gender reassignment on 2 year old

Young Children Do Not Receive Medical Gender Transition Treatment

By Kate Yandell

Posted on May 22, 2023

SciCheck Digest

Families seeking information from a health care provider about a young child’s gender identity may have their questions answered or receive counseling. Some posts share a misleading claim that toddlers are being “transitioned.” To be clear, prepubescent children are not offered transition surgery or drugs.

Some children  identify  with a gender that does not match their sex assigned at birth. These children are referred to as transgender, gender-diverse or gender-expansive. Doctors will listen to children and their family members, offer information, and in some cases connect them with mental health care, if needed.

But for children who have not yet started puberty, there are  no recommended  drugs, surgeries or other gender-transition treatments.

Recent social media  posts   shared  the misleading  claim  that medical institutions in North Carolina are “transitioning toddlers,” which they called an “experimental treatment.” The posts referenced a  blog post  published by the Education First Alliance, a conservative nonprofit in North Carolina that says  many schools are engaging in “ideological indoctrination” of children and need to be reformed.

The group has advocated the passage of a North Carolina bill  to restrict medical gender-transition treatment before age 18. There are now  18 states  that have taken action to restrict  medical transition treatments  for  minors .

A widely shared  article  from the Epoch Times citing the blog post bore the false headline: “‘Transgender’ Toddlers as Young as 2 Undergoing Mutilation/Sterilization by NC Medical System, Journalist Alleges.” The Epoch Times has a history of publishing misleading or false claims. The article on transgender toddlers then disappeared from the website, and the Epoch Times published a new  article  clarifying that young children are not receiving hormone blockers, cross-sex hormones or surgery. 

Representatives from all three North Carolina institutions referenced in the social media posts told us via emailed statements that they do not offer surgeries or other transition treatments to toddlers.

East Carolina University, May 5: ECU Health does not offer gender affirming surgery to minors nor does the health system offer gender affirming transition care to toddlers.

ECU Health elaborated that it does not offer puberty blockers and only offers hormone therapy after puberty “in limited cases,” as recommended in national guidelines and with parental or guardian consent. It also said that it offers interdisciplinary gender-affirming primary care for LGBTQ+ patients, including access to services such as mental health care, nutrition and social work.

“These primary care services are available to any LGBTQ+ patient who needs care. ECU Health does not provide gender-related care to patients 2 to 4 years old or any toddler period,” ECU said.

University of North Carolina, May 12: To be clear: UNC Health does not offer any gender-transitioning care for toddlers. We do not perform any gender care surgical procedures or medical interventions on toddlers. Also, we are not conducting any gender care research or clinical trials involving children. If a toddler’s parent(s) has concerns or questions about their child’s gender, a primary care provider would certainly listen to them, but would never recommend gender treatment for a toddler. Gender surgery can be performed on anyone 18 years old or older .

Duke Health, May 12: Duke Health has provided high-quality, compassionate, and evidence-based gender care to both adolescents and adults for many years. Care decisions are made by patients, families and their providers and are both age-appropriate and adherent to national and international guidelines. Under these professional guidelines and in accordance with accepted medical standards, hormone therapies are explicitly not provided to children prior to puberty and gender-affirming surgeries are, except in exceedingly rare circumstances, only performed after age 18.

Duke and UNC both called the claims that they offer gender-transition care to toddlers false, and ECU referred to the “intentional spreading of dangerous misinformation online.”

Nor do other medical institutions offer gender-affirming drug treatment or surgery to toddlers, clinical psychologist  Christy Olezeski , director of the Yale Pediatric Gender Program, told us, although some may offer support to families of young children or connect them with mental health care. 

The Education First Alliance post also states that a doctor “can see a 2-year-old girl play with a toy truck, and then begin treatment for gender dysphoria.” But simply playing with a certain toy would not meet the criteria for a diagnosis of gender dysphoria, according to the medical diagnostic manual used by health professionals.

