Dissecting statistical genomics and psychiatric epidemiology...
Gender-Affirming Care for Minors
Gender-affirming care for minors is one of the most contentious issues in the American public. In this post, I overview the current standards of practice in gender-affirming care for transgender youth, its benefits, risks, and opportunities for further research.
As of June 11, 2024, 25 states have enacted laws and policies limiting youth access to gender-affirming care, affecting about 39% of American trans youth [1]. 17 of those states are facing legal challenges to their policies, and 23 of those states impose professional or legal penalties on healthcare professionals providing gender-affirming care to minors [1].
Over 156,500 transgender youth live in 32 states where access to gender-affirming care has been restricted or was at risk of being banned due to legislation filed this legislative session [2]. Suicide is a pervasive issue among transgender youth, and the rates of suicide attempts vary with respect to various factors associated with trans existence [3].
Gender-affirming care is consistently shown to improve well-being of transgender and nonbinary youth, particularly with respect to self-harming and suicidal behaviorS.
For example, “passing” or being perceived as cisgender instead of transgender/sex assigned at birth, was associated with nearly half reduction in past-year suicide attempt (12.2% among those who never pass vs. 6.3% among those who always pass) [3]. In a similar fashion, the duration of gender-affirming care was also associated with nearly half reduction in past-year suicide attempt (9.7% among those who have received care for less than a year vs. 5.2% among those who have received care for 10 years or more) [3].
While currently taking hormones was not associated with any risk reduction, access to hormones among transgender individuals who want them was (8.9% among those who wanted hormones but didn’t have them vs. 6.5% among those who wanted hormones and had them) [3]. The source from which transgender individuals obtained their hormones was (5.8% among those who have received hormones from licensed professionals vs. 16.4% among those who have received hormones from someone other than licensed professionals) [3].
Individuals who have “de-transitioned” were also at a higher risk of suicide attempt (11.8% among those who have de-transitioned vs. 6.7% among those who didn’t), albeit individuals who have “de-transitioned” usually cited reasons such as pressure from family and friends or having experienced too much harassment or discrimination [3].
A recent study of 106 transgender and non-binary adolescents aged 13-20 (mean age 15.8) has found that receiving gender-affirming care was associated with 60% lower odds of moderate or severe depression and 73% lower odds of suicidality over a period of 12 months [4].
Given the beneficial effects of gender-affirmation therapy, particularly when considering severe outcomes related to mental health like suicidality, we are left wondering why this particular form of healthcare is regulated at the legislative level and why is it facing such a staunch opposition, predominantly from conservatives?
Politicization and Discrimination of Queer and Trans People as an Underlying Cause of Suffering
The politicization of the queer and trans identities has been on the rise over the past decade. The rise of populist and illiberal sentiments and candidates in the US and abroad has made queer and trans people one of the main targets of bigoted attacks in the media, legislation, and political campaigns [5].
Conservative politicians, pundits, and influencers regularly accuse queer and trans people of grooming, sexual abuse, and indoctrination, effectively spreading fear and hatred resulting in discriminative behaviors and policies targeting queer and trans people. In fact, 36% of queer- and trans-identifying individuals have reported experiences of discrimination in the past 12 months, compared to 19% of their cis-gendered, heterosexual counterparts [6]. These effects were ubiquitous, showing higher incidences of discrimination among queer and trans people, regardless of the racial group or disability status. Transgender and intersex people had reported past-year experiences of discrimination at substantially higher rates (56% and 67%, respectively) [6].
Queer and trans people were 1.6 times (and trans people were 2.5 times) more likely to experience discrimination in public spaces [6]. In the workplace, queer and trans people were 1.4 times (and trans people were 1.8 times) more likely to experience discrimination [6]. In schools, queer and trans people were 1.6 times (and trans people were 2.8 times) more likely to experience discrimination [6]. And in housing, queer and trans people were 2.6 times (and trans people were 2.8 times) more likely to experience discrimination [6].
Discrimination trans people experience causes adverse effects to their mental, physical, spiritual, and financial well-being.
