing fasciitis), but little additional information is provided.

Study 3: Costa, R., Dunsford, M., Skagerberg, E., Holt, V., Carmichael, P., & Colizzi, M. (2015). Psychological support, puberty suppression, and psychosocial functioning in adolescents with gender dysphoria. The Journal of Sexual Medicine, 12(11), 2206-2214.

This study is from the United Kingdom. They followed 101 adolescents who received pubertal suppression at the beginning of the study and 100 adolescents who, for a range of reasons, were deemed by the team not ready to start pubertal suppression and thus did not receive it over the course of the study. Both groups received supportive psychotherapy . Both groups saw improvement in mental health. While the pubertal suppression group had a 5-point higher mean score on the study's psychological functioning scale at the end of the study, the difference was not statistically significant. This could have been due to the small sample size by the end of the study (the researchers only had data from 36 participants in the therapy-only group and 35 participants in the pubertal suppression group at the final time point of the study). We will see that later studies were able to obtain larger sample sizes so that statistically significant differences between those who did and did not receive pubertal suppression could be detected.

Study 4: Allen, L. R., Watson, L. B., Egan, A. M., & Moser, C. N. (2019). Well-being and suicidality among transgender youth after gender-affirming hormones. Clinical Practice in Pediatric Psychology, 7(3), 302.

This study was from researchers at Children's Mercy Hospital Gender Pathway Services Clinic in Missouri. They followed 47 transgender adolescents who received gender-affirming hormones (estrogen or testosterone) to a mean 349 days after starting treatment. They found statistically significant increases in general well-being and a statistically significant decrease in suicidality. Of note, the adolescents also received psychotherapy.

Study 5: Kaltiala, R., Heino, E., Työläjärvi, M., & Suomalainen, L. (2020). Adolescent development and psychosocial functioning after starting cross-sex hormones for gender dysphoria. Nordic Journal of Psychiatry, 74(3), 213-219.

This study is from Finland. Researchers conducted a retrospective chart review of 52 adolescents who received gender-affirming hormones (estrogen or testosterone) and found statistically significant decreases in need for specialist level psychiatric treatment for depression (decreased from 54% to 15%), anxiety (decreased from 48% to 15%), and suicidality or self-harm (decreased from 35% to 4%) following treatment. However, the authors note that gender reassignment is "not enough to improve functioning and relieve psychiatric comorbidities among adolescents with gender dysphoria."

Study 6: de Lara, D. L., Rodríguez, O. P., Flores, I. C., Masa, J. L. P., Campos-Muñoz, L., Hernández, M. C., & Amador, J. T. R. (2020). Psychosocial assessment in transgender adolescents. Anales de Pediatría (English Edition), 93(1), 41-48.

This study is from Spain. It followed 23 transgender adolescents who received gender-affirming hormones (estrogen or testosterone) and 30 cisgender controls for approximately one year. They found the transgender adolescents at baseline had worse measures of mental health than the cisgender control adolescents but that this difference equalized by the end of the study. The transgender adolescents in the study who received gender-affirming hormones had statistically significant improvements in several mental health measures, including anxiety and depression.

Study 7: van der Miesen, A. I., Steensma, T. D., de Vries, A. L., Bos, H., & Popma, A. (2020). Psychological functioning in transgender adolescents before and after gender-affirmative care compared with cisgender general population peers. Journal of Adolescent Health, 66(6), 699-704.

This was another Dutch study, with an impressive sample size. Researchers compared 272 transgender adolescents referred to the gender clinic who had not yet received pubertal suppression with 178 transgender adolescents who had received pubertal suppression. They found those who received pubertal suppression had better mental health outcomes than those who did not receive pubertal suppression. However, because subjects received psychotherapy, the authors note that the study does not provide "direct evidence" that pubertal suppression improves mental health in transgender youth.

Study 8: Achille, C., Taggart, T., Eaton, N. R., Osipoff, J., Tafuri, K., Lane, A., & Wilson, T. A. (2020). Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results. International Journal of Pediatric Endocrinology, 2020(1), 1-5.