“With all kids, we want them to feel comfortable and confident in who they are. We want them to feel comfortable and confident in how they like to express themselves. We want them to be safe,” Olezeski said. “So all of these tenets are taken into consideration when providing care for children. There is no medical care that happens prior to puberty.”

Medical Transition Starts During Adolescence or Later 

The Education First Alliance blog post does not clearly state what it means when it says North Carolina institutions are “transitioning toddlers.” It refers to treatment and hormone therapy without clarifying the age at which it is offered. 

Only in the final section of the piece does it include a quote from a doctor correctly stating that children are not offered surgery or drugs before puberty.

To spell out the reality of the situation: The North Carolina institutions are not providing surgeries or hormone therapy to prepubescent children, nor is this standard practice in any part of the country.

Programs and physicians will have different policies, but widely referenced guidance from the  World Professional Association for Transgender Health  and the  Endocrine Society  lays out recommended care at different ages. 

Drugs that suppress puberty are the first medical treatment that may be offered to a transgender minor, the guidelines say. Children may be offered drugs to suppress puberty beginning when breast buds appear or testicles increase to a certain volume, typically happening between ages 8 to 13 or 9 to 14, respectively.

Generally, someone may start gender-affirming hormone therapy in early adolescence or later, the American Academy for Pediatrics  explains . The Endocrine Society says that adolescents typically have the mental capacity to participate in making an informed decision about gender-affirming hormone therapy by age 16.

Older adolescents who want flat chests may sometimes be able to get surgery to remove their breasts, also known as top surgery, Olezeski said. They sometimes desire to do this before college. Guidelines  do not offer  a  specific age  during adolescence when this type of surgery may be appropriate. Instead, they explain how a care team can assess adolescents on a case-by-case basis.

A previous  version  of the WPATH guidelines did not recommend genital surgery until adulthood, but the most recent version, published in September 2022, is  less specific  about an age limit. Rather, it explains various criteria to determine whether someone who desires surgery should be offered it, including a person’s emotional and cognitive maturity level and whether they have been on hormone therapy for at least a year.

The Endocrine Society similarly offers criteria for when someone might be ready for genital surgery, but specifies that surgeries involving removing the testicles, ovaries or uterus should not happen before age 18.

“Typically any sort of genital-affirming surgeries still are happening at 18 or later,” Olezeski said.

There are no comprehensive statistics on the number of gender-affirming surgeries performed in the U.S., but according to an insurance claims  analysis  from Reuters and Komodo Health Inc., 776 minors with a diagnosis of gender dysphoria had breast removal surgeries and 56 had genital surgeries from 2019 to 2021.

Research Shows Benefits of Affirming Gender Identity

Young children do not get medical transition treatment, but they do have feelings about their gender and can benefit from support from those around them. “Children start to have a sense of their own gender identity between the ages of 2 1/2 to 3 years old,” Olezeski said.

Programs vary in what age groups they serve, she said, but some do support families of preschool-aged children by answering questions or providing mental health care.

Transgender children are at increased risk of some mental health problems, including anxiety and depression. According to the WPATH guidelines, affirming a child’s gender through day-to-day changes — also known as social transition — may have a positive impact on a child’s mental health. Social transition “may look different for every individual,” Olezeski said. Changes could include going by a different name or pronouns or altering one’s attire or hair style.

Two studies of socially transitioned children — including one with kids as young as 3 — have found minimal or no difference in anxiety and depression compared with non-transgender siblings or other children of similar ages.

“Research substantiates that children who are prepubertal and assert an identity of [transgender and gender diverse] know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender and benefit from the same level of social acceptance,” the AAP  guidelines  say, adding that differences in how children identify and express their gender are normal.

Social transitions largely take place outside of medical institutions, led by the child and supported by their family members and others around them. However, a family with questions about their child’s gender or social transition may be able to get information from their pediatrician or another medical provider, Olezeski said.

Although not available everywhere, specialized programs may be particularly prepared to offer care to a gender-diverse child and their family, she said. A child may get a referral to one of these programs from a pediatrician, another specialty physician, a mental health care professional or their school, or a parent may seek out one of these programs.

