What the science says about trans kids and medical care
New laws targeting trans children and their parents are based on politics, not research.
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Editor’s note: The following story deals with suicide. If you have suicidal thoughts, the National Suicide Prevention Lifeline is 1-800-273-8255 (En Español: 1-888-628-9454; Deaf and Hard of Hearing: 1-800-799-4889).
For suicide prevention resources from the Centers for Disease Control and Prevention, click here.
Heather Crawford came home from work one day in October 2019 and found her 12-year-old child, Cass, unconscious on a bed. Cass had swallowed more than 60 pills, including a prescription antidepressant. There was a note written in blue glitter pen.
“I’m sorry. I just couldn’t take it any more. I want this. Life is too strong and I’m too weak. Don’t be too sad. It’s just me,” wrote Cass, who had come out as nonbinary that summer. “Now you can get a normal child who isn’t a complete fuck-up. I love you. Never forget that. I don’t belong here. This is better.”
Cass — who survived — is one of many transgender or nonbinary children who experienced harm because adults such as family, friends, teachers or coaches denied their gender identities. The results of this rejection of a fundamental part of a child’s self can be devastating. The odds of a suicide attempt for trans teens who are denied gender-affirming care are almost three times higher than those for cisgender teens.
“I know that gender-affirming care saves children’s lives because I almost had to learn the other lesson,” said Crawford, who at first rejected her child’s assertion of a nonbinary identity and new name.
Trans people have become more visible in public life and politics in recent years. A growing number of people in the U.S. say they know someone who is transgender or uses gender-neutral pronouns, according to polling by the Pew Research Center. But trans children have been placed at the center of a movement in state capitols across the country to limit their participation in school sports, their ability to use bathrooms that conform to their gender, and even their ability to receive gender-affirming medical care.
Texas, where the Crawfords live, has gone a step further, by classifying gender-affirming therapies as a form of child abuse, even though these therapies are endorsed by major medical groups. Plenty of research demonstrates benefits of access to this care — including improved mental health — and suggests that the earlier it’s accessed, with developmentally appropriate timing, the better. Evidence also shows that interfering with access can cause immeasurable and irreparable harm, including increased risk for significant mental health problems.
Despite this, in late February, Republican Texas Gov. Greg Abbott wrote a letter instructing employees of the state’s Department of Family and Protective Services (DFPS) to prosecute parents whose minor children had undergone gender-affirming therapies. The letter also asserted that mandated reporters such as teachers and doctors, and even regular citizens, were also obligated to turn parents in for child abuse.
A state court issued an injunction against the order soon after, which was upheld on appeal. The case is still moving through Texas’ legal system. If the order is ultimately allowed to stand, it would likely apply to a comparatively tiny number of people, yet its effects would be deeply disruptive and even fatal. Between 0.1 percent to 2.7 percent of the general population is transgender or gender nonconforming, including both adults and children. That includes about 150,000 children 13 to 17 years old, according to one report. Not everyone who identifies as transgender or nonbinary seeks gender-affirming care, in part because not all of them feel the need for medical support. But the effects of being denied care are profound for transgender adolescents.
Gender-affirming therapy for trans children has become the front line of a raging culture war. These tactics are counter to current medical guidelines and practices based on decades of research, and they rely on claims that scientific evidence does not support. Battles are being fought on many fronts, but families in states like Texas are under siege, targeted by state agencies weaponized by the government and facing an uncertain future for their families and their children’s lives. The national and international trends suggest an association of these actions with growing authoritarianism, according to the American Civil Liberties Union.
Gender-affirming care is standard of care
Major U.S. medical societies agree that gender-affirming care for children is appropriate healthcare. Opponents to providing this care for minors argue that the effects are damaging or irreversible. Their claims focus heavily on interventions that are vanishingly rare in the pediatric patient population and used for many reasons other than gender affirmation: removal of gonads — ovaries and testes — and other pelvic surgeries. Clinical experts say that the more common hormonal therapies have been used for years in non-trans children and that trans and nonbinary children are being singled out.
Most clinicians and societies reference global standards of care published by the World Professional Association for Transgender Health, known as the WPATH guidelines. These recommendations, first issued in 1979, emphasize uniquely tailoring gender-affirming support to each person’s needs because the spectrum of transgender and nonbinary identities requires a spectrum of care. Several U.S. medical societies, including the American Academy of Pediatrics (AAP), also have published guidance for the under-18 age group.
