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Content warning: This article discusses suicide.

For transgender youth in the United States, limited access to gender-affirming care is an ongoing issue stemming from multiple barriers, including lack of family support, a shortage of competent providers, and a surge in legislation banning or restricting gender-affirming care.

Barriers to Gender-Affirming Care

“Many transgender minors are fearful of coming out to their parents or have come out and their parents are not supportive of them,” explained Gloria A. Bachmann, MD, MMS, professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences and medical director of the PROUD Gender Center of New Jersey at the Rutgers Robert Wood Johnson Medical School in New Brunswick. “In this scenario, these individuals are unable to get the gender-affirming medical care that would benefit them because they do not have parental support for their health care.”

Even for transgender minors who have supportive guardians, a range of other obstacles may prevent access to needed care. “Gender-diverse youth face continued stigma and discrimination, even in the healthcare system, and as a result they may not access care for fear of not being accepted and affirmed of who they are,” said Samantha V. Hill, MD, MPH, assistant professor of the Department of Pediatrics at Emory University School of Medicine in Atlanta, Georgia.  

Furthermore, “There is a major shortage of both mental health and medical providers who are trained in providing gender-affirming care, which means families may wait for up to a year to receive care, if they are able to access it at all,” according to Jack L. Turban, MD, MHS, assistant professor in the Division of Child and Adolescent Psychiatry and director of the Gender Psychiatry Program at the University of California, San Francisco.

In recent years, a proliferation of passed and proposed legislative bills have added to the stigma, discrimination, and narrow access to care that gender-diverse individuals — and youth in particular — often experience.1,2

“There has been a dramatic increase in legislation geared at reducing or eliminating gender-affirming medical and surgical interventions in minors, and many states have passed these legislative bills into law,” Dr Hill stated.

As a result, some states have no providers who can offer gender-affirming treatment, Dr Turban said. Such legislation has prevailed despite opposition from all major medical organizations, including the American Medical Association, the American Academy of Pediatrics, and the American Psychiatry Association.2 “In some instances, states have even proposed legislation to limit or ban care for adults,” he noted.3 

In a study published in March 2023 in the Journal of Adolescent Health, Dr Hill and colleagues examined the number of anti-trans bills proposed each year in the US from 2010 to 2019 using data from several sources.4 They found that 189 anti-transgender bills were proposed and 13 were passed during the 10-year period.

“These bills focused on a variety of topics including healthcare, youth athletics, bathroom facilities, identity documents and nondiscrimination, and really emphasize that transgender youth and their subsequent health have become a major focus in this country,” Dr Hill explained.

In 2023, 503 anti-trans bills were proposed and 85 were passed, according to the Trans Legislation Tracker.4 Many of these carried over into 2024, and hundreds of new anti-trans bills have already been proposed as of February 2024.

“That is a dramatic increase, even if we look at 2021 and 2022, when only 125 and 148 bills were proposed, respectively,” Dr Hill said.

Negative Impact of Anti-Trans Legislation

In their study, Dr Hill and her team “found that this change in the legislative climate not only impacted self-reported feelings of being victimized and bullied by gender-diverse youth, but it also impacted non-gender-diverse youth,” she noted.4

In their statement to Endocrinology Advisor, the Endocrine Society said that such legislation is based on widespread misinformation and stated, “We recognize the risks of blocking adolescents from accessing gender-affirming care: It raises the risk of suicidal ideation and self-harm and denies patients the benefits of treatment, including improved psychological functioning.”6

As an example, the Endocrine Society pointed to a 2020 study by Dr Turban et al, which showed lower odds of lifetime suicidal ideation among transgender adults who received puberty-delaying medication during adolescence compared with those who did not receive such treatment, even after adjustment for demographic variables and family support (adjusted odds ratio, 0.3; 95% CI, 0.2-0.6). Approximately 9 out of 10 participants who wanted but did not receive pubertal suppression reported lifetime suicidal ideation.7

https://infogram.com/endo_feature_315-1h0n25o8n7q8l4p?live

Among other recent research in this area, a prospective cohort study of 104 transgender and nonbinary youths found that receipt of gender-affirming care (in this case, puberty blockers and gender-affirming hormones) was linked to 60% lower odds of depression and 73% lower odds of suicidality during the subsequent 12 months.6 A large, survey-based study published in 2022 in the Journal of Adolescent Health reported similar results.8

The Endocrine Society added that banning care for adolescents creates the need for additional gender-affirming procedures in adulthood.

“Blocking pubertal hormones early in puberty prevents a teenager from developing irreversible secondary sex characteristics, such as facial hair and breast growth,” it explained. “Transgender and gender-diverse individuals who did not have access to care as teenagers may need additional treatment to address hair growth, voice changes, and facial development.”