“We have created a space where parents can come with their youth when they’re young to ask questions about how to best support their child: what to do if they have questions, how to get support, what do we know about the best research in terms of how to allow kids space to explore their identity, to explore how they like to express themselves, and then if they do identify as trans or nonbinary, how to support the parents and the youth in that,” Olezeski said of specialized programs. Parents benefit from the support, and then the children also benefit from support from their parents. 

WPATH  says  that the child should be the one to initiate a social transition by expressing a “strong desire or need” for it after consistently articulating an identity that does not match their sex assigned at birth. A health care provider can then help the family explore benefits and risks. A child simply playing with certain toys, dressing a certain way or enjoying certain activities is not a sign they would benefit from a social transition, the guidelines state.

Previously, assertions children made about their gender were seen as “possibly true” and support was often withheld until an age when identity was believed to become fixed, the AAP guidelines explain. But “more robust and current research suggests that, rather than focusing on who a child will become, valuing them for who they are, even at a young age, fosters secure attachment and resilience, not only for the child but also for the whole family,” the guidelines say.

Mental Health Care Benefits

A gender-diverse child or their family members may benefit from a referral to a psychologist or other mental health professional. However, being transgender or gender-diverse is not in itself a mental health disorder, according to the  American Psychological Association ,  WPATH and other expert groups . These organizations also note that people who are transgender or gender-diverse do not all experience mental health problems or distress about their gender. 

Psychological therapy is not meant to change a child’s gender identity, the WPATH guidelines  say . 

The form of therapy a child or a family might receive will depend on their particular needs, Olezeski said. For instance, a young child might receive play-based therapy, since play is how children “work out different things in their life,” she said. A parent might work on strategies to better support their child.

One mental health diagnosis that some gender-diverse people may receive is  gender dysphoria . There is  disagreement  about how useful such a diagnosis is, and receiving such a diagnosis does not necessarily mean someone will decide to undergo a transition, whether social or medical.

UNC Health told us in an email that a gender dysphoria diagnosis “is rarely used” for children.

Very few gender-expansive kids have dysphoria, the spokesperson said. “ Gender expansion in childhood is not Gender Dysphoria ,” UNC added, attributing the explanation to psychiatric staff (emphasis is UNC’s). “The psychiatric team’s goal is to provide good mental health care and manage safety—this means trying to protect against abuse and bullying and to support families.”

Social media posts incorrectly claim that toddlers are being diagnosed with gender dysphoria based on what toys they play with. One post  said : “Three medical schools in North Carolina are diagnosing TODDLERS who play with stereotypically opposite gender toys as having GENDER DYSPHORIA and are beginning to transition them!!”

There are separate criteria for diagnosing gender dysphoria in adults and adolescents versus children, according to the Diagnostic and Statistical Manual of Mental Disorders. For children to receive this diagnosis, they must meet six of eight criteria for a six-month period and experience “clinically significant distress” or impairment in functioning, according to the diagnostic manual. 

A “strong preference for the toys, games or activities stereotypically used or engaged in by the other gender” is one criterion, but children must also meet other criteria, and expressing a strong desire to be another gender or insisting that they are another gender is required.

“People liking to play with different things or liking to wear a diverse set of clothes does not mean that somebody has gender dysphoria,” Olezeski said. “That just means that kids have a breadth of things that they can play with and ways that they can act and things that they can wear . ”

Editor’s note: SciCheck’s articles providing accurate health information and correcting health misinformation are made possible by a grant from the Robert Wood Johnson Foundation. The foundation has no control over FactCheck.org’s editorial decisions, and the views expressed in our articles do not necessarily reflect the views of the foundation.

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Rachmuth, Sloan. “ Transgender Toddlers Treated at Duke, UNC, and ECU .” Education First Alliance. 1 May 2023.

North Carolina General Assembly. “ Senate Bill 639, Youth Health Protection Act .” (as introduced 5 Apr 2023).

Putka, Sophie et al. “ These States Have Banned Youth Gender-Affirming Care .” Medpage Today. Updated 17 May 2023.