This study was from Stony Brook Children's Hospital in New York. It followed 50 transgender adolescents longitudinally. Over the course of the study, 23 received pubertal suppression only, 35 received gender-affirming hormones only, and 11 received both. Three participants received no gender-affirming medical interventions. Over the course of the study, there was a statistically significant decrease in depression scores in one group: Male-to-female transitioners who underwent puberty suppression only.

Study 9: Kuper, L. E., Stewart, S., Preston, S., Lau, M., & Lopez, X. (2020). Body dissatisfaction and mental health outcomes of youth on gender-affirming hormone therapy. Pediatrics, 145(4).

This study was from a gender clinic in Dallas, Texas. The researchers followed 148 transgender adolescents who were receiving gender-affirming medical treatment. 25 received pubertal suppression only, 93 received gender-affirming hormones (estrogen or testosterone) only, and 30 received both. 15 participants received gender-affirming chest surgery. When examining all participants together, the study found statistically significant improvements in body dissatisfaction, depressive symptoms, and anxiety symptoms.

Study 10: Turban, J. L., King, D., Carswell, J. M., & Keuroghlian, A. S. (2020). Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics, 145(2).

This study was conducted by myself along with several other researchers from Harvard Medical School. It utilized data from a non-probability sample of 20,619 transgender adults who reported ever wanting pubertal suppression. Of these, 89 actually received pubertal suppression. After adjusting for potentially confounding variables , access to pubertal suppression was associated with a lower odds of lifetime suicidal ideation. Of note, this study did not identify psychotherapy as a potentially confounding variable.

Study 11: Carmichael, P., Butler, G., Masic, U., Cole, T. J., De Stavola, B. L., Davidson, S., ... & Viner, R. M. (2021). Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. PLoS One, 16(2), e0243894.

This is another study from the United Kingdom. Researchers presented data for transgender adolescents who had received pubertal suppression. They had data for 44 patients after 12 months of treatment, 24 patients after 24 months of treatment, and 14 patients after 36 months of treatment. They were unable to detect any changes on their mental health measures (positive or negative).

Study 12: Grannis, C., Leibowitz, S. F., Gahn, S., Nahata, L., Morningstar, M., Mattson, W. I., ... & Nelson, E. E. (2021). Testosterone treatment, internalizing symptoms, and body image dissatisfaction in transgender boys. Psychoneuroendocrinology, 132, 105358.

This study recruited 42 birth-assigned female adolescents from a gender clinic in Ohio. Nineteen were receiving testosterone and 23 were not. Those not receiving testosterone were not receiving it due to a number of reasons (referred to endocrinology but hadn't started, parents not providing consent, and one was not interested in testosterone). The adolescents who were receiving testosterone treatment had lower scores on measures of generalized anxiety, social anxiety , depression, and body image dissatisfaction.

Study 13: Hisle-Gorman, E., Schvey, N. A., Adirim, T. A., Rayne, A. K., Susi, A., Roberts, T. A., & Klein, D. A. (2021). Mental healthcare utilization of transgender youth before and after affirming treatment. The Journal of Sexual Medicine, 18(8), 1444-1454.

This study utilized military healthcare data from transgender youth who received medical care through the U.S. military healthcare system. The researchers identified 963 transgender adolescents who had received some form of gender-affirming medical treatment. The mean age of starting any gender-affirming medical care was 18.2 (so this study may not technically qualify for our review of studies of adolescents). Their outcomes of interest were number of mental healthcare visits after gender-affirming medical care and number of days taking a psychiatric medication after starting gender-affirming medical care. In their adjusted models, there was no change in number of annual mental healthcare visits and an increase in days taking psychiatric medication from a mean 120 days per year to a mean 212 days per year. It's difficult to make firm conclusions based on this study, given the unusual outcome measure of number of days per year taking a psychiatric medication. The authors present a range of possible interpretations in the discussion section of the manuscript for those who are interested.

Study 14: Green, A. E., DeChants, J. P., Price, M. N., & Davis, C. K. (2021). Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth. Journal of Adolescent Health.