The experiences of discrimination have affected queer and trans individuals in multiple domains of life, including mental, spiritual, financial, and physical well-being. Trans people overall have reported experiences of discrimination negatively affecting their mental well-being 2.1 times more than their cisgender, heterosexual counterparts [6]. Similar was true for spiritual (2.5 times more), financial (1.5 times more), and physical (2.3 times more) well-being [6].
These experiences have led to trans people hiding their personal relationships (63%), avoiding houses of worship (57%), changing the way their dress or their mannerisms (64%), moving away from family (49%), avoiding public places (53%), and avoiding medical offices, mental health providers, or hospitals (55%) [6]. Trans people were also more likely, relative to their cisgender, heterosexual counterparts, to postpone or avoid getting needed medical care (3.0 times more) and preventative screenings (2.8 times more) due to cost [6]. They were also more likely to postpone or avoid getting needed medical care (5.3 times more) and preventative screenings (5.9 times more) due to discrimination or disrespect by the providers [6].
A particularly insidious form of discrimination queer and trans people face is false accusations of grooming and sexually abusing women and children [7]. Trans people have been on the receiving end of the majority of such accusations, particularly in the context of gender-inclusive restrooms, despite the fact that there is absolutely no evidence to support such claims [8].
Ironically, while queer and trans people are not more likely to be perpetrators of sexual abuse, queer and trans youth are 2.5 times more likely to be victims of sexual abuse [9, 10]. In fact, a separate study of 1,836 adolescents between ages of 14 and 18 has shown that transgender adolescents, relative to their cisgender heterosexual counterparts, had higher odds of experiencing psychological abuse (OR = 1.84), physical abuse (OR = 1.61), and sexual abuse (OR = 2.04) [11].
Gender-Affirming Care is Misrepresented as Child Abuse
In addition to the unsubstantiated accusations of grooming and sexual abuse against trans individuals, parents of trans youth as well as healthcare professionals providing much needed care to trans individuals are commonly accused of indoctrination and child abuse [12]. Majority of legislators and lobbying groups advocating for restrictions to gender-affirming care count on such false allegations to garner support among their constituents. Most common form of misrepresentation is that gender-affirming care for pre-pubescent children involves sterilizing hormone replacement therapy [13].
However, gender-affirming care involves more than just hormone replacement therapy, and the type of care is tightly controlled by best practices of care in developmentally appropriate manner. Generally speaking, gender-affirming care involves the following 4 types of care: (1) social affirmation, (2) puberty blockers, (3) hormone (replacement) therapy, and (4) gender-affirming surgeries [14].
Social affirmation, a completely reversible form of gender-affirming care provided at any developmental period, involves adaptation of gender-affirming presentation (e.g., clothing, hairstyles, names, gender pronouns, etc) [15]. Social affirmation has been associated with positive outcomes of psychological well-being, with psychological affirmation/gender comfort being associated with higher self-esteem (r = 0.27, p < 0.05), lower depressive symptoms (r = -0.21, p < 0.001), and lower endorsement of suicide ideation (t = 3.87, p < 0.001) [16].
Social affirmation as a form of revirsible and developmentally appropriate gender-affirming care for children has a demonstrably net-positive effect on their psychological well-being and development.
Another study has found that social gender transition has been associated with lower rates of self-harm (RR = 0.78, p < 0.05), depression diagnosis (RR = 0.71, p < 0.05), and depressive distress (RR = 0.42, p < 0.05) [17]. A separate study that examined self-reported depression, anxiety, and self-worth among socially transitioned children relative to age- and gender-matched controls and siblings of transgender children has found no difference between these three groups in terms of depression, anxiety, or self-worth (p > 0.05), indicating that social transitioning may ameliorate these symptoms [18].
Finally, a study examining relation between chosen name use as a proxy for social affirmation and mental health among transgender youth has shown that chosen name use was associated with overall lower depressive symptoms (β = -5.37), suicidal ideation (IRR = 0.71), and suicidal behavior (IRR = 0.44) [19]. Ultimately, social affirmation as a form of gender-affirmation care is demonstrably having a net-positive effect on psychological well-being of transgender youth.
