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Cutting through the Lies and Misinterpretations about the Updated Standards of Care for the Health of Transgender and Gender Diverse People

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Cutting through the Lies and Misinterpretations about the Updated Standards of Care for the Health of Transgender and Gender Diverse People

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The general pattern with each iteration of the SOC has been to remove arbitrary assessment procedures and to iteratively divest from the idea that being trans is a form of mental illness. However, the legacy of that association is still felt in each version. Not only were prior editions developed by people demonstrably hostile to fundamental rights for trans youth and adults, but they also gatekept care for arbitrary and dehumanizing reasons. The history of SOC revisions has been steadily rolling back these arbitrary requirements and acknowledging that conversion therapies are harmful.

Though the SOC7 were another leap forward from prior editions, trans experts such as Dr. Kelley Winters, Ph.D., have kept a wish list for the SOC8 edition. Broadly speaking, those wishes center upon divorcing the SOC from dubious evidence and completing the removal of frameworks that construe simply being trans as a form of mental illness. One wish is to contextualize and rebut the " 80% Desistance Myth," an idea that arose from systematically flawed studies using outdated, unclear standards for who qualifies as "trans youth", which holds that the majority of trans children will not identify as trans once they become adults. This conclusion has been staunchly discredited by scholarship and contradicted by recent research using modern standards but is not even fully supported by the authors of those studies. A related wish is for a more coherent and consistent working definition of gender dysphoria that does not construe the experience as simply being trans, removal of the requirement of a "12-month experience of living in an identity-congruent gender role", and more transparent, less discriminatory standards for psychiatric practice with trans people. These wishes suggest that the ideal for the SOC8 would be to overcome the historical biases and pathologizing frameworks that have led past SOC versions to fall short in the eyes of trans scholars.

According to a WPATH-authored press release from Sept 15, 2022, the SOC8 result from a rigorous 5-year scientific effort by over 120 health care and academic professionals around the globe, building on decades of research, clinical experience, and extensive literature reviews. The SOC8 are the first version to use an evidence-based approach and are 260 pages of the most comprehensive set of guidelines yet on trans health ("trans" is used as a term here to encompass people whose gender identities do not align with the sex they were assumed at birth, including transgender, nonbinary, gender diverse, and gender nonconforming individuals). The latest edition is the first time trans adolescents and trans children have separate chapters devoted to their care. The SOC7 and the SOC6, published in 2001, contained one chapter dedicated to the assessment and treatment of both children and adolescents, as part of a 122-page and 22-page document, respectively.

Sowing seeds of doubt

Trans health care is not without precedent, and the model of gender-affirming care is well-established. Despite this, a favored tactic of the anti-trans faction is to present what we do as health care providers working with trans patients as experimental and dangerous which it is not. Medscape's article on the SOC8 quotes Aaron Kimberly, a trans male RN who is the founder and director of the gender-critical Gender Dysphoria Alliance, saying the SOC are "broad and vague," and Erica Anderson, a clinical psychologist and trans woman, who is a proponent of gender exploratory therapy, calling those who do not observe the guidelines as "going rogue". Taken together, these statements imply that not only do the standards of care fail to provide any consensus in trans health care but that even if they did, health care providers don't follow them. The article neglects to mention that neither of the clinicians quoted is an unbiased, neutral party.

According to the Medscape article,

In North America, some clinics practice full "informed consent" with no assessment and prescriptions at the first visit, Kimberly said, whereas others do comprehensive assessments.

Given his membership in Genspect, it is unsurprising that Kimberly opposed a ban on conversion therapy. He sets up a false dilemma: informed consent does not mean that there are no comprehensive assessments. The WPATH endorses informed consent and the affirmative approach. Anything else contradicts the WPATH principles of depsychopathologization, harm reduction, medical necessity, and informed consent protocols.

Kimberly is not alone in promoting misinformation about the content and construction of the SOC8. The anonymous authors behind the website "Beyond WPATH" goes so far as to claim, without citation, that the SOC8 release delegitimizes WPATH as an organization. They state that there is a lack of evidence for gender-affirming care, a claim that doesn't hold to scrutiny. Beyond WPATH dismisses solid research in trans health as "low quality" research, a claim that reflects a fundamental lack of understanding of scientific studies; if we held all medical treatments to the same quality standards, we would have to outlaw cholesterol-lowering drugs. A numerical majority (7 out of 13) academic and clinical advisors to SEGM, specifically Mason, Ayad, Richard Byng, Marchiano, O'Malley, Michael Biggs, and Ring, signed Beyond WPATH's declaration to...

...stand together in supporting alternatives to WPATH's deeply flawed Standards of Care. We align with the most up-to-date science-based guidelines from those countries which have already evaluated and rejected the affirmative approach.

Anderson is a favorite source cited by "gender critical" pundits like Abigail Shrier and Jesse Singal, and a former board member of WPATH who resigned from the USPATH board of directors after a series of events sparked by reading Abigail Shrier's Irreversible Damage. Anderson recently participated in a debate entitled " A Pro-Human Approach to Adolescent Gender Dysphoria" for FAIR, the Foundation Against Intolerance & Racism. FAIR's Board of Advisors includes blackface defender Megyn Kelly, opponent of " cancel culture" and intersectionality and fan of the so-called Intellectual Dark Web Bari Weiss, anti-woke psychologist Steven Pinker, Abigail Shrier herself, opponent of Critical Race Theory Christopher Rufo, and anti-"woke" conservative Andrew Sullivan. In May 2022, FAIR filed an Amicus Curiae in support of Students for Fair Admissions, Inc, (SFFA), a nonprofit that challenged Harvard University's admission practices. SFFA alleged discrimination against Asian American applicants, which some saw as an attempt to invalidate affirmative action. FAIR dispensed with all pretenses and contended in their testimony that '"race" is an artificial, arbitrary, and ill-defined concept'.

In the very text of WPATH SOC8:

The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and for guiding treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria put forth in this document for gender-affirming interventions are clinical guidelines; individual health care professionals and programs may modify them in consultation with the TGD person. Clinical departures from the SOC may come about because of a patient's unique anatomic, social, or psychological situation; an experienced health care professional's evolving method of handling a common situation; a research protocol; lack of resources in various parts of the world; or the need for specific harm-reduction strategies. These departures should be recognized as such, explained to the patient, and documented for quality patient care and legal protection. This documentation is also valuable for the accumulation of new data, which can be retrospectively examined to allow for health care-and the SOC-to evolve.

The type of misrepresentation Kimberly and Anderson present has serious consequences, serving to weaponize those who would villainize and outlaw trans health care. Medscape should take better care to source actual experts in the field.

Lately, health care centers have been targeted, physicians threatened with murder, scandals manufactured in the media, and patients left without resources for care that is difficult to access in the first place. Matt Walsh and Chaya Raichik, who runs the popular-with-right-wingers social media account Libs of Tiktok (and appears to fall into the Venn diagram of gender-critical anti-vaxxer, with a side of January 6 insurrection), have tweeted about several transgender clinics, causing websites to shut down and support groups to be canceled. Outrage based on false information has spread.

Removal of age limits

In the SOC8 update, the WPATH removed age recommendations. Some media claim this change removes safeguards to care, protects clinicians from being sued, and is " evidence of 'ideology infecting medicine'". Lead author of the Child Chapter, Amy Tishelman, a psychologist in the Gender Management Service (GEMS) at Boston Children's Hospital, has been personally targeted. Comments she made at the WPATH conference were taken out of context and misrepresented to the point that the WPATH released a statement condemning dangerous misinformation and reinforcing their prior stance:

We are appalled at the specter of clinics and individual healthcare providers being harassed and having to engage armed security personnel. WPATH and USPATH call on all Americans to reject this repulsive and threatening behavior.

Age restrictions for gender-affirming medical care for youth have always been arbitrary and unscientific. Puberty starts at different ages for different people and develops at varying paces. Despite what Elon Musk, who isn't new to composing transphobic tweets, suggests, gender-affirming medical interventions are only indicated once a trans youth starts showing signs of puberty (Tanner Stage II development). The SOC8 are tailored to the development of the individual patient. Those of us in practice understand that every patient is different and requires individualized care. Treatment should be guided by Tanner stage, not age.

This principle applies to gender-affirming surgery as well. Though the WPATH SOC guidelines do not recommend considering gender-affirming surgical procedures with higher risks of complications in youth under 18 at this time, surgeons may rely on the maturity of a patient instead of chronological age to determine the readiness of a patient for a surgical procedure. Even then, records of minors having bottom surgery are rare, most of the minors are 17 years old, and procedures are not performed on young children. A 2019 review of the available research on gender-affirming surgery in trans youth noted that the reasons surgeons agreed to perform vaginoplasties on transfeminine minors included the patient having strong family support and the ability to recuperate in a safe environment, being able to "fully transition" before entering the workforce or college (which can be a safety issue), and future schedules that may impede post-operation outcomes.

Boston Children's Hospital received a bomb threat after being accused on social media of giving children vaginoplasties. BCH has an age minimum of 17 to qualify for vaginoplasty. However, no one has had a vaginoplasty that young at BCH. Being 17 years old allows a patient to ask for one, not to get one, i.e., in BCH terminology, "qualify" means "you get put into a schedule". A patient can schedule a vaginoplasty at 17 but cannot get one until the age of majority or 18. So no, Boston Children's Hospital is not performing gender-affirming bottom surgeries on minors.

An article from The Daily Caller ostensibly defending the BCH backlash cited a study on stats for gender-affirming top surgery on minors. The cited study, which identified 204 gender-affirming surgeries at BCH from 1/2017 to 8/2020 on patients aged 15 to 35, also notes that 0% of the patients who had gender-affirming bottom surgery at BCH were minors. Rather than apologize, Genspect, who promoted the misinformation against BCH, tried to claim that adolescence lasts until age 25; therefore, BCH does indeed do surgery on adolescents.

It is revealing to contrast this reaction to a much more common clinical situation, specifically that cisgender girls under 18 can and do undergo breast augmentation and reduction without the conservative hand-wringing over "body mutilation" that top surgery incurs despite its noted benefits on gender congruence and chest dysphoria. Even cisgender patients experience physical and psychosocial well-being following reduction mammaplasty; studies largely conclude that the benefits of breast reduction surgery can provide adolescents outweigh the risks. Surgeries on cisgender minors are up to 24 times more common than surgeries on trans minors. It is estimated that, in 2020, 3,200 cisgender girls aged 13 to 19 received breast implants, and over 4,600 cisgender teenagers had breast reductions, while only 203 trans minors had top surgery. Reuter recently ran the numbers to identify how many youth have accessed gender-affirming medical and surgical care. They identified 256 gender-affirming top surgeries performed on trans youth aged 13-17 in 2020. In three years - from 2019 to 2021 - there were only 56 genital surgeries among patients ages 13 to 17 with a gender dysphoria diagnosis. To get a sense of the numbers, the analysis drew on public and private health insurance claims for about 330 million U.S. patients over five years from 2017 to 2021. This hardly means that clinicians are "going rogue."

The moral panic about children having gender surgeries disregards the many obstacles trans people experience in access to surgical care, including socioeconomic barriers such as insurance access and out-of-pocket costs, barriers related to obtaining behavioral health letters in support of surgery, limited surgeon availability, and, for minors, the need for parental permission. Many insurance companies do not provide coverage for gender-affirming surgery on minors.

Parental involvement

According to some media outlets, under SOC8, parents will no longer have input into their children's care. The overreaction of the GC crowd is to the following statement:

We recommend when gender-affirming medical or surgical treatments are indicated for adolescents, health care professionals working with transgender and gender diverse adolescents involve parent(s)/guardian(s) in the assessment and treatment process, unless their involvement is determined to be harmful to the adolescent or not feasible.

The WPATH guidelines clarify that parents are an essential aspect of gender-affirming care:

Parent and family support of TGD youth is a primary predictor of youth well-being and is protective of the mental health of TGD youth (Gower, Rider, Coleman et al., 2018; Grossman et al., 2019; Lefevor et al., 2019; McConnell et al., 2015; Pariseau et al., 2019; Ryan, 2009; Ryan et al., 2010; Simons et al., 2013; Wilson et al., 2016). Therefore, including parent(s)/caregiver(s) in the assessment process to encourage and facilitate increased parental understanding and support of the adolescent may be one of the most helpful practices available.

Trans youth depend on their families for medical decision-making. Given that youth often need both parents' permission to make legal or medical changes, this can create the need for a holistic approach that educates and supports all family members.

The SOC8 are vague about how harmful parental/guardian involvement is determined; in practice, courts often place a high burden on showing that a medical treatment that parents object to is necessary. The state is more likely to interfere if it is established that a child's life is imminently endangered. The harm principle contends that state intervention is justified if parental refusal puts their child at significant risk of serious preventable harm; another long-used threshold, the "best interest standard", argues that state intervention is warranted if a parent acts contrary to the child's best interest. Genspect twists the SOC guidance by claiming that, in the SOC8:

There is a disregard parental authority by advising clinicians to prescribe hormone treatment to children without parental support. This creates triangulation, where the parent is deemed the persecutor, the child is the victim and the clinician is the apparent saviour. It is an unhealthy situation and causes unnecessary distress within families at an already very stressful time. WPATH's advice will lead to alienation of parents as they advise clinicians to "challenge" parents who are considered unsupportive because of any concerns about early and aggressive medical procedures.

Such misunderstandings of policies that, in theory, allow trans youth to obtain gender-affirming care without the involvement of a parent or guardian are routine in U.S. conservative news. When a 2015 Oregon procedural ruling held that, because the age of medical consent in Oregon generally is 15, state Medicaid could, in theory, be used by a minor without the need for parental consent to cover gender-affirming surgeries, conservative news engaged in dramatic fearmongering - even though not one of them could identify even a single case of such a circumstance happening, and despite even trans activist groups cautioning against such a procedure unless it was necessary, as in the case of a child without parents involved in their lives at all.

Social influence...or not

Some see it as a victory that Lisa Littman, the creator of the term "rapid-onset gender dysphoria" (ROGD), is referenced in the new guidelines. However, this inclusion does not legitimize Littman's pseudoscience nor give credence to social contagion theory. Littman is also a member of both the Gender Dysphoria Alliance and GenSpect. ROGD is not an actual medical diagnosis recognized by any major professional associations and has no good evidence to support its existence. The consensus of major health care associations, including the WPATH, is that ROGD should not be used in clinical and diagnostic applications. SOC8 may have referenced Littman due to the mass attention she has garnered in the mainstream and the transphobic fallout of her work.

The guidelines state:

Another phenomenon occurring in clinical practice is the increased number of adolescents seeking care who have not seemingly experienced, expressed (or experienced and expressed) gender diversity during their childhood years. One researcher attempted to study and describe a specific form of later-presenting gender diversity experience (Littman, 2018). However, the findings of the study must be considered within the context of significant methodological challenges, including 1) the study surveyed parents and not youth perspectives; and 2) recruitment included parents from community settings in which treatments for gender dysphoria are viewed with scepticism and are criticized. However, these findings have not been replicated.

There is a chasm of difference between Littman's proposed and debunked ROGD hypothesis, in which teens "suddenly" experience gender dysphoria, and the cohort mentioned above of adolescents "who have not seemingly experienced, expressed (or experienced and expressed) gender diversity during their childhood years." The latter cohort considers the multitude of factors related to coming out, the timing of identity disclosure, parental support and awareness, and the existence of identities beyond the binary.

Further, the guidelines state:

For a select subgroup of young people, susceptibility to social influence impacting gender may be an important differential to consider (Kornienko et al., 2016). However, caution must be taken to avoid assuming these phenomena occur prematurely in an individual adolescent while relying on information from datasets that may have been ascertained with potential sampling bias (Bauer et al., 2022; WPATH, 2018). It is important to consider the benefits that social connectedness may have for youth who are linked with supportive people (Tuzun et al., 2022) (see Statement 4). Given the emerging nature of knowledge regarding adolescent gender identity development, an individualized approach to clinical care is considered ethical and necessary. As is the case in all areas of medicine, each study has methodological limitations, and conclusions drawn from research cannot and should not be universally applied to all adolescents. This is also true when grappling with common parental questions regarding the stability versus instability of a particular young person's gender identity development. While future research will help advance scientific understanding of gender identity development, there may be some gaps. Furthermore, given the ethics of self-determination in care, these gaps should not leave the TGD adolescent without important and necessary care.

In other words: sure, consider 'susceptibility to social influence' as a factor impacting gender identity; however, we must think about it critically. A possible "social contagion" factor should not in itself guide treatment or delay access to gender-affirming care. Those of us health care professionals in the field who are experienced and culturally competent in what we do complete comprehensive assessments for all of our patients; the idea of ROGD is not the wildcard the gender-critical crowd wishes it was. As the SOC clearly state: Littman's "research" is flawed, nonreproducible, and should not be universally applied to guide adolescent care.

As with other statements in the document, this one should be worded more strongly: bias in Littman's study was not "potential," but deliberate. And though the guidelines source WPATH 2018, it would have been helpful to include their entire statement in the SOC8:

The term "Rapid Onset Gender Dysphoria (ROGD)" is not a medical entity recognized by any major professional association, nor is it listed as a subtype or classification in the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD). Therefore, it constitutes nothing more than an acronym created to describe a proposed clinical phenomenon that may or may not warrant further peer-reviewed scientific investigation. WPATH also urges restraint from the use of any term-whether or not formally recognized as a medical entity-to instill fear about the possibility that an adolescent may or may not be transgender with the a priori goal of limiting consideration of all appropriate treatment options in accordance with the aforementioned standards of care and clinical guidelines.

Regardless of the intent for including Littman in the guidelines, WPATH's bottom line is that the basis of care is still affirming.

Acknowledging re/detransition

A few pages later in the guidelines, Littman is cited to acknowledge the phenomenon of detransitioning. Littman's most recent study, just like the original, skewed results by drawing from blogs openly hostile to transgender youth, the same blogs where Littman developed the concept of ROGD in the first place. Curiously, Littman was chosen to represent this phenomenon instead of other work, and criticisms of Littman were not explicitly cited. A note here on language: where "detransition(/ing/ers)" identifies those who desist from a binary and static trans identity and has been predominately used by the GC faction to push an anti-gender-affirming care agenda, "retransition" acknowledges that some people halt transition for a time, that genderfluid and nonbinary identities exist, and that there are many reasons for re/detransition. Re/detransition is rare and does not mean regret, yet, naturally, as the number of trans people accessing gender-affirming care rises due to better access to resources and health care, even if the proportion of re/detransition remains the same, there will be a higher number of re/detransitioners. Contrary to the GC rhetoric, gender-affirming care includes support for re/detransitioners. As expert in trans health and researcher Dr. Johanna Olson-Kennedy, MD, testified in a federal lawsuit against Florida's anti-trans health care ruling:

The affirmative approach considers no gender identity outcome: transgender, cisgender, or otherwise, to be preferable. (Turban and Ehrensaft, 2018). It permits a child to explore gender development and self-definition within a safe setting. A fundamental concept of this approach is that gender diversity is not a mental illness. The gender-affirmative model is defined as a method of therapeutic care that includes allowing children to speak for themselves about their self-experienced gender identity and expressions and providing support for them to evolve into their authentic gender selves, no matter at what age. Under this model, a child's self-report is embedded within a collaborative model with the child as subject and the collaborative team including the child, parents, and professionals.

What is absent from the SOC8 commentary on re/detransitioners is actual guidance or recommendations for care of this patient population, as those who have stopped hormones for various reasons found re/detransition mentally and physically challenging and often avoided health care providers due to stigma. Retransitions happen infrequently and should be facilitated in a gender-affirming framework, as smoothly as possible for youth.

Gender exploration, not gender exploratory therapy

The latest attempt at couching conversion therapy in a palatable language is called " gender exploratory therapy". There is a difference between gender exploration and disaffirmation. Ongoing gender exploration, a natural and positive process for all youth, should be encouraged and should not be a barrier to accessing gender-affirming medical care. The SOC8 encourage healthy gender exploration while noting that attempts to force gender exploration onto a patient are ill-advised and unwelcome; not all gender-diverse youth want to explore their gender.

Cisgender children are not expected to undertake this exploration, and therefore attempts to force this with a gender diverse child, if not indicated or welcomed, can be experienced as pathologizing, intrusive and/or cisnormative (Ansara & Hegarty, 2012; Bartholomaeus et al., 2021; Oliphant et al., 2018).

Gender exploratory therapy means first-line "treatment" for trans youth with gender dysphoria is psychological and seeks to " avoid the risks of social and medical transition". In 2017, Dr. Richard Green published a legal strategy to circumvent laws and health policies prohibiting gender-conversion psychotherapies by simply labeling such practices as "gender identity exploration or development". To the opposition, the disapproval of pushing gender-diverse children into making sure they're confident they're not cisgender is equivalent to pushing children into being trans.

The SOC8 should have been firmer on their stance here. Conversion therapy increases psychological distress and suicide attempts and should be banned, plain and simple. Affirming interventions improve mental health, promote well-being, and mitigate anti-trans stigma. Additionally, it would have been helpful for the SOC8 to include a discussion of the dangers of disaffirming therapy, including gender exploratory therapy. Statement 7.5 condemns any efforts to discourage a child's gender-diverse expressions or identity:

We recommend health care professionals conducting an assessment with gender diverse children access and integrate information from multiple sources as part of the assessment. A comprehensive assessment, when requested by a family and/or an HCP can be useful for developing intervention recommendations, as needed, to benefit the well-being of the child and other family members. Such an assessment can be beneficial in a variety of situations when a child and/or their family/guardians, in coordination with providers, feel some type of intervention would be helpful. Neither assessments nor interventions should ever be used as a means of covertly or overtly discouraging a child's gender diverse expressions or identity.

Conclusion: progress, not perfection; improvement with room to grow

Those of us in the trans health field practice gender-affirming, informed consent care in the framework of science-based medicine, as bolstered by the WPATH SOC8. Are the WPATH SOC8 perfect? Far from it. Are they intended to be rigid, immovable, and followed without questions? That would be unscientific. The SOC8 are best practices meant to evolve as science evolves and new research develops and adapts to individual clinical situations.