Davis, Elliott Jr. “ States That Have Restricted Gender-Affirming Care for Trans Youth in 2023 .” U.S. News & World Report. Updated 17 May 2023.

Montgomery, David and Goodman, J. David. “ Texas Legislature Bans Transgender Medical Care for Children .” New York Times. 17 May 2023.

Ji, Sayer. ‘ Transgender’ Toddlers as Young as 2 Undergoing Mutilation/Sterilization by NC Medical System, Journalist Alleges .” Epoch Times. Internet Archive, Wayback Machine. Archived 6 May 2023.

McDonald, Jessica. “ COVID-19 Vaccines Reduce, Not Increase, Risk of Stillbirth .” FactCheck.org. 9 Nov 2022.

Jaramillo, Catalina. “ Posts Distort Questionable Study on COVID-19 Vaccination and EMS Calls .” FactCheck.org. 15 June 2022.

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Jaramillo, Catalina. “ WHO ‘Pandemic Treaty’ Draft Reaffirms Nations’ Sovereignty to Dictate Health Policy .” FactCheck.org. 2 Mar 2023.

McCormick Sanchez, Darlene. “ IN-DEPTH: North Carolina Medical Schools See Children as Young as Toddlers for Gender Dysphoria .” The Epoch Times. 8 May 2023.

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Duke Health spokesperson. Email with FactCheck.org. 12 May 2023.

Olezeski, Christy. Interview with FactCheck.org. 16 May 2023.

Hembree, Wylie C. et al. “ Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline .” The Journal of Clinical Endocrinology and Metabolism. 1 Nov 2017.

Emmanuel, Mickey and Bokor, Brooke R. “ Tanner Stages .” StatPearls. Updated 11 Dec 2022.

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“ What is Gender Dysphoria ?” American Psychiatric Association website. Updated Aug 2022.

Vanessa Marie | Truth Seeker (indivisible.mama). “ Three medical schools in North Carolina are diagnosing TODDLERS who play with stereotypically opposite gender toys as having GENDER DYSPHORIA and are beginning to transition them!! … ” Instagram. 7 May 2023.

Putting numbers on the rise in children seeking gender care

By ROBIN RESPAUT and CHAD TERHUNE

Filed Oct. 6, 2022, 11 a.m. GMT

Thousands of children in the United States now openly identify as a gender different from the one they were assigned at birth, their numbers surging amid growing recognition of transgender identity and rights even as they face persistent prejudice and discrimination.

As the number of transgender children has grown, so has their access to gender-affirming care, much of it provided at scores of clinics at major hospitals.

Reliable counts of adolescents receiving gender-affirming treatment have long been guesswork – until now. Reuters worked with health technology company Komodo Health Inc to identify how many youths have sought and received care. The data show that more and more families across the country are grappling with profound questions about what type of care to pursue for their children, placing them at the center of a vitriolic national political debate over what it means to protect youth who identify as transgender.

Diagnoses of youths with gender dysphoria surge

In 2021, about 42,000 children and teens across the United States received a diagnosis of gender dysphoria, nearly triple the number in 2017, according to data Komodo compiled for Reuters. Gender dysphoria is defined as the distress caused by a discrepancy between a person’s gender identity and the one assigned to them at birth.

Overall, the analysis found that at least 121,882 children ages 6 to 17 were diagnosed with gender dysphoria from 2017 through 2021. Reuters found similar trends when it requested state-level data on diagnoses among children covered by Medicaid, the public insurance program for lower-income families.

Gender-affirming care for youths takes several forms, from social recognition of a preferred name and pronouns to medical interventions such as hormone therapy and, sometimes, surgery. A small but increasing number of U.S. children diagnosed with gender dysphoria are choosing medical interventions to express their identity and help alleviate their distress.

These medical treatments don’t begin until the onset of puberty, typically around age 10 or 11.