The recommendations for transgender and nonbinary children range from social affirmation of their identity to medical interventions involving hormones and, in some cases, surgery to the chest area to remove breast tissue.
The affirmation begins with a series of conversations, said Scott Hadland, chief of the division of adolescent and young adult medicine at Massachusetts General Hospital for Children and Harvard Medical School. “The interventions that many people think of when they think of gender-affirming care, specifically hormones and surgeries, are much later in this trajectory and not even interventions that many kids end up desiring,” he said.
This care also takes place with the involvement of a relatively large number of clinicians. One study of U.S. military families found that adolescents seeking gender-affirming care saw an average of 12 primary care clinicians, such as pediatricians, and about 10 specialists. One reason may be the tight observation of this patient population. “There’s an assumption that we put people on a conveyor belt and press go,” said Ariel Frey-Vogel, a physician and director of child and adolescent services at the Massachusetts General transgender health program. “No. We are checking in all the time to make sure you are getting the goals you want, is this feeling right in your body.”
In a 2018 policy statement, the AAP listed the usual interventions, the appropriate age for their uses and whether their effects are reversible. Social affirmation, which includes gender-affirming hair and clothes, name, pronouns and restroom choice, is applicable at any age and reversible. Puberty-blocking medications can be used as soon as pubic hair and breast development or testicular and scrotal enlargement begin and the effects are reversible. Hormones such as estrogen or testosterone that promote features related to the gender identity can be used from early adolescence onward, with effects on skin, hair, muscle development and fat deposition that are partially reversible. These hormones can have some irreversible effects related to development of anatomical features, such as breasts or an Adam’s apple.
Research indicates that among transgender adults seeking gender-affirming surgery, their first experience of gender dysphoria, or feeling a mismatch between assumed gender and their gender identity, was on average at about age 5 years.
Some research with twins suggests a contribution of genetics to gender identity, but events in brain development, which continues long after gonads are in place, are likely important and lasting.
A gender-affirming approach in children who have not reached puberty does not include therapies with irreversible anatomical effects because our earliest identities — whether cis, trans or nonbinary — can shift. By adolescence, however, gender identity tends to be far more stable, although some people will be genderfluid throughout their lives.
“When I’m talking to a [younger] child, what I’m trying to figure out is what is their conception of their gender, and how did they develop that concept,” said Frey-Vogel. “What feels stressful, and how do we decrease stress and increase a sense of well-being with an alignment with body and identity?”
Puberty blockade and later gender-affirming hormone therapy with either estrogen or testosterone are options for older trans kids. Puberty-suppressing hormones have been used since the 1980s for children with extremely early puberty. For transgender children, AAP’s policy statement says that these reversible treatments are appropriate as a bridge up to age 16 years to prevent development of features that can be distressing. If these hormones are stopped, gonadally driven puberty resumes.
For adolescents, who overwhelmingly tend to have persistent gender identities, the conversations change. “We go through a lot of detail what about what’s reversible and what’s not, and effects on fertility, and what’s best to do to meet those goals,” said Frey-Vogel.
It can take up to six months for changes driven by estrogen or testosterone treatment to become apparent, and they generally intensify over two to three years. Because these treatments have the potential to affect fertility, clinicians can talk with the adolescent about banking sperm or eggs. Research suggests that transgender adolescents assigned male at birth express more interest in banking gametes than those who are assigned female at birth.
What if they want to stop these treatments? “They can just stop,” said Frey-Vogel, adding, “Incredibly, I have not encountered someone saying, ‘I don’t want this anymore, this was wrong for me.’” For people who have stopped, she said, the reasons have related to feeling unsafe or fearing stigma.
More permanent surgical changes are almost always delayed to the late teens, at the earliest, and then only with mental health support. “Genital surgery is almost never done before age 18, and gonadectomy [removal of ovaries or testes] is almost never done in the under 18,” said Benjamin Park, a research fellow in the plastic surgery department at Vanderbilt University School of Medicine, who works with gender-diverse patients. There are other reasons for these surgeries, he noted, including being intersex or having a congenital anomaly that needs to be addressed.
The only surgical procedure done on kids under 18, excluding emergency treatment, is “top surgery,” the removal of breast tissue. Before such a surgery, WPATH recommendations call for a letter from a mental health provider. Insurance often will not cover most other gender-affirming surgeries before adulthood.