Overall, the SOC8 guidelines are a step in the right direction: they endorse informed consent, gender-affirming care for gender incongruence (this is notable, as not every trans person experiences gender dysphoria), and dispense with arbitrary gatekeeping such as age-based guidelines. The SOC8 edition is at its most robust when it sets out why it has flexible guidelines for care and at its weakest when it tries to placate the GC crowd. The SOC8 attempted to throw several bones to the GC crowd-and the GC crowd still objected. This would be a win for them if they cared about the evidence. Of course, it's not about evidence, so they act as though it's a loss. What the GC crowd explicitly objects to in the SOC8 is that this latest edition doesn't advance their efforts to gatekeep care. That is because, regardless of their claims otherwise, those opposed to trans care aim to vilify trans people, delegitimize trans medicine, and put a full stop to any provision of gender-affirming health care, not to improve gender-affirming care based on science.

Dr. AJ Eckert, D.O. (they/them) is Connecticut's first out nonbinary doctor, Medical Director of Anchor Health's Gender and Life-Affirming Medicine (GLAM) Program, and Assistant Clinical Professor of Family Medicine at Frank H. Netter MD School of Medicine at Quinnipiac University. Dr. Eckert has been involved in LGBTQ healthcare for over fourteen years with seven years' experience as a provider of primary and preventative care and gender-affirming services, including hormone treatment and puberty blockers. Dr. Eckert hosts Queering Health with Dr. E, Anchor Health's bimonthly YouTube and IGTV show, which focuses on demystifying LGBTQ healthcare and promoting the wellness of queer people through open discussions, stories, interviews, and more.

Dr. Quinnehtukqut McLamore (they/them) is a social psychologist and biological psychologist with expertise in conflict narratives, group identities, and conspiracy theories as well as biopsychosocial models of stress and coping. They further have a background in research methods, research ethics, and quantitative analyses. They have provided consultation and guidance for researching trans issues to other psychologists for several years. They are currently a Postdoctoral Fellow at the University of Missouri at Columbia.

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Cutting through the Lies and Misinterpretations about the Updated Standards of Care for the Health of Transgender and Gender Diverse People | Science-Based Medicine

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The general pattern with each iteration of the SOC has been to remove arbitrary assessment procedures and to iteratively divest from the idea that being trans is a form of mental illness. However, the legacy of that association is still felt in each version.

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Camp Wild Heart - A Podcast About Raising Transgender Kids And Nurturing An Affirming Family - Wild Heart Society

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Camp Wild Hear is your free audio guide to raising a transgender kid and nurturing an affirming family.

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Yale Report on Flawed Science of Texas and Alabama Denial of Gender Affirming Care

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Yale Report on Flawed Science of Texas and Alabama Denial of Gender Affirming Care

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* We would like to thank Dr. Sundes Kazmir, M.D., FAAP, who provided helpful information on medical research on child abuse investigations. Calleigh Higgins, Christina Lepore, and Henry Robinson provided excellent research assistance.

1 Tex. Op. Att’y. Gen. No. KP-0401 (Feb. 18, 2022) (hereinafter, “AG Opinion”)

2 Letter from Greg Abbott, Governor of Texas, to Jaime Masters, Commissioner, Texas Department of Family and Protective Services, Feb. 22, 2022, at https://gov.texas.gov/uploads/files/press/O-MastersJaime202202221358.pdf

3 Vulnerable Child Compassion and Protection Act, 2022 Ala. Laws 289 (hereinafter, “Alabama Law”).

4 For legal analysis, see Plaintiffs’ Original Petition and Application for Temporary Restraining Order, Temporary Injunction, Permanent Injunction, and Request for Declaratory Relief, Doe Abbott, March 1, 2022, at https://www.aclu.org/legal-document/doe-v-abbott-petition.

5 See APA President Condemns Texas Governor’s Directive to Report Parents of Transgender Minors [Internet]. Washington, D.C.: American Psychological Association; 2022 Feb 24 [cited 2022 Apr 15]. Available from: https://www.apa.org/news/press/releases/2022/02/report-parents-transgender-children; American Academy of Pediatrics, AAP, Texas Pediatric Society Oppose Actions in Texas Threatening Health of Transgender Youth [Internet]. Itasca (IL): American Academy of Pediatrics; 2022 Feb 24 [cited 2022 Apr 15]. Available from: https://www.aap.org/en/news-room/news-releases/aap/2022/aap-texas-pediatric-society-oppose-actions-in-texas-threatening-health-of-transgender-youth/; AACAP Statement Opposing Actions in Texas Threatening the Health, Mental Health and Well-Being of Transgender and Gender Diverse Youth and Their Families [Internet]. Washington, D.C.: American Academy of Child & Adolescent Psychiatry; 2022 March 1 [cited 2022 Apr 22]. Available from: https://www.aacap.org/AACAP/zLatest_News/AACAP_Statement_Opposing_Actions_in_Texas.aspx.
See also Letter from James L. Madara, CEO and Executive Vice President of the American Medical Association, to Bill McBride, Executive Director of the National Governors Association, April 26, 2021 (opposing legislation in Arkansas and other states that would deny gender-affirming care), at https://www.ama-assn.org/press-center/press-releases/ama-states-stop-interfering-health-care-transgender-children; Clarke M, Farnan A, Barba A, Giovanni K, Brymer M, Julian J. Gender-Affirming Care Is Trauma-Informed Care [Internet]. Los Angeles (CA) and Durham (NC): National Child Traumatic Stress Network; 2022 [cited 2022 Apr 15]. Available from: https://www.nctsn.org/sites/default/files/resources/fact-sheet/gender-affirming-care-is-trauma-informed-care.pdf.

6 One study is Dhejne C, Lichtenstein P, Boman M, Johansson AL, Langstrom N, Landen M. Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PLoS One 2011 Feb 22;6(2):e16885. We discuss in Section 2 why Dhejne et al. is out of date and unsupportive of the AG’s claims. The AG Opinion also cites one study for the proposition that “hysterectomy, oophorectomy, and orchiectomy result in permanent sterility.” The cited study is Cheng PJ, Pastuszak AW, Myers JB, Goodwin IA, Hotaling JM. Fertility concerns of the transgender patient. Transl Androl Urol. 2019 Jun;8(3):209-218. As we explain in Section 1, current medical protocols do not authorize surgery on genitals or reproductive organs for anyone under the age of majority, and so the reference is irrelevant to the treatment of minors.

7 AG Opinion, p. 1. The AG Opinion also includes “(2) mastectomies; and (3) removing from children otherwise healthy or non-diseased body part or tissue.” These procedures do not affect fertility, which is the opinion’s stated concern, and they are common among cisgender adolescents (e.g., rhinoplasty and breast reduction). We do not address these procedures in this report.

8AG Opinion, p. 1.

9 AG Opinion, pp. 2-3.

10 Alabama Law, Section 2(6).

11 See Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, Fraser L, Green J, Knudson G, Meyer WJ, Monstrey S, Adler RK, Brown GR, Devor AH, Ehrbar R, Ettner R, Eyler E, Garofalo R, Karasic DH, Lev AI, Mayer G, Meyer-Bahlburg H, Hall BP, Pfafflin F, Rachlin K, Robinson B, Schechter LS, Tangpricha V, van Trotsenburg M, Vitale A, Winter S, Whittle S, Wylie KR, Zucker K. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th version [Internet]. East Dundee (IL): World Professional Association for Transgender Health; 2012 [cited 2022 Apr 17]. Available from: https://www.wpath.org/publications/soc(hereinafter, “WPATH (2012)”); Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, Rosenthal SM, Safer JD, Tangpricha V, T’Sjoen GG. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017 Sept 13;102(11):3869-3903 (hereinafter, “Endocrine Society (2017)”).

12 The AG Opinion quotes the WPATH standards once, but the opinion mischaracterizes the source material and persists in its repeated claims that gender-affirming care involves genital surgery on children. At page 4, the AG Opinion quotes WPATH (2012) to the effect that genital surgery should not be carried out before patients reach the age of majority. See AG Opinion, p. 4. The AG Opinion misleadingly uses the WPATH quotation as evidence that there is no benefit from gender-affirming care; in fact, WPATH (2012), pp. 10-21, acknowledges the benefits of psychotherapy and, in the case of adolescents, puberty blockers and hormone therapy. Apart from the isolated and misleading citation to WPATH (2012) at p. 4, the AG Opinion does not otherwise discuss the WPATH standards or correct its repeated assertion that children and adolescents are undergoing “sex change” procedures.

13 See Kuper LE, Stewart S, Preston S, Lau M, Lopez X. Body Dissatisfaction and Mental Health Outcomes of Youth on Gender-Affirming Hormone Therapy. Pediatrics 2020 Apr;145(4):e20193006. doi: 10.1542/peds.2019-3006 (stating that Endocrine Society guidelines are followed). The same is true of the Greenwich Center for Gender & Sexuality. The Yale Pediatric Gender Clinic generally follows WPATH standards.

14 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth edition. 2013.

15The current version is WPATH (2012). According to WPATH, the first six versions were published in 1979, 1980, 1981, 1990, 1998, and 2001.

16 WPATH (2012), at p. 21: “Genital surgery should not be carried out until (i) patients reach the legal age of majority to give consent for medical procedures in a given country, and (ii) patients have lived continuously for at least 12 months in the gender role that is congruent with their gender identity. The age threshold should be seen as a minimum criterion and not an indication in and of itself for active intervention.”

17 Who We Are [Internet]. Washington, D.C.: The Endocrine Society; c2022 [cited 2022 Apr 15]. Available from: https://www.endocrine.org/about-us.

18 Endocrine Society (2017).

19 Id. (Guideline 5.5).

20 AG Opinion, p. 2 (claiming that there is a “novel trend of providing these elective sex changes to minors,” with “sex changes” previously defined to include surgery and drug therapies).

21 WPATH (2012), p. 17.

22 Endocrine Society (2017) (Guideline 1.4).

23 AG Opinion, p. 4.

24 Alabama Law, Section 2(15).

25 While the law usually grants parents the final decision, bioethicists have found that adolescents can be meaningful participants in the consent process. Clark BA, Virani A. “This Wasn't a Split-Second Decision”: An Empirical Ethical Analysis of Transgender Youth Capacity, Rights, and Authority to Consent to Hormone Therapy. J Bioeth Inq. 2021 Mar;18(1):151-64; Vrouenraets LJJJ, de Vries ALC, de Vries MC, van der Miesen AIR, Hein IM. Assessing Medical Decision-Making Competence in Transgender Youth. Pediatrics 2021 Dec 1;148(6):e2020049643.

26 Endocrine Society (2017).

27 WPATH (2012), p. 18; Endocrine Society (2017) (Guidelines 2.1 and 2.2).

28 WPATH (2012), p. 16.

29 We quote the Endocrine Society phrasing, but the two protocols are substantively the same.

30 Endocrine Society (2017) (Table 5), citing WPATH (2012), p. 16.

31 Endocrine Society (2017) (Table 5).

32 Alabama Law, Section 2 and Section 2(4).

33 AG Opinion, at 3.

34 What is Gender Dysphoria? [Internet]. Washington, D.C.: American Psychiatric Association; 2020 Nov [cited 2022 Apr 15]. Available from:https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria.

35 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, D.C.: American Psychiatric Association; 2013.

36 Sorbara JC, Chiniara LN, Thompson S, Palmert MR. Mental health and timing of gender-affirming care. Pediatrics 2020 Oct 1;146(4):e20193600 (hereinafter, “Sorbara et al. 2020”).

37 Herman JL, Brown TNT, Haas AP. Suicide Thoughts and Attempts Among Transgender Adults [Internet]. Los Angeles (CA): The Williams Institute, UCLA School of Law; 2019 Sept [cited 2022 Apr 1]. Available from: https://williamsinstitute.law.ucla.edu/publications/suicidality-transgender-adults/. So-called “conversion” therapy (an extreme form of denying gender-affirming care, which attempts to change a person’s gender identity to match the sex assigned at birth) has been shown to create psychological distress and prompt suicide. Turban JL, Beckwith N, Reisner SL, Keuroghlian AS. Association Between Recalled Exposure to Gender Identity Conversion Efforts and Psychological Distress and Suicide Attempts Among Transgender Adults. JAMA Psychiatry 2019 Sept 11;77(1):68-76.

38 Coelho JS, Suen J, Clark BA, Marshall SK, Geller J, Lam PY. Eating Disorder Diagnoses and Symptom Presentation in Transgender Youth: a Scoping Review. Curr Psychiatry Rep. 2019 Oct 15;21(11):107; Kamody RC, Yonkers K, Pluhar EI, Olezeski CL. Disordered Eating Among Trans-Masculine Youth: Considerations Through a Developmental Lens. LGBT Health. 2020 May/Jun;7(4):170-73; Legroux I, Cortet B. Factors influencing bone loss in anorexia nervosa: assessment and therapeutic options. RMD Open. 2019 Nov 13;5(2):e001009.

39 Rafferty J, Committee on Psychosocial Aspects of Child and Family Health; Committee on Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics. 2018 Oct;142(4):e20182162; American Psychological Association. Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist 2015 Dec;70(9):832-64 (hereinafter, “American Psychological Association (2015)”); AAP Continues to Support Care of Transgender Youth as More States Push Restrictions [Internet]. Itasca (IL): American Academy of Pediatrics; 2022 Jan 6 [cited 2022 Mar 31]. Available from: https://publications.aap.org/aapnews/news/19021/AAP-continues-to-support-care-of-transgender; Criminalizing Gender Affirmative Care with Minors [Internet]. Washington, D.C.: American Psychological Association; [cited 2022 Mar 30]. Available from: https://www.apa.org/pi/lgbt/resources/policy/issues/gender-affirmative-care;AACAP Statement Opposing Actions in Texas Threatening the Health, Mental Health and Well-Being of Transgender and Gender Diverse Youth and Their Families, Washington, D.C.: American Academy of Child & Adolescent Psychiatry; 2022 March 1 [cited 2022 Apr 22=]. Available from: https://www.aacap.org/AACAP/zLatest_News/AACAP_Statement_Opposing_Actions_in_Texas.aspx; Statement of the Alabama Psychological Association (aPA) Supporting Gender-Affirming Care for Transgender Youth and Urging Opposition to Alabama SB184/HB266 [internet]. Alabama Psychological Association 2022. Available at https://cdn.ymaws.com/www.alapsych.org/resource/resmgr/2022/sb184-hb266_apa_statement_3-.pdf; Sorrel AL, TMA Supports Evidence-Based Gender-Affirming Care in Lawsuit [internet]. Texas Medical Association. March 14, 2022. Available from https://www.texmed.org/TexasMedicineDetail.aspx?id=59040.

40 APA Resolution on Gender Identity Change Efforts [Internet]. Washington, D.C.: American Psychological Association; 2021 Feb [cited 2022 Mar 31]. Available from: https://www.apa.org/about/policy/resolution-gender-identity-change-efforts.pdf.

41 Abreu RL, Sostre JP, Gonzalez KA, Lockett GM, Matsuno E. “I am afraid for those kids who might find death preferable”: Parental figures’ reactions and coping strategies to bans on gender-affirming care for transgender and gender diverse youth. Psychology of Sexual Orientation and Gender Diversity [Internet]. 2021 Jul 29 [cited 2022 Mar 31]; advance online publication. Available from: https://psycnet.apa.org/record/2021-67997-001; Hughes LD, Kidd KM, Gamarel KE, Operario D, Dowshen N. (2021). “These Laws Will Be Devastating”: Provider Perspectives on Legislation Banning Gender-Affirming Care for Transgender Adolescents. Journal of Adolescent Health 2021 Dec;69(6):976-82; Kidd KM, Sequeira GM, Paglisotti T, Katz-Wise SL, Kazmerski TM, Hillier A, Miller E, Dowshen N. “This could mean death for my child”: Parent perspectives on laws banning gender-affirming care for transgender adolescents. Journal of Adolescent Health 2021 Jun;68(6):1082-88.

42 AG Opinion, p. 4.

43 De Vries AL, Steensma TD, Doreleijers TA, Cohen-Kettenis PT. Puberty suppression in adolescents with gender identity disorder: A prospective follow-up study. The Journal of Sexual Medicine 2011 Aug;8(8):2276-83; De Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics 2014 Oct;134(4):696-704; Costa R, Dunsford M, Skagerberg E, Holt V, Carmichael P, Colizzi M. Psychological Support, Puberty Suppression, and Psychosocial Functioning in Adolescents with Gender Dysphoria. The Journal of Sexual Medicine 2015 Nov;12(11):2206-14 (hereinafter, “Costa et al. 2015”); Allen LR, Watson LB, Egan AM, Moser CN. Well-being and suicidality among transgender youth after gender-affirming hormones. Clinical Practice in Pediatric Psychology 2019 Sept;7(3):302-11 (hereinafter, (“Allen et al 2019”); Kaltiala R, Heino E, Tyolajarvi M, Suomalainen L. Adolescent development and psychosocial functioning after starting cross-sex hormones for gender dysphoria. Nordic Journal of Psychiatry 2020 Apr;74(3):213-19; de Lara DL, Rodriguez OP, Flores IC, Masa JLP, Campos-Munoz L, Hernandez MC, Amador JTR. Psychosocial assessment in transgender adolescents. Anales de Pediatria (English Edition) 2020 Jul;93(1):41-48; van der Miesen AI, Steensma TD, de Vries AL, Bos H, Popma A. Psychological Functioning in Transgender Adolescents Before and After Gender-Affirmative Care Compared with Cisgender General Population Peers. Journal of Adolescent Health 2020 Jun;66(6):699-704; Achille C, Taggart T, Eaton NR, Osipoff J, Tafuri K, Lane A, Wilson TA. Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results. International Journal of Pediatric Endocrinology 2020;2020:8; Kuper LE, Stewart S, Preston S, Lau M, Lopez X. Body Dissatisfaction and Mental Health Outcomes of Youth on Gender-Affirming Hormone Therapy. Pediatrics 2020 Apr;145(4):e20193006; Turban JL, King D, Carswell JM, Keuroghlian AS. Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation. Pediatrics 2020 Feb;145(2):e20191725; Carmichael P, Butler G, Masic U, Cole TJ, De Stavola BL, Davidson S, Skageberg EM, Khadr S, Viner RM. Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. PLoS One 2021 Feb 2;16(2):e0243894; Grannis C, Leibowitz SF, Gahn S, Nahata L, Morningstar M, Mattson WI, Chen D, Strang JF, Nelson EE. Testosterone treatment, internalizing symptoms, and body image dissatisfaction in transgender boys. Psychoneuroendocrinology 2021 Oct;132:105358; Hisle-Gorman E, Schvey NA, Adirim TA, Rayne AK, Susi A, Roberts TA, Klein DA. Mental Healthcare Utilization of Transgender Youth Before and After Affirming Treatment. The Journal of Sexual Medicine 2021 Aug;18(8):1444-54; Green AE, DeChants JP, Price MN, Davis CK. Association of Gender-Affirming Hormone Therapy with Depression, Thoughts of Suicide, and Attempted Suicide Among Transgender and Nonbinary Youth. Journal of Adolescent Health 2022 Apr;70(4):643-49 (hereinafter, “Green et al. 2022”); Turban JL, King D, Kobe J, Reisner SL, Keuroghlian AS. Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS One 2022 Jan 12;17(1):e0261039 (hereinafter, “Turban et al. 2022”); Tordoff DM, Wanta JW, Collin A, Stephney C, Inwards-Breland DJ, Ahrens K. Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care. JAMA Network Open 2022 Feb 1;5(2):e220978 (hereinafter, “Tordoff et al. (2022)”).

44 Russell ST, Pollitt AM, Li G, Grossman AH. Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. Journal of Adolescent Health 2018 Oct;63(4):503-05; Durwood L, McLaughlin KA, Olson KR. Mental health and self-worth in socially transitioned transgender youth. Journal of the American Academy of Child & Adolescent Psychiatry 2017 Feb;56(2):116-23.

45 Allen et al. 2019, cited in note 43; Green et al. (2022), cited in note 43; Connolly MD, Zervos MJ, Barone II CJ, Johnson CC, Joseph CL. The Mental Health of Transgender Youth: Advances in Understanding. Journal of Adolescent Health 2016 Nov;59(5):489-95; Turban et al. 2022, cited in note 43; Costa et al. (2015), cited in note 43; See also Witcomb GL, Bouman WP, Claes L, Brewin N, Crawford JR, Arcelus J. Levels of depression in transgender people and its predictors: Results of a large matched control study with transgender people accessing clinical services. Journal of Affective Disorders 2018 Aug 1; 235:308-15.

46 Rew L, Young CC, Monge M, Bogucka R. Review: Puberty blockers for transgender and gender diverse youth – a critical review of the literature. Child and Adolescent Mental Health 2021 Feb;26(1):3-14; de Vries AL, Steensma TD, Doreleijers TA, Cohen-Kettenis PT. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med. 2011 Aug;8(8):2276-83. Epub 2010 Jul 14 (hereinafter, “de Vries et al. (2011)”).

47 Tordoff et al (2022), cited in note 43; Sorbara et. al. (2020), cited in note 36.

48 Sorbara JC et. al. (2020), cited in note 36. Studies of adults confirm that gender-affirming treatment has been associated with marked improvement in mental health outcomes in transgender patients. See Almazan AN, Keuroghlian AS. Association Between Gender-Affirming Surgeries and Mental Health Outcomes. JAMA Surgery 2021 Jul 1;156(7):611-18; Marano AA, Louis MR, Coon D. Gender-Affirming Surgeries and Improved Psychosocial Health Outcomes. JAMA Surgery 2021 Jul 1;156(7):685-87; Swan J, Phillips TM, Sanders T, Mullens AB, Debattista J and Bromdal A. Mental health and quality of life outcomes of gender-affirming surgery: A systematic literature review, Journal of Gay & Lesbian Mental Health, 2022.

49 AG Opinion, at 4, citing Dhejne C, Lichtenstein P, Boman M, Johansson AL, Langstrom N, Landen M. Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PLoS One 2011 Feb 22;6(2):e16885 (hereinafter, “Dhejne (2011)”).

