An Update on Gender-Affirming Medical Care and Recent Controversies
Co-author: Christine Moser, PsyD | Clinical Psychologist, Division of Developmental and Behavioral Health | Director of Behavioral Health, Gender Pathway Services Clinic | Associate Professor of Pediatrics, UMKC School of Medicine
Co-author: Jill Jacobson, MD | Division of Endocrinology | Medical Director, Gender Pathway Services Clinic | Professor of Pediatrics, UMKC School of Medicine
Column Editor: Amita Amonker, MD, FAAP | Pediatric Hospitalist | Assistant Professor of Pediatrics, UMKC School of Medicine
Numerous studies document that gender-affirming medical care (GAMC) and gender-affirming hormone treatment (GAHT) improve mental health outcomes1 and reduce suicidality2 for transgender and gender-diverse (TGD) children. Increased attention to the mental and physical health of TGD individuals has led to clinical practice guidelines that outline standards for GAMC for TGD children. Many academic pediatric medical centers nationwide support interdisciplinary gender clinics. See https://www.hrc.org/resources/interactive-map-clinical-care-programs-for-gender-nonconforming-childr.
Referrals for pediatric gender care nationally have increased over the past decade. The prevalence of transgender youth in the U.S. is estimated to be about 0.7% of adolescents between the ages of 13 and 17 years.3 Prevalence rates for young children are difficult to estimate; in our Gender Pathway Services (GPS) clinic, 17% of our patient population is under 13 years old. In clinic samples, young children assigned male at birth are referred more often and adolescents assigned female at birth are referred more often.4
The Joint Commission provides guidance for best practices in providing medical care for TGD children. See https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/health-equity/lgbtfieldguide_web_linked_verpdf.pdf?db=web&hash=FD725DC02CFE6E4F21A35EBD839BBE97&hash=FD725DC02CFE6E4F21A35EBD839BBE97. The Joint Commission recommends that pediatricians ask patients about chosen names and pronouns and use those consistently during visits and in documentation. In addition, pediatricians should familiarize themselves with the following terms:
| Sexual orientation - One’s pattern of physical and emotional arousal toward other persons. Gender identity and sexual orientation can appear in all possible combinations and may be fluid over time.
| Gender expression - The way an individual expresses gender identity through appearance, dress and behavior.
| Gender identity - An individual’s internal sense of being male, female or somewhere on the gender spectrum.
| Social transition - Social, cosmetic or legal changes to live according to gender identity.
| Gender dysphoria - A Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnosis that describes a mismatch or a sense of unease between sex assigned at birth and gender identity.
| Gender variant (non-conforming) youth - Gender expression or identity is inconsistent with social expectations and norms.
| Assigned sex at birth - A label given at birth based on medical factors, including hormones, genitals and chromosomes. AFAB = assigned female at birth, AMAB = assigned male at birth.
| Gender non-binary - Identities that are not exclusively masculine or feminine — identities which are outside the gender binary.
| Cisgender - Individuals whose gender identity matches their assigned sex at birth.
| A gender-affirming model of care - Accepts gender variation as an expected part of human diversity not pathology.
GPS Clinic follows established clinical practice guidelines from the Endocrine Society5 and from the World Professional Association for Transgender Health.6 Children can conceptualize themselves as gendered individuals as young as 2-3 years old.4 Very young children may question gender-based expectations or assert that they are a different gender from the sex assigned at birth. However, not all TGD individuals express gender dysphoria as young children. Many individuals experience gender dysphoria at the onset of puberty or later, as adults. Knowledge of and disclosure of gender variance is based on a complex interweaving of language, cognitive ability, environment, and religious/cultural variables.
Clinical practice guidelines recommend that TGD children or those with gender dysphoria begin with a consultation by a mental health professional to assist in understanding the child’s conceptualization of gender and to provide information about family and environmental support. A social transition may follow the visit, allowing the child the experience to consolidate and clearly articulate gender identity. According to clinical practice guidelines, no medical treatments are initiated until the child reaches Tanner stage 2 of puberty. When a child reaches puberty, gonadotropin-releasing hormones may be considered to suppress unwanted sexual characteristics. Pubertal suppression is a reversible intervention sometimes used to “buy time” to allow the child to socially transition without the often distressing and irreversible physiologic changes of biological puberty. Around the age of 16, GAHT may be initiated to facilitate onset of puberty according to the child’s gender identity. Surgical interventions (commonly “top surgery” or mastectomy for transmasculine individuals) are typically initiated after the age of 18 years and with physical maturity.
