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.