For children at this age and stage of development, puberty-blocking medications are an option. These drugs, known as GnRH agonists, suppress the release of the sex hormones testosterone and estrogen. The U.S. Food and Drug Administration has approved the drugs to treat prostate cancer, endometriosis and central precocious puberty, but not gender dysphoria. Their off-label use in gender-affirming care, while legal, lacks the support of clinical trials to establish their safety for such treatment.

Over the last five years, there were at least 4,780 adolescents who started on puberty blockers and had a prior gender dysphoria diagnosis.

This tally and others in the Komodo analysis are likely an undercount because they didn’t include treatment that wasn’t covered by insurance and were limited to pediatric patients with a gender dysphoria diagnosis. Practitioners may not log this diagnosis when prescribing treatment.

By suppressing sex hormones, puberty-blocking medications stop the onset of secondary sex characteristics, such as breast development and menstruation in adolescents assigned female at birth. For those assigned male at birth, the drugs inhibit development of a deeper voice and an Adam’s apple and growth of facial and body hair. They also limit growth of genitalia.

Without puberty blockers, such physical changes can cause severe distress in many transgender children. If an adolescent stops the medication, puberty resumes.

The medications are administered as injections, typically every few months, or through an implant under the skin of the upper arm.

After suppressing puberty, a child may pursue hormone treatments to initiate a puberty that aligns with their gender identity. Those for whom the opportunity to block puberty has already passed or who declined the option may also pursue hormone therapy.

At least 14,726 minors started hormone treatment with a prior gender dysphoria diagnosis from 2017 through 2021, according to the Komodo analysis.

Hormones – testosterone for adolescents assigned female at birth and estrogen for those assigned male – promote development of secondary sex characteristics. Adolescents assigned female at birth who take testosterone may notice that fat is redistributed from the hips and thighs to the abdomen. Arms and legs may appear more muscular. The brow and jawline may become more pronounced. Body hair may coarsen and thicken. Teens assigned male at birth who take estrogen may notice the hair on their body softens and thins. Fat may be redistributed from the abdomen to the buttocks and thighs. Their testicles may shrink and sex drive diminish. Some changes from hormone treatment are permanent.

Hormones are taken in a variety of ways: injections, pills, patches and gels. Some minors will continue to take hormones for many years well into adulthood, or they may stop if they achieve the physical traits they want.

Hormone treatment may leave an adolescent infertile, especially if the child also took puberty blockers at an early age. That and other potential side effects are not well-studied, experts say.

The ultimate step in gender-affirming medical treatment is surgery, which is uncommon in patients under age 18. Some children’s hospitals and gender clinics don’t offer surgery to minors, requiring that they be adults before deciding on procedures that are irreversible and carry a heightened risk of complications.

The Komodo analysis of insurance claims found 56 genital surgeries among patients ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021. Among teens, “top surgery” to remove breasts is more common. In the three years ending in 2021, at least 776 mastectomies were performed in the United States on patients ages 13 to 17 with a gender dysphoria diagnosis, according to Komodo’s data analysis of insurance claims. This tally does not include procedures that were paid for out of pocket.

A note on the data

Komodo’s analysis draws on full or partial health insurance claims for about 330 million U.S. patients over the five years from 2017 to 2021, including patients covered by private health plans and public insurance like Medicaid. The data include roughly 40 million patients annually, ages 6 through 17, and comprise health insurance claims that document diagnoses and procedures administered by U.S. clinicians and facilities.

To determine the number of new patients who initiated puberty blockers or hormones, or who received an initial dysphoria diagnosis, Komodo looked back at least one year prior in each patient’s record. For the surgery data, Komodo counted multiple procedures on a single day as one procedure.

For the analysis of pediatric patients initiating puberty blockers or hormones, Komodo searched for patients with a prior gender dysphoria diagnosis. Patients with a diagnosis of central precocious puberty were removed. A total of 17,683 patients, ages 6 through 17, with a prior gender dysphoria diagnosis initiated either puberty blockers or hormones or both during the five-year period. Of these, 4,780 patients had initiated puberty blockers and 14,726 patients had initiated hormone treatment.

