Explainer: What medical treatments do transgender youth get?
Robin Rayne
FILE - Barbara Dale, from Atlanta, mother of a transgender child, waves sign reading "Love Knows No Gender" at Gay Pride Transgender March at Piedmont Park in the city's Midtown District in Atlanta, Ga, Saturday, Oct. 12, 2019. Transgender medical treatment for children and teens is increasingly under attack in many states, labeled child abuse and subject to criminalizing bans. But it has been available in the United States for more than a decade and is endorsed by major medical associations. (AP Photo/Robin Rayne, File)
Transgender medical treatment for children and teens is increasingly under attack in many states, labeled child abuse and subject to criminalizing bans. But it has been available in the United States for more than a decade and is endorsed by major medical associations.
Many clinics use treatment plans pioneered in Amsterdam 30 years ago, according to a recent review in the British Psych Bulletin. Since 2005, the number of youth referred to gender clinics has increased as much as tenfold in the U.S., U.K, Canada and Finland, the review said.
The World Professional Association for Transgender Health, a professional and educational organization, and the Endocrine Society, which represents specialists who treat hormone conditions, both have guidelines for such treatment. Here’s a look at what’s typically involved.
PUBERTY BLOCKERS
Children who persistently question the sex they were designated at birth are often referred to specialty clinics providing gender-confirming care. Such care typically begins with a psychological evaluation to determine whether the children have “gender dysphoria,” or distress caused when gender identity doesn’t match a person’s assigned sex.
Children who meet clinical guidelines are first offered medication that temporarily blocks puberty. This treatment is designed for youngsters diagnosed with gender dysphoria who have been counseled with their families and are mature enough to understand what the regimen entails.
The medication isn’t started until youngsters show early signs of puberty — enlargement of breasts or testicles. This typically occurs around age 8 to 13 for girls and a year or two later for boys.
The drugs, known as GnRH agonists, block the brain from releasing key hormones involved in sexual maturation. They have been used for decades to treat precocious puberty, an uncommon medical condition that causes puberty to begin abnormally early.
The drugs can be given as injections every few months or as arm implants lasting up to year or two. Their effects are reversible — puberty and sexual development resume as soon as the drugs are stopped.
Some kids stay on them for several years. One possible side effect: They may cause a decrease in bone density that reverses when the drugs are stopped.
HORMONES
After puberty blockers, kids can either go through puberty while still identifying as the opposite sex or begin treatment to make their bodies more closely match their gender identity.
For those choosing the second option, guidelines say the next step is taking manufactured versions of estrogen or testosterone — hormones that prompt sexual development in puberty. Estrogen comes in skin patches and pills. Testosterone treatment usually involves weekly injections.
Guidelines recommend starting these when kids are mature enough to make informed medical decisions. That is typically around age 16, and parents’ consent is typically required, said Dr. Gina Sequiera, co-director of Seattle Children’s Hospital’s Gender Clinic.
Many transgender patients take the hormones for life, though some changes persist if medication is stopped.
In girls transitioning to boys, testosterone generally leads to permanent voice-lowering, facial hair and protrusion of the Adam’s apple, said Dr. Stephanie Roberts, a specialist at Boston Children’s Hospital’s Gender Management Service. For boys transitioning to girls, estrogen-induced breast development is typically permanent, Roberts said.
Research on long-term hormone use in transgender adults has found potential health risks including blood clots and cholesterol changes.
SURGERY
Gender-altering surgery in teens is less common than hormone treatment, but many centers hesitate to give exact numbers.
Guidelines say such surgery generally should be reserved for those aged 18 and older. The World Professional Association for Transgender Health says breast removal surgery is OK for those under 18 who have been on testosterone for at least a year. The Endocrine Society says there isn’t enough evidence to recommend a specific age limit for that operation.
OUTCOMES
Studies have found some children and teens resort to self-mutilation to try to change their anatomy. And research has shown that transgender youth and adults are prone to stress, depression and suicidal behavior when forced to live as the sex they were assigned at birth.
Opponents of youth transgender medical treatment say there’s no solid proof of purported benefits and cite widely discredited research claiming that most untreated kids outgrow their transgender identities by their teen years or later. One study often mentioned by opponents included many kids who were mistakenly identified as having gender dysphoria and lacked outcome data for many others.
Doctors say accurately diagnosed kids whose transgender identity persists into puberty typically don’t outgrow it. And guidelines say treatment shouldn’t start before puberty begins.
Many studies show the treatment can improve kids’ well-being, including reducing depression and suicidal behavior. The most robust kind of study — a trial in which some distressed kids would be given treatment and others not — cannot be done ethically. Longer term studies on treatment outcomes are underway.
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Superficially, Americans and their legislators accept and understand LGBTQ+ individuals more now than even a decade ago. The Supreme Court's 2015 decision to legalize same-gender marriage stands as of the most tangible and significant wins for LGBTQ+ rights—yet the 2015 ruling only directly protected cisgender lesbian, gay, and bisexual individuals.
At least 19 states in 2016 considered bathroom bills, legislation that would force every person to use the gendered restroom matching the gender listed on their birth certificate. North Carolina passed this legislation, igniting conversations across the country and empowering lawmakers to draft similar bills in other states. But sister bills struggled to pass, and even North Carolina has since repealed its bathroom bill.
Several congressional representatives have turned to gender legislation to target a new group: transgender youth.
Stacker took a look at state-by-state data on sexual orientation and gender identity policies that affect transgender youth from the Transgender Law Center.
All 50 states and Washington D.C. were then ranked by their total “policy tallies” (the number of laws and policies driving equality for LGBTQ+ people), with #51 being the most restrictive state and #1 being the most protective state of trans youth. Negative tallies mean more discrimination laws exist than protection laws.
TLC's policy tally accounts only for passed legislation and does not take into account activism efforts, attitudes, and feelings expressed by people in the state, nor implementations of these laws. The core categories TLC considered revolve around relationships and parental recognition, nondiscrimination, religious exemptions, LGBTQ+ youth, health care, criminal justice, and identity documents.
TLC's findings capture how trans youth remain protected or vulnerable by statutory law, but legislation is elastic and lawmakers introduce new bills constantly. One category of these rankings only capture laws pertaining to sexuality since significant overlap exists within the queer community and within the legislation. Many lesbian, gay, or bisexual individuals also identify as transgender, nonbinary, or gender nonconforming, meaning LGBTQ+ individuals can identify with more than one queer identity.
Since 2020, anti-trans youth legislation claiming to protect children popped up more frequently in state legislatures, entering the more mainstream lexicon in 2021. During the first three months of 2022, lawmakers filed about 240 anti-LGBTQ+ laws—most of which targeted trans people.
Tennessee, the top state for anti-trans youth legislation, in 2017 signed a bill into law preventing trans children from receiving gender-affirming care. It was the fifth anti-trans law to pass in the state. Bills like these claim to protect parents and children, yet lawmakers in Tennessee are also considering a bill that would establish common-law marriages in the state between “one man and one woman” while eliminating age restrictions for marriage.
While anti-trans youth legislation outnumbers legislation to protect trans youth, several states have enacted or are considering laws intended to protect trans children. California has gone so far as to introduce a bill to accept families escaping anti-trans youth legislation. Colorado—formerly known as the “Hate State” for its history of passing anti-LGBTQ+ legislation throughout the ’90s—passed legislation banning conversion therapy, prohibiting bullying based on LGBTQ+ identities, and ending discrimination against LGBTQ+ families adopting children. Hawaii passed legislation in March that would require health insurance companies to pay for gender-affirming care—but not until 2060.
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