Puberty Blockers
Puberty blockers are a form of pharmacological therapy used to target gonadotropin releasing hormone (GnRH) receptors, also known as GnRH agonists. These GnRH agonists bind to GnRH receptors on the pituitary gland, and eventually lead to reduced secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). As LH and FSH stimulate production of estrogen in females and testosterone in males, their elimination effectively eliminates the production of testosterone and estrogen, thus delaying onset and/or progression of puberty.
It is important to note that, while the popularization of the term puberty blockers has squarely associated GnRH agonists with gender-affirming care, they have much broader applications in healthcare. For example, GnRH have been the gold standard treatment for precocious (premature) puberty [20], in vitro fertilization [21], hormonally sensitive cancers (breast, prostate) [22], endometriosis [23], etc. This class of medication has been in use since 1980s.
Puberty blockers are, after all, medications and all medications have side effects. While generally believed to be completely reversible [24, 25], some evidence from molecular studies has indicated some effects of puberty blockers may not be reversible [26]. The pediatric use of GnRH agonists for precocious puberty in cisgender youth and for puberty delay in transgender youth has been ongoing since 1990s. While no immediately apparent irreversible adverse effects have been documented in patients using these medications, more research needs to be done to fully characterize the extent of reversibility among individuals who chose to discontinue their transitions.
Very few individuals cease GnRH agonists, especially for the purposes of discontinuing their transition. A study of 143 adolescents who started GnRH agonists has identified only 5 (3.5%) chose to discontinue their treatment [27]. Based on the reports in the paper, 3/5 individuals who ceased their GnRH agonists have ultimately decided they are cisgendered and 2/5 individuals have decided they may be gender diverse but did not want to continue puberty blockers [27].
In another study of adolescents in Texas, 2/55 (3.6%) of adolescents taking puberty blockers have discontinued them during the follow-up period [28]. Similarly, in the Amsterdam Cohort of Gender Dysphoria Study, only 1.9% of individuals stopped taking puberty blockers [29]. Neither study indicated the reasoning behind stopping puberty blockers.
Puberty blockers are essential treatment for transgender youth, associated with benefits like improvement to psychological well-being and mental health, as well as decreased need of future plastic surgeries.
The overall trends indicate that transgender youth benefits from puberty blockers. In addition to the low cessation rates, GnRH agonists have been association with improvements in psychological and emotional well-being. One study reported 16.1% reduction in body dissatisfaction, 14.6% reduction in self-reported depressive symptoms, 7.9% reduction in anxiety symptoms, and 17.2% reduction in panic symptoms in 1.5 years of follow-up after initiating puberty blockers [28].
A study surveying 20,619 transgender adults has found that access to puberty blockers was associated with lower odds of 12-month (OR = 0.6, p = 0.006) and lifetime (OR = 0.3, p < 0.001) suicide ideation, as well as lower odds of past-month severe psychological distress (OR = 0.5, p = 0.001) [30]. In conclusion, absence of severe adverse effects, in conjunction with relatively low rates of cessation/regret and notable improvements in mental health, puberty blockers are an integral component of gender-affirming care for youth.
It is important to note that, usually, access to GnRH agonists/puberty blockers will depend on clinicians in charge of adolescent’s care. Medical societies issue guidelines for clinicians to follow when deciding if the use puberty blockers in trans youth is appropriate. Table 1. summarizes the criteria for GnRH agonist treatments adapted by the Endocrine Society.
