What does gender-affirming care for transgender children involve? Let’s clear up some misinformation.
A warning: This story contains reference to suicidal ideation. If you're struggling with depression or thoughts about suicide, you can reach out to the National Suicide Prevention Lifeline. If you are an LGBTQ+ youth struggling with mental health issues, you can reach out to The Trevor Project.
Texas officials are actively trying to investigate families seeking gender-affirming care for their transgender children after officials labeled it child abuse.
The matter, which has been tied up in courts, has left many Texans asking simple questions about the fundamentals of transgender health care.
We're here to answer those questions.
What is gender dysphoria?
Put simply, it’s when a person doesn’t feel comfortable in their own body and they don't identify with their sex assigned at birth. Gender dysphoria causes anxiety, distress and a host of negative mental and behavioral health outcomes. It’s important to start here, because that clinical diagnosis is the first step for trans and nonbinary folks to get health care to transition from their sex assigned at birth to the one they see themselves as.
Formally, the American Psychiatric Association defines gender dysphoria as “psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.”
But, the term “gender dysphoria” is a relatively new one.
For decades, the association’s clinical guidelines for psychiatric professionals, defined the feeling as a “gender identity disorder,” a classification that trans, intersex and nonbinary folks decried as stigmatizing. While APA nixed the classification as a “disorder” and created the term gender dysphoria in 2013, LGBTQ+ researchers argue the definition shouldn’t be in the same book that outlines mental health disorders.
Jonah DeChants, a researcher at The Trevor Project, a nonprofit focused on LGBTQ+ mental health, says it’s a double-edged sword. Folks need referrals from mental and behavioral health professionals to receive health care to transition.
“Having your identity be a diagnosis feels like a level of pathologizing that can feel like it’s being treated like something that’s inherently negative or disordered or diseased,” he said. “However, we also do need access to gender-affirming health care. … So that is where that kind of diagnosis I think … can be considered a tool that allows folks to access medical care, but, at the same time, can feel very icky and uncomfortable to be included in a list of mental disorders”
The nonbinding legal opinion Attorney General Ken Paxton issued last month suggests gender dysphoria is “novel,” likening diagnoses to “Munchausen by proxy,” a concept in which a parent effectively coaches a child into faking symptoms of a condition or illness.
Dr. Jane Wray, a pediatric endocrinologist who’s practiced in Central Texas since 1978, says it’s not a choice for children.
“It’s not something that the child chooses,” she said. “They don’t just think, ‘Well, let me make my life more complicated by pretending to be the other sex.’”
Wray adds that children and adolescents with gender dysphoria face substantially higher rates of suicidal ideation, suicide attempts, depression and anxiety than their peers.
What exactly is gender-affirming care?
It’s health care that helps someone with gender dysphoria transition into the gender they identify with. This care runs the gamut from treatment that is socially affirming and support-based to medical care that follows the guidelines laid out by the World Professional Association for Transgender Health.
Social affirmation is as simple as supporting a person for being who they want to be and allowing them to express their gender identity. This entails appreciating them wearing their hair how they want, supporting them wearing the clothes they want and using their preferred pronouns — essentially, just letting them be who they want to be, DeChants says.
“I think that what people don’t realize is that the whole health piece, the whole medical piece, doesn’t happen until much later, until they’re tweens.”Lindsey, mother of a trans child
“That is presenting your identity to the world and asking other folks to affirm that identity by using that correct name and that pronoun,” he said. “And that is, for transgender youth and especially for transgender children, the most common form of transition. In fact, for children prior to the age of puberty, that is really the only form of transition that is available to them. Because, at that point, medical intervention is not appropriate or necessary for them.”
Social affirmation helped Lindsey's 8-year-old daughter get out of an angry, anxious funk. The child, who came out as trans at 5, got super into the Disney movie Frozen, grew her hair out to look like Elsa, and said dresses made her feel magical and powerful, the Austin mom said.
“A lot of aggressive issues she’d been having and kind of anxiety — I mean, as much as a 5-year-old can have anxiety — a lot of that stuff went away,” she said. “I think that what people don’t realize is that the whole health piece, the whole medical piece doesn’t happen until much later, until they’re tweens.”
Gender-affirming medical care includes puberty-blockers, hormone-based treatment or surgical procedures to allow a person to transition into their gender identity. That care starts with hormonal-suppression that’s colloquially referred to as puberty blockers.
