It has been a record-breaking year for legislation aiming to limit the rights of transgender people in the United States. Twenty states proposed laws impeding gender-affirming medical care for minors in 2021, and Arkansas became the first state to outlaw gender-affirming care for adolescents under 18 years of age. Denying gender-affirming health care to anyone that is transgender is akin to withholding medical treatment. The American Academy of Pediatrics (AAP), American Medical Association (AMA), and American Academy of Family Physicians (AAFP) are just some of the leading medical organizations that have recently spoken out against such legislation targeting the health and welfare of transgender youth.
By the age of five or six, most children will recognize their gender. While most children identify with their birth-assigned sex, some experience incongruence that can affect their emotional and psychological wellbeing (a mental health condition known as gender dysphoria). In addition to depression, anxiety, social withdrawal, and self-harming behavior, transgender youth have high rates of suicidal ideation and suicide attempts, rates that increase during the physiological changes of puberty. However, not all persons with gender variance experience psychological distress and gender-affirming health care is appropriate for all persons with gender incongruence.
Ideally, gender-affirming health care for youth with gender variance consists of a multidisciplinary team of mental health and medical professionals to assist them and their families with the medical and social aspects of gender transitioning. While medical and surgical interventions can facilitate physical transitioning, social transitioning is a crucial component of comprehensive care. Social transitioning may involve a change in name and preferred pronouns as well as aesthetic choices regarding clothing, hairstyle, and comportment. Social support (including family support) and counseling can help tremendously during this time.
Many gender non-conforming youth experience discomfort during puberty as their bodies begin to change in undesirable ways. Puberty suppressing hormone therapy is a reversible intervention that delays puberty, allowing transgender or gender diverse youth more time to explore their gender identity and expression before many of the permanent physiologic changes of puberty take place. Notably, this therapy is recommended for pubescent youth during Tanner stages two-three (i.e., in whom puberty has begun) but not before. In a recent systematic review, pubertal suppression was associated with improvement in general functioning, depressive symptoms, emotional and behavioral issues, and suicidal ideation in adolescents.
If additional transitioning is desired after pubertal suppressive therapy, hormone therapy can further promote masculine or feminine characteristics and initiate puberty in the desired direction. Testosterone is the cornerstone of gender-affirming medical therapy for transgender males and estrogen with antiandrogen is commonly used for transgender females. A trial of 148 children receiving gender-affirming hormone therapy reported improvements in body satisfaction and a decrease in depression and anxiety.
Gender-affirming surgery is the most permanent medical intervention for transgender persons. Surgical options may include mastectomy, male chest contouring, breast augmentation, hysterectomy/oophorectomy, and genital reconstruction. Gender-affirming surgery is associated with lower rates of severe psychological distress, suicidal ideation and attempts, binge drinking, and smoking among transgender adults. It’s important to note that current guidelines recommend proceeding through social and hormone-based transitions before considering surgical options and being of legal age (18 years old in the United States), so few adolescents are offered this type of management.
While the true prevalence of gender variance is unknown, nearly 10 percent of high school students reported incongruence between gender identity and sex assigned at birth in a recent survey. Many transgender adolescents continue to identify as transgender into adulthood and benefit from gender-affirming care that is started before permanent, unwanted pubertal changes take place. A limited number of trials report improvements in a range of psychosocial outcomes in adolescents following gender-affirming hormone therapy, but more research is needed. While current antitransgender bills propose to “safeguard children”, the evidence to-date indicates the opposite, and their enforcement would undoubtedly do harm by denying necessary medical care during this very important window of time.
For more information, see the topic on Gender Dysphoria in DynaMed as well as topics on hormone therapy for adolescent female and adolescent male transgender patients.