| Table 1. Eligibility Criteria for GnRH agonist treatment |
|---|
| 1. A qualified mental health professional has confirmed that: • the adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed), • gender dysphoria worsened with the onset of puberty, • any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment, • the adolescent has sufficient mental capacity to give informed consent to this (reversible) treatment. |
| 2. The trans adolescent: • has been informed of the effects and side effects of treatment (including potential loss of fertility if the individual subsequently continues with sex hormone treatment) and options to preserve fertility, • has given informed consent and (particularly when the adolescent has not reached the age of legal medical consent, depending on applicable legislation) the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process. |
| 3. And a pediatric endocrinologist or other clinician experienced in pubertal assessment: • agrees with the indication for GnRH agonist treatment, • has confirmed that puberty has started in the adolescent (Tanner stage ≥ G2/B2), • has confirmed that there are no medical contraindications to GnRH agonist treatment. |
| Adapted from the Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline [31]. |
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Hormone Replacement Therapy
Unlike puberty blockers, which halt puberty by stopping production of male and female sex hormones, hormone (replacement) therapy is a form of gender-affirming care where individuals take sex hormones opposite of sex assigned at birth in order to facilitate medical transition [14]. In essence, trans individuals assigned male at birth would take female sex hormones, and trans individuals assigned female at birth would take male sex hormones (note: since we are talking about sex and sex hormones, the use of words like female and male, instead of women and men, here is very intentional).
Hormone therapy regiments in transgender females involve estrogen with or without anti-androgens (medications that suppress testosterone) or GnRH agonists [31]. We’ve discussed GnRH agonists above, so here we will briefly overview estrogen and anti-androgens. Estrogen is a class of sex hormones associated with the development and regulation of female reproductive systems and secondary sex characteristics [32]. Estrogens are composed of 4 major hormones: estrone (precursor to estradiol), estradiol (most abundant and responsible for reproductive development and secondary sex characteristics), and estriol and estetrol (produced during pregnancy) [32]. Estrogen is commonly used medication beyond hormone therapy for transfeminine persons, including in contraception, menopause and hypogonadism in cisgender females, in treatment of hormonal cancers, and other various conditions.
Anti-androgens are medications that target and suppress androgen receptors and/or inhibit/suppress androgen production [32]. Androgens, like their estrogen counterparts, are a class of sex hormones associated with the development and regulation of male reproductive systems and secondary sex characteristics [32]. Major classes of androgens include testosterone, dihydrotestosterone (a more potent testosterone derivative), dehydroepiandrosterone, androstenedione (also commonly used as muscle/performance enhancer in sports), androstenediol, androsterone, etc [32]. Anti-andorgens effectively counter the effects of androgens in bodies and are also commonly used medications beyond hormone therapy for transfeminine persons, including treatments for prostate cancer or enlarged prostate, scalp hair loss in cisgender males, acne and sexual dysfunctions in cisgender males, some skin and hair conditions in cisgender females, as well as hyperandrogenism and related conditions like polycystic ovarian syndrome in cisgender females.
Feminizing hormone therapy usually results in decreased body and facial hair, decreased
muscle mass, breast growth, and redistribution of fat [33]. The risks associated with feminizing hormone therapy are generally low and include thromboembolism (usually dependent on dose and route of administration), depression, and osteoporosis [33].
Hormone therapy regiments in transgender males usually involve administration of testosterone [31]. The desired effects of this masculinizing hormone therapy include increased facial and body hair, increased lean mass and strength, decreased fat mass, deepening of the voice, increased sexual desire, cessation of menstruation, clitoral enlargement, and reductions in gender dysphoria, perceived stress, anxiety, and depression [34]. Additional benefit of masculinizing hormone therapy is a reduced risk of breast cancer [34]. Potential risks associated with this therapy include acne, alopecia, reduced HDL cholesterol, increased triglycerides, and a possible increase in systolic blood pressure [34].
Hormone therapy is an essential step in transition of many trans individuals in adolescence and adulthood. These medication reduce secondary sex characteristics associated with sex assigned at birth and are associated with an overall improvement in quality of life of the trans people.
