Gender-affirming care has become an increasingly discussed and, at times, contentious topic in healthcare and public policy. While medical professionals and leading health organizations advocate for its necessity and positive impact, a growing number of legislative bodies are attempting to restrict or even criminalize certain aspects of this care, especially for young people. This article aims to provide a comprehensive understanding of what gender-affirming care truly is, drawing on expert opinions and established medical guidelines to clarify its purpose, scope, and importance.
Defining Gender-Affirming Care
The World Health Organization (WHO) defines gender-affirming care as encompassing a wide array of social, psychological, behavioral, and medical interventions. These interventions are specifically “designed to support and affirm an individual’s gender identity” when it differs from the sex they were assigned at birth. Essentially, gender-affirming care is about helping transgender and gender non-conforming individuals align their lives – emotionally, socially, and physically – with their deeply felt gender identity.
It’s crucial to understand that gender identity exists on a spectrum, as recognized by the American Psychiatric Association (APA). This spectrum includes not only the binary genders of man and woman but also combinations, neither, or fluid identities. Gender-affirming care respects this diversity and aims to support individuals wherever they fall on this spectrum.
The interventions themselves are also diverse, ranging from supportive counseling and social changes to medical treatments like hormone therapy and, in some cases, surgery. For children and adolescents, the approach to care is particularly nuanced, carefully considering their developmental stage, cognitive maturity, and the importance of parental consent. Surgical interventions are rarely considered for individuals under the age of 18.
Dr. Jason Rafferty, a pediatrician and child psychiatrist at Hasbro Children’s Hospital, emphasizes that gender-affirming care is far more than just medical procedures. “It’s not just medication. It’s much deeper than that,” he explains. The core of this care, especially for young people, is to create a safe and understanding environment where they can explore their feelings, questions, and concerns about their gender identity without judgment.
Why Individuals, Especially Youths, Seek Gender-Affirming Care
Many transgender individuals, including children, experience a deep-seated awareness of a difference between their assigned sex and their gender identity from a very young age. Dr. Deanna Adkins, director of the Duke Child and Adolescent Gender Care Clinic, notes that by the time adolescents seek gender-affirming care, they have often been grappling with these feelings for a significant period.
A key reason individuals seek gender-affirming care is to alleviate gender dysphoria. The APA defines gender dysphoria as the psychological distress that arises from the incongruence between a person’s assigned sex and their gender identity. While not all transgender individuals experience clinically significant dysphoria, for those who do, it can be profoundly distressing and impact various aspects of their lives. Gender dysphoria is recognized as a clinical condition in the APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM), characterized by a strong desire to possess the sex characteristics of a different gender, to be treated as that gender, and significant distress or impairment in social, occupational, or other areas of functioning.
Research consistently shows that transgender youth, particularly those experiencing gender dysphoria, are at a significantly higher risk for mental health challenges. They are more likely to experience emotional distress, depression, bullying, violence, self-harm, and suicidal ideation. A University of Minnesota study involving nearly 82,000 students found that a staggering 61% of transgender youths reported suicidal ideation, more than three times the rate among their cisgender peers.
The Mayo Clinic highlights the academic and social struggles faced by gender dysphoric youth in school. Pressure to conform to gender norms associated with their assigned sex and fear of harassment can create significant obstacles. Furthermore, fear of stigma and a lack of experienced healthcare providers can make accessing necessary health and mental health services challenging.
Types of Emotional, Social, and Psychological Gender-Affirming Care
Creating a culturally competent and medically safe environment is paramount in gender-affirming care. Dr. Katherine Imborek, co-director of the LGBTQ Clinic at UI Health Care, emphasizes that the most fundamental need for transgender individuals is a healthcare provider who understands their unique needs and provides care in a safe and affirming space. This affirming environment is itself a crucial aspect of primary care.
This environment encourages open and honest conversations about gender identity, related stress, sexual health, and the possibility of transitioning. The individual’s developmental stage, both physical and psychological, plays a critical role in determining the appropriate interventions and their timing.
It’s important to note that for children, gender dysphoria may not persist into adulthood, particularly for those who experience it in early childhood. However, the World Professional Association for Transgender Health (WPATH) notes that for adolescents, gender dysphoria is more likely to continue into adulthood.
Transition support can begin with social and cosmetic changes and progress to more intensive interventions as needed. This care is often delivered by a multidisciplinary team of physicians, mental health professionals, and other support providers. Examples of emotional, social, and psychological gender-affirming care include:
- Counseling: Providing support and guidance for individuals as they navigate coming out to family, friends, and others, including teachers and school administrators.
- Resources for Gender Expression: Offering resources to help individuals align their outward appearance and gender presentation with their gender identity. This can include referrals to services like hair salons experienced in working with transgender clients for hair and makeup guidance, as provided by UI Health Care’s LGBTQ Clinic.
- Speech Therapy: Assisting individuals in modifying their vocal characteristics, such as pitch and speech patterns, to better align with their gender identity.
- Hair Removal: Providing or facilitating access to hair removal services like electrolysis, laser treatment, or waxing to address gender dysphoria related to body hair.
- Binding and Padding: Guidance and resources for chest binding, genital tucking, and using padding to shape the hips or buttocks to achieve a more congruent gender presentation.
A key point stressed by specialists is that these social and psychological interventions are generally reversible. Individuals may choose to pause or stop their transition process at any point, whether to further explore their identity or because they have reached a point of comfort and congruence.