Medical care that isn’t gender-affirming can cause harm, including “severe mental health problems, issues with functioning in society because they can’t express themselves the way biology is telling them to, serious conflicts with society and family — kicked out of the house at an early age, experiencing disparate levels of poverty,” said Rishub Das, a second-year medical student whose research at Vanderbilt School of Medicine focuses on LGBQT care. “As medical providers, we can see that medical options help them function better and clearly outweigh risks.” Das and Park are co-authors of an editorial published in JAMA Pediatrics examining the evidence for gender-affirming therapy and the parallels between the political attacks on the access to this care and to abortion care in the United States.
Mental Health Lens
Evidence shows benefits from treatment — and the cost of denial
Gender-affirming care lifts the mental health burden for trans children, reducing their risks for depression, anxiety and suicide attempts. The vast majority of adolescents who receive this care — from affirmation of pronouns to hormone therapies to “top surgery” — do not regret it.
In the 1980s, clinicians in the Netherlands started to apply what became known as the “Dutch model” of care for transgender adolescents, finding a benefit of puberty suppression and related medical interventions. Later research revealed better outcomes if these medical therapies were added to psychological interventions that followed WPATH guidelines and focused on aspects of gender identity, body image, and resilience to stigma and transphobia, among other things.
Top surgery has proved successful in resolving chest dysphoria — a feeling of misfit with chest anatomy — and improving recipients’ quality of life and social functioning. In small 2021 study, 10 participants who had this surgery before age 18 were all “satisfied with their surgical outcomes.” In a larger 2018 study published in JAMA Pediatrics, only one of the 68 adolescents who had the surgery reported experiencing regret about it “sometimes,” and all 68 endorsed the statement “it was a good decision to undergo chest reconstruction.”
Mental health improvements with gender-affirming care are substantial. A 2022 study showed that initiating hormonal therapies versus not doing so reduced odds for depression by 60 percent among the 104 adolescent participants. Their odds of suicidality dropped by 73 percent. The decline is an important effect in a population that has up to six times higher odds of suicidal ideation and more than 12 times higher odds of a suicide attempt requiring medical care than do cisgender teens.
Research also shows clear benefits to accessing gender-affirming care during adolescence rather than later in life. Receiving care at ages 14 or 15 years meant 60 percent lower odds of suicidal ideation compared with never receiving care, according to a 2022 study with 21,598 participants. Delaying that to adulthood reduced the odds by only 21 percent, implying that earlier access maximizes benefit. A 2020 study published in Pediatrics showed a fivefold greater risk for depression and fourfold increased risk for anxiety among people who presented for gender-affirming care in late puberty compared with a younger age.
But even something as simple as using the chosen name of a transgender or nonbinary adolescent is associated with reductions in depression, suicidal ideation and suicidal behavior. The results of a recent survey by the Trevor Project of 34,759 LGBQT young people ages 13 to 24 years in the United States make these benefits clear. Young people whose family and friends respected their preferred pronouns had lower attempted suicide rates, at 14 percent compared with 22 percent among those whose wishes were ignored by everyone.
Crawford’s family knows far too well the costs of denying a transgender or nonbinary child’s gender identity. Before that horrible day in October 2019 when Cass attempted suicide, they had disclosed in a letter from summer camp that they were nonbinary. Heather Crawford described it as a “regular letter” from camp, “but at the bottom, in tiny letters written upside down, it said, ‘I am nonbinary and I want you to call me Cass.’”
Her reaction, she said, was “about as bad a reaction [could be] short of kicking them out of the house.” She didn’t know what nonbinary meant and tried to tell Cass that they were “going through a phase” and were “confused.” Crawford recalled saying, “I’m going to call you by the name I gave you because that is your name.” After that, “things got pretty uncomfortable and pretty rocky in our house. I knew something was wrong, but I didn’t know how to fix it.”
Cass, who is now 15, said they’d sent the note hoping that it would arrive home before they did so that their parents “could have time and process.” It got there first. Their parents’ reaction “hurt a lot.”
After Cass’ suicide attempt, Crawford and her husband got them to the emergency room where the preteen was in a precarious state, on the verge of a strokelike syndrome. It took about 12 agonizing hours to stabilize them.