Youth in Transition

By Robin Respaut and Chad Terhune

Photo editing: Corrine Perkins

Art direction: John Emerson

Edited by Michele Gershberg and John Blanton

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Children and gender identity: Supporting your child

Learn why you should talk with your child about gender identity and expression — and how to get the conversation started.

If your child has questions about gender identity or gender expression, you probably have questions too. Find out what you can do to help and support your child.

What are the basics of gender identity?

Sex assigned at birth and gender identity are two separate things. Sex assigned at birth is typically made based on external genital anatomy. But gender identity is the internal sense of being male, female, or a gender along the spectrum between male and female. People communicate their gender to others through gender expression. This may be done through mannerisms, clothing and hairstyles.

Gender identity develops separately from sexual orientation. People's sexual orientation is related to whom they're attracted to on a physical, emotional and romantic basis.

Is my child transgender?

Children who are transgender have a gender identity that doesn't match their assigned sex at birth.

In many cases, children will say how they feel. They may strongly identify as boys or girls. And sometimes they identify as neither or not fully male or female (nonbinary).

Most children go through periods of gender exploration through the way they dress and the toys they choose and by role-playing. Some may even insist that they are a gender that differs from that of their birth sex. However, this is likely not a phase if they continue to do so as they get older.

Most children between ages 18 and 24 months can recognize and label gender groups. They may identify others as girls, women or feminine. Or they may label others as boys, men or masculine. Most also label their own gender by the time they reach age 3.

However, society tends to have a narrow view of gender. As a result, some children learn to behave in ways that may not reflect their gender identity. At age 5 or 6, most children are rigid about gender and preferences. These feelings tend to become more flexible with age.

It's important to remember that gender identity and gender expression are different concepts. A child's gender identity doesn't always lead to a certain gender expression. And a child's gender expression doesn't always point to the child's gender identity.

Gender expressions and behaviors might include:

• Certain bathroom behavior, such as a girl insisting on standing up to urinate
• An aversion to wearing the bathing suit of the child's sex assigned at birth
• A preference for underwear typically worn by a different sex
• A strong desire to play with toys typically assigned to a different sex

Don't rush to label your child. Over time your child will continue to tell you what feels right.

How can I support a transgender child or a child who doesn't conform to assigned sex at birth?

Listen to your child's feelings about gender identity. Talk to your child and ask questions without judgment. To support your child, you can:

• Allow your child to express gender in public or at family activities. It's important to do this even if it makes you or someone else uncomfortable.
• Give your child access to gender-diverse friends, activities or resources.
• Don't assume your child's gender expression is a form of rebellion or defiance.
• Don't try to shame or punish your child for gender expression.
• Don't allow others in your family to belittle or ridicule your child's gender expression.
• Understand that experiencing discrimination isn't your child's fault.

Remember to speak positively about your child. Do this both to your child and to others. Show your approval for your child's gender identity and expression of it. You'll foster a positive sense of self in your child when you allow your child to express preferences. You'll also help keep lines of communication open.

Also, try to let go of expectations you might have had about your child's future. Instead, focus on what brings your child joy and security. A child living with supportive parents and caregivers is likely to be a happier child.

What kind of health care does my child need?

Your child needs a respectful and knowledgeable health care provider. Talk to your child's provider about your child's gender identity and behaviors. Your child's provider might recommend working with a specialist. If you're having trouble finding a provider with training in gender identity, ask a support group to recommend a specialist.

Talking to a therapist also is critical. Ask your child's health care provider to help you find a counselor with training in transgender needs.

What is social transitioning?

A social transition is a reversible step in which a child lives partially or completely in the preferred gender role. This can involve changing hairstyles, clothing, pronouns and, possibly, names. Limited research suggests that social transitioning might help ease depression or anxiety a child may have about gender identity.

Talk to your child and decide details about the transition. You may consider whom to tell about it. You might also plan which bathroom or locker room your child will use. You'll also need to consider whether transitioning at school or in the community will endanger your child. Seek the advice of a social agency or an advocacy group to help you determine the safety of the transition.

How can I advocate for my child?