This study was conducted by researchers from The Trevor Project. They recruited 5,753 transgender adolescents who said they wanted gender-affirming hormone treatment (estrogen or testosterone). Of these, 1,216 had accessed gender-affirming hormones treatment. To focus on the results for only participants who were under 18: After adjusting for potential confounding variables, access to gender-affirming hormones was associated with lower odds of recent depression and suicide attempts when compared to those who desired but did not access gender-affirming hormones.

Study 15: Turban, J. L., King, D., Kobe, J., Reisner, S. L., & Keuroghlian, A. S. (2022). Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS One, 17(1), e0261039.

This study was also conducted by me and other researchers at Harvard Medical School. We examined 21,598 adults who reported ever desiring gender-affirming hormones (estrogen or testosterone). Of these, 481 accessed gender-affirming hormones during adolescence, 12,257 accessed gender-affirming hormones as adults, and 8,860 were never able to access gender-affirming hormones. We found that regardless of age of initiation, accessing gender-affirming hormones was associated with lower odds of past-year suicidal ideation and past year severe psychological distress. We also found that access to gender-affirming hormones during adolescence was associated with a lower odds of these same adverse mental health outcomes when compared to not accessing gender-affirming hormones until adulthood. Because the study was cross-sectional, we created a variable for people who had suicidal ideation in the past but did not have it in the past year (a proxy for mental health improving over time). We found that people who accessed gender-affirming hormones were more likely to meet this criterion than people who desired but did not access gender-affirming hormones, arguing against reverse causation (a common problem with cross-sectional studies).

Study 16: Tordoff, D. M., Wanta, J. W., Collin, A., Stephney, C., Inwards-Breland, D. J., Ahrens, K. (2022) Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care. JAMA Network Open, 5(2), e220978.

This study was a prospective cohort study from Seattle Children's Gender Clinic. The researchers followed 104 transgender and non-binary youth who were receiving gender-affirming medical treatment. After adjusting for temporal trends and potential confounders, they found lower odds of depression and suicidality among young people who had started gender-affirming medical care, when compared to those who did not.

No Randomized Controlled Trials

One will notice that there have not been any randomized controlled trials. There is a general consensus in the field that such a trial would be unethical given the body of literature we have so far indicating that those in the control group would be likely to suffer adverse mental health outcomes compared to those randomized to the treatment groups. For this reason, it appears that no institutional review board would approve a randomized controlled trial at this time, under the principle of "equipoise" to which some bioethicists refer.

In summary, there have been, to my knowledge, 16 studies to date studying the impact of gender-affirming medical care for transgender adolescents. Taken together, the body of research indicates that these interventions result in favorable mental health outcomes. I will continue to update this post as new studies become available. Please feel free to contact me if you are aware of any new studies I have not yet included.

De Vries, A. L., Steensma, T. D., Doreleijers, T. A., & Cohen‐Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow‐up study. The Journal of Sexual Medicine, 8(8), 2276-2283.

De Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696-704.

Costa, R., Dunsford, M., Skagerberg, E., Holt, V., Carmichael, P., & Colizzi, M. (2015). Psychological support, puberty suppression, and psychosocial functioning in adolescents with gender dysphoria. The Journal of Sexual Medicine, 12(11), 2206-2214.

Allen, L. R., Watson, L. B., Egan, A. M., & Moser, C. N. (2019). Well-being and suicidality among transgender youth after gender-affirming hormones. Clinical Practice in Pediatric Psychology, 7(3), 302.

Kaltiala, R., Heino, E., Työläjärvi, M., & Suomalainen, L. (2020). Adolescent development and psychosocial functioning after starting cross-sex hormones for gender dysphoria. Nordic Journal of Psychiatry, 74(3), 213-219.

de Lara, D. L., Rodríguez, O. P., Flores, I. C., Masa, J. L. P., Campos-Muñoz, L., Hernández, M. C., & Amador, J. T. R. (2020). Psychosocial assessment in transgender adolescents. Anales de Pediatría (English Edition), 93(1), 41-48.

van der Miesen, A. I., Steensma, T. D., de Vries, A. L., Bos, H., & Popma, A. (2020). Psychological functioning in transgender adolescents before and after gender-affirmative care compared with cisgender general population peers. Journal of Adolescent Health, 66(6), 699-704.