Access to hormone therapy depends on clinicians in charge of adolescent’s care. Medical societies issue guidelines for clinicians to follow when deciding if the hormone therapy in trans youth is appropriate. Table 2. summarizes the criteria for hormone therapy adapted by the Endocrine Society. In their guidelines, the Endocrine Society emphasizes that hormone therapy should be limited to individuals who are 16 years or older, with some exceptions such as individuals who have experienced complications related to bone health, inappropriate height, or potential harm due to delay of initiation of secondary sex characteristics [31].
| Table 2. Eligibility Criteria for hormone therapy |
|---|
| 1. A qualified mental health professional has confirmed that: • the persistence of gender dysphoria, • any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start sex hormone treatment, • the adolescent has sufficient mental capacity (which most adolescents have by age 16 years) to estimate the consequences of this (partly) irreversible treatment, weigh the benefits and risks, and give informed consent to this (partly) irreversible treatment. |
| 2. The trans adolescent: • has been informed of the (irreversible) effects and side effects of treatment (including potential loss of fertility and options to preserve fertility), • has given informed consent and (particularly when the adolescent has not reached the age of legal medical consent, depending on applicable legislation) the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process. |
| 3. And a pediatric endocrinologist or other clinician experienced in pubertal assessment: • agrees with the indication for sex hormone treatment, • has confirmed that there are no medical contraindications to sex hormone treatment. |
| Adapted from the Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline [31]. |
Several studies have reported beneficial effects of hormone therapy on the mental health and psychological well-being of the transgender youth. A study of 123 transgender Texans who have undergone feminizing or masculinizing hormone therapy starting at the mean age of 16.2 has shown 27.3% reduction in body dissatisfaction, 22.9% reduction in depressive symptoms, 12.9% reduction in anxiety symptoms, 12.3% reduction in panic symptoms [28].
An Italian study of 83 trans individuals receiving hormone therapy has found a significant improvement of life and interpersonal relationships among their male-to-female (MtF) trans participants, and body image and interpersonal relationships among their female-to-male (FtM) trans participants [35]. A Spanish study of 23 transgender adolescents and 30 cisgender adolescent controls has shown a mean depression score on the Beck-II inventory from 19.3 to 9.7 (p < 0.001) after a year of hormone therapy, approximating their cisgender controls at Beck-II inventory depression score of 7.4 [36]. The same study found mean anxiety score decrease from 33.0 to 18.5, after a year of hormone therapy (p < 0.001) [36].
Notably, 97.8% of individuals who have started puberty blockers have continued on to hormone therapy [37]. In a cohort study of 548 individuals with closed referrals to an Australian pediatric gender clinic, 29 (5.3%) reportedly reidentified with their birth-registered sex before or during assessment [38]. 2 out of 29 (6.9%) reidentified during medical treatment, which corresponds to 1.0% of all patients who initiated medical treatment [38].
However, some researchers disagree and think that the science of detransition and regret among individuals who start medically transitioning is still very much in its infancy [39]. One study seemingly deviating for generally low reports for detransition is a recently published follow-up study of 139 Canadian boys with gender dysphoria that found 88% rate of diagnosis reversal, which they termed desisters [40]. The same study reports that none of the participants in this study initialized medical transition, and details regarding potential regret or detransition were not discussed [40]. In essence, this study reports on diagnostic remission or diagnostic reversal, at worst, and not at all on detransition or regret regarding medical transition.
Gender-Affirming Surgeries
Gender-affirming surgeries are mostly irreversible forms of plastic surgeries that aim to facilitate desired gender presentations of trans individuals. Some examples of gender-affirming surgeries include top surgeries to remove breast tissue in FtM or breast implants in MtF individuals, bottom surgeries like phalloplasty (creating a penis) in FtM or vaginoplasty (creating a vagina) in MtF individuals, and other surgeries like facial masculinization or feminization [14]. Gender-affirming surgeries are typically performed in adulthood, and only in rare cases when indicated in late adolescence [14].
Access to gender-affirming surgeries is generally less easy than pharmacological treatments discussed previously, due to clinical guidelines discussed in Table 3 and their cost-prohibitive nature.
| Table 3. Criteria for Gender-Affirming Surgery |
|---|
| 1. Persistent, well-documented gender dysphoria. 2. Legal age of majority in the given country. 3. Having continuously and responsibly used gender-affirming hormones for 12 months (if there is no medical contraindication to receiving such therapy. 4. Successful continuous full-time living in the new gender role for 12 months. 5. If significant medical or mental health concerns are present, they must be well controlled. 6. Demonstrable knowledge of all practical aspects of surgery (e.g., cost, required lengths of hospitalizations, likely complications, postsurgical rehabilitation). |
| Adapted from the Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline [31]. |
Much like pharmacological interventions, surgical interventions are found to improve overall quality of life and mental health among transgender individuals and are thus an integral part of gender-affirming health care.