You might worry that your transgender child will be shunned and experience discrimination. You may also worry your child could be physically harmed at school or in your community. Advocating for your child may help prevent these things from happening. Take these steps:

• Connect with other families who have gender-diverse children. This can help reduce isolation you and your child might be going through. Look for an in-person or online support group.

Work with your child's school and teachers. Talk to them about how to stop or prevent bias and bullying before it starts. Ask for gender training to be included in staff development.

Also come up with a plan for how your child will be addressed in school and which bathroom your child will use. It's helpful to talk to your child's school about how to interpret rules about taking part in team, club and overnight activities. Choose whether you want to share information about your child's gender identity with other parents.

If your child is being harassed or discriminated against at school, speak to the school administrators. If the school system fails to address the problem, research your legal options.

• Reach out within your community. Outside of school, work with local institutions to make them safer for gender-diverse and transgender children. Also consider supporting or volunteering for gender diversity groups to learn more and help others.

Whatever your child's gender identity, do your homework and seek proper care. Showing love and acceptance helps children feel comfortable in their bodies and in the world.

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• Healthy parenting tips. Gender Spectrum. https://genderspectrum.org/articles/healthy-parenting-tips. Accessed June 15, 2022.
• Claahsen-van der Grinten H, et al. Gender incongruence and gender dysphoria in childhood and adolescence — Current insights in diagnostics, management and follow-up. European Journal of Pediatrics. 2021; doi:10.1007/s00431-020-03906-y.
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• Rafferty J. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics. 2018; doi:10.1542/peds.2018-2162.
• Olson-Kennedy J, et al. Overview of the management of gender nonconformity in children and adolescents. https://www.uptodate.com/contents/search. Accessed June 14, 2022.
• AskMayoExpert. Gender diversity in childhood and adolescence. Mayo Clinic; 2022.
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• Copy URL https://www.pbs.org/newshour/health/what-medical-treatments-do-transgender-youth-get

What medical treatments do transgender youth get?

Transgender medical treatment for children and teens is increasingly under attack in many states, labeled child abuse and subject to criminalizing bans. But it has been available in the United States for more than a decade and is endorsed by major medical associations.

Many clinics use treatment plans pioneered in Amsterdam 30 years ago, according to a recent review in the British Psych Bulletin. Since 2005, the number of youth referred to gender clinics has increased as much as tenfold in the U.S., U.K, Canada and Finland, the review said.

The World Professional Association for Transgender Health, a professional and educational organization, and the Endocrine Society, which represents specialists who treat hormone conditions, both have guidelines for such treatment . Here’s a look at what’s typically involved.

Puberty blockers

Children who persistently question the sex they were designated at birth are often referred to specialty clinics providing gender-confirming care. Such care typically begins with a psychological evaluation to determine whether the children have “gender dysphoria,” or distress caused when gender identity doesn’t match a person’s assigned sex.

Children who meet clinical guidelines are first offered medication that temporarily blocks puberty . This treatment is designed for youngsters diagnosed with gender dysphoria who have been counseled with their families and are mature enough to understand what the regimen entails.

‘I know who I am’: Transgender youth on the value of support, respect for their identities

The medication isn’t started until youngsters show early signs of puberty — enlargement of breasts or testicles. This typically occurs around age 8 to 13 for girls and a year or two later for boys.

The drugs, known as GnRH agonists, block the brain from releasing key hormones involved in sexual maturation. They have been used for decades to treat precocious puberty, an uncommon medical condition that causes puberty to begin abnormally early.

The drugs can be given as injections every few months or as arm implants lasting up to year or two. Their effects are reversible — puberty and sexual development resume as soon as the drugs are stopped.

Some kids stay on them for several years. One possible side effect: They may cause a decrease in bone density that reverses when the drugs are stopped.

After puberty blockers, kids can either go through puberty while still identifying as the opposite sex or begin treatment to make their bodies more closely match their gender identity.

For those choosing the second option, guidelines say the next step is taking manufactured versions of estrogen or testosterone — hormones that prompt sexual development in puberty . Estrogen comes in skin patches and pills. Testosterone treatment usually involves weekly injections.