Achille, C., Taggart, T., Eaton, N. R., Osipoff, J., Tafuri, K., Lane, A., & Wilson, T. A. (2020). Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results. International Journal of Pediatric Endocrinology, 2020(1), 1-5.

Kuper, L. E., Stewart, S., Preston, S., Lau, M., & Lopez, X. (2020). Body dissatisfaction and mental health outcomes of youth on gender-affirming hormone therapy. Pediatrics, 145(4).

Turban, J. L., King, D., Carswell, J. M., & Keuroghlian, A. S. (2020). Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics, 145(2).

Carmichael, P., Butler, G., Masic, U., Cole, T. J., De Stavola, B. L., Davidson, S., ... & Viner, R. M. (2021). Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. PLoS One, 16(2), e0243894.

Grannis, C., Leibowitz, S. F., Gahn, S., Nahata, L., Morningstar, M., Mattson, W. I., ... & Nelson, E. E. (2021). Testosterone treatment, internalizing symptoms, and body image dissatisfaction in transgender boys. Psychoneuroendocrinology, 132, 105358.

Hisle-Gorman, E., Schvey, N. A., Adirim, T. A., Rayne, A. K., Susi, A., Roberts, T. A., & Klein, D. A. (2021). Mental healthcare utilization of transgender youth before and after affirming treatment. The Journal of Sexual Medicine, 18(8), 1444-1454.

Green, A. E., DeChants, J. P., Price, M. N., & Davis, C. K. (2021). Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth. Journal of Adolescent Health.

Turban, J. L., King, D., Kobe, J., Reisner, S. L., & Keuroghlian, A. S. (2022). Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS One, 17(1), e0261039.

Tordoff, D. M., Wanta, J. W., Collin, A., Stephney, C., Inwards-Breland, D. J., Ahrens, K. (2022) Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care. JAMA Network Open, 5(2), e220978.

Jack Turban MD MHS is a writer and fellow in child and adolescent psychiatry at Stanford University School of Medicine, where he researches the mental health of transgender and gender diverse youth.

• Find a Therapist
• Find a Treatment Center
• Find a Psychiatrist
• Find a Support Group
• Find Online Therapy
• United States
• Brooklyn, NY
• Chicago, IL
• Houston, TX
• Los Angeles, CA
• New York, NY
• Portland, OR
• San Diego, CA
• San Francisco, CA
• Seattle, WA
• Washington, DC
• Asperger's
• Bipolar Disorder
• Chronic Pain
• Eating Disorders
• Passive Aggression
• Personality
• Goal Setting
• Positive Psychology
• Stopping Smoking
• Low Sexual Desire
• Relationships
• Child Development
• Self Tests NEW
• Therapy Center
• Diagnosis Dictionary
• Types of Therapy

Sticking up for yourself is no easy task. But there are concrete skills you can use to hone your assertiveness and advocate for yourself.

• Emotional Intelligence
• Gaslighting
• Affective Forecasting
• Neuroscience

• New Hampshire
• North Carolina
• Pennsylvania
• West Virginia
• Online hoaxes
• Coronavirus
• Health Care
• Immigration
• Environment
• Foreign Policy
• Kamala Harris
• Donald Trump
• Mitch McConnell
• Hakeem Jeffries
• Ron DeSantis
• Tucker Carlson
• Sean Hannity
• Rachel Maddow
• PolitiFact Videos
• 2024 Elections
• Mostly True
• Mostly False
• Pants on Fire
• Biden Promise Tracker
• Trump-O-Meter
• Latest Promises
• Our Process
• Who pays for PolitiFact?
• Advertise with Us
• Suggest a Fact-check
• Corrections and Updates
• Newsletters

Stand up for the facts!

Our only agenda is to publish the truth so you can be an informed participant in democracy. We need your help.

I would like to contribute

• Health Check

Florida Gov. Ron DeSantis speaks during a news conference on Aug. 4, 2022, in Tampa. (AP)

Transition-related surgery limited to teens, not 'young kids.' Even then, it's rare

If your time is short.