It's worth emphasizing there isn’t a straight line of health care treatment for trans and nonbinary youth. The progression of social to medical to legal (i.e., a name change) can take different courses for different people.
Overall, experts roundly agree gender-affirming care is lifesaving. Trans and nonbinary youth face disproportionate rates of suicide ideation and depression. A study released in the Journal of the American Medical Association found trans youth undergoing gender-affirming health care showed a 60% drop in depression and a 73% drop in thoughts of suicide a year into their therapy.
What exactly do puberty blockers do?
It’s pretty much right there in the name. The hormone-suppression regimen pauses puberty, giving a person time to explore their gender identity. For example, it can halt muscular growth or facial hair growth in
A referral from a mental health professional is first required. Then pediatric endocrinologists prescribe and administer the treatments, monitoring a child’s growth. Blood tests are administered frequently to ensure the medication’s working effectively.
It’s a health care regimen that’s been roundly supported by pretty much every major medical association for youth with gender dysphoria, but Paxton’s opinion suggests the treatment effectively sterilizes children and is irreversible.
Wray and other medical professionals say that's not true.
“This is a very reversible form of therapy. What we do is, at the time of puberty, is shut off those hormones, so the person doesn’t convert to the sex that they are not,” she said. “And then, at the time that they are older and are still sure of their gender identity, we can stop the puberty-blockers and begin transition.”
That transition involves hormone therapy — which not as reversible.
DeChants says the framing of this discussion — that puberty-blocking should be criminalized — belies the fact that there are certain developments that can’t be undone during puberty for folks who may be experiencing gender dysphoria, like the growth of body hair and breasts.
“There are these irreversible changes that are going on when young people don't have access to gender-affirming hormone therapy to the gender-affirming health care that are both irreversible and deeply distressing to trans and nonbinary youth,” he said, “And [those] have serious impacts on their mental health.”
Paxton’s opinion classifies puberty-blocking care as child abuse, selectively leaning on peer-reviewed research to make his claim. But several authors of studies cited in the attorney general’s 13-page opinion told the Fort Worth Star-Telegram he mischaracterized their research.
Paxton specifically cited the World Professional Association for Transgender Health's standards to suggest puberty blockers weren’t appropriate for young Texans. The organization said his inclusion of its standards was “completely at odds with WPATH guidance,” as he cited the section on standards for surgery — not puberty-blockers.
Wray notes the American Academy Pediatrics, the American Academy of Pediatric Endocrinology, the American Academy of Family Physicians, the Endocrine Society, the American Academy of Endocrinology and every major Texas medical organization have also spoken out in support of gender-affirming care.
“I don’t think that many doctors would be recommending that if it weren’t the best thing for children," she said.
Is hormone therapy permanent?
Hormone treatments typically follow the use of puberty blockers, when a patient is around 16 years old. Children and adolescents cannot receive this therapy.
Doctors are required to get parental consent and ensure the person is committed to either feminizing or masculinizing hormone therapy.
Some effects are reversible, while others — like the growth of breasts by taking estrogen or the deepening of one's voice by taking testosterone — are not.
When can someone undergo gender-affirming surgery?
When they’re 18, and only with the referral of a doctor once they've completed hormone therapy — a yearslong process.
Paxton’s opinion and a followup memo issued by Gov. Greg Abbott repeatedly mention “genital mutilation” as it relates to health care for trans youth, suggesting surgery is available to minors in Texas.
It is discouraged under WPATH’s clinical guidelines.
While Wray would not comment on Paxton’s opinion or Abbott’s directive, she and DeChants note that there is widespread ignorance about gender-affirming care for youth.
"We do not do that surgery unless they are adults, she said. "As far as genital surgery [goes], that doesn’t occur unless they’re adults.”
DeChants says Paxton and Abbott are capitalizing on the ignorance surrounding transgender health care.
“I think that is sort of a scare tactic, to sort of use the most dramatic kind of gender-affirming [care], which actually many, many, many young people under the age of 18 don't have access to and sort of misconstrue it as a way of causing fear or building off of folks’ ignorance," he said. "Young children, before the age of puberty, do not require any sort of medical intervention. So, they are not on hormones. They are not getting surgeries."
It's worth stressing that it's exceedingly rare for someone to regret their health care transition and seek to reverse it.
The latest U.S. Trans Survey from the National Center for Transgender Equality found 0.4% of respondents decided to "de-transition" because they decided "gender transition was not for them."