Regret and reversals of gender-affirming surgeries are very rare. In a study of 6,793 individuals in the Amsterdam Cohort of Gender Dysphoria Study, 5,913 have undergone a genital gender-affirming surgery, and only 14 (0.5%) have expressed regret or attempted to reverse the surgery [29]. Out of 14 that have expressed regret, 7 cited true regret, 5 cited social acceptance, and 2 cited feeling nonbinary [29].
A study of national insurance claims of 3,134 individuals with gender dysphoria has found an absolute decrease of 8.8% in anti-depressant prescription after gender affirming plastic surgery (p < 0.001), as well as significant decreases in post-operative depression (7.7%), anxiety (1.6%), suicidal ideation (5.2%) and attempts (2.3%), alcohol abuse (2.1%), and drug abuse (1.9%) [41]. Another study of 3,559 individuals from the 2015 US Transgender Survey found that undergoing gender-affirming surgery was associated with lower past-month psychological distress (OR 0.58; P < 0.001), past-year smoking (OR = 0.65; P < 0.001), and past-year suicidal ideation (OR = 0.56; P < 0.001) [42].
Why do Some People Detransition?
While uncommon, detransition and regret regarding transition do occur and are important areas of further research. Unfortunately, research in individuals who detransition/regret their transition is very limited. However, it’s important to emphasize that these individuals deserve proper healthcare and managements, as well as consideration by the research community.
4/5 individuals who detransition cite an external reason for doing so, most often due to pressure from family, friends, or workplace.
A survey of 27,715 US transgender individuals, 17,151 (61.9%) have reported pursuing broadly defined gender affirmation, and 2,242 (13.1%) individuals from those who have reported pursuing gender affirmation have reported a history of detransition (either temporary or permanent) [43]. Those with a history of detransition commonly cited fluctuations in identity or desire (10.5%), difficulty of the process (33.6%), pressure from a parent (35.6%), pressure from community or societal stigma (32.5%), pressure from my employer (17.5%), having trouble getting a job (26.9%), pressure from friends or roommates (14.2%), pressure from other family members (25.9%), and pressure from spouse or partner (20.2%) as reasons for their detransition [43].
In fact, over 82.5% of those who detransitioned cited an external reason for doing so [43]. In conclusion, detransition is still very much an active area of research. While, at the first glance, detransition may appear to be due to gender identity reversal, currently available research demonstrates that, for majority of people, detransition is an attempt to deal with social pressures of transphobic parent, friends, or coworkers/employers.
Where do Expert Clinicians and Scientists Stand?
Gender-affirming care is supported and endorsed by virtually all relevant expert organizations and societies. Table 4 lists professional organizations supporting gender-affirming care for transgender individuals.