• We found no examples of "young kids" receiving transition-related surgery. The Florida Department of Health differentiates between children - under 10 -  and adolescents -  between 10 and 18. DeSantis' office provided PolitiFact with two cases involving adolescents.

Florida Gov. Ron DeSantis suspended Hillsborough State Attorney Andrew Warren, in part, for signing a pledge against the criminalization of gender-affirming health care.

Although Florida has not enacted any law prohibiting transgender medical treatment for children, DeSantis cited Warren's pledge not to prosecute doctors who offer these services as evidence of his neglect of duty.

DeSantis has mocked the term "gender-affirming care," which the U.S. Department of Health and Human Services says can include medical, surgical and mental health services for transgender and nonbinary people.

"When you have the 2021 letter saying … no matter what a state declares about protecting child welfare with respect, I mean, you know, they use these euphemisms," DeSantis said at an Aug. 4 press briefing announcing the suspension. "But what it is, is they're literally chopping off the private parts of young kids, and that's wrong."

This isn't the first time DeSantis suggested that "young kids" in the U.S. receive transition-related surgeries. DeSantis criticized these procedures in an Aug. 3 conference : 

"They want to castrate these young boys, that's wrong. We stood up and said, from the health and children's well-being perspective, you don't disfigure 10, 12, 13-year-old kids based on gender dysphoria."

We found no examples of doctors "literally chopping off the private parts of young kids," as DeSantis said. 

"That is not true under any existing medical guidelines," said Dr. Jack Turban, assistant professor of child and adolescent psychiatry at the University of California, San Francisco. "No medical or surgical interventions are considered for prepubertal children."

The governor's office sent PolitiFact two examples of people who received transition-related surgeries in their mid to late teenage years  — one at 15 and one at 17. DeSantis' Florida Department of Health differentiates between children (under 10) and adolescents (10-18). In one case DeSantis provided, an individual from California received masculinizing chest surgery at 15. Under existing California law, an insurer cannot deny coverage for the surgery — which includes double mastectomies —  based on a patient's age alone. 

The procedure is mostly offered to teenagers 15 and older, The New York Times reported. However, we found one report of a 14-year-old who obtained the procedure, and there isn't a consensus on a specific age requirement among medical guidelines.

The other case involved Jazz Jennings, a transgender woman who stars in a reality television show on TLC. Jennings received genital reassignment surgery at 17.

Genital reassignment surgery should be reserved for those 18 and older, according to guidelines for the medical care of transgender patients developed by the Endocrine Society and the World Professional Association for Transgender Health , or WPATH.

Featured Fact-check

C.P. Hoffman, senior policy counsel for the National Center for Transgender Equality, told PolitiFact that cases like Jennings are not common. 

"Even when a minor has parental support for their transition, transition-related surgeries are not typically performed prior to the age of 18," Hoffman said. "While there are some reports of transgender teens between the ages of 16 and 18 receiving transition-related surgical care, these cases are exceedingly rare and based on the specific medical needs of the teen."

The American Academy of Pediatrics recommends what it terms a "gender-affirmative care model" for prepubescent children experiencing gender dysphoria  — distress people may experience because of the discrepancy between their gender identity and the sex assigned to them at birth. Gender-affirmative care is oriented toward understanding and appreciating a child's gender identity rather than providing puberty blockers, hormone therapy or surgery. 

"Before any physical interventions are considered for adolescents, extensive exploration of psychological, family and social issues should be undertaken," the WPATH guideline reads.

The beginning of puberty, which generally occurs between the ages of 10 and 12, is a baseline for medical intervention.

The Endocrine Society recommends against puberty blockers, which suppress the release of testosterone and estrogen during puberty, for prepubescent children. An adolescent can be prescribed the treatment at the onset of puberty.

Hormone therapy can follow the use of puberty blockers, although it isn't typically considered for patients younger than 16 years old, according to the Endocrine Society. 

WPATH recommends that "moving from one stage to another should not occur until there has been adequate time for adolescents and their parents to assimilate fully the effects of earlier interventions."

The association's criteria for initiating surgical treatment include "documentation of persistent gender dysphoria" and the "capacity to make a fully informed decision and to consent for treatment."