“The very first thing they said when they woke up was ‘I’m sorry,’” said Crawford. “At that point, I came to the very hard and fast conclusion that I had done something very wrong that my 12-and-a-half-year-old would rather die than go on living the way they had. That was really a turning point.”
The family immediately started using Cass’ chosen name and correct pronouns. Cass underwent weeks of inpatient mental health treatment followed by intensive outpatient care. They now are attending a brick-and-mortar high school after a stint of home schooling.
The 2021 Trevor Project survey showed that 52 percent of transgender and nonbinary youth had considered attempting suicide in the past year, compared with 32 percent among LGBTQ respondents who were cisgender. It found similar patterns for generalized anxiety disorder and depression.
Gender-affirming treatment “is lifesaving treatment,” said Frey-Vogel. With the fusillade of political efforts to prevent access to these treatments for transgender children, “I really worry that there will be increased suicide rates,” she added.
“Put simply: These policies will kill,” said Hadland.
Big actions against a small population
Gender-affirming medical care for Cass and other children like them is at risk across more than a dozen states. The Williams Institute at the University of California, Los Angeles, School of Law has reported that more than 58,000 young people in the United States are at risk of losing or have lost access to this care because of proposed or existing laws in more than a dozen states. Some states — including Oklahoma and Alabama — are trying an even longer reach, attempting to block access for adults ages 18 to 21 years.
The language of these bills can bury the specifics; the text of the Alabama Senate Bill 184, for example, does not specify an age range and references only “minors.” For the definition of “minor,” the bill cites a statute regarding wills in probate that in turn describes “minors” as people under the age of 19, thus capturing 18-year-old legal adults under the proposed bill.
“You can see the creep into care for adults, with some states having bills that criminalize care up to age 21 or banning state funding for care including at state hospitals at any age,” said Chase Strangio, deputy director for trans justice with the American Civil Liberties Union’s LGBTQ and HIV Project. “The justification starts with ‘we are protecting minors,’ then it actually goes up to 19, up to 21, up to 25. It’s not about age, and it’s not about minors. It’s to stop people from being trans altogether.”
In 2016, then-North Carolina Gov. Pat McCrory (R) signed into law a “trans bathroom” ban, which triggered billions in losses for the state after major employers and the National Basketball Association pulled the plug on associations with the state. Later that year, McCrory lost his reelection bid to Democrat Roy Cooper, but he has revived his political hopes with a run for the U.S. Senate.
In the meantime, the political landscape in the U.S. has shifted more toward McCrory’s point of view. Last year set a record for anti-transgender bills introduced in state legislatures, with 147 in 34 states, according to the Human Rights Campaign, an LGBTQ advocacy group. This year, Tennessee alone has 17 anti-LGBTQ bills pending in the state legislature.
In Utah, Gov. Spencer Cox (R) rocked a few boats by vetoing a bill that would have barred transgender youth from participating on public school sports teams aligned with their gender. Cox explained his decision in a letter detailing the costs of legislation that would have affected a current grand total of four children in Utah. And he emphasized the high rates of suicide among transgender youth. “I don’t understand what they are going through or why they feel the way they do. But I want them to live,” Cox wrote. Despite this appeal to hearts and minds, the Utah legislature overrode the veto, making the bill a law. Fifteen legislators who had previously voted against it flipped after the governor’s veto.
Legal challenges have stalled an Arkansas ban on gender-affirming care for minors and Texas’ attempt to criminalize parents. But according to the Williams Institute, bills pending in some states would criminalize providers themselves for giving this care. Other bills target barring insurance coverage — private and public. Missouri has a bill in progress that would mimic Texas in categorizing standard-of-care for transgender and nonbinary children as child abuse.
Back in Texas, in early March, District Judge Amy Clark Meachum issued a statewide injunction against any departmental response to Abbott’s directives, calling it “beyond the scope of his duty and unconstitutional.” The state appealed to the 3rd District of the Texas Court of Appeals, where the three-judge panel upheld the injunction on March 21, but the long-term outcomes remain uncertain.
The Texas policy has already left a mark, regardless. Children undergoing bloodwork for starting puberty blockers have found their doctors suddenly cutting off all contact or declining to proceed, devastating them and their families.
Texas parent L.R., whose initials are being used to protect their identity, was an immediate target of the state DFPS following Abbott’s February letter to the agency. L.R. described being in the shower when an agent banged on the door and advised them that DFPS had received “multiple reports of genital mutilation, hormone abuse, physical abuse against your child.”
