Gender-Affirming Care Saves Lives

Growing legislative attempts to ban or limit access to this critical model of medical care endangers the health and well-being of transgender and nonbinary youth 

Research demonstrates that gender-affirming care – medical and psychosocial health care designed to affirm individuals' gender identities – greatly improves the mental health and overall well-being of gender diverse, transgender, and nonbinary (TGNB) children and adolescents. 
 
Unfortunately, 2021 has been a record-breaking year for legislation attempting to limit or ban access to gender-affirming treatments for transgender youth under 18. In April, Arkansas passed a law prohibiting doctors from treating TGNB minors with puberty blockers and gender-affirming surgery, and similar bills are pending in at least 20 other states.
 
Most of these bills attempt to bar gender-affirming health care for minors by criminalizing medical providers and, in some cases, parents who consent to procedures. Measures to restrict this critical care not only run counter to scientific evidence but also threaten the mental health of TGNB youth, many of whom experience gender dysphoria – clinically significant distress or impairment caused by a discrepancy between a person’s sex assigned at birth and their gender identity.
 
The gender-affirming model of care affirms diversity in gender identity and assists individuals in defining, exploring, and actualizing their gender identity, allowing for exploration without judgments or assumptions. This does not mean that all youth need to undergo medical intervention; indeed, this is often not the case. Gender-affirming care is highly individualized and focuses on the needs of each individual by including psychoeducation about gender and sexuality (appropriate to the age and developmental level), parental and family support, social interventions, and gender-affirming medical interventions. 
 
It is well documented that TGNB adolescents and young adults experience anxiety and depression, as well as suicidal ideation, at a much higher rate than their cisgender peers. According to The Trevor Project’s 2020 National Survey on LGBTQ Youth Mental Health, 54 percent of young people who identified as transgender or nonbinary reported having seriously considered suicide in the last year, and 29 percent have made an attempt to end their lives. In contrast, numerous research studies have found that gender-affirming care leads to improved mental health among TGNB youth.
 
Social interventions, which are considered reversible (meaning that if gender identity shifts in the future, these decisions can be adapted), are often attempted in a step-wise manner. For example, children may first begin to use a new name or pronouns in the home, and if this feels positive, they may start to do so in other environments, such as school. Social transition may also involve use of different clothing or engagement in new activities, such as transferring to a new a camp or sports league, that are more congruent with the child’s gender. Social interventions have been found to lower the rates of depression and anxiety in TGNB children. 

Pubertal suppression, also considered fully reversible, allows for a “pause” on puberty and for further development of gender identity. Delaying puberty to promote physical development that is consistent with a child’s gender identity is associated with better mental health outcomes, improved functioning, and life satisfaction. Gender-affirming hormone therapy, which involves the use of feminizing or masculinizing hormones to allow the body to develop physical changes that align with a person’s gender identity, also significantly decreases gender dysphoria
 
Although less frequent than other forms of gendering-affirming care, medical procedures, such as chest surgery, may be performed on older adolescents who have shown a consistent and persistent gender identity, are stable with respect to their mental health, and have parental support. These decisions are made by a multidisciplinary team of medical experts in conjunction with the adolescent and their parents. In particular, transmasculine adolescents who have undergone chest surgery report significant relief in dysphoria and very rare regret. 
 
The World Professional Association for Transgender Health provides guidelines through their Standards of Care for providers working with TGNB individuals. Providers following these ethical guidelines are obliged to facilitate and encourage family support and involvement. All medical interventions for any child under the age of 18 require parental consent, as well as the child’s assent. It is recommended that adolescents and their parents be involved in psychological care to help them best understand the benefits, risks, and permanent effects of gender-affirming interventions. Youth undergoing medical interventions are also carefully monitored by a specialized endocrinologist to ensure for their safety and well-being. Moreover, when possible, adolescents are provided with options for fertility preservation. 
 
Multiple medical groups, including the American Medical Association and the American Academy of Pediatrics, endorse gender-affirming care for TGNB youth and have been vocal in their opposition of efforts that restrict access. The American Civil Liberties Union has brought a lawsuit on behalf of four transgender youth and their families, as well as two doctors, challenging the Arkansas law that prohibits health care professionals from providing or even referring transgender young people for medically necessary health care. 
 
It is already clear that these proposed laws are having a negative impact on TGNB youth and their families, compounding the prejudice, discrimination, violence, and other forms of stigma they continue to face in their daily lives. Indeed, research has demonstrated that the sociopolitical climate and legislation targeting the LGBTQ+ community impair the mental and physical health of individuals in the community. 
 
Tragically, many families have considered fleeing their home states in order to maintain appropriate medical care. This is simply unacceptable: vulnerable TGNB children and adolescents must continue to have access to affirming and evidence-based transgender health care, regardless of where they live.  
   
Kareen M. Matouk, PhD (she/her/hers), Columbia University Irving Medical Center/Gender Identity Program and Melina Wald, PhD (she/they), Columbia University Irving Medical Center/Gender Identity Program