Under Florida law , a health care practitioner cannot provide or arrange medical services for a minor without parental consent. And many health insurance providers, including Aetna and Anthem , require a patient seeking genital reassignment surgery to be 18 or older to qualify for coverage.

DeSantis said, "They are literally chopping off the private parts of young kids."

DeSantis' office provided two examples of teenagers who received transition-related surgeries. The Florida Department of Health would define both cases as involving adolescents, and experts say the procedures are rare for minors and aren't typically recommended. There are no examples we could find, or the governor's office provided, of transition-related surgeries for people under the age of 14. 

Medical transitioning is not recommended for prepubescent children, as DeSantis suggested. We rate his claim Mostly False. 

Read About Our Process

The Principles of the Truth-O-Meter

Our Sources

Youtube, Governor DeSantis makes a major announcement in Tampa , Aug. 4, 2022

WFLA, Gov. DeSantis announces addiction program to combat overdoses, fentanyl deaths , Aug. 3, 2022

Email interview with Christina Pushaw, DeSantis' press secretary, Aug. 5, 2022

Email interview with C.P. Hoffman, senior policy counsel for the National Center for Transgender Equality, Aug. 5, 2022

Phone interview with Susan Boulware, medical director of the Yale Pediatric Gender Program, Aug. 8, 2022

Email interview with Jack Turban, assistant professor of child and adolescent psychiatry at the University of California, Aug. 4, 2022

Email interview Scott VanDeman, communications coordinator for Florida Chapter of American Academy of Pediatrics, Aug. 5, 2022

The New York Times, DeSantis Suspends Tampa Prosecutor Who Vowed Not to Criminalize Abortion , Aug. 4, 2022

PolitiFact, No, young children cannot take hormones or change their sex , March 5, 2021

PolitiFact, Rep. Mary Miller says White House is encouraging kids to take "castration" drugs, undergo surgeries , April 17, 2022

Endocrine Society, Gender Dysphoria/Gender Incongruence Guideline Resources , Sept. 1, 2017 

World Professional Association for Transgender Health, Standards of Care , 2012 

Tampa Bay Times, DeSantis removes Hillsborough County State Attorney Andrew Warren , Aug. 4, 2022

Fair and Just Prosecution, Trans Criminalization Joint Statemen t, June 2021

Dade County Medical Association, Treating Minors Under Florida's New 'Parental Consent' Law , July 12, 2021

The Washington Post, FAQ: What you need to know about transgender children , Feb. 25, 2022

​​World Health Organization, Adolescent health , assessed Aug. 4, 2022

Office of Population Affairs and U.S. Department of Health and Human Services, Gender-Affirming Care and Young People Guidance , March 2022

American Academy of Pediatrics, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents , Oct.1, 2018

U.S. National Library of Medicine, Medline Plus, " Puberty ," accessed Aug. 5, 2022

Browse the Truth-O-Meter

More by yacob reyes.

Transition-related surgery limited to teens, not 'young kids.' Even then, it's rare

Support independent fact-checking. Become a member!

Kate Sosin, The 19th Kate Sosin, The 19th

Leave your feedback

• Copy URL https://www.pbs.org/newshour/health/most-state-bans-on-gender-affirming-care-for-trans-youth-still-allow-controversial-intersex-surgery

Most state bans on gender-affirming care for trans youth still allow controversial intersex surgery

This article was originally published by The 19th on March 23, 2023.

When Georgia lawmakers advanced a bill earlier this month that would ban gender-affirming care for youth, many argued that kids were too young to be making big health care decisions.

“We’re asking that children be 18 years old before they make this decision that will alter their lives forever,” Republican Sen. Carden Summers said, according to an ABC news article.

Summers’ argument is not uncommon. Opponents of trans rights have argued that kids are ill-equipped to decide on gender-related medical interventions. Those arguments largely confuse what gender-affirming health care for youth is.

READ MORE: The fight to end intersex surgeries at a top hospital took a deep toll on activists

Still, Georgia’s bill does not outlaw irreversible gender-related surgeries on all kids. In fact, if the bill becomes law, Georgia will become one of several states to pass laws backing pediatric sex-related surgeries that have been condemned by the United Nations for more than a decade: those for people born intersex.

