Clarifying Misconceptions About Youth Gender-Affirming Care

As part of a series on the effects of state bans on gender-affirming care for youth, MedPage Today spoke with more than a dozen experts, including transgender people, clinicians, families, and staff at clinics and resource centers that serve the LGBTQ+ community. We heard some of the same points being made, time after time, about gender-affirming care, and what this community hoped the public could understand about it.

Here are their answers to some of the most commonly asked questions about gender-affirming care.

What difference does gender-affirming care make for transgender youth?

Charlie Adams (he/him), medical student at Kansas City University College of Osteopathic Medicine:

Notably, this is lifesaving care because of the high suicide rates of teens for whom such treatments are medically indicated but they are unable to receive....

I'm living my best life now, and for that I'm grateful, but it would've saved me a lot of very rough years of confusion and poor mental health, and to not have to go backwards to try to undo my puberty through surgery and hormones (testosterone for me) starting at age 23. I've always known I wanted to be a physician since I was 11 years old. The joy I feel now, the excitement I feel now thinking about my future, I had all of that taken away because of dysphoria ruling my life for over a decade.

But now I'm free. I get to show up as myself, I love who I am, and I'm insanely excited for my future as an emergency medicine physician. Lots of kids won't make it and live to that point, to experience the joy I now have, without this care. That very easily could have been me. ... There was a long time in my life where before I started hormones, I didn't want to live because that's how distressing gender dysphoria was for me. I had a lot of other things to live for and a lot of success but my dysphoria often overshadowed everything. I'm lucky to still be here.

Andi Gunter, health clinic manager at the Dennis R. Neill Equality Center in Tulsa, Oklahoma and mother of a trans child:

Whereas it might sound easy for some people to tell them, you know, "Well, they just have to wait till their 18th birthday." It's just not that simple. For some of them, it's life or death. And for others, they can do things like just socially transition with clothing or hair, or things of that nature, but for some kids, it's more detrimental to their mental health.

Nick Bates, Evangelical Lutheran Deacon, and father of a nonbinary child:

I'm a white male, but I've supported women's health care and women's rights and racial justice issues. But now as a parent of a trans child, no longer am I just an ally, but this impacts me. ... And to be under attack by our government, and being told by many in our government that we aren't welcomed in our own state, that we've invested our time and energy for our entire lives to try to build up a better community – is, it's difficult and it's exhausting.

Frances Lim-Liberty, MD, pediatric endocrinologist and medical director of the Pediatric and Adolescent Transgender Program at Dartmouth Health Children's in New Hampshire:

That is probably the big difference between the other patients, is I don't worry about them at night. I don't worry that they're going to be bullied, I don't worry that they won't be able to get the care that they need, or discriminated against. And so what is different now is that in my clinic visit, [is that] we do a lot of processing in terms of where do you feel safe at school? Who are your allies at school? Who are the people that you go to if you're feeling really alone and scared? Are you safe where you go? If something happens in New Hampshire with the legislation, where will you go for care? We have this whole other built-in dialogue regarding safety plans, frankly, and that's really hard and heartbreaking.

Molly McClain, MD, a family medicine doctor at the University of New Mexico (UNM) and a provider of gender-affirming care:

My favorite visit is the visit after they [a trans/gender-diverse child] start their hormone therapy, and they're just like, different. You can see that they feel more grounded. They feel safer. They feel more connected to their own bodies. I think if you see that, even if it's just once, you can't pretend that it's not helpful.

It changes people's lives, like what they can imagine for themselves ... what they have access to inside their own capacity ... what they deserve. I think that's true for every kid. And then when you stack [on] the discrimination part, which is so strong, and stronger in some states, that is really isolating and terrifying. You just learn that there is no place that is safe, and that breaks my heart for everybody who has that experience.

What happens before someone under 18 receives puberty-blocking medication and/or hormone replacement therapy?

Meredithe McNamara, MD, MS, adolescent medicine specialist and assistant professor of pediatrics at Yale University in New Haven, Connecticut:

It very much is the standard of care that adolescents should receive a thorough assessment in preparation for potentially receiving gender-affirming medical treatments. That mental health assessment includes consideration of co-occurring mental health issues. ... People should have those issues well managed, or managed as well as possible prior to receiving those treatments. The thing is, these are very slow processes. They take place over several visits, several months, years even, and slow, intentional, thoughtful decision making is not known to be impacted by mental health conditions.