The Endocrine Society also cited research showing that state restrictions on gender-affirming care have increased median drive times to medical appointments for youth seeking such care, with the largest absolute increases observed in Florida (8.5 hours), Texas (6.7 hours), and Utah (5.0 hours).  According to the study authors, increased travel times and associated costs may further impede treatment access and negatively affect mental health among transgender youths.1  

"
Transgender and gender-diverse teenagers, their parents, and physicians should be able to determine the appropriate course of treatment, and banning evidence-based medical care based on misinformation takes away the ability of parents and patients to make informed decisions.

“Bans and restrictions on gender-affirming care contradict mainstream medical practice and scientific evidence, and these policies are taking medical decision-making out of the hands of transgender and gender-diverse teenagers, their families, and their physicians,” the Endocrine Society told Endocrinology Advisor. “Cisgender teenagers, together with their parents or guardians, are currently deemed competent to give consent to various medical treatments, and transgender teenagers should be afforded the same legal rights.”9,10

Dr Bachman emphasized that gender-affirming care for minors is provided by a healthcare team that thoroughly evaluates each patient, and many studies have shown high rates of patient satisfaction with such care: “The largest of these studies was the 2022 US Trans Survey that included 92,329 respondents, in which 98% who were given hormones for their gender identity or transition were either a lot more satisfied or a little more satisfied.”11

Increasing Competency in Gender-Affirming Care

The experts interviewed for this article recommend various strategies for increasing clinical competency in gender-affirming care and advocating for gender-diverse individuals at large.

“There are 2 major sets of guidelines for providing gender-affirming medical care — the Endocrine Society Guidelines and the World Professional Association for Transgender Health Standards of Care — that physicians should use to inform their practice,” Dr Turban said.12,13 

The Endocrine Society guideline, which cites more than 260 research studies, states that adolescents are eligible for hormone therapy when they are mentally competent to fully understand and consent to this partially irreversible treatment, which is typically around the age of 16 years.12 

The Endocrine Society has also published a position statement on transgender health and the importance of access to gender-affirming care, as well as a toolkit for clinicians who want to advocate for transgender health care in their home states.14,15 In addition, providers can check the Kaiser Family Foundation’s policy tracker to follow emerging developments in restrictive legislation regarding gender-affirming care.16

“Sadly, the media landscape in this area has been saturated with non-experts and political propaganda that is not evidence-based, so it’s essential that the voices of physicians be heard both in the media and in legislative debates,” Dr Turban stated. “I encourage physicians to write evidence-based op-eds in their local or state papers when legislation arises and to reach out to their local representatives to educate them on the science relevant to bills that would impact the care of transgender patients.”17

In terms of treatment, “For those clinicians who do not have the clinical background to provide gender-affirming care, referral to medical establishments that do, such as the PROUD Gender Center of New Jersey, is extremely important,” Dr Bachman advised.

Dr Hill said more work is needed to educate all health care workers about gender-affirming care and how to link gender-diverse youth to these services. “There is a lack of a road map for gender-diverse youth and those who support them, and many families are unaware of how to access care from providers knowledgeable in gender-affirming care.”

She provided the following recommendations for clinicians interested in providing gender-affirming care in their practices:

  • A great place to start is with creating a welcoming environment for gender-diverse youth in clinical settings, as recommended by many professional organizations including the American Academy of Pediatrics.18 This includes documenting asserted names and pronouns in the electronic medical record, use of gender-neutral language, and educating staff in affirming all patients.
  • It is important for clinicians to educate themselves about appropriate ways to affirm someone's gender and to understand gender expression and gender identity. There are many resources for clinicians to access, such as those provided by Fenway Health. They can also follow the vast literature on the subject that is evidence-based.
  • In general, clinicians can advocate for gender-diverse youth by correcting people who have misconceptions about these individuals or who misgender them by using the wrong pronouns.
  • Clinicians can be agents of change wherever they are providing care and introducing the topic if gender-affirming policies are not already in place.
  • Clinicians can sign up to receive updates as legislation is proposed within local, state, and national jurisdictions so they can be informed about how the law changes and help disseminate accurate information to their colleagues and the communities they serve.
  • Engaging in advocacy days at the state or national capitol and sharing scientifically accurate information about gender-diverse youth and their families are other great ways to advocate.
  • For more ideas, clinicians can visit the National Institute for Children’s Health Quality website.19 

“Transgender and gender-diverse teenagers, their parents, and physicians should be able to determine the appropriate course of treatment, and banning evidence-based medical care based on misinformation takes away the ability of parents and patients to make informed decisions,” according to the Endocrine Society. “Medical evidence, not politics, should inform treatment decisions.”

Further Reading

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