50 “It is therefore important to note that the current study is only informative with respect to [transgender] persons’ health after sex reassignment; no inferences can be drawn as to the effectiveness of sex reassignment as a treatment for transsexualism. In other words, the results should not be interpreted such as sex reassignment per se increases morbidity and mortality. Things might have been even worse without sex reassignment.” Dhejne (2011) at 7 (emphasis added).

51 Nelson R. Transgender People in Sweden No Longer Face Forced Sterilization. Time [Internet]. 2013 Jan 14 [cited 2022 Apr 1]; Available from: https://newsfeed/time.com/2013/01/14/transgender-people-in-sweden-no-longer-face-forced-sterilization/. The presence of this law alone might account for the higher risk of suicide attempts and risky behavior in the transgender population at the time.

52 AG Opinion, at 3-4, citing Jensen TS, Chin J, Rollins J, Koller E, Gousis L. Decision Memo for Gender Dysphoria and Gender Reassignment Surgery (CAG-00446N). Baltimore (MD): Centers for Medicare and Medicaid Services; 2016 Aug 30 [cited 2022 Feb 18]. Available from: https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&NCAId=282.

53 Id.

54 Id. (“We acknowledge that [gender reassignment surgery] may be a reasonable and necessary service for certain beneficiaries with gender dysphoria. The current scientific information is not complete for CMS to make a [national coverage decision] that identifies the precise patient population for whom the service would be reasonable and necessary.”)

55 Id.

56 The CMS Decision Memo notes that “the Medicare population is different from the general population in age (65 years and older) and/or disability as defined by the Social Security Administration. Due to the biology of aging, older adults may respond to health care treatments differently than younger adults. These differences can be due to, for example, multiple health conditions or co-morbidities, longer duration needed for healing, metabolic variances, and impact of reduced mobility. All of these factors can impact health outcomes. The disabled Medicare population, who are younger than age 65, is different from the general population and typical study populations due to the presence of the causes of disability such as psychiatric disorders, musculoskeletal health issues, and cardiovascular issues.” Id

57 A G Opinion, at 4.

58 Alabama Law, Section 2(4).

59 Steensma TD, McGuire JK, Kreukels BP, Beekman AJ, Cohen-Kettenis PT. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc Psychiatry. 2013 Jun;52(6):582-90.

60 Steensma TD, Cohen-Kettenis PT. A critical commentary on follow-up studies and “desistence” theories about transgender and gender non-conforming children. Int J Transgend. 2018 May; 19(2):225-30.

61 See American Psychological Association (2015), p. 842 (noting that several studies categorized youth who did not return to the clinic after initial assessment as “desisters” who no longer identified with a gender different than sex assigned at birth; “As a result, this research runs a strong risk of inflating estimates of the number of youth who do not persist with a TGNC identity”).

62 Id.

63 American Psychological Association (2015), p. 843; WPATH (2012), p. 11; Endocrine Society (2017). See also Turban JL, DeVries ALC, Zucker K. Gender Incongruence & Gender Dysphoria. In Martin A, Bloch MH, Volkmar FR (editors): Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, Fifth Edition. Philadelphia: Wolters Kluwer 2018, pp. 20-21 (“we must recognize that [the existing studies of persistence] have been quite limited in power and generalizability and should not be misused to create barriers for TGD youth seeking gender-affirming care. The most relevant conclusions from these studies are that insistent cross-gender identification in adolescence most often correlates with persistent TGD identities in adulthood”).

64 de Vries et al. 2011, cited in note 43 (“None of the gender dysphoric adolescents in this study renounced their wish for [gender reassignment] during puberty suppression. This finding supports earlier studies showing that young adolescents who had been carefully diagnosed show persisting gender dysphoria into late adolescence or young adulthood”).

65 Wagner S, Panagiotakopoulos L, Nash R, Bradlyn A, Getahun D, Lash TL, Roblin D, Silverberg MJ, Tangpricha V, Vupputuri S, Goodman M. Progression of Gender Dysphoria in Children and Adolescents: A Longitudinal Study. Pediatrics. 2021 Jul;148(1):e2020027722. doi: 10.1542/peds.2020-027722. Epub 2021 Jun 7. PMID: 34099504; PMCID: PMC8276590. Wagner et. al (2021) studied this cohort for only (on average) 3.5 years; by the end of the study period, roughly 35% of teens but only about 15-18% of prepubertal children received a formal diagnosis of gender dysphoria. Note that these data do not establish that only 35% of teens with gender dysphoria persist in their diagnosis. This was not a population already diagnosed with dysphoria, and so the persistence rate cannot be calculated. Rather, Wagner et al. (2021) shows that, among a population with some evidence of dysphoria, adolescents are far more likely than young children to continue to a formal diagnosis.

66 Endocrine Society (2017). See Wallien MS, Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry. 2008 Dec;47(12):1413-23. doi: 10.1097/CHI.0b013e31818956b9. PMID: 18981931.

67 American Psychological Association (2015), pp. 841-2 (“existing research suggests that between 12% and 50% of children diagnosed with gender dysphoria may persist in their identification with a gender different than sex assigned at birth into late adolescence and young adulthood”).

68 See Temple Newhook J, Pyne J, Winters K, Feder S, Holmes C, Tosh J, Sinnott ML, Jamieson A, and Pickett S, A critical commentary on follow-up studies and “desistance” theories about transgender and gender-nonconforming children, International Journal of Transgenderism, vol. 19(2), pp. 212-224 (2018) doi:10.1080/15532739.2018.1456390.

69 Endocrine Society (2017).

70 Steensma TD, McGuire JK, Kreukels BP, Beekman AJ, Cohen-Kettenis PT. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc Psychiatry. 2013 Jun;52(6):582-90 (finding that “children with persistent GID are characterized by more extreme gender dysphoria in childhood than children with desisting gender dysphoria”).

71 AG Opinion, at 3 (stating that “the spike in [surgical and drug] procedures is a relatively recent development”).

72AG Opinion, at 4.

73 The AG Opinion cites to the website of the Society for Evidence-Based Gender Medicine (SEGM). SEGM’s homepage provides an uncredited and unverifiable graph, which claims to depict referrals to an undefined term, “GIDS.” SEGM [Internet]. c2020 [cited 2022 Apr 1]. Available from: https://segm.org/. Although GIDS is not defined on the SEGM site, it appears to refer to the Gender Identity Development Service, a specialized UK gender clinic for children and adolescents. GIDS [Internet]. c2022 [cited 2022 Apt 1]. Available from:https://gids.nhs.uk/about-us#main-content.

74 A referral means that a medical provider (or, possibly, the patient) has suggested an appointment with GIDS. A referral does not equate to the receipt of gender-affirming care. See GIDS [internet]. Available from https://gids.nhs.uk/about-us#main-content.

75 Johns MM, Lowry R, Andrzejewski J, Barrios LC, Demissie Z, McManus T, Rasberry CN, Robin L, Underwood JM. Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students – 19 States and Large Urban School Districts, 2017. MMWR Morb Mortal Wkly Rep. 2019 Jan 25;68(3):67-71.

76 AG Opinion, at 4.

77 Littman L. Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria. PLoS One. 2018 Aug 16;13(8):1-44; Littman L. Correction: Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria. PLoS One. 2019 Mar 19;14(3):1-7.

78 WPATH Global Board of Directors. WPATH Position on “Rapid-Onset Gender Dysphoria” [Internet]. 2018 Sep 4 [cited 2022 Apr 1]. Available from: https://www.wpath.org/media/cms/Documents/Public% 20Policies/2018/9_Sept/WPATH%20Position%20on%20Rapid-Onset%20Gender%20Dysphoria_9-4-2018.pdf (stating that ROGD “constitutes nothing more than an acronym created to describe a proposed clinical phenomenon that may or may not warrant further peer-reviewed scientific investigation”).

79 Restar AJ. Methodological Critique of Littman's (2018) Parental-Respondents Accounts of "Rapid-Onset Gender Dysphoria". Arch Sex Behav. 2020 Jan;49(1):61-66. doi: 10.1007/s10508-019-1453-2 (hereinafter, “Restar 2020”); Temple Newhook, J, Pyne, J, Winters, K, Feder, S, Holmes, C, Tosh, J, and Pickett, S. A critical commentary on follow-up studies and “desistance” theories about transgender and gender-nonconforming children. International Journal of Transgenderism, 19(2), 212-224. (2018).

80 Littman L. Correction: Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria. PLoS One. 2019 Mar 19;14(3):1-7 (altering the original article to, inter alia, clarify that the article collected no data from adolescents or clinicians and generates only a hypothesis for further exploration).

81 Bauer GR, Lawson ML, Metzger DL; Trans Youth CAN! Research Team. Do Clinical Data from Transgender Adolescents Support the Phenomenon of “Rapid Onset Gender Dysphoria”? J Pediatr. 2022 Apr; 243:224-227. See also Arnoldussen M, Steensma TD, Popma A, van der Miesen AIR, Twisk JWR, de Vries ALC. Re-evaluation of the Dutch approach: are recently referred transgender youth different compared to earlier referrals? Eur Child Adolesc Psychiatry. 2020 Jun;29(6):803-811. Erratum in: Eur Child Adolesc Psychiatry. 2020 Dec 16 (concluding that there has been no marked change in the characteristics of the population of adolescents referred for gender dysphoria from 2000 to 2016; the authors hypothesize that the increase in number of referrals reflects the increasing social acceptability of seeking treatment).

82 Restar (2018), cited in note 79.

83 AG Opinion, at 2-3. The AG Opinion repeats its claim about sterilization. Id. at 5 (“The surgical and chemical procedures you ask about can and do cause sterilization.”)

84 Alabama Law, Sections 2(9), 2(11), 2(12), 2(13) and 2(14)

85 AG Opinion, at 5.

86 Alabama Law, Sections 2(7), (11), (12) and (13).

87 Manasco PK, Pescovitz OH, Feuillan PP, Hench KD, Barnes KM, Jones J, Hill SC, Loriaux DL, Cutler Jr GB. Resumption of puberty after long term luteinizing hormone-releasing hormone agonist treatment of central precocious puberty. J Clin Endocrinol Metab. 1988 Aug 1;67(2):368-72; Heger S, Muller M, Ranke M, Schwarz H, Waldhauser F, Partsch C, Sippell WG. Long-term GnRH agonist treatment for female central precocious puberty does not impair reproductive function. Mol Cell Endocrinol. 2006 Jul 25;254-255:217-220; Feuillan PP, Jones JV, Barnes K, Oerter-Klein K, Cutler Jr GB. Reproductive Axis after Discontinuation of Gonadotropin-Releasing Hormone Analog Treatment of Girls with Precocious Puberty: Long Term Follow-Up Comparing Girls with Hypothalamic Hamartoma to Those with Idiopathic Precocious Puberty. J Clin Endocrinol Metab. 1999 Jan;84(1):44-49; Bertelloni S, Baroncelli GI, Ferdeghini M, Menchini-Fabris F, Saggese G. Final height, gonadal function and bone mineral density of adolescent males with central precocious puberty after therapy with gonadotropin-releasing hormone analogues. Eur J Pediatr. 2000 May;159(5):369-74 (hereinafter, “Bertelloni et al (2000)”); Bertelloni S, Mul D. Treatment of central precocious puberty by GnRH analogs: long-term outcome in men. Asian J Androl. 2008 Jul;10(4):525-34; Luo X, Liang Y , Hou L, Wu,, Ying Y, YeF. Long-term efficacy and safety of gonadotropin-releasing hormone analog treatment in children with idiopathic central precocious puberty: A systematic review and meta-analysis . Clin Endocrinol.2021 May ; 94(5) :786-96.

88 Klink D, Caris M, Heijboer A, van Trotsenburg M, Rotteveel J. Bone mass in young adulthood following gonadotropin-releasing hormone analog treatment and cross-sex hormone treatment in adolescents with gender dysphoria. J Clin Endocrinol Metab. 2015 Feb;100(2):E270-75 (hereinafter, “Klink et al. 2015”); Schagen SEE, Wouters FM, Cohen-Kettenis PT, Gooren LJ, Hannema SE. Bone Development in Transgender Adolescents Treated With GnRH Analogues and Subsequent Gender-Affirming Hormones. J Clin Endocrinol Metab. 2020 Dec 1;105(12): e4252-e4263 (hereinafter, Schagen et al. 2020”); Delemarre-van de Waal HA, Cohen-Kettenis PT. Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects. Eur J Endocrinol. 2006;155:S131-S137. Studies of children treated for precocious puberty found that BMD was normal at final height attainment. Alessandri SB, Pereira F de A, Villela RA, Antonini SRR, Elias PCL, Martinelli Jr CE, de Castro M, Moreira AC, de Paula FJA. Bone mineral density and body composition in girls with idiopathic central precocious puberty before and after treatment with a gonadotropin-releasing hormone agonist. Clinics (Sao Paulo). 2012;67(6):591-96; Antoniazzi F, Zamboni G, Bertoldo F, Lauriola S, Mengarda F, Pietrobelli A, Tato L. Bone mass at final height in precocious puberty after gonadotropin-releasing hormone agonist with and without calcium supplementation. J Clin Endocrinol Metab. 2003 Mar;88(3):1096-1101 (hereinafter, “Antoniazzi et al. (2003)”); Heger S, Partsch CJ, Sippell WG. Long-term outcome after depot gonadotropin-releasing hormone agonist treatment of central precocious puberty: final height, body proportions, body composition, bone mineral density, and reproductive function. J Clin Endocrinol Metab. 1999 Dec;84(12):4583-90; Neely EK, Bachrach LK, Hintz RL, Habiby RL, Slemenda CW, Feezle L, Pescovitz OH. Bone mineral density during treatment of central precocious puberty. J Pediatr. 1995 Nov;127(5):819-22.

89Antoniazzi et al. (2003), cited in note 88.

90 Klink et al. (2015), cited in note 88; Schagen et al. (2020), cited in note 88. Bertelloni et al. (2000), cited in note 87; Pasquino AM, Pucarelli I, Accardo F, Demiraj V, Segni M, Di Nardo R. Long-term observation of 87 girls with idiopathic central precocious puberty treated with gonadotropin-releasing hormone analogs: impact on adult height, body mass index, bone mineral content, and reproductive function. J Clin Endocrinol Metab. 2008 Jan;93(1):190-195; Magiakou MA, Manousaki D, Papadaki M, Hadjidakis D, Levidou G, Vakaki M, Papaefstathiou A, Lalioti N, Kanaka- Gantenbein C, Piaditis G, Chrousos GP, Dacou-Voutetakis C. The efficacy and safety of gonadotropin-releasing hormone analog treatment in childhood and adolescence: a single center, long-term follow-up study. J Clin Endocrinol Metab. 2010 Jan;95(1):109-17; Bertelloni S, Baroncelli GI, Sorrentino MC, Perri G, Saggese G. Effect of central precocious puberty and gonadotropin-releasing hormone analogue treatment on peak bone mass and final height in females. Eur J Pediatr. 1998 May;157(5):363-67.

91AG Opinion, at 5.

92 The AG Opinion’s citation is “see generally Hennessy-Waller v. Snyder, 529 F. Supp. 3d 1031, 1042 (D. Ariz. 2021), citing Bell v. Tavistock and Portman NHS Foundation Trust, 2020 EWHC 3274, para. 134 (Dec. 1, 2020) (referring to Bell’s conclusion that a clinic’s practice of prescribing puberty-suppressing medication to individuals under age 18 with gender dysphoria and determining such treatment was experimental).” Id. at 5-6.

93 Hennessy-Waller is a decision that denies a motion for preliminary injunction against an insurance company for failure to cover gender-affirming surgery. The decision involves surgery, not puberty blockers, and it is not a fully-adjudicated factual determination about either surgery or puberty blockers. Hennessy-Waller v. Snyder, 529 F. Supp. 3d 1031 (D. Ariz. 2021).

94 Bell v. The Tavistock and Portman NHS Foundation Trust [2021] EWCA (Civ) 1363 [38] (Eng.) (noting that the claimant’s (plaintiff’s) expert evidence was faulty: “None of it complied with the rules regarding expert evidence and a good deal of it is argumentative and adversarial.”). For a scientific review of the evidence in the lower court decision, see de Vries ALC, Richards C, Tishelman AC, Motmans J, Hannema SE, Green J, Rosenthal SM. Bell v Tavistock and Portman NHS Foundation Trust [2020] EWHC 3274: Weighing current knowledge and uncertainties in decisions about gender-related treatment for transgender adolescents. Int J Transgend Health. 2021 Apr 5;22(3):217-24.

95AG Opinion, at 5.

96 Alabama Law, Section 2(7).

97 The quote is from the American Academy of Pediatrics Committee on Drugs. See Frattarelli DA, Galinkin JL, Green TP, Johnson TD, Neville KA, Paul IM, Van Den Anker JN; American Academy of Pediatrics Committee on Drugs. Off-label use of drugs in children. Pediatrics. 2014 Mar;133(3):563-7 (hereinafter, “AAP Committee on Drugs (2014)”); see also Allen HC, Garbe MC, Lees J, Aziz N, Chaaban H, Miller JL, Johnson P, DeLeon S. Off-Label Medication use in Children, More Common than We Think: A Systematic Review of the Literature. J Okla State Med Assoc. 2018 Oct;111(8):776-783.

98 AAP Committee on Drugs (2014), cited in note 97.

99AAP Committee on Drugs (2014), cited in note 97 (emphasis added). See also Schrier L, Hadjipanayis A, Stiris T, Ross-Russell RI, Valiulis A, Turner MA, Zhao W, De Cock P, de Wildt SN, Allegaert K, van den Anker J. Off-label use of medicines in neonates, infants, children, and adolescents: a joint policy statement by the European Academy of Paediatrics and the European society for Developmental Perinatal and Pediatric Pharmacology. Eur J Pediatr. 2020 May;179(5):839-847.

100 Hoon D, Taylor MT, Kapadia P, Gerhard T, Strom BL, Horton DB. Trends in Off-Label Drug Use in Ambulatory Settings: 2006-2015. Pediatrics. 2019 Oct;144(4):1-10 (emphasis added).

101 AG Opinion, at 3.

102 Alabama Law, Section 2(13).

103 Endocrine Society (2017). Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol.2014;124(6):1120–1127 (hereinafter, “Light et al. 2014”); Pelusi C, Costantino A, Martelli V, et al. Effects of three different testosterone formulations in female-to-male transsexual persons. J Sex Med. 2014;11(12):3002–3011.; Smith KP, Madison CM, Milne NM. Gonadal suppressive and cross-sex hormone therapy for gender dysphoria in adolescents and adults. Pharmacotherapy. 2014;34(12):1282–1297.

104 Light et al. (2014), cited in note 103; Light A, Wang LF, Zeymo A, Gomez-Lobo V. Family planning and contraception use in transgender men. Contraception. 2018 Oct;98(4):266-69.

105 Leung A, Sakkas D, Pang S, Thornton K, Resetkova N. Assisted reproductive technology outcomes in female-to-male transgender patients compared with cisgender patients: a new frontier in reproductive medicine. Fertil Steril. 2019 Nov;112(5):858-65; Wallace SA, Blough KL, Kondapalli LA. Fertility preservation in the transgender patient: expanding oncofertility care beyond cancer. Gynecol Endocrinol. 2014;30(12):868-71; Maxwell S, Noyes N, Keefe D, Berkeley AS, Goldman KN. Pregnancy outcomes after fertility preservation in transgender men. Obstet Gynecol. 2017 Jun;129(6):1031-34.; Gale J, Magee B, Forsyth-Greig A, Visram H, Jackson A. Oocyte cryopreservation in a transgender man on long-term testosterone therapy: a case report. F S Rep. 2021 Feb 20;2(2):249-51.

106 Schneider F, Kliesch S, Schlatt S, Neuhaus N. Andrology of male -to-female transsexuals: influence of cross-sex hormone therapy on testicular function. Andrology. 2017 Sept;5(5):873-80.

107 Schneider F, Neuhaus N, Wistuba J, Zitzmann M, Heß J, Mahler D, van Ahlen H, Schlatt S, Kliesch S. Testicular functions and clinical characterization of patients with gender dysphoria (GD) undergoing sex reassignment surgery (SRS). J Sex Med. 2015 Nov;12(11):2190-2200.

108 de Nie I, Mulder CL, Meißner A, Schut Y, Holleman EM, van der Sluis WB, Hannema SE, den Heijer M, Huirne J, van Pelt AMM, van Mello NM. Histological study on the influence of puberty suppression and hormonal treatment on developing germ cells in transgender women. Hum Reprod. 2022 Jan 28;37(1):297-308.

109 The AG Opinion cites to Timothy Cavanaugh, M.D., Cross-Sex Hormone Therapy, FENWAY HEALTH (2015), https://www.lgbtqiahealtheducation.org/wp-content/uploads/Cross-Sex-Hormone-Therapy1.pdf. A search conducted in March 2022 found that the link was broken and the document could not be found on the Fenway Health website or elsewhere on the Internet.

110 The iatrogenic (drug-induced) risks of hepatotoxicity, meningioma, and prolactinoma are now zero, because the medication associated with those risks (cyproterone) is no longer in use in the United States. WPATH (2012), p. 48.

111 Connelly PJ, Marie Freel E, Perry C, Ewan J, Touyz RM, Currie G, Delles C. Gender-Affirming Hormone Therapy, Vascular Health and Cardiovascular Disease in Transgender Adults. Hypertension. 2019 Dec;74(6):1266-1274. doi: 10.1161/HYPERTENSIONAHA.119.13080. Epub 2019 Oct 28. Erratum in: Hypertension. 2020 Apr;75(4):e10. PMID: 31656099; PMCID: PMC6887638.

112 Oral estradiol, the preferred estrogen formulation that is given to transgender women in the United States, carries a VTE risk of <1%. T'Sjoen G, Arcelus J, Gooren L, Klink DT, Tangpricha V. Endocrinology of Transgender Medicine. Endocr Rev. 2019 Feb 1;40(1):97-117. In transgender men, the overall risk of VTE ranges from 0% to 0.34%. Maraka S, Singh Ospina N, Rodriguez-Gutierrez R, Davidge-Pitts CJ, Nippoldt TB, Prokop LJ, Murad MH. Sex Steroids and Cardiovascular Outcomes in Transgender Individuals: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab. 2017 Nov 1;102(11):3914-23.