Jennifer Abbott, MD, a family physician at Western North Carolina Community Health Services in Asheville, North Carolina:

Of course, every family comes with their own set of questions and their own concern for their child, as is appropriate. It's not a decision that's made lightly to see a doctor for gender-affirming hormone therapy or puberty suppression for your child with gender dysphoria. I mean, it's always a well-considered decision that involves mental health support and education, evaluation, and assessment.

Parental support is the number one most important piece. I mean, that's more important, even, than the medications that we can prescribe, because the parents – that's the child's lifeline right there.

Lim-Liberty:

We talk about normal growth and development and we make sure that all the mental health supports are in place that they're supported by family in the community. You know, we really focus on all of that and make sure that the kid in front of us really is in a supportive place. And then, if the family wants to talk about gender-affirming hormone therapy, we talk about that, and we discuss it, like ad nauseam, discuss it to the point where like, sometimes I'll be bringing up a side effect and they'll be like, 'we just went over that last week.' ... So just like any other care that I give -- insulin, growth hormone, puberty blockers for central precocious puberty, any other hormone that I prescribe -- you know, we talk in depth about risks and benefits and let the family decide together, shared medical decision-making, what's going to be the best approach for the kid in front of them.

"Puberty blockers are known to affect bone health. If you continue a puberty blocker for more than a couple of years without any other puberty hormones, this is something that is known in the medical literature. And as a result, we don't indefinitely prescribe a puberty blocker. We usually give it one to two years in order for families to have the time to explore gender identity and do gender work. And then we get DEXA [Dual-energy X-ray absorptiometry] scans, which measure bone health, and then we have discussions like, 'Okay, we're coming up on the year mark, or we're coming up on the two year mark, and really need to focus on what's the next step going to be?' It's something that is brought up in those opinion pieces as something that –the way it is brought up makes it sound like providers don't know about it. And in actuality, we spend a lot of time talking about that."

Christopher Bolling, MD, retired pediatrician who has testified on behalf of the American Academy of Pediatrics against state bans:

I'm a general pediatrician and there's this mythology, I think, that kids would come in and say, "Oh, I'm questioning. Oh, here's your puberty blocker." I'm like, "What?" I mean, these medications, they've been around since the early 90s for things like congenital adrenal hyperplasia. And they're critical. And do they have side effects? Of course, everything's got side effects. But they're medications that we've used for these other conditions to prevent puberty from progressing when it would be inappropriate for it to start -- we've been using them for 30 years almost now.

McClain:

My job isn't to alienate the children from the parents. My job is to create a safe space for everybody, even when they're kind of in totally different spaces. ... I think the important thing is the recognition that truly the parents do care about their kids or they also, they don't want to hurt their kid. They don't want to restrict choice for their kids in the future. And they are oftentimes worried that this is a decision that the kid cannot make at that age. ... So I try to be an intermediary between them because I know the first most important thing to protect these kids and support them is family support.

How often do youth under 18 get gender-affirming surgery?

Lily Piña, APRN, NP-C, of the Dennis R. Neill Equality Center

[Lawmakers in favor of bans] used a lot of fear tactics, if you will, saying how these children were getting altering interventions, surgical interventions, and if they grew up, they wouldn't be able to reverse them, but nobody in Oklahoma does surgical interventions on minors. And people actually believed it. Like that's one of the things that some people would clarify with me, "But aren't these kids getting surgeries?" and no, no kid is getting surgeries.

Bolling:

Gender-affirming care is not just puberty delaying medications, or using estrogen or testosterone, it's not the surgical aspect of it. They [lawmakers] act like the surgery happens, can happen anywhere. I guess honestly, parents can consent their kids for any sort of plastic surgery, some crazy things -- but none of the children's hospitals, and none of my colleagues. I cannot name anybody who can name a child who got a surgery under age 18. It does not happen.

McClain:

No kids get surgery here. That's not a thing.

Abbott:

It's very rare. It's not genital surgery, and it's just a very rare top surgery. And that is, in my experience, that's always driven by the family and the parents. It's not driven by me when the family seeks to have top surgery for their 17-year-old. That's not something that I'm promoting or that I'm doing. I just think that there's so much misinformation, and that it's just about this misperception of what we do.

What if a child goes on to regret gender-affirming medical treatments?

