Gender Affirming Care in Youth
I want to start off by saying thank you everyone for subscribing. I am only one week in, and I already have 50 subscribers! This week, I want to jump right into the deep end: What is Gender Affirming Care for youth? This week, we are going to be specifically talking about youth for two reasons: 1) because care for youth is different than care for adults and 2) this is the care Republicans in many states have either outlawed or are attempting to outlaw. In some cases, teens are being detransitioned, which means they are losing access to gender affirming care, with a quick signature by a governor who doesnât care about the damage they are doing.
This is a complicated topic because gender affirming care is different for each kid, based on their identity and needs. But with so much misinformation around, it is important to understand what this care looks like for transgender and nongender conforming youth and why it is so important. And if you are new to this newsletter, donât forget to subscribe for weekly information on how nonprofits can support LGBTQIA+/Queer communities and individuals.
Why is care so important?
I cannot emphasize this enough; gender affirming care saves lives. Transgender youth have a substantially higher rate of suicidality and depression than their cisgendered peers (Connolly et al., 2016). Transgender children who are supported in their gender identity, though, have significantly lower levels of depression than those who are not (Olson et al., 2016). Transgender children who have access to gender-affirming hormones and puberty blockers led to lower levels of sucidial ideations and depression than those who do not have access to gender-affirming care (Baker et al., 2021; Tordoff et al., 2022; Turban et al., 2022).
These are just several of the studies I have that show the immense benefit of gender affirming care for youth. Furthermore, many of the major medical societies have put out statements in support of gender affirming care (TLDEF, 2023). And many of the youth who start gender affirming care continue it into their adulthood (Hannema et al., 2022; Roberts et al., 2022). As will be seen below, some of the aspects of gender affirming care for youth can be reversed if thatâs the childâs wish.
Gender Affirming Care for Youth: What is it?
Gender affirming care is a diverse area which includes a lot of different steps and options (Colman et al., 2022; OASH, 2022; Rafferty et al., 2018). Importantly, not every person goes through all of these different steps; each person has a different plan for their own gender affirming care.
To start off, there is social affirmation. This means supporting individuals in their pronouns, gender expression (e.g. clothes and hair), bathroom, and name. Social affirmation is different for everyone (Transhub, from Australia, has a great resource for individuals on different aspects of social affirmation. It can be found here.). For some people, social affirmation might be the only step taken for gender affirming care (Coleman et al., 2012).
Next there are puberty-blockers. This is a fully-reversible treatment (Rafferty et al., 2018) which delay the onset of puberty. For transgender and nonbinary youth, puberty can be a distressing time. Puberty-blockers delays the onset of puberty, and have been shown to significantly improve the mental health of transgender youth entering puberty (Mayo Clinic, 2022).
The next step is hormone treatment or hormone therapy. Usually for older teens, hormone therapy is used to help develop sex characteristics which match their gender identity (ACOG, n.d.). A recent study of 315 transgender individuals, aged 12-20, who received gender-affirming hormones and were followed over two years, found an increase in life satisfaction and a decrease in depression and anxiety (Chen et al., 2023). Some of these changes are reversible, while others are not (ACOG, n.d.; OASH, 2022).
Gender-affirming surgeries are rarely done on adolescents (OASH, 2022). For adolescents, the most common type of surgery is mastectomy, or top surgery, after the age of 16. This often helps lower distress among transmasculine youth and satisfaction remains stable over time (Mehringer et al., 2021) with rate of regret remains less than 4% (Colman et al., 2022).
Overall, gender affirming care is an individual process, with each person working with their doctors and specialists for what is right for them. Especially in adolescence, it is important to create an environment where individuals can explore their gender identity in a way where they feel safe.
Where is this illegal?
Currently, the ACLU has identified 399 anti-LGBTQ bills across the US. Of those, 112 are attacking LGBTQ healthcare in some form (ACLU, 2023). Erin in the Morn has done an amazing job at tracking anti-trans bills in particular and has identified the states which have been enacting medical care bans. While mostly focused on gender affirming care for youth, some have also targeted adults. These require youth to be detransitioned, sometimes quite suddenly (Erin in the Morn, 2023). In this link provided, she also provides a map of the states which have enacted medical care bans. These bans have large impacts on transgender youth, even if the bills arenât enacted.
What can nonprofits do?
This is a complicated question, as what nonprofits would LIKE to do to support transgender youth who have gone through any of these steps and, in some states, what they CAN do (especially in states with mandated reporting) are different. In some states, teachers and others are required to inform parents of any transitions which can be dangerous. Even if these laws arenât being talked about in your state, they can still have a negative impact on your transgender clients. These laws are awful and send a specific message to transgender youth that we must work to mitigate.
Nonprofits can provide the opportunity for people to change their names so that it reflects their name gender identity, as well as their pronouns (I often recommend asking âWhat are your pronounsâ and not âWhat are your preferred pronounsâ). Make sure that your forms and information donât have just two genders and also allows people to change their gender as they understand it better. Remember to let the individual guide their own care; a person may be exploring what their gender identity means for them, and that could include transgender and nonbinary identities. If a youth wants to know more about transitioning, connecting them to a clinic or specialist is the best approach. Even if there isnât one in your state, many clinics can talk to youth about resources.