113 All SEGM.org website citations reflect visits to the site in March 2022.

114 Of the 123 listed papers (some are listed more than once), 49 (or 40%) are letters to the editor or opinion pieces.

115 These findings are based on the biographical data posted on the SEGM.org website, supplemented with searches of Google (to determine academic appointments and listed publications) and the database PubMed (to determine medical publication records).

116 AG Opinion, at 4 (citing Anderson RT, George RP. Physical Interventions on the Bodies of Children to “Affirm” their “Gender Identity” Violate Sound Medical Ethics and Should Be Prohibited [Internet]. Public Discourse: The Journal of the Witherspoon Institute; 2019 Dec 8 [cited 2022 Mar]. Available from: https://www.thepublicdiscourse.com/2019/12/58839/.

117 “ Public Discourse is the online journal of the Witherspoon Institute, a 501(c)3 research center located in Princeton, New Jersey”. Our Mission. Public Discourse: The Journal of the Witherspoon Institute ; c2022 [cited 2022 Mar]. Available from: https://www.thepublicdiscourse.com/our-mission/.

118 “Founded in 1976, the Ethics and Public Policy Center” works “to apply the riches of the Judeo-Christian tradition to contemporary questions of law, culture, and politics, in pursuit of America’s continued civic and cultural renewal.” About. Ethics & Public Policy Center; c2022 [cited 2022 Mar]. Available from: https://eppc.org/about/ . The EPPC’s programs include “Catholic Studies” and the “Catholic Women’s Forum. Programs. Ethics & Public Policy Center; c2022 [cited 2022 Mar]. Available from: https://eppc.org/program/ Anderson is listed as the president. Ryan T. Anderson. Ethics & Public Policy Center; c2022 [cited 2022 Mar]. Available from:https://eppc.org/author/ryan_anderson/.

119 About. American Principles Project; c2020 [cited 2022 Mar]. Available from: https://americanprinciplesproject.org/about/. On another page, the website states that the American Principles Project was founded in 2009 by George and “veteran political strategist Frank Cannon.” History. American Principles Project; c2020 [cited 2022 Mar]. Available from: https://americanprinciplesproject.org/about/history-story/

120 For examples, see Kimberly LL, Folkers KM, Friesen P, Sultan D, Quinn GP, Bateman-House A, Parent B, Konnoth C, Janssen A, Shah LD, Bluebond-Langner R, Salas-Humara C. Ethical Issues in Gender-Affirming Care for Youth. Pediatrics. 2018 Dec;142(6):e20181537; Bizic MR, Jeftovic M, Pusica S, Stojanovic B, Duisin D, Vujovic S, Rakic V, Djordjevic ML. Gender Dysphoria: Bioethical Aspects of Medical Treatment. BioMed Res Int. 2018 Jun 13;2018:9652305; Strang JF, Powers MD, Knauss M, Sibarium E, Leibowitz SF, Kenworthy L, Sadikova E, Wyss S, Willing L, Caplan R, Pervez N, Nowak J, Gohari D, Gomez-Lobo V, Call D, Anthony LG. “They Thought It Was an Obsession”: Trajectories and Perspectives of Autistic Transgender and Gender-Diverse Adolescents. J Autism Dev Disord. 2018 Dec;48(12):4039-55.

121 Steensma TD, Wensing-Kruger SA, Klink DT. How Should Physicians Help Gender-Transitioning Adolescents Consider Potential Iatrogenic Harms of Hormone Therapy? AMA J Ethics. 2017 Aug 1;19(8):762-70.

122 Vrouenraets LJJJ, Hartman LA, Hein IM, de Vries ALC, de Vries MC, Molewijk BAC. Dealing with Moral Challenges in Treatment of Transgender Children and Adolescents: Evaluating the Role of Moral Case Deliberation. Arch Sex Behav. 2020 Oct;49(7):2619-34.

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On February 18, 2022, Texas Attorney General Ken Paxton issued an interpretation of Texas state law (the “AG Opinion”), taking the position that certain medical

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Gender Identity 5 Years After Social Transition 

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Gender Identity 5 Years After Social Transition 

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Transgender children are unlikely to "detransition," or come to identify with their birth sex, five years after their social transition, a new study found.

The findings, published Wednesday in the journal Pediatrics, come from a larger project called the Trans Youth Project. Researchers at Princeton University began in 2013 to track 317 kids between ages 3 and 12 who socially transitioned - the first and largest sample of its kind, according to Kristina Olsen, the study's lead author and a professor of psychology at Princeton.

The results showed that five years after their initial social transition, 94 percent of the study participants were living as either trans girls or trans boys. The remaining youth had "retransitioned," as the study called it, and no longer identified as binary transgender. Of that group, 2.5 percent came to identify with their birth sex.

The findings come as Republican lawmakers in more than two dozen states have tried, over the last two years, to restrict access to gender-affirming care for transgender minors.

Social transitions can include wearing different clothing and using a different name and pronouns, but the study defined a complete social transition as changing one's pronouns "to the binary gender pronouns that differed from those used at their births."

Olsen said the study's long-term scope has enabled researchers to see how gender identity language has evolved.

"When we started, we had no families contacting us who had kids who use they/them pronouns, and almost no one was using the term nonbinary amongst the community of families we were working with," she said. "This is one of the interesting things about a prospective study, of tracking a cohort over time - not only are they developing and getting older and having a sense of maybe changes or not of their identity, but also culture is changing. Our words are changing, our understanding of gender is changing."

The study's findings are relevant to recent legislative efforts to limit gender-affirming care for minors, which includes puberty blockers, hormones and surgeries. The number of proposed bills that aim to restrict such care for transgender youth has grown from one in 2018 to 36 this year, according to an analysis by NBC News.

Three states - Arkansas, Tennessee and Alabama - have passed laws restricting or banning gender-affirming health care for transgender minors. Alabama last month became the first state to make it a felony for doctors to provide such care.

In guidance issued last month, Florida's surgeon general recommended against medical transition for minors due to "the potential for long-term, irreversible effects" and condemned social transition for children.

Supporters of these restrictions say trans youth are too young to know what their gender is, and many cite research that found that most trans youth come to identify with their birth sex later.

The Princeton findings contradict that prior research. In the study, just one child of the 190 who went on puberty blockers or hormones later came to identify as cisgender. Puberty blockers are medications that suppress the body's release of sex hormones, but puberty resumes if a person stops taking them.

"With regard to this debate or discussion that's going on, I think the critical piece is that we're seeing the retransitioning happening before the ages at which kids were beginning medical transition, at least so far in our data," Olsen said.

The other seven children in the study who socially transitioned and then came to identify with their birth sexes did so "before blockers were even on the table," Olsen added.

Some researchers and doctors have questioned studies that purport to show that a majority of trans youth later detransition. A report released Monday from researchers at Yale University and the University of Texas Southwestern refutes "flawed science" that officials in Texas and Alabama have cited to support restrictions on gender-affirming medical care.

"These are not close calls or areas of reasonable disagreement," the authors wrote, adding that both Alabama and Texas leaders "ignore established medical authorities and repeat discredited, outdated, and poor-quality information."

Olsen said that comparisons of previous research on the topic to her team's study are like "apples to oranges," because many participants in past studies had not socially transitioned. In one oft-cited 2013 study, researchers classified participants who didn't return to their clinic as "desisters" of gender dysphoria rather than "persisters," and assumed they no longer identified as trans.

Olsen's team plans to follow the cohort in the study for 20 years, well into adulthood, and will track life experiences that affect their mental health.

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Trans youths who socially transition are unlikely to 'detransition' later, study finds

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Transgender children are unlikely to "detransition," or come to identify with their birth sex, five years after their social transition, a new study found. The findings, published Wednesday in the journal Pediatrics, come from a larger project called the Trans Youth Project.

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Protecting Trans Kids and Their Families 

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Protecting Trans Kids and Their Families 

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The Truman Center hosted a conversation focused on ways to stand beside transgender youth and their families

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Transgender rights have once again emerged as a political flash point in America.

While President Biden signed an executive order expanding protections for LGBTQ people, Republican lawmakers have sought to roll back the rights of the transgender community - especially the rights of children. Across the country, conservative legislators have introduced and passed a wave of bills that would ban medical treatments for transgender children and restrict transgender students from playing in sports according to their gender identity.

Many of these political debates are laden with misinformation and misunderstandings about what it means to be a transgender teenager today, advocates and medical experts say.

Informed by medical guidelines, and interviews with doctors and experts, The Washington Post compiled answers to some of the most commonly asked questions about transgender young people.

Understanding the transgender community: The basics

What does it mean to be transgender?

Transgender is an umbrella term for anyone whose gender does not align with their sex assigned at birth. Cisgender is a term applied to people who are not transgender - people whose gender identity matches their assigned sex.

Gender identity is not the same thing as gender expression. For example, a cisgender woman might present in a more stereotypically "masculine" way but still identify as her female sex assigned at birth.

How do doctors diagnose gender dysphoria?

Gender dysphoria is defined as "psychological distress" that results from a mismatch between one's sex assigned at birth and one's gender identity, according to the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association (APA).

Not everyone who is transgender is diagnosed with gender dysphoria. Some transgender people do not feel discomfort or distress in their bodies. And not all people diagnosed with gender dysphoria will choose to undergo medical treatments or transition-related surgeries.

For adolescents to be diagnosed with gender dysphoria, they must have experienced "a marked incongruence" between their gender and their assigned sex at birth, lasting at least six months, according to the APA diagnostic manual. For young adolescents, this can be manifested as a strong desire to prevent the development of secondary sex characteristics, such as facial hair or breast growth.

Gender dysphoria can have serious health impacts. It can affect a person's ability to function at school or work and can lead to intense anxiety, depression and suicide risk. Some adolescents or adults have experienced distress using the bathroom and developed gastrointestinal issues as a result, said Jack Turban, a doctor and fellow in child and adolescent psychiatry at Stanford University School of Medicine. Some transgender people who bind their chests have experienced skin infections and respiratory problems, Turban said.

A recent study from Turban and a team of other researchers found that exposure to gender identity conversion therapy - attempts by a professional to force a transgender person to be cisgender - was associated with increased odds of attempting suicide. Instead, major medical organizations such as the American Academy of Pediatrics have encouraged doctors and parents to take a gender-affirming approach to a transgender child's care.

At what age do young people realize they are transgender?

This depends entirely on each individual case. With more information about the transgender community becoming available to young people and their parents, more children are coming out at earlier ages than in the past, and more transgender clinics are available to provide them with care.

Some people don't realize they are transgender until they reach puberty, or later in adulthood. But some children show signs that they are transgender early on in childhood. "Not everybody puts their puzzle together in the same way or at the same time," said Johanna Olson-Kennedy, medical director of the Center for Transyouth Health and Development at Children's Hospital Los Angeles, one of the largest transgender clinics in the country.

Olson-Kennedy said the vast majority of transgender youth patients at the clinic first arrive when they have already reached puberty. The average age for presentation for services at the clinic is 15, she said. Despite the intense political focus on young transgender children, only 10 percent of the children arriving at her clinic are pre-pubertal.

How many young people identify as transgender?

The Williams Instituteat the UCLA School of Law estimates that 0.7 percent of teens ages 13 to 17 identify as transgender. A recent Gallup poll found that 11 percent of LGBT adults identify as transgender. Re-basing this percentage to represent the share of the U.S. adult population, Gallup found that 0.6 percent of U.S. adults identify as transgender. But among Generation Z adults, about 2 percent identify as transgender, and researchers expect that number to continue to grow.

[1 in 6 Gen Z adults are LGBT. And this number could continue to grow.]

Does this mean there are more transgender people than before? Advocates say it's merely a sign that more transgender people have the information and language available to understand and describe their identities. Transgender people have existed throughout history, including transgender children. But many clinics have been treating transgender children only in recent decades. Olson-Kennedy said her clinic has been taking care of trans young people since the 1990s.

"What's happening now is not a massive surge in transgender people," said transgender advocate Gillian Branstetter. "It's an understanding that gender, much like sexuality, exists on a spectrum and is more fluid than people allow."

What does it mean to be nonbinary?

Nonbinary is a term used to describe people who do not identify exclusively as male or female. Some nonbinary people also identify as transgender, and some are also diagnosed with gender dysphoria, but others are not. Many - but not all - nonbinary people use they/them pronouns, instead of he/him or she/her. Some nonbinary people will use a combination of different pronouns.

What does it mean to be intersex?

Intersex is an umbrella term used to describe people with differences in sex traits or reproductive anatomy, which can include variations in genitalia, internal anatomy, hormones or chromosomes. Some people are born with these differences, while others develop them in childhood, according to the organization InterACT.

Transgender medical care for children

How does a young child transition?

For pre-pubertal transgender children diagnosed with gender dysphoria, doctors recommend avoiding gender-affirming medications, according to the Endocrine Society's Clinical Practice Guideline, which sets standards of care for transgender people.

"If you have not yet started puberty, there's nothing to block and nothing to add," Olson-Kennedy said. "It's about creating environments that are supportive."

Rather than beginning a medical transition, pre-pubertal transgender children may begin a social transition, changing one's name and pronouns, and wearing different clothing or hairstyles. This transition can in some cases involve legal changes to names and genders listed in identifying documents. Transgender children are not offered puberty blockers or hormone treatments until they reach puberty. Medical guidelines generally do not recommend genital gender-affirming surgeries before a child reaches age 18.

What are puberty blockers and when are they offered to transgender children?

Once a transgender child has met diagnostic criteria for gender dysphoria, and after the child first shows physical changes of puberty, clinicians may recommend puberty-suppressing treatments, also known as puberty blockers.

Puberty blockers are fully reversible. The medications pause puberty and prevent unwanted changes to teenagers' bodies, such as periods in transgender boys or the deepening of the voice in transgender girls. The puberty blockers are intended to give young people more time to decide what to do next. At any point, a transgender teenager can stop taking puberty blockers and will continue to go through the puberty of their sex assigned at birth.

[A transgender girl struggles to find her voice as lawmakers attack her right to exist]

For decades, puberty suppression has been used by doctors to treat precocious puberty - abnormally early onset of puberty - in children, as well as endometriosis and prostate cancer in adults. But it was first used as gender-affirming treatment in the 1990s, at a transgender clinic in the Netherlands.

Politicians critical of puberty blockers have at times focused on federal approvals for the drugs. While puberty suppressants are approved by the Food and Drug Administration to treat children with precocious puberty, the medications have not been approved specifically for gender-affirming care. Olson-Kennedy argues that this lack of approval is because drug firms have declined to perform the studies necessary to get these approvals.

In general, because many drug companies avoid performing trials on children, it is common in pediatric medicine for doctors to prescribe drugs off-label.

What are hormone treatments and when are they offered to transgender youth?

Once a transgender teenager reaches later years in adolescence, some may request sex hormone treatment - estrogen for transgender girls and testosterone for transgender boys. These medications can help align a transgender person's body to their gender identity, leading to facial hair growth and a deeper voice in transgender boys, for example, and breast growth in transgender girls.

Since these are partly irreversible treatments, the Endocrine Society recommends waiting to begin treatment until after a person has "sufficient mental capacity to give informed consent," which the society said most adolescents have by age 16. In some cases, according to the 2017 guidelines, transgender youth may have this capacity by age 14. Each teenager's ability to consent has to be determined individually, Olson-Kennedy said. "One person's 14 is very different from another person's 14."

[As senators debate her rights, a transgender teenager gives a confident testimony]

The Endocrine Society recommends starting treatment with a gradually increasing dose schedule carefully monitored by a multidisciplinary team of doctors.

In recent debates over transgender medical care, politicians have made claims that transgender children are undergoing genital surgeries at young ages. Current medical guidelines say children should not undergo gender-affirming genital surgery before they turn 18.

Chest surgeries can be performed on transgender teenagers before theage of majority in a given country (age 18 in the United States), according to standards of care from the World Professional Association for Transgender Health, "preferably after ample time of living in the desired gender role and after one year of testosterone treatment."

What does scientific research tell us about these treatments and their impacts?

Research on these medications is still evolving, due in part to the nascent nature of the treatments, the challenges of performing studies on children and the small size of the transgender youth population. But several studies on puberty blockers have found that transgender young people who were treated with the medications showed lower rates of depression and anxiety, and demonstrated better global functioning.

A study conducted by Turban and colleagues, published in the journal Pediatrics in 2020, showed that young people who wanted a puberty suppressant and were able to access it had lower odds of considering suicide.

Critics of gender-affirming treatments often argue that children are too young to make these decisions and may regret them in adulthood. Skeptics will often cite statistics from studies suggesting that a majority of young transgender children will eventually grow out of their transgender identity later in life. But Turban and other experts have argued the methodology used in these studies is flawed because the researchers included a large cohort of children referred to transgender clinics, not children who actually met the criteria for gender dysphoria. He argued that many of these children were not transgender to begin with and may have simply been brought to the clinics by their parents because they were "tomboys" or gender-nonconforming children.

A new study by Turban and other researchers from the Fenway Institute and Harvard Medical School found that 13.1 percent of currently identified transgender people have "detransitioned" at some point in their lives but that 82.5 percent of those people attributed their decision to external factors such as pressure from family, school environments and vulnerability to violence.

What are some of the risks of these medications?

Since puberty blockers are reversible, they do not impair fertility or lead to other permanent changes to a child's body. Puberty suppressants do come with some risks, and the Endocrine Society's 2017 guidelines mentioned the need for more research on the effects of the prolonged delay of puberty in adolescents.

Puberty suppression may include adverse effects on bone mineralization, according to the Endocrine Society, but the estimated calculated risk of bone fracture remains extremely low, Turban said, citing a recent paper in Pediatrics. For each patient, this likely low risk of fracture needs to be weighed against the risk of adverse outcomes from gender dysphoria itself, Turban said.

If a child has been on puberty blockers for years, "most endocrinologists will say by the time you get to 16, you make a decision. Either come off the blocker or start estrogen or testosterone to mineralize your bone," Turban said.

For transgender teenagers who first take puberty blockers and then take estrogen and testosterone treatments, the Endocrine Society warns that the treatment may compromise fertility later in life. But Turban says more research is needed on the subject. The Endocrine Society recommends that clinicians counsel all transgender people seeking hormone treatments on their options for fertility preservation before they start taking estrogen or testosterone.

What legislation has advanced in the U.S. to restrict these medications?

As of April, at least 18 states have introduced bills to criminalize or ban access to puberty blockers, hormone treatments and transition-related surgeries for transgender minors. Legislators in Arkansas in early April voted to pass the nation's first ban on gender-affirming medical treatments for transgender youth, overriding a veto from their governor. Gov. Asa Hutchinson (R) described the bill as a "vast government overreach" that would interfere with physicians and parents "as they deal with some of the most complex and sensitive matters involving young people."

Major medical organizations including the American Psychiatric Association, American Academy of Pediatrics and the American College of Physicians have written in opposition to these bills. And according to the Williams Institute at UCLA School of Law, an estimated 45,100 transgender youth ages 13 and older in the United States are at risk of being denied gender-affirming medical treatments due to proposed and enacted state bans.

Transgender youth and sports

What are the current guidelines in the U.S. for the participation of transgender people in sports?

Policies on the participation of transgender students in high school sports vary from state to state. At least 16 states and the District of Columbia have policies that help facilitate the full inclusion of transgender, nonbinary and gender-nonconforming students in high school sports, according to TransAthlete.com and the American Civil Liberties Union.A patchwork of policies exists in other states, with at least 10 states requiring trans athletes to undergo some treatment, and 12 states effectively banning participation, including four that passed new laws and executive orders this year.

At the college level, NCAA guidelines require at least a full year of testosterone suppression before a transgender woman is allowed to compete with other women. That guidance, published in 2011 and citing medical experts, notes that transgender women "display a great deal of physical variation, just as there is a great deal of natural variation in physical size and ability among non-transgender women and men. ... It is important not to overgeneralize." The assumption that all people assigned male at birth are "taller, stronger, and more highly skilled in a sport" is not accurate, the handbook states.

At elite levels, policies also vary across national and international associations and federations. The International Olympic Committee issued guidance in 2015 for determining eligibility. According to the guidance, transgender men can compete in male categories without restriction, but transgender women must meet certain conditions, including demonstrating that their total testosterone level in serum has been below 10 nmol/L for at least 12 months before their first competition.

What research is available about transgender athletes and whether they have an advantage over cisgender athletes?

Across the country, more than half of U.S. states have introduced bills in 2021 that would bar transgender participation in school sports according to their gender identity. Many of these bills argue that transgender women and girls have a biological advantage over cisgender girls when competing in sports. An Idaho bill, which was signed into law in 2020 but has been stalled in court proceedings, argues that transgender girls and women have "denser, stronger bones" and "larger hearts, greater lung volume per body mass" and other characteristics that lawmakers claimed would give transgender women an athletic edge.

But studies of the performance of transgender athletes so far are limited and based on small, narrow samples that some researchers say cannot necessarily be applied to high school sports.

One study published in the British Journal of Sports Medicine in 2020 suggested that transgender women in the U.S. Air Force retained certain athletic advantages over cisgender female peers for about two years into hormone therapy. The researchers assessed the medical records and fitness tests of 29 transgender men and 46 transgender women from 2013 and 2018, reviewing the number of push-ups and sit-ups they could perform in a minute and the time required to run 1½ miles.

[Transgender rights emerge as a growing political flash point]

The study's authors found that when it comes to muscle strength, after two years of hormone therapy "you can't distinguish the performance of the trans women with the average performance of cis women in the Air Force," said the study's lead author, Timothy Roberts, director of the adolescent medicine training program at Children's Mercy Hospital in Kansas City, Mo. When it came to running times, the transgender women's times did slow down but were still 12 percent faster on average than those of their cisgender female peers. But looking at the spread of run times among cisgender women, the transgender women were still slower than 9 percent of them.

"There's natural variation in talent, there's natural variation in testosterone levels," Roberts said. "There's never really been a level playing field."