Hormone-Related Therapies in Gender-Affirming Care
For many transgender individuals, medical interventions like hormone therapy are a vital part of gender-affirming care. These therapies are carefully considered and implemented based on established guidelines and individual needs.
Puberty Blockers: For transgender youth who have not yet started or are in the early stages of puberty, puberty blockers can be a valuable option. These medications temporarily suppress the release of sex hormones like testosterone and estrogen. As the Mayo Clinic explains, for individuals assigned male at birth, puberty blockers can prevent the development of facial and body hair, voice deepening, and limit genital growth. For those assigned female at birth, these medications can limit or halt breast development and menstruation.
The primary purpose of puberty blockers is to provide young people with time to explore their gender identity and consider their transition options before irreversible secondary sex characteristics develop. Dr. Rafferty describes them as a way to “slow things down” during early puberty, giving youth the space to understand themselves better when they express that their assigned gender “doesn’t feel right.”
It is important to emphasize that the effects of puberty blockers are reversible. If the medication is stopped, puberty will resume naturally. Puberty blockers are generally not initiated after puberty is complete, as they are no longer necessary and the hormones they suppress are essential for healthy adult development, such as estrogen for bone health.
Hormone Therapy: For older adolescents and adults, hormone therapy is often a crucial step in medical gender affirmation. This involves administering hormones, either estrogen or testosterone, to induce the development of sex characteristics that align more closely with the individual’s gender identity. For individuals transitioning to a more masculine presentation, hormone therapy leads to increased hair growth and muscle mass. For those transitioning to a more feminine presentation, it promotes breast development and testicular atrophy.
The changes from hormone therapy occur gradually, and it’s common for individuals to adjust or stop therapy before fully developing all secondary sex characteristics, having achieved their desired level of biological transition. Depending on when hormone therapy is discontinued, some effects can partially or completely reverse, such as shoulder broadening in those taking testosterone and early breast development in those taking estrogen.
Determining Eligibility and Criteria for Gender-Affirming Care
Established guidelines from organizations like WPATH, AAP, and the Endocrine Society provide clear criteria for gender-affirming care, including hormone-related therapies. These guidelines emphasize the importance of a thorough assessment process. The WPATH Standards of Care stress that for adolescents, “before any physical interventions are considered… extensive exploration of psychological, family, and social issues should be undertaken.”
Dr. Imborek at the Iowa clinic describes the initial phase as an exploratory period. Individuals in a “questioning phase” work closely with therapists to understand their gender dysphoria and determine if hormone therapy would be beneficial.
Typical criteria for initiating hormone-related therapies for youth include:
- Persistent Gender Dysphoria: A diagnosis of gender dysphoria, based on experiencing several DSM-listed symptoms for at least six consecutive months.
- Mental Health Support: A letter of support from the youth’s licensed therapist and concurrence from another mental health professional.
- Parental Consent: For individuals under 18, parental consent is required.
- Ongoing Psychotherapy: Continued engagement in psychotherapy is often recommended to support the individual throughout their transition journey.
Providers have a responsibility to ensure that young people and their families fully understand the potential permanent changes and risks associated with hormone therapy, including potential impacts on fertility. Despite these well-established guidelines and the medical consensus supporting gender-affirming care, it faces political challenges. For example, in Texas, an opinion issued by the Attorney General cited potential risks like infertility, cardiovascular disease, and elevated blood pressure as grounds to argue that these therapies constitute child abuse – a claim strongly refuted by medical organizations.
The Positive Impact of Gender-Affirming Care
Numerous studies have demonstrated the positive impact of gender-affirming care on the mental health and well-being of transgender individuals. A Stanford University School of Medicine study published in January found that adolescents who began hormone therapy earlier experienced significantly lower rates of suicidal ideation, mental health disorders, and substance abuse compared to those who started later.
While the WPATH acknowledges that there is less long-term data on outcomes for younger children who receive gender-affirming care, the existing evidence strongly supports its benefits. Contrary to claims made by some opponents, such as the Texas Attorney General’s opinion asserting a lack of evidence for improved long-term mental health outcomes or reduced suicide rates, healthcare providers witness these positive changes firsthand.
Dr. Adkins at the Duke Child and Adolescent Gender Care Clinic attests to the transformative effects of gender-affirming care. “Most of them are happier, less depressed, and less anxious,” she states. Furthermore, she notes improvements in school performance and overall safety for her patients.
The positive impact of gender-affirming care is profound and, for many, life-saving. As Dr. Rafferty emphasizes, even simple acts of affirmation, such as using a person’s correct name and pronouns, can have a significant positive influence on their health and development. He urges healthcare providers to recognize all forms of gender affirmation as essential healthcare, stating, “It’s important for providers to know that what they do, even if it’s just affirming someone’s [asserted] name, can have a positive influence on the health and development of that child. This support has to take place within a clinic. It’s not something that can be legislated.”
In conclusion, gender-affirming care is a comprehensive, evidence-based approach to healthcare that supports the well-being of transgender and gender non-conforming individuals. It is rooted in established medical guidelines and driven by the goal of helping individuals live authentically and healthily in alignment with their gender identity. Despite ongoing political challenges and misinformation, the medical consensus remains clear: gender-affirming care is medically necessary, beneficial, and, for many, life-saving.
