To mark International Transgender Day of Visibility, Medical News Today spoke to several mental health professionals and a suicide prevention organization for LGBTQ people to see if science fully backs gender-affirming care for trans and nonbinary youth
*March 31 is International Transgender Day of Visibility, an annual event dedicated to raising awareness of the discrimination faced by transgender and gender nonconforming people and celebrating their contributions to society.
Gender-affirming healthcare is a topic of discussion that has gained renewed attention recently after becoming politicized by the so-called “Don’t Say Gay” bill, or HB 1557. The new law in Florida bars the instruction and discussion around gender identity and sexuality in K-3 classrooms.
Gender-affirming care can best be defined as the psychological, social, and medical healthcare designed to affirm individuals’ gender identities.
“Gender identity is essentially an individual’s perception of having a specific gender, which may not align with his, her, or their birth sex. It is the internal, intuitive sense of being female, male, both, or neither,” Dr. Leela R. Magavi, a Hopkins-trained psychiatrist and regional medical director for Mindpath Health, told Medical News Today.
Some people may wish to receive gender-affirming healthcare if their gender identity does not match their sex assigned at birth.
In the United States alone, an estimated 1.4 million people identify as transgender, and a further 1.2 million adults ages 18-60 identify as nonbinary.
It is a common misconception that individuals are not aware of their gender identity until later in life. By age 3-5, kids already have an established awareness of gender identity and gender-specific behaviors.
“Children can recognize and identify gender groups between ages 18 and 24 months, and most can identify their own gender by age three,” said Dr. Magavi.
Gender-affirming healthcare comes in many forms. It is not one-size-fits-all; like many medical therapies and treatments, it depends on the person’s age, condition, etc.
The type and method of gender-affirming care look different for different age groups. Gender-affirming care could be as simple as using a different name and the correct pronouns for kids. It may involve taking drugs to delay puberty or receiving hormone therapy for adolescents. Later in life, these individuals may want to undergo surgery.
“After assessing and really getting to know the child or teen, and if appropriate, I encourage parents to utilize their children’s preferred name and pronoun, and to encourage their family members, friends, and neighbors to do the same. This could help prevent social isolation, depression, and suicidal thoughts in children and teens,” said Dr. Magavi.
“Physicians and clinicians who are trans-affirming can alleviate their patients’ fears by validating them and encouraging them to speak about their beliefs, goals, strengths, weaknesses, and uncertainties. [I]t is pivotal for clinicians to understand LGBTQIA individuals and their needs in order to individualize treatment.”
– Dr. Leela R. Magavi
Dr. Jonah DeChants, a research scientist at The Trevor Project, the world’s largest suicide prevention and crisis intervention organization for LGBTQ youth, said it was important to note that no gender-affirming medical treatments are prescribed to prepubescent children.
Gender-affirming care for kids focuses on the social and psychological aspects. Such changes are also easier to implement for families.
“[P]arents can help their children feel more safe and comfortable by discussing redecoration of bedrooms or transitions in wardrobes to align with nonbinary themes,” said Dr. Magavi.
Dr. DeChants reiterated that there are many ways in which people can act to affirm and support trans youth without medical intervention.
“[O]ur research has found that respecting a young person’s pronouns is associated with lower suicide risk and that transgender and nonbinary youth with access to binders, shapewear, and gender-affirming clothing reported lower rates of attempting suicide in the past year compared to transgender and nonbinary youth without access,” he said.
All research so far underscores that a multidisciplinary approach—one that includes questions about fertility, mental health support, and hormone therapy, if necessary—is needed while providing gender-affirming care.
Sarah Harte, a licensed independent clinical social worker and the director for the Washington D.C. branch of The Dorm, a full-service treatment community for youth, said there were many options for gender-affirming care throughout an individual’s lifespan.
“Most gender diverse people benefit from the support of their social transition, as well as family support, education, and mental healthcare,” she said.
Harte also pointed out the importance of support and education for the family.
“[P]arents, siblings, and other family members need and deserve their own support in navigating social transition and gender diversity. The more support and resources the family has in their system, the better equipped they will be to support their gender diverse family members,” she told MNT.
The statistics speak for themselves. Research shows that transgender people are 2 to 3 times more likely to have depression or anxiety and are at severe risk of depression and self-harm.
A study published in the journal Pediatrics in 2020 found that of over 20,500 transgender adults surveyed in the U.S., only 2.5% received puberty blockers despite almost 17% expressing their wish to do so. The adults who received treatment were 70% less likely to have considered suicide.
“Both societal stigma and the symptoms of gender dysphoria can exacerbate overall struggles with mental health, which often go untreated due to a hesitancy to seek care.”
– Sarah Harte, director of The Dorm D.C.