Roberts and the other authors of the study have cautioned against applying the study's findings to high school athletics. The average age of the U.S. Air Force members in the study was 26. The athletic abilities of a trans person undergoing hormone therapy as an adult are going to be vastly different from those transitioning as teenagers. Roberts said. For transgender teenage girls who took puberty blockers followed by estrogen treatments, "they probably have absolutely no advantages over the other cisgender women."

LGBTQ advocates and health experts say that assertions about the biological advantages of transgender athletes also fail to take into account social hurdles that may affect a transgender athlete's ability to compete.

"Harassment and discrimination, years of internal turmoil and shame and a lack of validation ... that inhibits the ability to thrive," said Chase Strangio, an attorney and deputy director for transgender justice at the ACLU.

[The fight for the future of transgender athletes]

Olson-Kennedy said many of the trans girls she treats in her clinic avoid playing sports, in part because they don't want to build muscle, but also because "in competitive sports ... everything about it is dysphoria-producing," she said. "What are people going to say? Are they going to accept me on the girls' team? What's the locker room situation going to be like?" These are the kinds of questions transgender girls ask before even considering playing sports, Olson-Kennedy said.

Some of the recent legislation has raised questions about how the restrictions would be enforced, and whether high school athletes would be subject to physical exams. LGBTQ advocates and transgender health experts say demanding certain hormone levels or requiring sex-verification exams to determine eligibility in sports can be harmful to both transgender and cisgender young people.

How has the participation of transgender girls in sports impacted outcomes for cisgender high school athletes?

As lawmakers across the country introduced bills to restrict transgender participation in sports, the Associated Press contacted two dozen state lawmakers sponsoring such legislation. In almost every case, the AP reported, lawmakers could not cite "a single instance in their own state or region where such participation has caused problems."

Many supporters of these bills point to a 2020 case in Connecticut. The families of three Connecticut high school track and field athletes filed a federal lawsuit objecting to a Connecticut Interscholastic Athletic Conference rule that allows high school athletes to compete in sports corresponding with their gender identity.

The lawsuit centered on transgender runners Andraya Yearwood and Terry Miller, who won a combined 15 state titles in different events. But two days after the Connecticut lawsuit was filed, one of the cisgender plaintiffs defeated one of the transgender girls in a state championship.

"We've had years and, in some cases, decades of inclusion ... and just quite simply there are no examples of trans people taking over or winning in any sort of significant numbers," Strangio said. "And there's been zero examples of a trans girl in high school getting an athletic scholarship to compete in college."
Typography animation by Sarah Hashemi and Audrey Valbuena. Editing by Annys Shin. Copy editing by Mike Cirelli. Design by J.C. Reed.

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FAQ: What you need to know about transgender children

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Transgender rights have once again emerged as a political flash point in America. While President Biden signed an executive order expanding protections for LGBTQ people, Republican lawmakers have sought to roll back the rights of the transgender community - especially the rights of children.

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The Pronoun Game (Practice to Use Correct Pronouns) 

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The Pronoun Game (Practice to Use Correct Pronouns) 

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Pronouns are basically words used to refer to a person other than their name. When a trans person comes out they may have new pronouns they want to use

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9 tips to resist conversion therapy for trans/nonbinary people

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Affirmative Therapy with LGBTQAI+ Youth and Families

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Affirmative Therapy with LGBTQAI+ Youth and Families

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FEATURE

When youth are expressing gender expansiveness or claiming a trans identity, it is common for parents to seek therapy for help navigating their child's process. Parental attitudes vary widely and may include full support, relief, confusion, disbelief, fear, loss, anger, or outright rejection. Regardless of a family's level of attunement with the youth's expression/identity, it is vital for therapists to use a gender affirmative approach. TGE youth face minority stress and are often experiencing dysphoria, stressors that can lead to increased mental health problems, including depression, anxiety, and suicidality. A gender affirmative approach is the first step to counterbalancing the negativity youth face both in their external environments and within self (i.e., internalized transphobia, dysphoria). This approach assumes that no gender identity or expression is pathological (Keo-Meier & Ehrensaft, 2018), that they are all natural variations of humanity (Coolhart & Shipman, 2017), and that any pathology that is present is a result of transphobia, homophobia, and sexism, rather than a disturbance in the child (Coolhart, 2012; Hidalgo et al., 2013).

Following are some strategies for working with TGE youth and their parents. For a deeper discussion of interventions, please see other published works on this model (Coolhart, 2012; Coolhart, 2018; Coolhart, 2019; Coolhart, Baker, Farmer, Malaney, & Shipman, 2013; Coolhart, Ritenour, & Grodzinski, 2018; Coolhart & Martin, in press; Coolhart & Shipman, 2017).

Assessing parental attunement and deciding on the structure of sessions

Starting with the first phone call, therapists can begin to assess how much harmony, understanding, and peace parents are experiencing around their child's gender expression/identity. When parental attunement is low, therapists should work with parents separately from the child in order to provide space for the parents' concerns without sending harmful messages to the child. Family sessions can begin when therapy can be an emotionally safe place for all members, where youth and parents can have healthy and productive discussions about gender expression/identity.

Supporting gender expansiveness

TGE youth have often experienced a broad range of disapproval of and opposition to how they experience and express gender, coming from multiple sources such as parents, siblings, peers, neighbors, teachers, religion, and media. Therapists aim to balance these negative messages by 1) delivering positive messages about TGE expressions/identities, 2) normalizing and validating TGE experiences, and 3) recognizing the strengths and resiliencies TGE youth have as a result of their journey with gender. Therapists should ask about chosen name and pronouns and use them with the youth, creating a "gender expansive safe zone," where youth are free to dress and express themselves in congruent ways.

When TGE youth are requesting the use of pronouns that differ from those assigned at birth, parents sometimes struggle to make the transition. Therapists can help parents understand why pronouns are so important and the pain it causes when one is misgendered. If it feels emotionally safe for the youth, therapists can coach youth in talking to their parents about the impact on them when incorrect pronouns are used. A strong therapeutic relationship with parents is important so therapists can begin to challenge parents' behavior that is not supportive of their child's expression/identity, including using incorrect pronouns. When parents have particularly low attunement, therapists can use they/them pronouns and gender neutral language (i.e., "your child") in order to respect both the parents and the youth in their processes.

It is vital to follow the lead of youth and listen to what they need to feel congruent.

Providing psychoeducation

Parents of TGE youth often need accurate information about gender-related concepts (i.e., the differences between sex, gender identity, gender expression, and orientation) as well as TGE experiences (i.e., TGE kids can grow up to be healthy adults).Therapists can also educate parents about the importance of parental support, which can buffer youth from negative mental and physical health outcomes. Youth with rejecting parents are at increased risk for suicide ideation and attempts, depression, illegal drug use, alcohol abuse, smoking, homelessness, engaging in unprotected sex, and sex work; those with supportive parents may experience higher self-esteem, social support, general health status, school belonging, academic achievement, life satisfaction, and overall mental health. Thus, even when parents are struggling to accept their child's TGE expression/identity, therapists can gently coach parents to decrease their rejecting messages. Finally, parents sometimes worry about what caused their child to be TGE. Therapists can reassure parents that being TGE is a natural variation of humanity, that TGE people have existed over time and across cultures, and that there is nothing they did or didn't do that caused their child to be TGE.

Supporting parents' emotional process

Parental reactions to having a TGE child vary and can include many different emotions, such as joy, relief, anxiety, embarrassment, worry, anger, denial, shame, self-blame, disappointment, loss, confusion, or fear for their child's safety. Therapy can be a space for parents to express and process all of these feelings so that parents can be freed up to be more attuned to their child. When parents are expressing particularly negative views about their child's TGE expression/identity, it can be difficult as an affirmative therapist to listen to these anti-affirmative views. However, it is important that therapists manage their reactivity and find a way to feel compassion for these parents. It is the children of these more rejecting parents who need us the most and if a therapist loses the parent, they likely lose the ability to help the child.

While supporting parents in their process, therapists can explore the context in which parents developed their views about gender. After exploring gendered messages received by parents' families of origin, religion, racial/ethnic community, or media, therapists can begin to challenge parents to stretch and expand. Therapists may discover that parents also had experiences in which gender expectations didn't fit; the feelings around these experiences may be explored in order to find connections between parents' and their child's experiences.

Finally, parents sometimes have a sense of urgency, wanting to know whether or not their child is "actually" transgender and if their child will need to socially and/or medically transition. Parents can be encouraged to focus on the child's journey rather the outcome. Therapists can emphasize that what their child is experiencing right now is important and real for them, and parents can be encouraged to respond to their child in the moment by listening with compassion, patience, and support.

Listening to youth about what they need to feel congruent

This final technique is really the central goal in therapy. Once the parent-child dynamics are stabilized, it is vital to follow the lead of youth and listen to what they need to feel congruent. Some TGE youth very clearly and persistently assert a gender identity that is different from their assigned sex, while other youth simply need space for a gender expression that differs from the expectations of their assigned sex. The latter youth are gender expansive and may not ever need to transition to another gender identity. They may just need to feel free to express gender in a way that feels congruent. Parents can be encouraged to support their child's creativity and talk with their child about how to handle opposition to their expression when it arises in contexts such as school or with extended family.

Other youth assert a non-binary identity, and identify as both female and male, neither female nor male, or more female at times and more male at other times. Again, therapists can encourage parents to support whatever gender expressions feel congruent for the youth. Non-binary youth often request the use of genderless pronouns, such as they and them, and sometimes the use of a chosen name. Non-binary youth may or may not experience body dysphoria, therefore the path to congruence may or may not include social and/or medical transition.

Finally, many youth assert a binary gender identity (female or male) that is different from their assigned sex. Some youth are very clear about their identity as early as they can remember, while other youth may not understand their gender identity until adolescence. When youth become clear about their binary identity, most wish to take steps towards gender transition in order to experience congruence. Based on a growing body of research that suggests positive outcomes for youth who are able to transition early, the gender affirmative approach supports exploring youth and parental readiness for gender transition options.

When this balance is achieved, it can sometimes provide the loving space needed for parents to grow in their attunement with their child, learning to really listen to what their child needs to feel congruent.

While there may be reasons to delay transition for some youth (i.e., uncertainty with identity, lack of support), transition can be urgent for other youth. When youth are experiencing high levels of distress (i.e., dysphoria, depression, anxiety) and demonstrating persistence with their gender identity, transition may be vital for the youth's mental health. Transition is a process that is unique to each person and can involve many steps. As youth take small steps in the process, therapists can then check in to make sure the steps taken are resulting in increased feelings of congruence. For example, when a youth starts using their chosen name, how does it feel? Better?

Transition can also be thought of as having both social and medical steps. Social transition typically includes coming out to others and choosing clothing, hairstyle, name, and pronouns that feel congruent with the youth's gender identity. Medical transition may be considered as puberty draws near or if youth is already in puberty.Prepubescent youth may desire the use of hormone blockers to delay puberty. Hormone blockers give youth more time before initiating less reversible treatments, prevent the body from going into the "wrong" puberty, and can reduce distress for youth who are concerned about their body changing. Because pubertal delay prevents the development of secondary sex characteristics, it may lead to more body satisfaction and a desire for fewer medical/surgical treatments later in the transition process. Additionally, hormone blockers, which are fully reversible, allow parents more time to process their child's gender transition before taking less reversible steps.

As youth get further into puberty, many wish to begin feminizing or masculinizing hormonal treatment in order to experience pubertal changes that are typical of their gender identity. Many youth beginning hormone therapy experience excitement and relief because their bodies are beginning to match their minds, thus decreasing dysphoria and often decreasing mental health symptoms. While many of the physical changes caused by hormone therapy will reverse if discontinued, some effects of hormones are not fully reversible, such as breast growth, voice pitch drop, and facial/chest hair. Long-term data on the health risks of hormonal intervention in youth are not available due to the relative newness of the gender affirmative approach. While there are some potential risks involved in these treatments, such as the loss of reproductive ability, the benefits to the child's mental health and future adult functioning often heavily outweigh the risks (i.e., suicidality).

While genital surgery is not available for youth under the age of 18 at the time of this writing, some transmasculine youth undergo chest reconstruction surgery. This eliminates the need for youth to bind (compress) their chest, which can be painful, hot, uncomfortable, and can restrict breathing. Chest dysphoria is often very intense for transmasculine youth and chest reconstruction can often eliminate this distress.

Systemic therapists, with their openness to understanding multiple perspectives, are in a unique position to support not only TGE youth, but also their parents. While some parents are able respond to their TGE youth with full acknowledgement and support, other parents struggle to understand, accept, and affirm their children's TGE expressions/identities. Family therapists can meet parents where they are and allow space for their emotional process, while at the same time support TGE youths' expressions and identities. When this balance is achieved, it can sometimes provide the loving space needed for parents to grow in their attunement with their child, learning to really listen to what their child needs to feel congruent.

Deb A. Coolhart, PhD, LMFT, is an AAMFT Clinical Fellow and Approved Supervisor. Coolhart's scholarly interests include clinical issues related to marginalized and queer experiences/relationships and intersectionality, with a particular focus on clinical issues of trans people and their families. Her research and publications have focused on trans youth and their families, trans family support, nonbinary experiences, and trans sexuality. Clinically, Coolhart has been working with trans people for over 20 years and has become a nationally recognized expert in the area, providing regular consultation for professionals working with the trans population. She is a national speaker, regularly presenting on working with LGBTQ youth, their families, and school systems. In 2004, Coolhart created the Gender Expansive Support Team, housed in Syracuse University's Couple and Family Therapy Center, where students gain specialized training working with trans people and their families, including working with clients regarding their readiness for medical gender transition. Additionally, Coolhart is coauthor of The Gender Quest Workbook, which has sold over 20,000 copies.

REFERENCES

Coolhart, D. (2012). Supporting transgender youth and their families in therapy: Facing challenges and harnessing strengths. In J. Bigner & J. Wetchler's (Eds.), Handbook of LGBT-affirmative couple and family therapy. New York: Routledge Press.

Coolhart, D. (2018). Helping families move from distress to attunement. In C. Meier & D. Ehrendaft's (Eds.), The gender affirmative model: An interdisciplinary approach to supporting transgender and gender expansive children (pp. 125-140).Washington, DC: American Psychological Association.

Coolhart, D. (2019). Please stop calling my daughter 'he': Advocating for teens and pre-teens in the school setting. In A. I. Lev & A. Gottlieb's (Eds.), Families in transition: Parent perspectives on raising the gender nonconforming or trans child. New York: Harrington Park Press.

Coolhart, D., Baker, A., Farmer, S., Malaney, M., & Shipman, D. (2013). Therapy with transsexual youth and their families: A clinical tool for assessing youth's readiness for gender transition. Journal of Marital and Family Therapy, 39(2), 223-243.

Coolhart, D., & Martin, T. K. (in press). Gender affirmative therapy with trans and gender expansive youth: Listening to youth and thoughtfully following their lead.In R. Harvey & M. Murphy's (Eds.) Handbook of LGBT-affirmative couple and family therapy (Second Edition). New York: Routledge Press.

Coolhart, D., Ritenour, K., & Grodzinski, A. (2018). Experiences of ambiguous loss for parents of transgender male youth: A phenomenological exploration. Contemporary Family Therapy, 40(1), 28-41.

Coolhart, D., & Shipman, D. L. (2017). Working towards family attunement: Family therapy with transgender and gender nonconforming children and adolescents. Psychiatric Clinics of North America, 40, 113-125.

Hidalgo, M. A., Ehrensaft, D., Tishelman, A. C., Clark, L. F., Garofalo, R., Rosenthal, S. M., Spack, N. P., & Olsen, J. (2013). The gender affirmative model: What we know and what we aim to learn. Human Development, 56, 285-290.

Keo-Meier, C., Ehrensaft, D. (2018). The gender affirmative model: An interdisciplinary approach to supporting transgender and gender expansive children. Washington, D.C.: American Psychological Association.

Trans feminine individuals, particularly those of color, are considered greatly marginalized, facing a host of daunting issues including higher prevalence of mental health issues, financial hardship, rejection, abuse, and sexual stigmatization.
Jennifer Coppola, PhD

The jarring and persistent rise of hate crimes against transgender people has gotten more attention from social scientists and the media of late, which may bring more resources to the problem and prompt more victims to seek help.
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Sexuality models and interventions often leave trans people neglected, as they are not afforded the same sexual privilege as cisgender clients, a topic that is often dismissed in sexuality research.
Tristan K. Martin, PhD

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Affirmative Therapy with Trans and Gender Expansive (TGE) Youth and Their Parents - Family Therapy Magazine

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FEATURE When youth are expressing gender expansiveness or claiming a trans identity, it is common for parents to seek therapy for help navigating their child's process. Parental attitudes vary widely and may include full support, relief, confusion, disbelief, fear, loss, anger, or outright rejection.

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Abstract
Growing numbers of trans children are being supported by their families in childhood, including support for a pre-pubertal social transition. Existing literature provides limited insights into how parents reflect upon and evaluate their experience of supporting a trans child's social transition. This article draws upon qualitative semi-structured interviews with thirty parents who had supported thirty trans children to socially transition at an average age of seven years old. Data were analyzed through inductive thematic analysis, with five themes presented. 1) loss of control, and loss of security 2) feeling support for social transition was their only viable option 3) evaluating affirmation 4) the risks of transition, and the risks of rejection 5) and advice for other families to support their child. Overall, parents evaluated the benefits of social transition, describing it as protective for their child's happiness and well-being. These experience-based parental insights on the positive outcomes of pre-pubertal social transition, hold relevance for institutional policy and practice toward pre-pubertal social transition, with implications for health services, courts, schools and social services.

Introduction

Within the academic literature, there is limited insight into how parents make decisions on supporting a pre-pubertal trans child, or on how parents, with hindsight, reflect on those decisions (Olson et al., ). This research brings a unique and important perspective to the topic of pre-pubertal social transition. It focuses on a cohort of parents who have supported a trans child to socially transition under the age of eleven in the UK, a cohort with extensive experience-based knowledge and insight into this topic. This research takes place at a time of increased media-driven backlash against trans rights in the UK, with concerted attacks on trans children's rights and well-being, including legal challenges to trans adolescent healthcare (Faye, ; Jackson, ). At this time of precarity for trans children, this research listens to parental insights on how they navigated decision making related to social transition, and how, an average of four years later, parents reflect upon those decisions.

Materials and methods

Theoretical framework

The research is underpinned by a trans-emancipatory theoretical framework, building on wider work on emancipatory research (Noel, ). Here a trans-emancipatory framework is one that recognizes, and takes account of, the role of cisnormativity, and pathologisation of gender diversity, in upholding structural injustice (Wesp et al., ). Cisnormativity is the assumption that everyone is cisgender (not trans) or should be (Keo-Meier and Ehrensaft et al., ). Newbury () discusses the ways in which structural or institutional cisnormativity permeates societies and institutions, invisible to most cis people, yet exacting harm on trans people, in structures and systems that were not designed to include trans lives. The research recognizes the negative impacts of cisnormativity on trans children, in research, as in society (Ansara & Hegarty, ). Herein the word 'trans' is used to include those who are binary-oriented as well as non-binary (Vincent, ). The research recognizes the continued legacy of past pathologisation of gender diversity, from decades where gender diversity was deemed a disorder, to be prevented or reformed (Bryant, , ). The research is also cognizant of the intersectional barriers to trans-emancipation, recognizing overlapping and intersecting oppressions tied up in racism, classism, sexism, and inequality and that impede equality and justice (Gill-Peterson, ). The research maintains an ethical commitment to trans-emancipatory research, recognizing that gender diversity is neither pathological nor problematic, acknowledging that trans lives are equal to cis lives, and being attentive to cisnormativity or pathologisation of gender diversity within and across the research.

Research question

The existing literature provides limited insights from those with an experience-based perspective on supporting pre-pubertal social transition. Given the importance of this topic for families and those working with trans children, this research explored the following research questions:

How do parents who have supported a child's social transition reflect upon their experience?

How do such parents evaluate the risks and benefits of pre-pubertal social transition, and what experience-informed advice do they have for other families?

Sample

Thirty parents were interviewed from across England, Scotland and Wales. Individualized demographic information is not presented, responding to participant requests for additional privacy, in a small, vulnerable and potentially identifiable cohort. 100% of interviewees were cis, 90% were white, 93% were female and 23% were disabled. 70% were aged 40-50 years old, and 10% were immigrants to the UK. Interviewees had a wide range of levels of household income, and a range of levels of education, with 20% reporting secondary education as their highest qualification, 37% reporting a graduate degree and 43% a post-graduate degree as their highest qualification. In terms of sexual orientation, the cohort was diverse, 60% of parental interviewees were heterosexual, 23% pansexual, 10% bisexual and 7% gay or lesbian. A majority of interviewees were white cisgender women. The parents interviewed shared experiences of 30 socially transitioned trans children (80% white), including 15 girls, 12 boys and 3 non-binary children. These children socially transitioned at an average age of 7 years old (range 3-10 years old). At time of parental interview, the trans children of these parents were on average age 11 years old (range 6-16 years old).

Study design

The research presented here is a portion of a wider PhD on cisnormativity, rights and well-being of trans children who socially transition pre-adolescence in the UK. The wider PhD included insights from children as well as from parents, though this specific article deals only with data from parents. The inclusion criteria for parent interviewees were i) being a parent or carer of a socially transitioned trans child in the UK ii) their child having socially transitioned under the age of eleven iii) their child currently being under age 16 (one child in the sample had just turned 16 by the time the interview took place). To recruit participants, details about the study were shared on closed online spaces in six UK support groups for parents of trans children. None of these six support groups are actively trans-hostile, with group moderators ensuring the groups are a safe space away from transphobic discourse. Avoidance of advertisement on trans-hostile parenting fora was judged as unlikely to affect the sample, as trans-hostile parents would by definition not support a trans child's social transition under the age of eleven, and therefore would not fall into the cohort prioritized in this research. Additional interviewees were brought in via snowball sampling, through introduction from other members of these parent support groups. Access to hard-to-reach families and children was enabled by the author's positionality as a non-binary parent of a trans child, helping overcome trust related barriers to hearing from this cohort. The author is themselves a member of four of these closed online spaces and posted there directly, with other parents sharing details on two other groups. No incentive or token of appreciation was provided to interviewees, beyond the opportunity to anonymously share their experiences with broader audiences. Research participants received a project information sheet in advance, outlining the purpose of the research, their rights, and how their data would be used, with all participants signing a consent form indicating their willingness to participate and have their data included in this research and associated publications. After interview each interviewee completed a short demographic survey.