More than two-thirds of the bills introduced this year that would ban gender-affirming care for transgender youth have specific intersex exemptions. The controversial exemptions allow doctors to assign minors who are born with secondary sex characteristics as “male” or “female” through surgeries, hormones or other interventions.

“So you’re saying that trans kids are too young to consent, but intersex kids aren’t?” asked Bria Brown-King, director of engagement for the intersex rights group InterAct. “How does that make sense?”

Sean Saifa Wall, an intersex scholar and activist, believes that medical interventions for trans kids and intersex kids have become conflated.

“We as a society do not understand the experiences of trans people and trans children,” said Wall. “A lot of trans young people don’t get surgeries until they’re 18. That’s what often happens to intersex young people, but because we don’t understand, we don’t understand neither trans nor intersex experiences, these bills float on by.”

Intersex conditions are common, according to scientists. A 2000 study by Brown University professor Dr. Anne Fausto-Sterling found that 1.7 percent of the population is born intersex. That’s about the same percentage of people born with red hair.

While doctors have operated on intersex minors to assign them “male” or “female” sexes for decades, human rights organizations have long condemned the surgeries on kids as cosmetic, unnecessary and inhumane. That’s because many procedures are done on kids in infancy, without their knowledge or consent.

Intersex adults often only discover they are intersex by accident, they report . Some have grown up being told by doctors or parents that they had painful surgeries because they had cancer . In reality, they learned, the surgeries were done to assign them a binary sex.

In 2013, the United Nations issued a report that called for an end to “genital-normalizing surgery, involuntary sterilization, unethical experimentation, medical display, ‘reparative therapies.’”

“A lot of these things are presented as medical problems that require fixing that are not actually medical problems,” Maddie Moran, director of communications for InterACT, said.

The movement to outlaw intersex surgeries in the United States has made big strides in the last three years. Two prominent hospitals — Chicago’s Lurie Children’s Hospital and Boston Children’s Hospital — have stopped offering pediatric intersex procedures. The Biden administration has also been meeting with intersex advocates to talk about how to end the surgeries nationwide. In the meantime, California, often a leader on LGBTQ+ rights, has introduced a bill to ban pediatric intersex surgeries. The bill has yet to gain enough support to pass.

But as the intersex rights movement becomes more mainstream, it has also become a target. According to InterAct and the National Center for Transgender Equality, more than two-thirds of the bills that target transgender medical care introduced this year (82 out of 120) have carve-outs for pediatric intersex procedures. Those carve-outs have consequences, advocates say:  Some of the first explicit anti-intersex language is being written into law.

“The bills are really authorizing in the law, the practice of performing these unnecessary surgeries,” Moran said. “They are surgeries that are already happening . . . but they are now authorizing that practice in the law, which is the opposite of the direction that we want to be going.”

Wall thinks the bills are not about protecting children at all and said they are really about reinforcing rigid gender ideals and heterosexuality.

“I see the attack on trans people, and I see the mandates to continue doing surgeries on intersex infants and children as a way of crushing bodily autonomy as a way of upholding ‘male’ and ‘female’ as sacred,” he said. “This harm has been really endemic and it’s been long-standing. The scary part about it, though, is when there’s a codifying it into law.”

Support Provided By: Learn more

Educate your inbox

Subscribe to Here’s the Deal, our politics newsletter for analysis you won’t find anywhere else.

Thank you. Please check your inbox to confirm.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• JAMA Network
• PMC10448302

National Estimates of Gender-Affirming Surgery in the US

Jason d. wright.

1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York

Yukio Suzuki

Koji matsuo.

2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

Dawn L. Hershman

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 .

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 .

Associated Data

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

This cohort study examines trends in inpatient and outpatient gender-affirming surgical procedures in the US and explores the temporal trends in the types of procedures across age groups.

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

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.

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.

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.

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.

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.

Introduction

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 , 3 , 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 , 3 , 4 , 5 , 6 , 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.

Data Sources

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.

Patients and Procedures

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.

Statistical 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.