The hitch, or so it seemed, was that L.R.’s child was an adult, having turned 18 the preceding month. That wasn’t enough to stop the DFPS. They insisted that because L.R.’s job involved contact with people who are elderly or disabled, the agency could still retroactively investigate them for child abuse. Agency representatives contacted L.R.’s workplace, a co-worker and their adult son at his out-of-state college.
The upshot is that L.R. and their son had to lawyer up to deal with it all. “I am not sleeping. I can barely eat. My stomach hurts,” L.R. said. “I know I didn’t do anything wrong.”
“What’s different about [the Texas policy] is that it weaponizes the state control apparatus of child protective services in a way that’s not just extralegal but is also outside the normal realm of oversight,” said Khadijah Silver, director of communications at the Transgender Legal Defense and Education Fund. “This basically is like a very efficient eradication of process between accusation and punishment for deigning to love your child and to try to give them the care that you know is medically necessary for them.”
As part of that eradication, DFPS employees were instructed not to follow the agency’s usual processes. One former employee testified in a court hearing that staff were ordered to investigate every call claiming child abuse because of gender-affirming care. That instruction was against the usual agency practice of prioritizing calls based on apparent imminent danger to the child. Case workers also had been advised not to put specifics about the cases in writing, an unprecedented directive. The employee had left the agency after six years because of Abbott’s order.
Strangio said that this kind of resistance from inside institutions is telling. “Within the agency, there is a lot of resistance. People don’t want to be investigating these cases, by and large,” he said.
Other winds also may not be blowing in favor of anti-trans efforts. In California, a state senator has proposed a bill that would protect families against court judgments threatening custody loss in their home states if they bring their children to California for gender-affirming care.
A red flag for fascism
The World Health Organization estimates that about 0.3 to 0.5 percent of people globally fall under the transgender identity umbrella. The Dutch model for gender-affirming youth care led the way after the first pediatric clinic for this population opened in the Netherlands in 1987. It serves as the basis for adolescents seeking gender-affirming care in many regions of the world, including Canada, some European countries, Australia and New Zealand.
Most European countries allow children access to gender-affirming medical care under age 18, usually setting the threshold at age 14 or higher. Seven countries say that it “depends on the maturity of the child,” in line with WPATH recommendations. And some place limits on the types of affirming care a child or teen can receive. Finland has decided to make psychotherapy the first-line approach for this population, with limits on offering hormones or surgery. The U.K. issued a controversial report in 2021 claiming that evidence supporting gender-affirming medical treatment with puberty blockers was “low quality,” which it recently removed from its website. That conclusion caused considerable controversy and drew critiques from clinicians, journal editorial boards and researchers, especially for its omission of many of studies that strengthen the evidence. The aftermath has been a series of court rulings that currently leave adolescents able to access puberty blockers.
But in more than a dozen countries worldwide as of 2020, most of them already known for conservative cultures, being transgender is criminalized. According to the advocacy group ILGA World, these countries include Brunei, Jordan, Nigeria, Indonesia and the United Arab Emirates. In a 2016 poll and ranking developed by BuzzFeed working with the Williams Institute, covering 23 countries and attitudes about transgender rights, Russia emerged as “the most anti-trans country.” As remarks Russian President Vladimir Putin has made in the last year attest, that attitude is top-down.
These patterns, along with the loud anti-trans drumbeats in countries like Hungary and in the U.K., exemplify a “loose alignment in the rise of far-right governments with the rise of these policies,” said Strangio. “There are different strains of far-right government, but all of them have this orientation toward an anti-trans discourse and rhetoric.” The purpose, said Strangio, is to use scapegoating and narratives of fear to consolidate the power of their base.
In the end, “you can’t extricate these efforts from the efforts to ban trans people from bathrooms and sports,” said Strangio. He added that these attempts all triangulate on a claim “that ‘it is harmful to be trans, and we are going to stop you.’ Which they simply cannot do.”
Opponents of gender-affirming care for trans and nonbinary kids and teens often claim that these therapies harm children. But extensive research endorsed by major U.S. medical groups finds the exact opposite conclusion: Gender-affirming care improves the health of trans and nonbinary children and teens, reducing their otherwise significant risk of severe mental health problems and suicide.
Thanks to Lillian Barkley for copy editing this article.