Data collection

Interviews were conducted remotely via Microsoft Teams during the period December 2020 to September 2021. Semi-structured interviews, covering broad topics including healthcare, education and families, lasted 1-3 hours (average 2 hours). This article considers a sub-set of the wider data corpus, focusing on portions of the interviews discussing social transition, and specifically portions of interviews discussing parental reflections on their experiences of supporting a child's social transition. Key questions relating to parental reflections on social transition included: 'Can you tell me about your thinking and decision making related to social transition?', 'How do you reflect upon those decisions now?', 'What do you think are the risks or benefits of social transition for your child?' Interviews were recorded, stored securely on an encrypted platform, and transcribed by the author. Transcripts were checked against the recording, with anonymised transcripts uploaded into NVivo.

Data analysis

Data were analyzed through inductive reflexive thematic analysis (Braun & Clarke, ), to understand parental reflections on their experience supporting a pre-pubertal social transition, with data-driven development of codes and themes. The analysis comprised re-reading each transcript to become familiar with the data, generation of initial codes through line-by-line or section-by-section coding, coding diversely without pre-conceived coding categories. The initial codes were then reviewed to identify broader themes, with all extracts for each theme collated and re-read. The initial themes were then reviewed, and themes and sub-themes revised to ensure they were internally coherent, consistent, distinctive, and accurately capture the dataset. Each sub-theme was analyzed, and interpreted, including with reference to existing literature. Indicative quotations from a range of interviewees were selected to accurately illustrate each sub-theme. Efforts were made to include multiple quotations in this article, with this decision informed by the underpinning emancipatory theoretical perspective. A number of interviewees expressed a hope that their voices would be shared directly, noting a lack of voice of parents of socially transitioned trans children in the literature or wider discourse, and emphasizing the privacy and safety concerns that limit their ability to safely share their experiences in other fora. The analysis accompanying the quotations is recognized as the author's interpretation, acknowledging the role of any researcher in actively interpreting data (Braun & Clarke, ; Charmaz, ).

Ethics

The research received ethical approval from the author's university. The research built in ethical best practices for trans-related research (Adams et al., ; International Transgender Health Forum (ITHF), ; Vincent, ). Participant anonymity was a high priority, with interviewees further emphasizing the importance of individual quotes not being identifiable, given the vulnerable and small population that this research cohort is taken from. For this reason, joint with research participants, it was agreed to go a step beyond the usual criteria for anonymity, and to avoid linking individual quotes to specific pseudonyms, as well as omitting child ages from specific parental quotes, thereby preventing patchwork identification. This particular cohort places a high level of importance on privacy and safety, and a strong duty of care was upheld to respecting interviewee preferences in how their data were shared.

Results

Parents reflected upon their experiences of supporting their child's social transition. Five themes are presented: 1) loss of control, and loss of security 2) feeling support for social transition was their only viable option 3) evaluating affirmation 4) the risks of transition, and the risks of rejection 5) advice for other families to support their child.

1. Loss of control, loss of security

A number of parents described how moves toward affirmation were scary for them, even though they felt it was the right step for their child.

We just knew, in our guts, it was the right thing to do. Even though it was the terrifying, scary thing to do. It was the right thing to do for her.

Several parents described how each step of affirmation felt like a step into the unknown, with the parents reluctant and fearful of each step, and only able to see the positive impacts on the other side.

I think it's a step thing. I think whenever there is a significant and clear change, that's always hard. So, the cutting of the hair was very, it's a step. The changing of the name was a step. The transition in school was a step ... and looking back ... of course, it was the right thing to do. But it was hard at the time.

Some parents referenced how following a trans child's lead, affirming them in childhood, can feel like a loss of parental control, and a step into the unknown, with the unknown feeling unsafe and threatening. One parent highlighted, that faced with a child asking for affirmation, parental control is illusionary, and that the real choice may be between a happy trans child, or a sad trans child.

I would say make a child happy, you know, at all costs, listen to your child, ... there's nothing you can do to make the kid trans, and there's nothing you can do to make your kid not trans if that's who they are - the only thing you can do is create an unhappy trans kid, or a sad trans kid. That's the only control you have.

One parent described how supporting a trans child feels like a step away from the comfort and safety of the known, a step that takes parental courage to take.

That point at which your child comes out to you, at that point, all you can see is the fear of the future, but you haven't yet experienced the happiness of your child. So, it's this precipice that you know, you have to, you have to have the courage to jump off of with, holding your child's hand, you know, they've been brave enough to tell you, now, you have to be brave enough to take this leap with them. And, and I can promise you that your child will thank you, and your child will be happier if you do that. But it is, it's really, it's a leap of faith in themselves, and a leap of faith in their child. It does take courage.

2. Feeling support for social transition was the only viable option

A majority of parents emphasized that they had reached a point where they did not see affirmation as a choice, but as their only positive option.

I feel that we couldn't have not done it. She would have been miserable. So, it's not like I think, oh, this was a great thing. But I'd, we wouldn't have had a happy child had we not done it. So, it feels like we had to.

If your child is insistent, then what other choice do you have really? ... I do think they've experienced that acceptance and that that has benefited them.

It felt like something that was an unstoppable momentum that needed to happen at that time.

Parents had come to understand that not supporting a social transition, was forcing their child to pretend to be someone they were not.

It was just calling what he wanted, he wanted to be called a boy's name... It wasn't going to work for him, to simply pretend and to carry on as he was.

Because she was so unhappy. I guess, we could have just delayed it for another year, but we would have had a very, very unhappy child. I don't think we could have avoided it forever.

Unless you see the effect it's having on the child, you don't, you know, there's no doubt in my mind that this was needed. That he would, he would be miserable, now, if we had forced him to continue as he was.

Others were prompted to support when they realized the extent of their child's distress.

That was the point where I was like, I can't keep making this child go to school in boy's uniforms. It was a struggle every day. And I think that was the turning point for me.

I felt quite calm about it once we decided that we needed to do it, because at the end of the day, when your child, when you're being told that your child is having suicide ideation, the idea of them changing their name suddenly becomes much less upsetting. Because you've got something to compare it to, which is actually bad.

3. Evaluating affirmation

Almost all the parents in this sample talked about their child's improved happiness after social transition, and regarded affirming their child as critical in protecting their child's happiness and well-being.

I think, as parents, we see, we get to look through that window more than most people do. And we see the distress, and we see the unhappiness and the frustration with 'Why do these people keep calling me the wrong thing? You know, can't they see?'

Well, I think if you're a parent, and you see your child in distress, you know, a little child feeling like they don't want to live, and that you can, that can stop, by you just saying, Okay, wear what you want, we'll call you [Name]. You know, it's literally, you know, how could you live? How could you tell your child that that's wrong? She was so precious, I just wanted her to be happy, and to want to live, you know?

So, for me, it's about making sure that I don't do any damage to my child emotionally. ... my main objective is that they are - have good self-esteem, they're happy.

Reflecting on the benefits of acceptance for their child, a majority of parents were categorical that affirmation had been a positive thing for their child.

I think it was the best thing to happen to my child.... And for everybody to know that this is who she is - it was definitely the right thing for her to do.

It's the best thing for her. And it's the best thing for her mental health.... In terms of like, is this the right thing for [Child]? Yeah. Hundred percent.

An improvement in their child's current happiness was a key reassurance that affirmation was the right approach.

So, when you see that enormous change in your child, and you just know that what you're doing is right for them. And you don't care what barriers you face when that's, when that's what you've got, living with, you know, a happy child, that's all we want.

Every kind of step we took towards affirming her just felt right.

Several parents emphasized the importance of children knowing that they have their parents' unconditional affirmation and acceptance.

If you're tuned in to your child, and you're listening to your child, you really can't go very far wrong. And that kind of mantra we had in our head of, well, you know, even if she changes her mind, we've shown that we'll support and love regardless, and that's never a bad message for a child to grow up with. You know, and even if she changed her mind now, next week, next month, next year. All of our kids have grown up knowing that, you know, they're loved and supported for who they are. And that, that can't ever be wrong.

4. Risks of transition, risks of rejection

Parents were asked to share reflections on what they saw as the risks of supporting a social transition. Most outright rejected the idea that there was any risk associated with accepting their child.

100% of, no harm has ever come of showing somebody unconditional acceptance...I don't think there are any risks.

Instead, most parents emphasized the risks inherent in not supporting trans children.

The risk was that my child was unhappy. The risk was that my child felt unaccepted.

I think for me, why would I make him live his childhood feeling unhappy with who people see him as? Why would I do that? I'm not gonna make him live repressed and unhappy.

Several parents noted shame as an important risk they wanted to protect their child from.

I don't see what benefit can come of telling them that they can't do that. Because it's, it could be shame inducing.

Other families shared their views on the negatives that they had seen in families where children's transition was blocked.

I know people who have allowed their children to be girls at home, but boys at school, because, that suits them, but it is like, I accept you, I accept you at home, but I'm embarrassed for you to be yourself in the world. That's not a great message for a child... I never wanted her to feel shame about who she is.

Some cis parents described having greater appreciation of the risks of rejecting their child, from talking with trans adults about their childhood experiences.

You just have to talk to some trans adults, and listen to them ... because a lot of trans adults will talk about the trauma of being forced not to be transgender. You know, it didn't change them, it just gave them mental health scars.

Several parents expressed guilt about not understanding their child quickly enough.

And you know, I still feel tremendous guilt that we that we didn't see her for so long.

You know, it's - six is still really, really young. But I still feel tremendous guilt that she was trying to communicate to us all that time, that we, and we didn't get that.

5. Advice for other families to support their child

Parents recommended other families support and affirm their trans children, prioritizing their current happiness.

I think it's the best thing to do. I truly believe it's the best thing to do for a child. And if they change their mind, doesn't matter, does it? You know, they've been happy for that period. So, yeah, I can't see why anyone would not do it.

I just want him safe and well and happy. And if us accepting this does that, well, then why wouldn't we?

There was consensus from all interviewees that the social transition had been a positive thing for their child, and that they would recommend prompt affirmation to other families with trans children.

I'd do it all the same again, just quick and, quick and sharp, just do it.

A number of parents referenced negative media and societal discourses surrounding pre-pubertal trans children's social transition. Several interviewees commented on where they felt those critiques failed to understand their situation.

They haven't seen that impact of, of a child who's desperately sad and angry all the time - who's not participating in life, who's not - yeah who's not participating in life, that, that's the clearest I can put it really, and allowing her to socially transition and be who she was, set her free - it allowed her to fully participate in life. And, again, nothing's irreversible. It was hair, and clothes and names, all of which could have reversed at any time.

Parents who had experienced supporting a trans child, felt strongly that listening to children, respecting them, accepting them, and following their lead, is hugely important.

I think by the time they come to you and ask that, the chances are they've been through enough shit. And the least you can do is support them. As a parent, that's literally your job.

I mean, I would just say, listen, listen to what your child's saying. Don't brush it under the carpet. Don't make them feel ashamed or don't ostracise them for them telling you who they truly are, and support them.

Parents within this sample were unanimous in their perception that social transition had been pivotal and beneficial for their child.

The only thing that I'd like to say, is that it's an absolute vital and pivotal moment for it to happen for a trans child...It's been one of the best things that happened for us and [Child] - the happiness that it has brought.

Discussion

Parents reflected upon their experiences of supporting a trans child's social transition. Parents spoke of a lack of control and a loss of security as their life moved in a direction they had not anticipated, and did not feel prepared for. This finding resonates with other qualitative research on the challenges parents of trans children can encounter (Pullen Sansfaçon et al., ), as well as echoing literature on parental experiences of 'ambiguous loss' (Bartholomaeus & Riggs, ).

Many parents described support for their child's social transition as the only positive option available to them, with parents reluctantly and fearfully taking that step. This finding aligns with other studies showing social transition is driven by trans children rather than by parents (Olson et al., ; Rae et al., ). It illustrates how parents, whose lives and worldviews are shaped by cisnormativity (Newbury, ; Serano, ), can be reluctant or resistant to embracing 'trans possibilities' (Pearce, ). These findings emphasize the support parents may require, to overcome their own cisnormativity, to relinquish 'control', and to become open to showing love, support and genuine acceptance of trans children.

This research provides a unique addition to the literature, being the first study to explore how parents with experience-based insights navigate and evaluate the risks and benefits of pre-pubertal social transition. One limitation of this research is the exclusive focus on parental reflections, offering a partial and limited perspective, without inclusion of child perspectives. Further research, including work by this author (forthcoming), can incorporate children's own experience-informed perspectives on pre-pubertal social transition. Additional retrospective research could focus on the experiences and reflections of trans youth who had wanted their parents to support a pre-pubertal social transition, but did not receive this support. A second sample limitation is noted with interviewees being 90% white (and children 80% white), although this percentage is in keeping with other UK research, with the biggest national LGBT survey having 92.4% white respondents ( Government Equalities Office, 2018). Further targeted research can examine experiences of parents of color, or young parents, exploring how intersecting axes of inequality or discrimination impact on parental capacity and ability to support a child's social transition. A further limitation is recognized with interviewed parents being 100% cis and 93% female, a profile that aligns with researcher experience of UK parent support groups being largely populated by cis women, and research from other countries that has similarly noted an over-representation of women in active roles advocating for (or against) their children (Kuvalanka et al., ). Further research can explore fathers' experiences and perspectives, as well as considering the experiences of trans parents. Finally, the research sample includes 3 parents of non-binary children, who face distinct challenges due to a lack of institutional and social recognition of non-binary identities (Paechter, Toft, and Carlile et al., ). Further research can examine the specific challenges faced by young non-binary children and their families.

The findings presented in this research, in combination with wider evidence on the protective health benefits of childhood affirmation, hold relevance for institutional policy and practice toward pre-pubertal social transition, with implications for health services, schools and social services. Obstacles to parental support for trans children, grounded in individual, societal and institutional cisnormativity, also reinforce the importance of parents finding support to help them to effectively affirm and advocate for a trans child (Riggs & Bartholomaeus, ). These areas where parents may need support in order to effectively protect the well-being of trans children have implications for professionals interacting with parents of trans children, including social workers, counselors, children's Gender Service clinicians, and primary healthcare providers including General Practitioners.

Disclosure statement

No potential conflict of interest was reported by the author.

Cal Horton undertakes research on the experiences of trans children who socially transition in pre-adolescence. They are interested in trans children and families' experiences navigating cisnormativity, pathologisation and Gender Minority Stress.

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"I never wanted her to feel shame": parent reflections on supporting a transgender child

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Abstract Growing numbers of trans children are being supported by their families in childhood, including support for a pre-pubertal social transition. Existing literature provides limited insights into how parents reflect upon and evaluate their experience of supporting a trans child's social transition.

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Bunnybear. Andrea J. Loney. (Pre-K - 1) Although Bunnybear was born a bear, he feels more like a bunny. The other bears don't understand him, and neither do the bunnies. Will Bunnybear ever find a friend who likes him just the way he is? Pair with the Gender Snowperson Lesson Plan.

I am Jazz. Jessica Herthel and Jazz Jennings. (K - 5) From the time she was two years old, Jazz knew that she had a girl's brain in a boy's body. She loved pink and dressing up as a mermaid and didn't feel like herself in boys' clothing. Based on the real-life experience of Jazz Jennings. Lesson Plan.

Introducing Teddy: A gentle story about gender and friendship. Jess Walton. (Pre-K - K) Introduces the youngest readers to understanding gender identity and transition in an accessible and heart-warming story about being true to yourself and being a good friend. Lesson Plan.

It Feels Good to Be Yourself. Theresa Thorn. (Pre-K - 3) Some people are boys. Some people are girls. Some people are both, neither or somewhere in between. A straightforward exploration of gender identity, providing young readers and adults with the vocabulary to discuss the topic with sensitivity. Pair with the Gender Snowperson Lesson Plan.

Jacob's New Dress. Sarah and Ian Hoffman. (Pre-K - 2) Jacob loves playing dress-up, when he can be anything he wants to be. Some kids at school say he can't wear "girl" clothes, but Jacob wants to wear a dress. Can he convince his parents to let him wear what he wants? Speaks to the unique challenges faced by boys who don't identify with traditional gender roles. Lesson Plan.

Julián Is a Mermaid. Jessica Love. (Pre-K - 2) While in the subway with his abuela, Julián sees three women spectacularly dressed up and he wants to dress up just like them. But what will his Abuela think? A story about the power of been seen and affirmed. Lesson Plan.

Red: A C rayon's Story. Michael Hall. (Pre-K - 1) A blue crayon mistakenly labeled as "red" suffers an identity crisis. Almost everyone tries to "help" him be red until a friend offers a new perspective. He's blue! About finding the courage to be true to your inner self. This can be read on multiple levels. Lesson Plan.

They, She, He easy as ABC. Maya and Matthew Smith-Gonzalez. (Pre-K - 1) Inclusive pronouns are featured alongside the alphabet. An introduction to the many different ways people identify and use pronouns. Shows that including everyone is all part of the dance. "No one left out and everyone free." Lesson Plan.

When Aidan Became a Big Brother. Kyle Lukoff and Kaylani Juanita. (Pre-K - 2) When Aidan was born, everyone thought he was a girl, but as he grew older, he realized he was a trans boy. When he finds out he is going to be a big brother, he learns the most important thing about being an older sibling: how to love with his whole self. Pair with the Gender Snowperson Lesson Plan.

Middle Grade Books

Better N ate Than Ever. Tim Federle. Nate plans an overnight escape to New York for an open casting call for E.T.: The Musical, knowing this could be the difference between small-town blues and big-time stardom. Also: Five, Six, Seven, Nate! and Nate Expectations.(4 - 8)

Felix Yz. Lisa Bunker. (5 - 8) When Felix Yz was three he is accidentally fused with a fourth-dimensional being. Now he's on the brink of a risky procedure that will free him. With an awkward crush on a boy at school, a gender fluid grandparent and a Bi mom, family, bullying and identity are woven into the story.

George. Alex Gino. (3 - 6) When people look at George, they think they see a boy. But she knows she's not a boy. She knows she's a girl. George really wants to play Charlotte in Charlotte's Web. Will she be able to?

Gracefully Grayson. Ami Polonsky. (5 - 7) Grayson has been holding onto a secret for what seems like forever: "he" is a girl on the inside. Will new strength from an unexpected friendship and a caring teacher's wisdom be enough to help Grayson?

Lizard Radio. Pat Schmatz. (5 and up) In a futuristic society, Kivali is a Bender - not quite boy or girl. Sent to CropCamp, a commune meant to steer teens toward a lifetime of good citizenship and "proper" gender roles, Kivali, called Lizard, wrestles with friendship, love, and the price of being true to oneself.

The Moon Within. Aida Salazar. (4 - 7) Celi Rivera's life swirls with questions. About her changing body. Her first attraction to a boy. And her best friend's exploration of what it means to be genderfluid. But most of all, her mother's insistence she have a moon ceremony, an ancestral Mexica ritual, when her first period arrives.

Not Your Sidekick. C.B. Lee. (5 - 8) Welcome to Andover, where superpowers are common, but internships are complicated. On the upside, Jessica gets to work with her longtime secret crush, Abby. With a sudden and dangerous turn, she uncovers a plot larger than heroes and villains altogether. Also see: Not Your Villain.

The Pants Project. Cat Clarke (3 - 6) Liv knows he was always meant to be a boy but he hasn't told anyone - even his two moms yet. Now, his new school has a terrible dress code, he can't even wear pants. Only skirts. The only way for Liv to get what he wants is to go after it himself. But to Liv, this isn't just a mission to change the policy―it's a mission to change his life.

Riding Freedom. Pam Muñoz Ryan. (4 - 6) A fictionalized account of the true story of Charley (Charlotte) Parkhurst who ran away from an orphanage, lived as a boy, moved to California, and became a stagecoach driver.

Roller Girl. Victoria Jamieson. (4 - 7) An inspiring coming-of-age story about friendship, perseverance, and girl power! And so begins the most difficult summer of Astrid's life as she struggles to keep up with the older girls at camp, hang on to the friend she feels slipping away, and cautiously embark on a new friendship. Graphic novel.

Steven Universe. Rebecca Sugar. (2 - 6) Many books and graphic novels are set in the "Steven Universe", an Emmy award winning animated series on Cartoon Network. Follow the adventures of Steven and the Gems. This series Includes LGBTQ, non-binary characters, and an intersex character.

Zenobia July. Lisa Bunker. (5 - 9) Zenobia July is starting a new life in Maine with her aunts. People used to tell her she was a boy; now she's able to live openly as the girl she always knew she was. When someone anonymously posts hateful memes on her school's website, Zenobia knows she's the one with the hacking skills to solve the mystery

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Diverse Children's Books Trans and Non-Binary Children

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Annie's Plaid Shirt. Stacy B. Davids. (K - 1) Annie's mom tells her that she must wear a dress to her uncle's wedding. Annie protests, but her mom buys her a fancy new dress anyway. Annie is miserable. Why can't her mom understand? Then, Annie has an idea.

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DIRECT ONLINE AND PHONE SUPPORT SERVICES FOR LGBTQ YOUTHDirect Online and Phone Support Services for LGBTQ Youth

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DIRECT ONLINE AND PHONE SUPPORT SERVICES FOR LGBTQ YOUTHDirect Online and Phone Support Services for LGBTQ Youth

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The Youth Well-Being program at HRC Foundation has compiled the following direct service resources for LGBTQ+ youth and families.

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Affirmative Perspective on Hormonal Interventions for Youth 

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Affirmative Perspective on Hormonal Interventions for Youth 

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Posted on March 31, 2019 at 4:33 PM

by Florence Ashley B.C.L., LL.B

Hormonal interventions for trans youth are subject to controversy in the media and certain clinical circles. A recent blog post for BMJ EBM Spotlight described hormonal interventions for trans youth as "largely experimental" and cautioned that the available evidence didn't allow informed clinical decision making. This assessment stands in stark contrast with the commonplaceness of hormonal interventions in trans youth care.