| Organization | Membership |
|---|---|
| American Academy of Child and Adolescent Psychiatry [44] | 8,000 |
| American Psychological Association [45] | 157,000 |
| American Psychiatric Association [46] | 37,400 |
| American Academy of Family Physicians [47] | 136,700 |
| American Academy of Pediatrics [48] | 67,000 |
| American College of Physicians [49] | 163,000 |
| American College of Obstetricians and Gynecologists [50] | 60,000 |
| American Osteopathic Association [51] | 151,000 |
| American Medical Association [52] | 271,600 |
| American Academy of Dermatology [53] | 20,500 |
| American Academy of Physician Assistants [54] | 100,000 |
| American Nurses Association [55] | 4,000,000 |
| American Association of Clinical Endocrinology [56] | 5,700 |
| American Association of Geriatric Psychiatry [57] | 2,000 |
| American College Health Association [58] | 10,000 |
| American College of Nurse-Midwives [59] | 6,500 |
| American Counseling Association [60] | 58,000 |
| American Heart Association [61] | 30,000 |
| American Medical Student Association [62] | 68,000 |
| American Society of Plastic Surgeons [63] | 11,000 |
| American Society for Reproductive Medicine [64] | 9,000 |
| American Urological Association [65] | 23,000 |
| Endocrine Society [66] | 18,000 |
| Federation of Pediatric Organizations [67] | – |
| GLMA: Health Professionals Advancing LGBTQ Equality [68] | 1,000 |
| The Journal of the American Medical Association [69] | – |
| National Association of Nurse Practitioners in Women’s Health [70] | 13,000 |
| National Association of Social Workers [71] | 6,300 |
| Ohio Children’s Hospital [72] | *40,000 |
| Pediatric Endocrine Society [73] | 1,600 |
| Texas Medical Association [74] | 57,000 |
| Texas Pediatric Society [75] | 4,800 |
| United States Professional Association for Transgender Health (USPATH) [76] | 4,000 |
| World Health Organization (WHO) [77] | – |
| World Medical Association [78] | 10,000,000 |
| World Professional Association for Transgender Health [79] | 2,700 |
| Table 4. Organizations supporting gender-affirming care. |
What Can Parents of Transgender Children Do?
Being transgender in today’s society is not easy, nor is being a parent of transgender child. Parents often feel confused, anxious, and uncomfortable. However, accepting family environment is associated with optimistic life outlook among queer and trans youth [80]. The following set of books may also serve as a useful resource while raising a transgender child.
Stephanie Brill, Rachel Pepper
This comprehensive first of its kind guidebook explores the unique challenges that thousands of families face every day raising their children in every city and state. Through extensive research and interviews, as well as years of experience working in the field, the authors cover gender variance from birth through college. What do you do when your toddler daughter’s first sentence is that she’s a boy? What will happen when your preschool son insists on wearing a dress to school? Is this ever just a phase? How can you explain this to your neighbors and family? How can parents advocate for their children in elementary schools? What are the current laws on the rights of transgender children? What do doctors specializing in gender variant children recommend? What do the therapists say? What advice do other families who have trans kids have? What about hormone blockers and surgery? What issues should your college-bound trans child be thinking about when selecting a school? How can I best raise my gender variant or transgender child with love and compassion, even when I barely understand the issues ahead of us? And what is gender, anyway? These questions and more are answered in this book offering a deeper understanding of gender variant and transgender children and teens.
Stephanie Brill, Lisa Kenney
Is it just a phase, a fad, or a real issue with your teen? This comprehensive guidebook explores the unique challenges that thousands of families face every day raising a teenager who may be transgender, gender-variant or gender-fluid. Covering extensive research and with many personal interviews, as well as years of experience working in the field, the author covers pressing concerns relating to physical and emotional development, social and school pressures, medical options, and family communications. Learn how parents can advocate for their children, find acceptable colleges and career paths, and raise their gender variant or transgender adolescent with love and compassion.
Diane Ehrensaft
In her groundbreaking first book, Gender Born, Gender Made, Dr. Diane Ehrensaft coined the term gender creative to describe children whose unique gender expression or sense of identity is not defined by a checkbox on their birth certificate. Now, with The Gender Creative Child, she returns to guide parents and professionals through the rapidly changing cultural, medical, and legal landscape of gender and identity. In this up-to-date, comprehensive resource, Dr. Ehrensaft explains the interconnected effects of biology, nurture, and culture to explore why gender can be fluid, rather than binary. As an advocate for the gender affirmative model and with the expertise she has gained over three decades of pioneering work with children and families, she encourages caregivers to listen to each child, learn their particular needs, and support their quest for a true gender self.
Jazz Jennings
At the age of five, Jazz Jennings’s transition to life as a girl put her in the public spotlight after she shared her story on national television. She’s since become one of the most recognizable and prominent advocates for transgender teens, through her TV show, interviews, and social media. Jazz’s openness has led to bullying and mistreatment from those who don’t understand her choices. She’s fought for the right to use the girls’ bathroom and to play on a girls’ soccer team, paving the way for others. And in this book, Jazz faces an even greater struggle—dealing with the physical and social stresses of being a teen. But being on the front lines of trans activism doesn’t stop Jazz from experiencing the joys of growing up, from day camp to first dates. Jazz Jennings is one of the youngest and most prominent voices in the national discussion about gender identity. This remarkable memoir is a testament to the power of accepting yourself, learning to live an authentic life, and helping everyone to embrace their own truths.