Readers may be aware of recent socio-political controversies involving GAMC. A 2020 court decision in the United Kingdom case of Bell v. Tavistock addressed children’s ability to consent for their own gender-affirming medical treatment. The court ruled that TGD children under 16 years do not have “Gillick competence” and thus cannot make medical decisions for themselves. Instead, an individual with parental decision-making responsibility or the court must give (or withhold) permission for treatment based on their assessment of the child’s interests. This controversial decision was overturned in September 2021. Several states in the U.S. have proposed or enacted legislation to restrict children’s access to gender-affirming treatments and to subject providers of such care to criminal penalties. Such laws fly in the face of the medical and psychological consensus. Controversies often arise around the following topics:
1. Informed consent/assent for GAMC. In the United States children under 18 years old require parental consent to proceed with GAMC. Some states, including Missouri and Kansas, allow for single parent consent for non-emergency medical procedures. Questions frequently arise about the extent to which TGD children should be allowed to make decisions about their gender and medical care. Caregivers can make informed decisions based on the child’s experiences with social transition, which allows the child to learn about their gender identity and determine whether their quality of life and well-being will improve with transition. As socially transitioned children develop and age, they should participate in discussions with their family and health care team about options and risks of treatment (including future fertility) and should be given increased responsibility for articulating their own values and goals.
2. Some individuals consider treatment with puberty-blocking medications to be “experimental.” Many professional associations, including those cited above, the American Academy of Pediatrics7 and the American Psychological Association,8 have published practice guidelines for providing GAMC medical care. The international evidence base shows gender-affirming hormone treatment to be both safe and highly effective in treating gender dysphoria.9 Aside from psychotherapy, there is no alternative treatment for gender dysphoria, and the detrimental effects of withholding care are substantial. The high-level suicidal ideation3 associated with gender dysphoria suggests that untreated gender dysphoria can be fatal.
3. Treatment with puberty blockers may encourage persistence of gender dysphoria. The assumption that gender transition is a negative outcome is questionable. Not all children with gender dysphoria prior to onset of puberty will seek medical transition later; level of intensity and persistence of gender dysphoria may indicate a higher likelihood of later gender transition. Pubertal suppression has few known risks. Yet there is substantial risk to withholding pubertal suppression, a treatment that is considered to be “life-saving” by many TGD children and their parents to avoid the lifelong physical and mental health consequences of undergoing the “wrong puberty.”
4. Regret. Little is known about TGD youth who discontinue medical care. Recent adult studies indicate that very few individuals (0.6% of transwomen and 0.3% transmen) who undergo surgical gender transition experience regret.10 In an internet survey of TGD individuals, 61.9% reported pursuing gender affirmation and, of these, 13.1% reported “detransitioning.” Those who detransitioned reported many reasons for doing so, including pressure from family or societal stigma, internal uncertainty or fluidity, or a desire to stop medical interventions.11
- Olson KR, Durwood L, DeMeules M, McLaughlin KA. Mental health of transgender children who are supported in their identities. Pediatrics. 2016;137(3):e20153223.
- Allen LR, Watson LB, Egan AM, Moser CN. Well-being and suicidality among transgender youth after gender-affirming hormones. Clin Pract Pediatr Psychol. 2019;7(3):302-311.
- Herman JL, Flores, AR, Brown, TNT, Wilson, BDM, Conron, KJ. Age of individuals who identify as transgender in the United States. The Williams Institute; 2017.
- Ehrensaft D. The Gender Creative Child: Pathways for Nurturing and Supporting Children Who Live Outside Gender Boxes. The Experiment; 2016.
- Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. Endocr Pract. 2017;23(12):1437.
- Coleman E, Bockting, W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgend. 2012;13(4):165-232.
- Rafferty J. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics. 2018;142(4).
- American Psychological Association. Guidelines for psychological practice with transgender and gender nonconforming people. Am Psychol. 2015;70(9):832-864.
- 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;134(4):696-704.
- Wiepjes CM, Nota NM, de Blok CJM, et al. The Amsterdam cohort of gender dysphoria study (1972-2015): trends in prevalence, treatment, and regrets. J Sex Med. 2018;15(4):582-590.
- Turban JL, Loo SS, Almazan AN, Keuroghlian AS. Factors leading to "detransition" among transgender and gender diverse people in the United States: a mixed-methods analysis. LGBT Health. 2021;8(4):273-280.