Determining how much evidence is needed for a practice to be deemed sufficiently safe involves a value judgement. Although more evidence on various hormonal regimens is welcomed by trans health clinicians, current evidence demonstrates enough safety to justify the prescription of puberty blockers and hormone replacement therapy. Transition-related care is unlike traditional medicine insofar as it doesn't aim at curing an illness, but rather at enabling self-actualisation and promoting bodily autonomy. Being trans, as the World Professional Association for Transgender Health states, is not an illness but part of normal human variation.

The present blog article aims at providing a gender-affirmative perspective on the reported data, highlighting the normative component of evaluating safety, and addressing some common misconceptions about the risks of hormonal interventions.
Size of trans youth populations and the clinical picture
The prevalence estimates of 1 in 27,000 to 1 in 10,000 offered by the BMJ EBM blog post are misleading: They do not represent the proportion of people who are trans or have gender dysphoria, but rather the proportion of youth attending gender identity clinics (GICs). A report by the Williams Institute, which draws from population-based surveys, estimates that the number of youth from ages 13 to 17 who identify as transgender is closer to 1 in 145. No authoritative explanation for the discrepancy has been offered by GICs, but fear of parental rejection and community distrust for GICs are likely contributors. Being trans is common.

The authors also report that approximately ¾ of pre-pubescent children will "change their minds as they age". As experts in trans health explain, this statistic is misleading for a number of reasons: Many children referred to GICs never claimed to have a gender different from the one they were assigned at birth and didn't meet the full criteria for diagnosis, and various theoretical and methodological assumptions artificially inflated the reported percentage.

Most importantly, those numbers are irrelevant to puberty blockers and hormone replacement therapy. The ¾ statistic is based on flawed studies and only refers to pre-pubertal youth, whereas puberty blockers and hormone replacement therapy are only offered after the beginning of puberty. A 2011 study conducted at the clinic from which the ¾ statistic arises has shown that children who decide to initiate puberty blockers all continued to be trans years later.
Puberty blockers
The primary evidence base regarding the safety of puberty suppression is the use of GnRHa for precocious puberty. Since the underlying biology remains the same, the primary difference between GnRHa for precocious puberty and as part of puberty suppression is the length of treatment, especially in relation to bone density. Because longer use of GnRHa leads to poorer bone density compared to peers of the same age, many clinicians recommend initiating hormone replacement therapy before 16 years old among youth who have been on blockers for multiple years.

The impact of puberty blockers on bone density is a common concern. As reported by the BMJ blog, a 2015 study found decreased bone density for trans girls which "did not increase following oestrogen treatment." However, their bone density was being compared to the bone density of age-matched cisgender (not transgender) men rather than cisgender women and was a relative measurement rather than a measurement of absolute density. This is an inappropriate comparator when attempting to establish safety profiles.

To the extent that long-term use of puberty blockers may have an impact on bone density, initiating hormone replacement therapy earlier may be indicated. This would also allow youth to undergo puberty alongside their peers, reducing risks of ostracization.
Hormone replacement therapy
Different hormone replacement therapy regimes come with different safety profiles. In the past, ethinyl estradiol was commonly prescribed; it was associated with significant risks of adverse cardiovascular events and is no longer commonly prescribed. Cyproterone acetate is associated with depressive symptoms and, more recently, with risks of brain tumours. Other options should be considered, where appropriate, and suppression with only estrogen should be considered.

Hormone replacement therapy impacts haematocrit levels. The blog post cites a 2017 study as showing significant elevation in haemoglobin and haematocrit among trans men. However, both haematocrit and hemoglobin are on average higher in men than in women, and the increase in both counts merely bridges that gap. The haematocrit of 44.5% and hemoglobin count of 15.0 g/dL reported in the study are well within normal ranges for men and do not pose significant concerns.

Data on the metabolic impact of hormone replacement therapy should be read cautiously, keeping in mind that many metrics vary between cis men and women, and that undergoing hormonal interventions will impact metabolic parameters accordingly. In adults, higher rates of adverse cardiovascular events were found in transfeminine individuals but may be due to higher rates of smoking and stress. Nonetheless, the incidence of venous thrombosis incidence was lower for trans women than for cis women on birth control, suggesting that it is well within acceptable risks. Where risk factors such as smoking and stress are present, non-oral forms of estrogen can be used to further lower risk.
Frames of evaluation
Assessing safety is relative and value-laden. We accept greater negative effects before we call a cancer treatment unsafe than we do for Ibuprofen. Our evaluation of the importance and purpose of hormonal interventions sets the preliminary threshold for assessing whether a treatment is sufficiently safe to be indicated.

Hormonal interventions are offered because trans people deserve to have a gendered body that suits their self-image, just like cis people, even if this requires bodily interventions. Much like access to abortion, it is a matter of fundamental bodily autonomy. Access to hormonal interventions is correlated with better mental health and quality of life in both youth and adults. These metrics are admittedly subjective, as the blog authors point out, but this is a by-product of interventions justified by bodily autonomy and psychological wellbeing-psychology and psychiatry, by and large, work from such subjective measures.

Physical health is difficult to compare to mental health, let alone abstract notions like bodily autonomy. This makes hormonal interventions ethically atypical: they are not a cure for an illness, unlike most endocrinological interventions, but a tool of self-actualisation. This difference in the fundamental logic of puberty blockers and hormone replacement therapy makes adopting a high evidentiary threshold for safety unreasonable. Would we prohibit abortions because their safety hasn't been sufficiently proven, especially when little interest has been historically shown in exploring its safety?

Although hormonal interventions raise some safety concerns and better studies are needed in elucidating the comparative benefits of different regimens, they are sufficiently safe for current practices. According to the systematic review Hormonal Treatment in Young People With Gender Dysphoria which the blog authors relied upon: "Overall, hormonal treatments for transgender youth were observed to be relatively safe but not without potential adverse effects."
Conclusion
Longitudinal studies comparing different hormonal regimes are necessary to the development of trans health. These studies will inevitably be neither blinded nor randomised, as blinding is impossible, and randomisation would be impractical and unethical. Controlled groups should be used and matched on risk factors such as stress levels, physical activity, and smoking.

The current practice of prescribing puberty blockers and hormone replacement therapy to trans youth is legitimate. The positive impacts on bodily autonomy and mental health outweigh the apparent risks. A critical reading of the scientific literature is necessary, as studies do not always frame their data in the most informative way for subsequent analysis. The risks of hormonal interventions should not be overstated, as can happen when comparing trans participants to controls of the same gender assigned at birth. Risk can be minimised through individualised hormonal regimens, and remaining concerns about risk are appropriately addressed by obtaining properly informed consent or assent.

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An evidence-based affirmative perspective on hormonal interventions for trans youth | Bioethics.net

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Posted on March 31, 2019 at 4:33 PM by Florence Ashley B.C.L., LL.B Hormonal interventions for trans youth are subject to controversy in the media and certain clinical circles. A recent blog post for BMJ EBM Spotlight described hormonal interventions for trans youth as "largely experimental" and cautioned that the available evidence didn't allow informed clinical decision making.

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Editors' note: The link to the original book review, which is now a retraction notice, can be found here. Dr. Hall's book review has been republished by Michael Shermer on Skeptic here.

Introduction: Why Dr. Harriet Hall's review of Abigail Shrier's Irreversible Damage was retracted

Science-Based Medicine as a philosophy, blog, and approach to medical practice is primarily about optimizing and affirming the relationship between science and critical thinking with healthcare. One of our core principles has always been that the best evidence available must always inform the standard of care, and that therefore an objective and clear-eyed view of that evidence is critical.

Naturally, we tend to focus the most attention on issues that are controversial or where there is a motivated campaign of anti-science, pseudoscience, or science denial, because that is where the principles of SBM are most needed. Examples include cancer quackery, antivaccine pseudoscience, and, for the last 16 months, misinformation and disinformation about the COVID-19 pandemic and the public health measures instituted to slow its spread. SBM is not apolitical. It can't be, because the promotion of effective science-based laws and regulations in medicine is an inherently political activity. However, we do strive to be non-partisan. It is not our job to promote a specific political ideology, but we do strive to do our best to make sure that political, social, and personal decisions are informed by the best science possible.

For further background, the SBM blog articles published here are not considered peer-reviewed, but we do have a strict editorial policy. Outside submissions undergo review by our full editorial board, and most are rejected or require revisions prior to publishing. Our own editors, however, have earned the privilege of publishing articles without prior review, since they have a proven track record. They post, and often neither Dr. Gorski nor I see the articles until they are live. That does not mean, however, that we do not have mechanisms of quality control.

If any concerns about accuracy, fairness, or completeness come to our attention, we deal with them in a number of ways. Often, clarification in the comments is sufficient. Sometimes we make corrections to the original text of the article. When we receive outside complaints, one or more of the non-author editors (usually David Gorski or myself) will re-read the original article to determine if, in our view, it was fair and appropriate, which is almost always the case. That doesn't mean we have to agree with everything in the article, as long as the article adheres to defensible science-based standards.

It further needs to be noted that because of the nature of SBM we often tackle topics from two perspectives simultaneously. Our articles are primarily critical analyses of various topics through the lens of SBM principles. Alternatively, they consist of a discussion of those principles themselves. Often pseudoscience is fairly blatant, so that even general medical knowledge, combined with a thorough understanding of SBM and review of the relevant literature, is sufficient to grasp the relevant science. However, some topics are scientifically more complex, requiring reliance on topic experts if not within our areas of expertise. We are also aware that we have "holes" in our scientific expertise, given the professions and areas of expertise of our editors and contributors.

That is why, when discussing topics outside of our professional areas of expertise, we are acting more like science communicators than scientific experts. Our relevant expertise there is SBM itself, but otherwise we defer to the consensus of expert opinion with regard to technical analysis of the literature and relevant basic science. This is standard science journalist practice. However, this can be a delicate balance.

Two weeks ago, one of our editors published a book review that raised concerns with Dr. Gorski and me, as well as at least one other editor, soon after it published. Reading it, we both feared that this book review had probably strayed beyond evidence or expert opinion and thus required a robust response. This was a review of a book by Abigail Shrier titled Irreversible Damage: The Transgender Craze Seducing Our Daughters. This particular book discussed a complex area of medical practice that also happens to be one embroiled in heated political debate. Because of the context of this topic, we believed it especially critical that SBM be perceived as a politically neutral and reliable source of information about the relevant science. Unfortunately, Dr. Hall's fellow editors were concerned that the review in question did not achieve this goal.

Our first step was to carefully review the article and then discuss our concerns directly with Dr. Hall to hopefully find a solution. The challenge here was that, while we had enough background knowledge to immediately see there were serious problems with the review, none of us are topic experts. Reviews outside SBM by those with expertise in this area seemed to be making valid scientific criticisms of the opinions and claims in Ms. Shrier's book, which the review took at face value.

Clearly what we needed was time to do a deeper dive on this complex controversy, to wrap our heads around the published evidence, and to vet the claims and arguments on both sides. This is something we would have preferred to do prior to publication, but we no longer had that luxury. Giving an immediate half-baked analysis would not do SBM readers justice. Ultimately, we decided to hit the "pause" button, to withdraw the review for a time while we consulted outside experts and did our own internal review. Since Dr. Hall indicated she would publish her article on an alternate site (and immediately did), we saw no pressing need to leave the article on SBM while this review was underway.

Having completed what we consider to be a minimally sufficient review, David Gorski and I now present a summary of our reading of the primary literature addressing the core claims of Ms. Shrier's book, in addition to articles and interviews by Ms. Shrier and other reviews and commentary on the topic. Because Dr. Hall has already republished her review on Michael Shermer's website, we link to it here and include a link to where her article was originally published on SBM, which now contains our first retraction statement. We also have solicited outside expert reviews which we will publish if after editorial review we deem them to meet the publication standards of SBM.

To be absolutely clear, we encourage full and open scientific debate on this and any topic relevant to SBM. All the SBM editors are passionate about our project because we care deeply about every patient receiving the best medical care possible. This requires not only that medicine be science-based, but that we demand open and transparent discussion of medical science and practice without political or ideological tampering. We regret that many people outside SBM have simply assumed (without evidence or just cause) that our actions were based on a desire to censor open discussion. Nothing could be further from the truth, and our multi-year history of tackling controversial topics and taking many unpopular positions is evidence of that.

Further, we wish to make it clear that Dr. Hall still remains an editor of SBM in good standing. She has worked tirelessly to promote SBM and its principles, contributing over 700 articles to SBM since 2008, all without any compensation or possibility of reward beyond public service. However, at SBM quality matters first, and so we have to remain open to correction when necessary.

Abigail Shrier's claims and transgender care

In her book, Ms. Shrier creates a very specific narrative. In the last two decades there has been a dramatic increase in the number of youth openly identifying as transgender and seeking gender-affirming interventions. This observation is not controversial. What is controversial is Shrier's claim that this increase in the number of adolescents "coming out" as trans is likely due to a social contagion, in which social media influencers convince young people they are trans when they are not, which leads them to be herded into irreversible transitional medical procedures they will later regret, all aided and abetted by doctors whose treatment is based more on ideology than science. This narrative, however, is not supported by any evidence and is cobbled together with a gross misreading of the scientific evidence. Unfortunately, Dr. Hall did not discuss the numerous errors of science in Ms. Shrier's book and, even though she did recognize that much of the evidence was anecdotal, still more or less accepted Ms. Shrier's narrative at face value.

Let's review what research there is on transgender care, starting with what is the standard of care for trans youth, since that seems to be the focus of much of the political attention. In her book, as quoted in Dr. Hall's review, Ms. Shrier likens the current state of transgender care as if one were dealing with anorexia as, "If you think you are fat, then you are. Let's talk about liposuction and weight-loss programs". For emphasis Dr. Hall writes: "We are asked to disregard DNA and accept the ineffable feelings of an eight-year-old".

The analogy here is not apt. Eating disorders are clearly disorders, with now well-established diagnostic criteria and medical risks. The assumption behind the analogy is that feeling as if you are a different gender than the one assigned at birth is also a harmful disorder that should be "cured". This assumption is not valid and is itself likely harmful. In fact Ms. Shrier relies on an outdated definition from the DSM-IV to make this case. The DSM-V now recognizes that having a gender identity that differs from the gender assigned at birth is not a disorder. Having dysphoria resulting from that fact combined with social factors is.

Further, DNA is demonstrably not determinative when it comes to sexual orientation and gender identity. There are developmental factors, for example. Elsewhere Dr. Hall characterizes the notion that a person can have a female brain in a male body as "biologically nonsensical", but this is also demonstrably not true. It absolutely is possible to have the secondary sexual characteristics of one gender with the gender identity of another because of other genetic, hormonal, and developmental factors.

Further, looking at published standards and countless interviews with practitioners, the notion that those involved in gender care are caving to political correctness rather than best practice is an unfair caricature that is clearly motivated more by ideology than science and medicine. For example the World Professional Association for Transgender Health publishes treatment guidelines that are widely accepted. First, however, we have to distinguish between transgender children (pre-puberty) and adolescents (something which Ms. Shrier often conflates, causing confusion). The standard of care for children is that they get no medical intervention at all - no hormones, no surgery. Their treatment is entirely confined to psychological assessment and psychosocial interventions. Medical treatment options begin only after children enter puberty (the exact stage varies from country to country). At that point, there are standards that apply.

In order for adolescents to receive puberty-suppressing hormones, the following minimum criteria must be met:

The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed);

Gender dysphoria emerged or worsened with the onset of puberty;

Any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent's situation and functioning are stable enough to start treatment;

The adolescent has given informed consent and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.

For those who are interested, the entire document is worth reading. It gives a fairly concise review of the literature.

These standards are for fully reversible interventions. Partially reversible interventions, including cross hormone therapy, have stricter criteria for assessment and informed consent. For irreversible surgical interventions, the following must be met:

Genital surgery should not be carried out until (i) patients reach the legal age of majority to give consent for medical procedures in a given country, and (ii) patients have lived continuously for at least 12 months in the gender role that is congruent with their gender identity. The age threshold should be seen as a minimum criterion and not an indication in and of itself for active intervention.

In other words, surgical interventions are reserved for legal adults who demonstrate sufficient maturity and at least 12 months living in their congruent gender identity.

Other published standards are similarly rigorous. The Endocrine Society clinical practice guidelines recommend hormone therapy for gender dysphoria only for those who, "have undergone psychiatric assessment, and have maintained a persistent transgender identity".

Of course, these are standards, and not every practitioner adheres perfectly to the standard of care in any aspect of medicine. But we don't take outliers and use that to criticize the standard or pretend it is typical or common. Interviews with those involved in transgender care indicate that adherence to rigorous standards as outlined above are the norm.

What about the claim that those who identify as trans are going through a phase not likely to persist into adulthood? This, too, is false or misleading. Dr. Hall wrote:

Historically, the conviction that one's gender doesn't match one's anatomical sex typically began around age 2-4. It affected only .01 percent of children, almost exclusively boys. And in 70% of cases, they eventually outgrew it. Prior to 2012, there was no scientific literature on girls age 11-21 ever having developed gender dysphoria at all.

The term "children" above is vague and also critical. Nowhere does Dr. Hall explicitly explain that the literature on the trans phenomenon specifically divides children into prepubescent and adolescents. This is critical, because some of the statistics she is citing above apply only to prepubescent children - that they outgrow their trans identity and that they are "almost exclusively" boys. That latter point is an exaggeration. Data shows that the ratio of AMAB (assigned male at birth) to AFAB (assigned female at birth) prior to puberty identifying as trans is between 6:1 and 3:1 - more boys than girls, but not "almost exclusively".

Furthermore, the fact that young children may alter their identity as they mature is based on highly flawed research, studies with methods so fatally flawed that the results cannot be trusted, let alone cited as facts. But even if this statistic were reliable, it is less relevant to the discussion. As stated above, there are no medical interventions for this group of children. Medical gender-affirming interventions are reserved for adolescents and older. The data on adolescents is very different. While more data is certainly desired, the statistics we have indicate that nearly all adolescents who identify as trans maintain that identity into adulthood.

Therefore, what Ms. Shrier, and by extension Dr. Hall, are doing is misleadingly using (flawed) statistics for young children to criticize interventions reserved for adolescents and adults who do not share those statistics. To be fair, Ms. Shrier also uses those statistic to argue that young children should not be receiving even social interventions affirming their gender identity, Dr. Hall, however, conflates these age groups. No medical interventions will happen until trans youth are at an age when their trans identity is very likely to be permanent, which is further supported by extensive evaluation according to published standards of care.

What about the alleged spike in people identifying as trans and the shift from predominantly AMAB to AFAB? This is misleading also. Part of the change in male to female ratio is just shifting statistics to different age groups. While young children historically have been 6:1 to 3:1 AMAB, adolescents and adults have always been from 2:1 to 1:1 AMAB to AFAB. The ratio has been shifting over the last two decades, but bringing the ratio closer to parity of 1:1.

Let's also delve further into the prevalence statistics.

Again, there is no question that the apparent prevalence of trans individuals has increased in the last two decades. The immediate question should be, however, is this a real increase in the underlying phenomenon or simply an increase in the counted number? We see this all the time in medicine. Most analogous to this situation is perhaps the dramatic increase in the number of autism diagnoses from the early 1990s to the 2010s. We have discussed this at length on SBM. It is clear from the data that most of this increase is due to an increase in awareness, availability of services, shifting diagnostic criteria, and diagnostic substitution. Screening can also play a role. As Dr. Gorski likes to say, if you look for something more intensively, you will find more of it. Even with all these factors, it is difficult to rule out a small real increase, but that is certainly not the core of the phenomenon.

There are even examples that are not psychological or neurodevelopmental disorders, like autism, for which the diagnostic criteria can be more subjective than they are for "hard" diagnoses like cancer. In fact, let's talk about cancer. There is a phenomenon known as ductal carcinoma in situ, which is a premalignant lesion that frequently progresses to breast cancer. Before 1970, it was a very uncommon, even rare, diagnosis. However, since the 1970s, the incidence of DCIS has increased by 16-fold. How could this be? Remember, this is a "hard" pathological diagnosis. The diagnostic criteria for DCIS have not changed; the diagnosis still requires a biopsy showing the characteristic lesions growing within the milk ducts. So what has changed? As discussed here many of times, it's screening. The increase in incidence of DCIS corresponds very closely to the introduction of mammographic screening programs in the late 1970s. Similar increases have been observed for prostate cancer after the introduction of PSA screening.

Our point here is not to revisit the controversies over screening for cancer and the potential for overdiagnosis engendered by overly intensive screening. These have been discussed on SBM many times before, and not just by Dr. Gorski. Dr. Hall has also written about overdiagnosis. Rather, by bringing up the examples of autism and DCIS, we simply wish to emphasize that it is not at all unusual for the incidence of a medical condition or disease to increase, sometimes dramatically, based on factors that have nothing to do with an underlying change in the prevalence of the condition, factors such as screening, acceptance, and changes in diagnostic criteria. Moreover, this sort of phenomenon has been observed even for diagnoses that are considered "hard", not just "softer" diagnoses like autism or other neurodevelopmental or psychological conditions. When such an increase in a condition is observed, it is not surprising that scientists (and the public) look for causes. Unfortunately, some will be tempted to latch onto causes that most jibe with their preexisting beliefs. It happened for autism, which was blamed on vaccines. It is happening for trans youth, which is being blamed on a number of causes not well supported by science.

Basically, what appears to be behind the increase in young people identifying as trans is similar to what is behind the increase in autism prevalence. Over the last two decades, the culture has shifted, with greater acceptance of trans individuals and openness to a non-binary approach to gender. There also has been an increase in the availability and visibility of support services for trans individuals and of gender-affirming interventions. Further, the historic numbers prior to the cultural shift were extremely low, around 0.1% in the US, which almost certainly was a gross undercounting. So of course the numbers have significantly increased - we would predict nothing else. Recent surveys put the figure at about 0.4%, a four-fold increase.

