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Gender-Affirming Science

What the Science on Gender-Affirming Care for Transgender Kids Really Shows

For the first 40 years of their life, Texas resident Kelly Fleming spent a portion of most years in a deep depression. As an adult, Fleming—who uses they/them pronouns and who asked to use a pseudonym to protect their safety—would shave their face in the shower with the lights off so neither they nor their…

gender Dysphoria : an acute and persistent distress caused by living in a body that doesn’t reflect one’s gender and the desire for bodily characteristics that are similar to that gender. Fleming found research that linked access to gender-affirming hormone therapy and lower levels of depression among transgender individuals. The depression episodes were less severe when they started taking a low dose of estradiol. They now look at their bodies with joy.

So when Fleming sees what authorities in Texas, Alabama, Florida and other states are doing to bar transgender teens and children from receiving gender-affirming medical care, it infuriates them. And they are worried for their children, ages 12 and 14, both of whom are agender–a identity on the transgender spectrum that is neither masculine nor feminine.

” I’m so happy to see them be able to present themselves in ways that make them happy,” Fleming said. Fleming says, “They are living the best life no matter what other people think. That’s a privilege I didn’t have as a younger person .”

Laws Based on “Completely Wrong” Information

Currently more than a dozen state legislatures or administrations are considering–or have already passed–laws banning health care for transgender young people. On April 20 the Florida Department of Health issued guidance to withhold such gender-affirming care. This includes social gender transitioning–acknowledging that a young person is trans, using their correct pronouns and name, and supporting their desire to live publicly as the gender of their experience rather than their sex assigned at birth. This comes nearly two months after Texas Governor Greg Abbott issued an order for the Texas Department of Family and Protective Services to investigate for child abuse parents who allow their transgender preteens and teenagers to receive medical care. Alabama recently passed SB 184, which would make it a felony to provide gender-affirming medical care to transgender minors. In Alabama, a “minor” is defined as anyone 19 or younger.

If such laws go ahead, 58,200 teens in the U.S. could lose access to or never receive gender-affirming care, according to the Williams Institute at the University of California, Los Angeles. Research has shown that such treatment can reduce depression, suicide risk, and other negative consequences for trans teens and those who are forced to have puberty in the sex they were given at birth.

The bills are based on “information that’s completely wrong,” says Michelle Forcier, a pediatrician and professor of pediatrics at Brown University. Forcier literally helped write the book on how to provide evidence-based gender care to young people. Assistant dean of admissions at Brown University’s Warren Alpert Medical School, Forcier is also a professor of gender-affirming care. She says that these laws are “absolutely, absolutely wrong” regarding the science of gender-affirming treatment for young people. “[Inaccurate information] exists to create drama. It’s there .”

to make people see the other side.

The truth is that data from more than a dozen studies of more than 30,000 transgender and gender-diverse young people consistently show that access to gender-affirming care is associated with better mental health outcomes–and that lack of access to such care is associated with higher rates of suicidality, depression and self-harming behavior. Gender diversity is the degree to which someone’s gendered behavior, appearance, and identity are not in line with their birth gender. Some people identify as transgender, but not all. Major medical organizations, including the American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry, the Endocrine Society, the American Medical Association, the American Psychological Association and the American Psychiatric Association, have published policy statements and guidelines on how to provide age-appropriate gender-affirming care. These medical societies consider such care medically necessary and evidence-based.

AAP guidelines and the Endocrine Society guidelines recommend developmentally appropriate care. This means that young people should not be given hormones or puberty blocks until they are ready to go through puberty. Joshua Safer, the executive director of Mount Sinai Center for Transgender Medicine and Surgery, New York City, and co-author the Endocrine Society guidelines, says that there are no hormonal differences between prepubertal children. Those guidelines provide the option of gonadotropin-releasing hormone analogues (GnRHas), which block the release of sex hormones, once young people are already into the second of five puberty stages–marked by breast budding and pubic hair. These options are only available to teens who are not ready for puberty. Access to gender-affirming hormones and potential access to gender-affirming surgery is available at age 16–and then, in the case of transmasculine youth, only mastectomy, also known as top surgery. The Endocrine Society doesn’t recommend minors have genital surgery.

Before puberty, gender-affirming care is about supporting the process of gender development rather than directing children through a specific course of gender transition or maintenance of cisgender presentation, says Jason Rafferty, co-author of AAP’s policy statement on gender-affirming care and a pediatrician and psychiatrist at Hasbro Children’s Hospital in Rhode Island. Rafferty states that the current research shows that rather than trying to predict or prevent what a child will become, it is better to accept them as they are, even at a young age.

A Safe Environment to Explore Gender

A 2021 systematic review of 44 peer-reviewed studies found that parent connectedness, measured by a six-question scale asking about such things as how safe young people feel confiding in their guardians or how cared for they feel in the family, is associated with greater resilience among teens and young adults who are transgender or gender-diverse. Rafferty states that he views his role in the care of prepubertal children as providing a safe place for them to explore their gender identity and allow parents to ask questions. Safer states that the gender-affirming approach does not involve a railroad of people going to surgery and hormones. “It is talking and watching and being conservative.”

Only when children have reached adulthood and the incongruence between their birth sex and their experience gender persists, can medical transition be discussed. First a gender therapist has to diagnose the young person with gender dysphoria.

After a gender dysphoria diagnosis–and only if earlier conversations suggest that hormones are indicated–guidelines call for discussion of fertility, puberty suppression and hormones. For cisgender children starting puberty at an early age, hormone-suppressing drugs have been used for decades. However, they are not intended to be used indefinitely. GnRHa therapy should be limited to two years, according to the Endocrine Society guidelines. This is to give children more time to identify their gender before they go through puberty to get their sex assigned at their birth.

“[Puberty blockers] are part the process of “do no harm”,” Forcier said, referring to a phrase that describes the Hippocratic Oath which many doctors recite before they start practicing.

Hormone blocking treatment can have side effects. A 2015 longitudinal observational cohort study of 34 transgender young people found that, by the time the participants were 22 years old, trans women experienced a decrease in bone mineral density. A 2020 study of puberty suppression in gender-diverse and transgender young people found that those who started puberty blockers in early puberty had lower bone mineral density before the start of treatment than the public at large. The authors suggested that GnRHa may not be the reason for low bone mineral density in these young people. They found that a lack of exercise was the primary cause of low bone-mineral density in transgender girls, particularly among those who were not physically active.

Other side effects of GnRHa therapy are weight gain, hot flashes, and mood swings. But studies have found that these side effects–and puberty delay itself–are reversible, Safer says.

Gender-affirming hormone therapy often involves taking an androgen blocker (a chemical that blocks the release of testosterone and other androgenic hormones) and estrogen in transfeminine teens, and testosterone supplementation in transmasculine teens. Such hormones may be associated with some physiological changes for adult transgender people. For instance, transfeminine people taking estrogen see their so-called “good” cholesterol increase. Transmasculine transsexuals who take testosterone have their good cholesterol drop. Some studies have hinted at effects on bone mineral density, but these are complicated and also depend on personal, family history, exercise, and many

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