What is 'gender-affirming care' for trans youth?

Despite wars, gun violence and climate disasters around the world, some American politicians continue to be hyper-focused, and highly opinionated, on the subject of transgender youth.

Former president Donald Trump recently released a nearly four-minute-long video in which he vows, if reelected, to punish doctors who provide “gender-affirming care” to minors, likening it to “child abuse.”

President Joe Biden, meanwhile, implored the Senate during his State of the Union Address to “pass the bipartisan Equality Act to ensure LGBTQ Americans, especially transgender young people, can live with safety and dignity.”

And for a while now, conservative lawmakers have been, like Trump, hell-bent against trans youth receiving the medical care they need. In fact, state legislators in Missouri, Kentucky, Georgia, Utah Alabama, Arkansas, Arizona and Tennessee have passed laws that restrict trans youth’s access to gender-affirming care. This year alone, nearly 160 bills have been introduced in at least 43 states that target the trans community, over 20 of which specifically block minors from receiving such care.

But what, exactly, is gender-affirming care? And why is everyone so invested in what it means for transgender youth?

What gender-affirming care is, and who it’s for

In a broad sense, gender-affirming care refers to a spectrum of health care services — possibly, but not always, including hormonal treatments, mental health services, hair removal, vocal therapy and various surgeries, such as facial reconstructions to provide a more feminine or masculine appearance, for example, “top surgeries,” in which breasts are removed or implanted, and “bottom surgeries,” which alter genitalia in individuals experiencing gender dysphoria.

Gender dysphoria, according to the American Psychiatric Association, is a diagnosis given to transgender individuals experiencing “psychological distress that results from an incongruence between one's sex assigned at birth," based on external genitalia, "and one's gender identity," meaning the psychological sense of one's gender.

For many transgender adults, gender-affirming care is one of the most vital steps toward living full lives — just as it is for transgender youth, according to the many leading healthcare organizations that back it, such as the American Psychiatric Association, the American Academy of Pediatrics and the American Academy of Child & Adolescent Psychiatry, partially because such care has been linked to lower risks of suicide among trans youth. And in 2021 alone, there were 42,167 new diagnoses of gender dysphoria in patients between the ages of 6 and 17, according to a Reuters and Komodo Health Inc. analysis of insurance claims, released in Oct. 2022.

What’s specific about gender-affirming care for youth?

First and foremost, “gender-affirming care entails meeting a child and their family” and listening to the child “talk about their gender experience, in the context of a thorough and complete medical and psychosocial history and evaluation,” Dr. Michelle Forcier, a professor of pediatrics at Alpert School of Medicine, Brown University, and Clinician at Folx Health, tells Yahoo Life. From there, professionals work with the family to discuss their individual needs and options.

“Many children come to these visits very self-educated and very clear about what they need; others need more information and time to explore,” Forcier says. “Like any other clinical intervention, we put together a menu of safe, effective, low-risk, high-benefit options for the parents to learn more about,” while also informing them about measures that “would not be safe, or potentially be harmful.”

Then, “as a team,” which includes the parents, the patient and other medical professionals involved, the family can “start a process of learning more and/or making decisions about next steps to support their child,” she explains.

Below are some of the main forms that a minor’s gender-affirming care can take:

Mental health support for socially transitioning

This is often the first step, and it simply involves mental health professionals who provide a safe space for youth to “socially transition” by adopting gender-affirming hairstyles, clothing, names and pronouns — none of which require medical interventions.

“There are some who believe that gender-affirming care pushes families to move forward on things like gender-affirming medical procedures. That’s simply not true,” Derrick Jordan, director of the Gender and Family Project at the Ackerman Institute for the Family in New York City, tells Yahoo Life, adding that mental health providers aim to offer an encouraging space to "allow families to explore and better understand" decisions that are "most helpful and supportive for them."

“Prepubertal children do not need any medications or surgeries, but medical or mental interactions, education, resources and [emotional] support can be super-helpful" so families can "support their child in a safe and healthy way," adds Forcier.

Puberty blockers and hormones

In some cases, doctors may prescribe puberty blockers. Technically called gonadotropin-releasing hormone analogues (GnRHas), these work by temporarily pausing development in children who have entered puberty. Research, including a 2020 study published in Pediatrics, has found an association between the use of puberty blockers and decreased thoughts of suicide. Originally used — for over 30 years — to treat young people with puberty that starts too early (called precocious puberty), puberty blockers’ results are safe and reversible, say experts who support their use.

“Puberty blockers are used for many conditions,” says Forcier. “They are safe, completely reversible, temporary pause and halt puberty. Saying puberty blockers are ‘chemical castration’ [as critics have said] is not medically correct for how they are used for [trans] pubertal youth."