The real question is - are these known factors, increased acceptance and availability of resources, enough to explain the increase in people identifying as trans, or do we need to invoke a new phenomenon, such as Ms. Shrier does in supporting the notion that a social contagion is convincing children they are trans when they are not? We clearly need more and better evidence to address this question, but the evidence we currently have strongly favors the former, and there is no evidence to specifically support Ms. Shrier's view.

For example, a 2019 review of the demographics found:

Flores and colleagues note that their 2016 estimate of the percentage of transgender-identifying adults in the U.S. is double their 2011 estimate, which they attribute to improvement in survey methods ( 11). Arcelus et al. also describe a general increase in TGNB [transgender non-binary] individuals in Europe within their study period. Greater visibility and acceptance of TGNB individuals, and as a result, greater willingness to self-identify as TGNB and seek transition, may contribute to these trends.

But also, according to USTS results by age 20, 94% of transgender respondents began to feel that their gender was different from the sex assigned at birth, 73% of respondents began to think they were transgender, and 52% began to tell others that they were transgender. These findings were consistent across respondent age groups, which may suggest that reports of growing TGNB prevalence could be attributed to increased awareness, acceptance and self-reporting of TGNB identities among younger generations than an actual increase in prevalence.

It should also be noted that prevalence data is almost all based on those presenting to clinics. This is a self-selective population, and is certainly a subset of the overall trans population. What we are seeing is an increase in those presenting to clinics, with no reason to think there is an increase in the total population.

Ms. Shrier's narrative is that mostly young girls are being convinced that they are trans, and she offers as evidence the fact that the ratios of AMAB to AFAB trans individuals are shifting. But as we discussed above, we are not observing a flood of AFAB exceeding AMAB, but rather a coming to 1:1 parity, or close to it. The most parsimonious explanation here is that AFAB were previously underreported, and in this case the most parsimonious explanation is likely to be the most accurate. More AFAB are presenting to clinics requesting gender-affirming interventions. And this has two obvious and likely causes. One is the availability of top surgery for AFAB individuals, which is more available and less costly than genital surgery. The other is that the shifting of the gender ratio could mean that there was likely a backlog of AFAB demand for services.

One way to differentiate between these dueling narratives about the causes of the increase in people identifying as trans and requesting gender-affirming interventions is to look at the rate at which trans individuals who did undergo a medical intervention later express regret or detransition. If Ms. Shrier's fears are valid then we should already be seeing an increase in the incidence of regret and detransition.

About this Dr. Hall writes:

We are starting to see desisters (those who stop identifying as transgender) and detransitioners (those who had undergone medical procedures, regretted it, and tried to reverse course). No statistics are available on how often this happens.

This is misleading. First, it is not true that we have no statistics. But further, if it were true, then how would we know that the incidence is increasing? Her two claims, which appear to come from Ms. Shrier's book, contradict each other. It turns out, both are wrong.

A 2021 meta-analysis of regret following gender affirming surgery, combining 27 studies and 7,928 transgender patients, found that the pooled prevalence was 1%.

A 2018 survey of surgeons about their own patient statistics found that out of 22,725 patients who underwent GAS only 62 later expressed regret, and out of these only 22 said it was because of a change in their gender identity. The rest cite reasons such as conflict with family or dissatisfaction with the surgical outcome.

Other reviews also find extremely low rates of regret, ranging from 0.3% to 3.8%. Further, if anything the rate of regret is decreasing over time as social support and surgical procedures improve.

The bottom line is that regret is rare and decreasing, which convincingly falsifies Ms. Shrier's narrative that it is significantly increasing (based entirely on anecdotal evidence). In fact, this is powerful evidence against Ms. Shrier's entire social contagion narrative.

To bolster the "social contagion" hypothesis, Dr. Hall cites the controversy over "Rapid Onset Gender Dysphoria (ROGD)". This idea was proposed in 2016, based on a single study that even Dr. Hall now acknowledges to have been bad science. The journal later published a "correction" that mainly added a proper discussion of the preliminary nature of the study. At this point is it not valid to cite ROGD to support the social contagion hypothesis, nor is it valid to suggest that there is now a burden of proof to rule it out, or that it should in any way inform medical practice. This is a thin hypothesis based on shoddy science; it should no more affect medical practice than similar-quality studies should impact the vaccination program.

Further, Dr. Hall's review creates the impression that gender-affirming interventions are risky or harmful, but to support that narrative she distorts the evidence. She states:

Suicide is common, but there is evidence that factors other than gender dysphoria may be causing the suicidal ideation, and there is evidence that affirmation does not ameliorate mental health problems. In one study of adult transsexuals, there was a rise in suicidality after sex reassignment surgery.

We do not believe that this is a fair assessment of the evidence. A 2016 systematic review of psychological well-being following gender-affirming interventions found:

Two studies showed a significant improvement in psychological functioning at 3-6 months and 12 months compared with baseline after initiating hormone therapy. The third study showed improvements in quality of life outcomes 12 months after initiating hormone therapy for FTM and MTF participants; however, only MTF participants showed a statistically significant increase in general quality of life after initiating hormone therapy.

A 2021 systematic review of gender affirming surgery specifically found:

Findings from this review indicate that GAS [gender-affirming surgery] can lead to multiple, significant improvements in psychological functioning.

A 2020 study of hormonal therapy in trans teens found it decreased suicidal ideation and improved quality of life. A 2020 study of pubertal blockers and suicidal ideation found:

This is the first study in which associations between access to pubertal suppression and suicidality are examined. There is a significant inverse association between treatment with pubertal suppression during adolescence and lifetime suicidal ideation among transgender adults who ever wanted this treatment. These results align with past literature, suggesting that pubertal suppression for transgender adolescents who want this treatment is associated with favorable mental health outcomes.

There are more studies, but the summary is that the research over years has consistently shown that gender affirming interventions improve mental health and reduce risk of suicide in trans patients.

Where we agree with Dr. Hall is that the current state of this evidence is far from ideal. Mainly for practical reasons, most of this research is not blinded or controlled. To put this into context, however, most surgical interventions are not studied in blinded trials, and sham surgical interventions are rare. You cannot blind a trans individual to whether or not they received a gender affirming intervention.

But we do agree that given this reality, we need to continue to study and monitor such interventions for both medical and psychological outcomes. This is where an informed medical and ethical discussion should take place, balancing the risks and benefits of interventions given the limitations of the research. There is also a meaningful ethical conversation to be had about the proper age of consent and balancing that with risks vs. benefits of gender-affirming interventions.

Conclusion: There is science supporting transgender care

Abigail Shrier's narrative and, unfortunately, Dr. Hall's review grossly misrepresent the science and the standard of care, muddying the waters for any meaningful discussion of a science-based approach to transgender care. They mainly rely on anecdotes, outliers, political discussions, and cherry-picked science to make their case, but that case is not valid.

Most significantly, they warn about medical interventions for children, citing mainly the notion that children are not able to make such choices at such a young age and will likely change their minds, regretting their decision because their gender identity is still developing. However, the age group for which they cite (fatally flawed) statistics do not receive medical interventions, and the age group that is eligible are not likely to change their gender identity. This is a statistical bait-and-switch.

The standard of care waits until children are at an age where their gender identity is generally fixed, and then phases in interventions from most reversible to least, combined with robust psychological assessments. Further, regretting these interventions remains extremely rare, and does not support the social contagion hypothesis.

At this point there is copious evidence supporting the conclusion that the benefits of gender affirming interventions outweigh the risks; more extensive, high-quality research admittedly is needed. For now, a risk-benefit analysis should be done on an individual basis, as there are many factors to consider. There is enough evidence currently to make a reasonable assessment, and the evidence is also clear that denying gender-affirming care is likely the riskiest option.
Steven Novella, MD, Founding Editor, SBM
David Gorski, MD, PhD, Managing Editor,SBM
Coming up - Part II of this series will include a far more detailed discussion of the key claims in Abigail Shrier's book and where she goes wrong by an expert in the care of trans children and adolescents.

Founder and currently Executive Editor of Science-Based Medicine Steven Novella, MD is an academic clinical neurologist at the Yale University School of Medicine. He is also the host and producer of the popular weekly science podcast, The Skeptics' Guide to the Universe, and the author of the NeuroLogicaBlog, a daily blog that covers news and issues in neuroscience, but also general science, scientific skepticism, philosophy of science, critical thinking, and the intersection of science with the media and society. Dr. Novella also has produced two courses with The Great Courses, and published a book on critical thinking - also called The Skeptics Guide to the Universe.

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The Science of Transgender Treatment | Science-Based Medicine

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Editors' note: The link to the original book review, which is now a retraction notice, can be found here. Dr. Hall's book review has been republished by Michael Shermer on Skeptic here. Science-Based Medicine as a philosophy, blog, and approach to medical practice is primarily about optimizing and affirming the relationship between science and critical thinking with healthcare.

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The Lies and Dangers of "Conversion Therapy"

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"Reparative" or "conversion" therapy is a dangerous practice that targets LGBTQ youth and seeks to change their sexual or gender identities.

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JAMA Infographic-Transgender and Gender Diverse Youth 

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JAMA Infographic-Transgender and Gender Diverse Youth 

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The Trevor Project- Research Brief on Gender Affirming Care for Youth 

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The Trevor Project- Research Brief on Gender Affirming Care for Youth 

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Historically, any identification with activities or expression outside of strict gender roles that were expected to align with one's sex assigned at birth (SAB) have been frowned upon. Today, there is recognition of the differences between concepts such as gender roles, SAB, gender identity, and gender expression. Youth who do not identify with their SAB may identify as transgender and/or nonbinary (TGNB). TGNB individuals experience higher rates of mental health challenges, with anxiety and depression experienced at nearly 10 times the rate of their cisgender peers (Becerra-Culqui et al., 2018). Furthermore, according to The Trevor Project's 2019 National Survey on LGBTQ Youth Mental Health, 54% of transgender and non-binary youth reported seriously considering suicide in the last year, and 29% made a suicide attempt (The Trevor Project, 2019a). Building on decades of empirical evidence linking minority stress to health disparities, research has recently begun to elucidate the relationship between chronic discrimination against TGNB individuals and the mental health disparities they experience (Hatzenbuehler, 2009, Testa et al., 2017).

While minority stress increases these mental health disparities - including the risk of anxiety, depression, and suicidality - among TGNB individuals, gender-affirming care has been shown to improve mental health. Gender-affirming care for TGNB youth may involve social, medical, and legal aspects. Gender-affirming care has been shown to reduce suicide ideation and attempts in transgender individuals, along with social support, familial support, and reduction of discrimination (Bauer et al., 2015, The Trevor Project, 2019b). This brief will review the empirical evidence on psychosocial outcomes related to gender-affirming care for youth with implications for how TGNB youth can be supported.

Results

Social

Social transition is the primary affirmative care intervention for prepubertal TGNB youth and involves encouraging them to present in the way that feels most genuine to them. It may also include the use of a different name or pronouns aligned with their gender identity.

The evidence for social transition builds upon what is already known regarding positive family and social support; that is, family acceptance of LGBTQ youth is associated with positive mental health (Ryan et al., 2010), whereas higher rates of family rejection are associated with the opposite. For example, young adults from highly accepting families attempt suicide at significantly reduced rates compared to those in low accepting families (31% versus 57%) (Ryan et al., 2009).

TGNB children who have socially transitioned demonstrate comparable levels of self-worth and depression as non-TGNB children. This has been demonstrated in research that asks parents to report on their child's mental health (Olson et al., 2016) as well as asking the youth themselves (Durwood et al., 2017). Although TGNB youth who have socially transitioned report slightly higher levels of anxiety compared to non-TGNB peers (Durwood, et al., 2016; Olson et al., 2016) the fact that self-worth and depression outcomes are equal is powerful due to the significantly worse mental health outcomes experienced by non-supported TGNB youth.

Further, research has specifically shown lower suicidal ideation and suicidal behavior when a TGNB youth's chosen name is consistently used. The more contexts that it is used (home, school, work, and friends), the stronger the effects (Russell et al., 2018). Usage of chosen name resulted in a 29% decrease in suicidal ideation and a 56% decrease in suicidal behavior for each additional context in which it was used.

Medical

Medical affirming care can include treatments that postpone physical changes as well as treatments that lead to changes that would affirm one's gender identity. Pubertal suppression, commonly known as "puberty blockers," is used to delay the onset of puberty, and hormone therapy is used to promote gender-affirming physical changes. Pubertal suppression and hormone therapy are two components of patient-centered care for youth that have been supported by empirical evidence (WPATH, 2012).

Pubertal suppression may be used for youth currently in the early stages of puberty who are experiencing distress over their sex assigned at birth and their gender identity. Delaying puberty can provide youth more time to explore their gender identity without the development of unwanted physiological changes and may also serve as a precursor to gender-affirming hormone therapy (GAHT). GAHT allows TGNB youth to develop physical characteristics that align with their gender identity. GAHT is specifically appropriate for TGNB youth who have already entered puberty or following a period of pubertal suppression.

Pubertal suppression is associated with decreased behavioral and emotional problems as well as decreased depressive symptoms (de Vries et a., 2011). Prior to pubertal suppression, 44% of youth experienced clinically significant behavioral problems; however, after an average of two years of pubertal suppression only 22% experienced them. And 30% experienced clinically significant emotional problems prior to pubertal suppression compared to 11% after two years of care. Pubertal suppression has also been shown to significantly improve overall psychological functioning after only six months of care (Costa et al., 2015). Additionally, transgender individuals who desired and received pubertal suppression as adolescents have significantly lower lifetime suicidal ideation compared to those who desired but did not receive it (Turban et al., 2020).

Research on GAHT for youth demonstrates positive effects on body image and overall psychological well-being as well as reduced suicidality. GAHT decreases both emotional and behavioral problems (de Vries et al., 2014), similar to what is seen in pubertal suppression. Recent research has also shown that GAHT decreases suicidality, with one study of transgender youth demonstrating that after approximately 1 year of treatment the average level of suicidality was 1/4th what it was before treatment (Allen et al., 2019).

Legal

Affirmative legal interventions allow a young person to change their name and/or gender on their legal documents, including their birth certificate, driver's license, passport, and social security card. The laws on changing birth certificates or driver's licenses vary on a state by state basis, whereas changes to a passport or social security card are determined at a federal level.

Early research with TGNB adults has shown that a legal name change may be considered a structural public health intervention that improves access to care and increases socioeconomic stability (Hill 2018). Research has also shown that discriminatory social policies, such as same sex marriage bans, directly contribute to adverse mental health outcomes (Hatzenbuehler 2010). Although more research on the psychosocial benefits of legal interventions for TGNB youth is necessary, existing research on affirming social transitions provides support for the expected psychosocial benefits of legal support for TGNB identities.

Looking Ahead

There have been many opponents to gender-affirming care for TGNB youth. Some of the hesitance regarding gender-affirming care may be due to a misunderstanding of the causes of mental health challenges in TGNB individuals. This brief demonstrates why such care is not only ethical, but medically-necessary (WPATH, 2016). Further, regret is low for gender-affirming care interventions, and a study of 55 transgender adults who had received gender-affirming care as adolescents showed that not one individual experienced regret (de Vries et al., 2014).

As the evidence for gender-affirming care grows, medical and mental health organizations are increasingly shifting to support it. Many major medical organizations have guidelines for working with transgender individuals centered around respect for the patient and shared decision making (American Psychological Association, 2015; American Psychiatric Association, 2018), with some organizations releasing statements explicitly opposing any efforts to prevent access to gender-affirming care. (American Academy of Child and Adolescent Psychiatry, 2019). Given the well-documented risks of negative mental health and suicidality outcomes among TGNB, it is necessary that those serving TGNB provide care that is patient-centered, affirming, and evidence-based.

Although available data solidly highlight the psychosocial benefits of gender-affirming care for TGNB youth, there remains a critical need for additional physical and mental health outcomes data, including through longitudinal studies. Large-scale data collection will better elucidate the risks and benefits of individual treatment options, so that youth and their families can make evidence-informed decisions regarding care. There is also a need for research on how legal and policy decisions about TGNB individuals impact their mental health and well-being. Such data will be crucial to advocacy efforts aimed at supporting TGNB youth.

The Trevor Project is committed to promoting the wellness of all LGBTQ young people and supports gender-affirming care as an evidence-based practice to support TGNB youth. Trevor's advocacy team is dedicated to fighting against anti-TGNB policy positions and for policies that ensure that young people have access to beneficial gender-affirming care. Our research team conducts studies which seek to improve our understanding of ways to end suicide and reduce disparities for LGBTQ youth, including ways to better support TGNB youth. Our public education programs aim to further increase knowledge of ways to support TGNB youth in schools and communities. And our 24/7 crisis services via call, text, or chat ensure that every young person who reaches out to us receives the help they need in that moment.

ReferencesAllen, L. R., Watson, L. B., Egan, A. M., & Moser, C. N. (2019). Well-being and suicidality among transgender youth after gender-affirming hormones. Clinical Practice in Pediatric Psychology, 7(3), 302-311.American Academy of Child and Adolescent Psychiatry (2019). Statement Responding to Efforts to ban Evidence-Based Care for Transgender and Gender Diverse Youth. Available at: https://www.aacap.org/AACAP/Latest_News/AACAP_Statement_Responding_to_Efforts-to_ban_Evidence-Based_Care_for_Transgender_and_Gender_Diverse.aspx. Accessed January 1, 2020.American Psychiatry Association (2018). Position Statement on Access to Care for Transgender and Gender Variant Individuals Available at: https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-2018-Access-to-Care-for-Transgender-and-Gender-Diverse-Individuals.pdf. Accessed January 1, 2020.American Psychological Association. (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832- 864.Bauer G.R., Scheim A.I., Pyne J., Travers R., Hammond R. (2015). Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health, 15, 525.Becerra-Culqui T.A., Liu Y., Nash R., et al. (2018). Mental health of transgender and gender nonconforming youth compared with their peers. Pediatrics, 141(5),e20173845.Chew, D., Anderson, J., Williams, K., May, T., & Pang, K. (2018). Hormonal treatment in young people with gender dysphoria: a systematic review. Pediatrics, 141(4), e20173742.Costa R., Dunsford M., Skagerberg E., Holt V., Carmichael P., & Colizzi M. (2015). Psychological support, puberty suppression, and psychosocial functioning in adolescents with gender dysphoria. Journal of Sexual Medicine,12, 2206-2214.de Vries A.L., McGuire J.K., Steensma T.D., Wagenaar E.C., Doreleijers T.A., & Cohen-Kettenis P.T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134, 696-704.de Vries A.L., Steensma T.D., Doreleijers T.A., and Cohen-Kettenis P.T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow-up study. Journal of Sexual Medicine, 8, 2276-2283.Durwood L., McLaughlin K.A., & Olson K.R. (2017). Mental health and self-worth in socially transitioned transgender youth. Journal of the American Academy of Child & Adolescent Psychiatry, 56, 116-123.Hatzenbuehler M.L. (2009). How does sexual minority stigma "get under the skin"? A psychological mediation framework. Psychological Bulletin, 135(5),707-730.Hatzenbuehler, M. (2010). Social factors as determinants of mental health disparities in LGB populations: Implications for public policy. Social Issues and Policy Review. 4(1):31-62.Hill, B.J., Crosby, R., Bouris, A. et al. (2018). Exploring transgender legal name change as a potential structural intervention for mitigating social determinants of health among transgender women of color. Sex Res Soc Policy, 15(1):25-33.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), e20153223.Ryan C., Huebner D., Diaz R.M., & Sanchez J. (2009). Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics, 123(1), 346-352.Ryan C., Russell S.T., Huebner D., Diaz R., & Sanchez J. (2010) Family acceptance in adolescence and the health of LGBT young adults. Journal of Child & Adolescent Psychiatric Nursing, 23(4):205-213.Russell S.T., Pollitt A.M., Li G., & Grossman A.H. (2018). Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. Journal of Adolescent Health, 63(4), 503-505.Testa R.J., Michaels M.S., Bliss W., Rogers M.L., Balsam K.F., Joiner T. (2017). Suicidal ideation in transgender people: Gender minority stress and interpersonal theory factors. Journal of Abnormal Psychology,126(1), 125-136.The Trevor Project. (2019a). National Survey on LGBTQ Mental Health. New York, New York: The Trevor Project.The Trevor Project. (2019b). The Trevor Project research brief: Fostering the mental health of LGBTQ youth. Available at: https://www.thetrevorproject.org/2019/05/30/research-brief-fostering-the-mental-health-of-lgbtq-youth Accessed January 21, 2020.Turban, J.L., King, D., Carswell J.M., & Keuroghlian, A.S. (2020). Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics, 145(2), e20191725WPATH (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People Version 7. Available at: https://www.wpath.org/publications/soc Accessed January 22, 2020.WPATH (2016). Position Statement on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A. Available at: https://www.wpath.org/newsroom/medical-necessity-statement Accessed January 1, 2020.

For more information please contact: [email protected]

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Gender-Affirming Care for Youth - The Trevor Project

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Historically, any identification with activities or expression outside of strict gender roles that were expected to align with one's sex assigned at birth (SAB) have been frowned upon. Today, there is recognition of the differences between concepts such as gender roles, SAB, gender identity, and gender expression.

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WPATH Statement on Medical Affirming Treatment for Children and Adolescents 

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WPATH Statement on Medical Affirming Treatment for Children and Adolescents 

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Detransition, Stigma and Family Pressure

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Detransition, Stigma and Family Pressure

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Fenway Health: Health Care Is A Right, Not A Privilege.

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New Study Shows Discrimination, Stigma, and Family Pressure Drive "Detransition" Among Transgender People - Fenway Health: Health Care Is A Right, Not A Privilege.

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BOSTON, April 7, 2021-A new study published in LGBT Health found that 13.1% of currently identified transgender people have detransitioned at some point in their lives, but that 82.5% of those who have detransitioned attribute their decision to at least one external factor such as pressure from family, non-affirming school environments, and increased vulnerability to [...]

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American Academy of Pediatrics Statement on Gender Affirming Care 

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American Academy of Pediatrics Statement on Gender Affirming Care 