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

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%]).

Abbreviations: GAS, gender-affirming surgery; NA, not available; NOS, not otherwise specified.

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 ).

Abbreviations: GAS, gender-affirming surgery; NOS, not otherwise specified.

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.

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.

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.

Limitations

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.

Conclusions

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.

Supplement 1.

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

Supplement 2.

Data Sharing Statement

Connection denied by Geolocation Setting.

Reason: Blocked country: Russia

The connection was denied because this country is blocked in the Geolocation settings.

Please contact your administrator for assistance.

Musk says estranged child's gender-affirming care sparked fight against 'woke mind virus'

Tesla CEO Elon Musk said his estranged transgender daughter was "killed" by the "woke mind virus" after he was tricked into agreeing to gender-affirming care procedures .

In an interview with psychologist and conservative commentator Dr. Jordan Peterson , the X owner called gender-reassignment surgery "child mutilation and sterilization." He then discussed his 20-year-old child Vivian Jenna Wilson , who he said underwent the procedures during the pandemic.

"I was essentially tricked into signing documents for one of my older boys," Musk told Peterson in a Daily Wire interview during which he referred to his child by their deadname. "This was really before I had any understanding of what was going on, and we had COVID going on, so there was a lot of confusion and I was told (Musk's child) might commit suicide."

The SpaceX founder claimed the process is done to children "who are far below the age of consent" and said he agreed with Peterson's belief that anyone who promotes the practice should go to prison.

"I was tricked into doing this," Musk said. "I lost my son, essentially. They call it 'deadnaming' for a reason. The reason they call it ‘deadnaming’ is because your son is dead."

Musk went on to say that the experience set him on a mission.

"I vowed to destroy the woke mind virus after that," Musk said. "And we’re making some progress."

Twitter AI: Elon Musk is quietly using your tweets to train his chatbot. Here’s how to opt out.

Vivian Jenna Wilson cut ties with father in 2022

Wilson was legally granted her name and gender change at age 18 at the Santa Monica courthouse in California on June 22, 2022.

She said the name change was due to gender identity and an apparent dislike of Musk, according to a petition filed on April 18, 2022, in Los Angeles County Superior Court.

"I no longer live with or wish to be related to my biological father in any way, shape or form," Wilson wrote in the petition.

Wilson's mother is Justine Wilson, a Canadian author who divorced Musk in 2008; the couple shares six children.

Musk called 'woke mind virus' threat to modern civilization

Musk has previously criticized what he calls "woke mind virus"  in a December 2021 interview with conservative outlet The Babylon Bee, where said called it "a world without humor"  and "arguably one of the greatest threats to modern civilization."

Musk announced his intent to buy Twitter for $44 billion on April 25, 2022 , and closed the deal about six months later . He promised to restore "free speech" on the platform and has increased his conservative political commentary since the purchase.

Earlier this month, Musk said he fully endorsed former President Donald Trump after the attempted assassination at a Pennsylvania rally on July 13.

Gender-affirming care is a valid, science-backed method

Gender-affirming care  is a  valid, science-backed method  of medicine that saves lives for people who require care while navigating their gender identity. Gender-affirming care can range from talk or hormone therapy to  surgical intervention .

Some experts claim that that  gender-affirming care  should be viewed like other forms of medicine where methods of treatment can be debated and discussed rather than the validity of it's need.

"In any medical field, we're continuously improving the care, changing the care, developing new  guidelines , developing research," Dr. Ximena Lopez, a pediatric endocrinologist in California, previously told USA TODAY. "So it should not be a surprise that it's the same in gender care."

Transgender adults  make up less than 2% of the U.S. population with about 5% of young adults identifying as  transgender  or nonbinary.

"We need to take a step back from acknowledging yes, they might have side effects, but that's why they're not done so flippantly," Dr. Ramiz Kseri , assistant professor in the department of clinical sciences at Florida State University College of Medicine, previously told USA TODAY. "That's why there is conversation about it, there is discussion, in terms of which outcomes are desired, and which outcomes are not desired."

Contributing: Natalie Neysa Alund, Jessica Guynn and David Oliver, USA TODA Y