Bolling:

You hear the proponents of these bills saying, "Listen to the detransitioners. Listen to the detransitioners." And the detransitioners are a very, very small group of people. And honestly, they're like, the only people they are listening to, because they will give all this airtime to people that will fly around the country, who have received terrible care -- I mean, some of them just flat-out received terrible care – and your heart goes out to them because they just received terrible care, from what they report. But then they have these families, family upon family saying, "Please don't take our care away. Please don't take our care away." And they just don't listen to them.

Piña:

Another thing I do clarify a lot, just so people know, is that the majority of people that transition, greater than 95%, continue to identify the way that they identify [See: U.S. Trans Survey 2022, "Satisfaction with life since transitioning gender"] because the news when these laws are being passed like to say how many people regret it, and how they had these changes that they can't reverse, and stuff like that. And so I let them know that that's a very, very small percentage of people who detransition.

McClain:

It's totally safe to detransition. That's not a big deal. I think my clinical anecdotal evidence really matches the data that it's pretty rare. And also not a big deal if it happens. It doesn't invalidate the construct of gender as a spectrum. ... Gender-affirming surgeries, including breast augmentation, and like, Brazilian Butt Lifts for cis people -- those are all gender-affirming surgeries, and cis people have -- sometimes they're sad after getting those kinds of surgeries too.

It was helpful for me to see kind of what upset people about gender care, just so ... I can talk better to families about the things that I think are really scary for people, that I wouldn't ever even think about. Because detransitioning is not scary.

What else would you like people to know about gender-affirming care?

Fion Alfson, of Albuquerque, New Mexico:

[I am] also just wanting to encourage transgender health care, learning about it in non-transgender healthcare settings, [so] that you ... can look at things other than testosterone as the cause [of the visit]. Because also with it, there continues to be the stigma of, in healthcare women are seen as just attention-seeking or are not taken as seriously, and then when you become a trans guy, some people will see you as a woman who is just doing it for attention-seeking and so will continue to dismiss.

[You'll say], "Oh, but I know my body. I know it's not the testosterone that's making me like this." And they're like, "Oh, but you're a woman because you're biologically born a woman, so you can't know what you're talking about." The sort of thing that already is perpetuated in our society and healthcare. And then they just add the transness on top of it.

Adams:

In Missouri, we cannot get a single physician to show up, which is why I as a third-year medical student have had to serve as the medical expert, because that was the best we have. I know for a fact there are a ton of Missouri physicians who are against these bills and yet. ... There is an understanding that any sort of involvement will put a target on your back if you speak out. Ever since last spring, there have been many occurrences of providers who do any GAC [gender-affirming care] whatsoever having all of their medical records summoned by the [Missouri] Attorney General. It's an intimidation tactic, quite literally so they can keep tabs on trans people, and to send a message that these clinics are being watched under a microscope.

The only way these providers can continue their work is by drawing the least attention possible to what they are doing. We desperately need physicians who are allies to their peers providing GAC to show up and testify in opposition to this harmful legislation. The way it stands, Missouri has relied entirely on the voices of medical students to oppose anti-LGBTQ bills for as long as I have been involved in this work in the state.

Bates:

It's one of these things where I really see the need for healthcare practitioners across the spectrum to have more resources, more training on these issues so they can identify it and be sympathetic and empathetic towards it. You know, asking kids on their registration form for their pronouns. Even things that simple go such a long way.

Piña:

It would be great to see trans care being part of regular care, because it's just normalizing hormones, as you would for a cis man or a cis woman. ... Many providers feel comfortable providing hormonal care, so if a cis man is low on testosterone, or if a woman needs estrogen, they feel comfortable doing that. But then when it comes to offering the same hormones to trans people, they feel like it's some sort of care from a whole different planet and they have no idea where to start.

McClain:

Gender care is 100% appropriate in a primary care setting. The amount of discrimination that trans folks face means that as physicians who care about people's health, we should be making every effort that we can to make sure that people are not facing discrimination in the healthcare system, that's not necessary. So this should be in medical school. This should just be part of how we talk about gender. ... And I think it's a lot easier than people think. I think it's really really gratifying. ... We [family medicine] deal with hyper-, hypothyroid, we deal with diabetes. We deal with all sorts of endocrinology issues in primary care. And then if we get stuck, we might have to send someone to endocrinology, but it's pretty rare that we have to, and I think exactly the same is true for gender care. It just might have not been set up that way in systems where there are a lot more specialists available, which we don't have in New Mexico.