But they are not uncontroversial. The New York Times found emerging evidence that blockers may potentially have long-term effects on bone health, leading to heightened risk of debilitating fractures earlier in life. In cases where they are prescribed to patients at the “first stage of puberty” — as early as 8, and before progressing to hormones as soon as 12 or 13 — some doctors fear the treatment will force children's bodies to “lock in” place, before they have a full understanding of their gender identity (which typically begins at puberty).

In addition to the blockers, hormone therapy, which involves estrogen for trans women or testosterone for trans men, for those who choose it, is typically administered in the form of weekly shots, which can be prescribed at early adolescence and are partially reversible later in life once you stop taking them, as noted by the University of California San Francisco.

The degree to which they can be reversed depends on how long a patient has been taking them, noted researchers. For those taking estrogen, some breast growth, and possibly reduced or absent fertility, are not reversible. Similarly, for those taking testosterone, clitoral growth, facial hair growth, voice changes and male-pattern baldness are not reversible.

Top surgery

Despite alarmist claims like that of Florida Gov. Ron DeSantis, who accused physicians of “chopping off the private parts of young kids,” medical providers rarely provide gender-affirming surgeries without careful evaluations by healthcare providers and the child’s family.

“There's a strong recommendation for there to be a multidisciplinary evaluation, with multiple meetings with parents and the patients, to have a conservative evaluation and understanding of exactly where and what role surgery plays in a patient’s gender transition,” Dr. Fan Liang, medical director of the Johns Hopkins Center for Transgender Health, tells Yahoo Life. She notes that it’s a misconception to assume that “surgery is very easily scheduled” for minors without multiple layers of vetting.

Forcier says surgeries are done only on minors with "severe" cases of gender dysphoria.

"Some asserting males will benefit from top surgery or male chest construction," she says. "Say, for example, you identify as male, have had breasts since age 10 and have significant chest dysphoria. At 15 they and their parents would say, 'Testosterone is not enough.'" Even rarer are bottom surgeries, which, again, are done only for minors experiencing severe dysphoria, Forcier explains. "Vaginoplasty requires more post-operative care, so again, it's approached case-by-case."

According to the most recent version of best practices by the World Professional Association for Transgender Health, an international group of gender experts who make medical recommendations, “irreversible surgeries” (like hysterectomies or phalloplasties) are recommended for only those 18 and older, except in the case of mastectomies for trans men, which have a recommended age minimum of 16.

While there are no official U.S. statistics on such surgeries for trans youth, the Reuters and Komodo Health Inc. analysis found, through insurance claims, that there were 56 genital surgeries among gender-dysphoric patients ages 13 to 17 between 2019 and 2021. During that same time period, researchers found at least 776 mastectomies performed on the same demographic. (These don’t include procedures that were paid for out of pocket.) Furthermore, a recent New York Times survey of leading pediatric gender clinics across the country found that 11 clinics performed a total of 203 top surgeries on minors in 2021, and that many had long waiting lists.

Stresses Liang: ”As physicians, we all take the Hippocratic Oath: ‘First, do no harm.’ There is a lot of forethought and consideration that goes into each child that we take care of."

Still, those who oppose gender-affirming care worry about mental anguish that may arise should young patients regret their choices later in life. It’s just a part of why so many bills have been put forth to prohibit such treatments.

Real-life impacts of banning gender-affirming care

Should a federal ban on such care ever come to fruition, Forcier says it will have a “devastating” impact on trans youth. And in many state-by-state cases, it already has: Research from the Trevor Project, an LGBTQ youth suicide-prevention organization, found that 93% of transgender youth have worried about trans people being denied access to gender-affirming medical care due to state or local laws.

“Parent and family support really makes a difference in keeping kids safe and healthy,” Forcier explains. “All kids do better in spaces where they feel safe and loved.”

“The political and media messaging are immensely harmful,” she adds. "Think of it: These are adults, politicians, publicly bullying children. These are mostly non-medical persons, who have no experience with the transgender community, the gender-diverse experience and the actual experiences and needs of a gender-diverse child, inserting themselves in a private clinical experience between the pediatrician and the child/family. Do they really belong there? Do we want politicians making personal and family medical decisions? I certainly don't.”

Terminating gender-affirming care across the nation would also “significantly impact” the way society views trans issues as a whole, adds Jordan.

“Gender-affirming care is not all about medical procedures and surgery, as some often make it out to be,” he says. “Gender-affirming care is grounded in the respect of the client or patient, and care that’s non-judgmental and affirming of the client’s whole self — including, of course, their gender identity.”

He adds that transgender and gender-nonconforming young people “experience depression, anxiety and suicidal ideation at much higher rates than cisgender individuals. What gender-affirming care aims to do is destigmatize gender diversity, and create a non-judgmental, safe and affirming space for … youth and their families to explore and understand their gender identity — care which often translates to better mental health outcomes.”

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