I will probably talk more about homelessness in the LGBTQIA+ community in the future, but it is high. Donât assume that a youthâs parents know about their social transitions. Furthermore, donât assume that a youthâs parent will support their child if they found out. Informing a youthâs parent about their sexual orientation can lead to physical and emotional abuse by parents and it may not be safe for youth to be out. Importantly, it is not your place to out someone, it is the individuals decision how they want to continue this journey.
Along with caring for your clients, donât forget to take care of your staff. Specifically, what are your health insurance policies which you are offering. Do they support gender affirming care? Specifically, if any of your employeeâs have children who require gender affirming care, can they get it through the health plans you offer? Another way to support staff with transgender and nonbinary children is providing remote work options. As people are making decisions on where to live based on the laws for transgender individuals (especially around gender affirming care), if your state has become unsafe, can you create remote options of your employees decide to leave for a safer state?
Lastly, let teens be teens. Create spaces where transgender and nonbinary teens donât feel like they have to talk about/defend their gender identity and expression but are just treated like teens, whatever that means for them. Teenage years are an awful period of discovery. Allowing teens a space where they can be themselves, whatever that is, and a place of discovery for them is sometimes one of the most important thing you can do.
Have any questions?
Have any questions that you would like me to answer? Any feedback on how this newsletter can be more useful? Leave a comment. And donât forget to subscribe and share!
References:
American College of Obstetricians and Gynecologists (n.d.) Health Care for Transgender and Nonbinary Teens: Frequently Asked Questions. https://www.acog.org/womens-health/faqs/health-care-for-transgender-and-nonbinary-teens.
ACLU (2023). Mapping Attacks on LGBTQ Rights in U.S. State Legislatures https://www.aclu.org/legislative-attacks-on-lgbtq-rights?impact=health
Baker, K. E., Wilson, L. M., Sharma, R., Dukhanin, V., McArthur, K., & Robinson, K. A. (2021). Hormone therapy, mental health, and quality of life among transgender people: a systematic review. Journal of the Endocrine Society, 5(4), bvab011.
Chen, D., Berona, J., Chan, Y. M., Ehrensaft, D., Garofalo, R., Hidalgo, M. A., ... & Olson-Kennedy, J. (2023). Psychosocial Functioning in Transgender Youth after 2 Years of Hormones. New England Journal of Medicine, 388(3), 240-250.
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., ... & Zucker, K. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International journal of transgenderism, 13(4), 165-232.
Coleman, E., Radix, A. E., Bouman, W. P., Brown, G. R., De Vries, A. L. C., Deutsch, M. B., ... & Arcelus, J. (2022). Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health, 23(sup1), S1-S259.
Connolly, M. D., Zervos, M. J., Barone II, C. J., Johnson, C. C., & Joseph, C. L. (2016). The mental health of transgender youth: Advances in understanding. Journal of Adolescent Health, 59(5), 489-495.
Erin in the Morn (2023). Anti-trans Legislative Digest: Drag Bans, Bounty Hunters, And More. erininthemorn.substack.com/p/anti-trans-legislative-digest-drag
Hannema, S. E., Klink, D. T., den Heijer, M., & Wiepjes, C. M. (2022). Continuation of gender-affirming hormones in transgender people starting puberty suppression in adolescence: a cohort study in the Netherlands. The Lancet Child & Adolescent Health, 6(12), 869-875.
Mayo Clinic (2022). Pubertal blockers for transgender and gender-diverse youth. https://www.mayoclinic.org/diseases-conditions/gender-dysphoria/in-depth/pubertal-blockers/art-20459075.
Mehringer, J. E., Harrison, J. B., Quain, K. M., Shea, J. A., Hawkins, L. A., & Dowshen, N. L. (2021). Experience of chest dysphoria and masculinizing chest surgery in transmasculine youth. Pediatrics, 147(3).
OASH (2022). Gender-Affirming Care and Youth People. https://opa.hhs.gov/sites/default/files/2022-03/gender-affirming-care-young-people-march-2022.pdf.
Olson, K. R., Durwood, L., DeMeules, M., & McLaughlin, K. A. (2016). Mental health of transgender children who are supported in their identities. Pediatrics, 137(3).
Rafferty, J., Yogman, M., Baum, R., Gambon, T. B., Lavin, A., Mattson, G., ... & Committee on Psychosocial Aspects of Child and Family Health. (2018). Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics, 142(4).
Roberts, C. M., Klein, D. A., Adirim, T. A., Schvey, N. A., & Hisle-Gorman, E. (2022). Continuation of gender-affirming hormones among transgender adolescents and adults. The Journal of Clinical Endocrinology & Metabolism, 107(9), e3937-e3943.
Tordoff, D. M., Wanta, J. W., Collin, A., Stepney, C., Inwards-Breland, D. J., & Ahrens, K. (2022). Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA network open, 5(2), e220978-e220978.
Transgender Legal Defense & Education Fund (2023). Medical Organizations Statements https://transhealthproject.org/resources/medical-organization-statements/
Turban, J. L., King, D., Kobe, J., Reisner, S. L., & Keuroghlian, A. S. (2022). Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLos one, 17(1), e0261039.