Irwin Krieger
Going through puberty and adolescence presents unwelcome changes for many transgender youth, and this book provides advice to parents of transgender teens to help them understand what their child is experiencing and feeling during this challenging time. Addressing common fears and concerns that parents of transgender teens share, the book guides them through steps they can take with their child, including advice on hormones and surgery and how to transition socially. It addresses the recent increase in teens presenting with non-binary identities, and reflects major legal, social and medical developments regarding transgender issues. The author’s insights are gained from his professional experience of providing psychotherapy regarding gender identity. He provides resources and further reading to help parents expand their knowledge. Although aimed predominantly at parents, this book is useful for anyone working with teenagers and young adults as it provides many answers to common questions about adolescent gender identity.
Jennifer L. Levi, Elizabeth E. Monnin-Browder
Transgender people have unique needs and vulnerabilities in the family law context. Any family law attorney engaged in representing transgender clients must know the ins and outs of this rapidly developing area of law. Transgender Family Law: A Guide to Effective Advocacy is the first book to comprehensively address legal issues facing transgender people in the family law context and provide practitioners the tools to effectively represent transgender clients. Transgender Family Law: A Guide to Effective Advocacy is written by attorneys with expertise in both family law and advocacy for transgender clients, including: Kylar W. Broadus, Patience Crozier, Benjamin L. Jerner, Michelle B. LaPointe, Jennifer L. Levi, Morgan Lynn, Shannon Price Minter, Elizabeth E. Monnin-Browder, Zack M. Paakkonen, Terra Slavin, Wayne A. Thomas Jr., Deborah H. Wald, and Janson Wu. This is a must-have, practical guide for attorneys interested in becoming effective advocates for their clients. It is also a valuable resource to consult for any transgender person who is forming, expanding, or dissolving a family relationship.
Amy Ellis Nutt
When Wayne and Kelly Maines adopted identical twin boys, they thought their lives were complete. But by the time Jonas and Wyatt were toddlers, confusion over Wyatt’s insistence that he was female began to tear the family apart. In the years that followed, the Maineses came to question their long-held views on gender and identity, to accept Wyatt’s transition to Nicole, and to undergo a wrenching transformation of their own, the effects of which would reverberate through their entire community. Pulitzer Prize–winning journalist Amy Ellis Nutt spent almost four years reporting this story and tells it with unflinching honesty, intimacy, and empathy. In her hands, Becoming Nicole is more than an account of a courageous girl and her extraordinary family. It’s a powerful portrait of a slowly but surely changing nation, and one that will inspire all of us to see the world with a little more humanity and understanding.
Denise O’Doherty
A parent’s life can change forever when a child “comes out” and says they are transgender. Whether your child is 5 or 50, the words “transgender” or “transition” can often cause a multitude of conflicting emotions and countless questions. This book was written to provides direction and suggestions for parents on how to make the adjustment process easier. Although It addresses how to communicate with your child effectively, and facts about transitioning, it primarily focuses on the different stages parents and caregivers face, and how they can take care of themselves in the transition process. It gives direction on how to work through feelings such as disbelief, grief, denial, depression, shame, guilt and what to say to others. It provides techniques and insights on how parents and caregivers can take care of themselves with insight, awareness and self-compassion.
Abbreviations
| β | Beta, coefficient |
| FSH | Follicle-Stimulating Hormone |
| FtM | Female-to-Male |
| GnRH | Gonadotropin-Releasing Hormone |
| IRR | Incidence Rate Ratio |
| LH | Luteinizing Hormone |
| MtF | Male-to-Female |
| OR | Odds Ratio |
| RR | Rate Ratio |
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Featured photo by Alexander Grey.
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Social Affirmation