Another study conducted in the Netherlands saw that kids and teens who had visited a gender clinic but had not yet received puberty blockers were more likely to die by suicide than their non-transgender peers. When kids started taking puberty blockers, their mental health improved and was similar to or better than their non-trans peers.
Similarly, a 2019 study on transgender teens revealed that 21 out of the 47 trans teens surveyed had suicidal tendencies before starting hormone therapy. After treatment, that figure dropped to 6.
The American Academy of Pediatrics endorses gender-affirming care. It also acknowledges that limiting or banning access to healthcare for transgender and nonbinary people may cause these individuals’ mental health to deteriorate further.
“Recent polling shows that 85% of transgender and nonbinary youth — and two-thirds of all LGBTQ youth (66%) — say recent debates about anti-trans laws have negatively impacted their mental health,” said Dr. DeChants.
How anti-trans bills affect LGBTQ youth
“When asked about proposed legislation that would ban doctors from prescribing gender-affirming medical care like puberty blockers or hormone therapy, 73% of transgender and nonbinary youth said it made them feel angry, 57% felt sad, 47% felt stressed, 40% felt scared, and more than 1 in 3 felt hopeless, helpless, and/or nervous.”
– Dr. Jonah DeChants
When it comes to gender-affirming care, timing also proves crucial.
“[C]onsensus among researchers in this area is that transgender and gender-diverse people of all ages benefit from trauma-informed and evidence-based care and that the earlier the care is given, the greater the benefit to the patient’s overall health – both mentally and physically,” said Harte.
One of the biggest benefits of gender-affirming healthcare is that it can be “life-saving.”
“A 2021 peer-reviewed study by The Trevor Project’s researchers, published in the Journal of Adolescent Health, found that gender-affirming hormone therapy is significantly related to lower rates of depression, suicidal thoughts, and suicide attempts among transgender and nonbinary youth,” said Dr. DeChants.
Research continues to demonstrate the benefits of gender-affirming and trauma-informed care to mental health and overall well-being and functioning, said Harte.
Not only are transgender and gender nonconforming people more likely to experience mental health problems, but they are also at a higher risk than the general population to experience trauma related to poverty, homelessness, and violence, she said.
According to Harte, the negative impact of limiting access to gender-affirming care can be categorized into two main outcomes:
“Laws and systems barring gender-affirming healthcare will contribute to higher rates of significant mental health problems, including deaths by suicide. Additional barriers to safe, well-informed care will also lead to more unsafe and unreliable self-care practices, where people seek out treatments and procedures in unregulated and unsafe environments.”
Harte also reiterated that the healthcare received and attitudes expressed toward the patient early in life profoundly affect the individual’s life.
“[It] is particularly important when early experiences of healthcare, both affirming and discriminatory, have the potential to influence a patient’s attitude toward healthcare for the rest of their lives. This impacts all areas of health, not only gender-affirming procedures, but the frequency of people proactively seeking medical and psychological care for all areas of health, such as heart health, sexual health, and mental healthcare,” she explained.
Those supporting anti-transgender bills often argue that individuals may express regret after undergoing medical interventions, and hormonal therapies may also affect their bone health or fertility.
Existing data suggest that bone growth catches up once people stop taking puberty blockers. Doctors also prescribe vitamin D and calcium supplements to offset this side effect and recommend weight-bearing exercises to
Puberty blockers are also reversible. Individuals typically start hormone therapy around ages 14-16. Although breast development and voice deepening are permanent from hormone therapy, muscle mass and body fat distribution changes can be reversed when the treatment stops.
“The effects of puberty blockers are reversible, which is why they are frequently prescribed as a first step to provide transgender and nonbinary young people, their families, and their doctors with more time to determine if other forms of gender-affirming healthcare are needed,” pointed out Dr. DeChants.
“Puberty blockers are also not intended to be a long-term treatment,” he added.
Dr. DeChants acknowledged that while
“Just like any medical treatment, potential side effects must be considered with the positive effects. For many youth, families, and doctors, the positive effects of mitigating dysphoria and distress are seen as crucial to ensuring a young person’s overall health and well-being,” he told MNT.
“Preventing trans and nonbinary youth from accessing GAHT makes it more likely that their bodies will change irreversibly in ways that are highly distressing to them.”
– Dr. Jonah DeChants
Before an individual undergoes medical interventions, doctors consider all outcomes and do a risk-benefit analysis with the patient. Regardless of the individual’s age, communication throughout also proves crucial as they may decide to stop or postpone treatment.
Harte highlighted the importance of having “a trusting and collaborative relationship” with healthcare professionals to ensure that both the trans or nonbinary individual and their families are aware of any side effects or other risks, “both from intervention or the lack thereof.”