READ MORE: The history behind International Transgender Day of Visibility

Guidelines recommend starting these when kids are mature enough to make informed medical decisions. That is typically around age 16, and parents’ consent is typically required, said Dr. Gina Sequiera, co-director of Seattle Children’s Hospital’s Gender Clinic.

Many transgender patients take the hormones for life, though some changes persist if medication is stopped.

In girls transitioning to boys, testosterone generally leads to permanent voice-lowering, facial hair and protrusion of the Adam’s apple, said Dr. Stephanie Roberts, a specialist at Boston Children’s Hospital’s Gender Management Service. For boys transitioning to girls, estrogen-induced breast development is typically permanent, Roberts said.

Research on long-term hormone use in transgender adults has found potential health risks including blood clots and cholesterol changes.

Gender-altering surgery in teens is less common than hormone treatment, but many centers hesitate to give exact numbers.

Guidelines say such surgery generally should be reserved for those aged 18 and older. The World Professional Association for Transgender Health says breast removal surgery is OK for those under 18 who have been on testosterone for at least a year. The Endocrine Society says there isn’t enough evidence to recommend a specific age limit for that operation.

Studies have found some children and teens resort to self-mutilation to try to change their anatomy. And research has shown that transgender youth and adults are prone to stress, depression and suicidal behavior when forced to live as the sex they were assigned at birth.

Opponents of youth transgender medical treatment say there’s no solid proof of purported benefits and cite widely discredited research claiming that most untreated kids outgrow their transgender identities by their teen years or later. One study often mentioned by opponents included many kids who were mistakenly identified as having gender dysphoria and lacked outcome data for many others.

READ MORE: Giving homeless transgender youth a safe haven from the streets

Doctors say accurately diagnosed kids whose transgender identity persists into puberty typically don’t outgrow it. And guidelines say treatment shouldn’t start before puberty begins.

Many studies show the treatment can improve kids’ well-being, including reducing depression and suicidal behavior. The most robust kind of study — a trial in which some distressed kids would be given treatment and others not — cannot be done ethically. Longer term studies on treatment outcomes are underway.

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2021 set a record for anti-transgender bills. Here’s how you can support the community

Nation Dec 30

Trans kids’ treatment can start younger, new guidelines say

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A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Assn. for Transgender Health said hormones could be started at age 14, two years earlier than the group’s previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association, known as WPATH, provided an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn’t match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group’s standards of care and director of the University of Minnesota Medical School’s human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents’ consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

“Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision,” he said. “That is why we recommend a careful multidisciplinary assessment.”

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment , along with new efforts to prevent or restrict the treatment.

World & Nation

A transgender psychologist has helped hundreds of teens transition. But rising numbers have her concerned

Erica Anderson took more than half a century to come out as a woman. Now she works with teens in a rush to transition.

April 12, 2022

Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of WPATH last year after voicing concerns about “sloppy” treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn’t always happen.

“They tell me horror stories. They tell me, ‘Our child had 20 minutes with the doctor’” before being offered hormones, she said. “The parents leave with their hair on fire.”

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association’s new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8% in kids.

Anderson said she’s heard recent estimates suggesting the rate in kids is as high as 1 in 5 — which she strongly disputes. That number probably reflects gender-questioning kids who aren’t good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

“That’s just absolutely cruel,” she said.

Dr. Marci Bowers, the transgender health group’s president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been “forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis.”

Op-Ed: Denying trans youth gender-affirming care is an affront to science and medical ethics

States are pushing anti-trans policies that fly in the face of research and medical expertise.

June 13, 2022

Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, N.C., resident struggled miserably with gender discomfort before his treatment.

Poulos said he’s glad he was able to get treatment at a young age.

“Transitioning under the roof with your parents so they can go through it with you, that’s really beneficial,” he said. “I’m so much happier now.”

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

“Those decisions are best made by patients and patient families and medical professionals,” they said. “It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together.”

Science & Medicine

Early transgender identity in kids tends to endure, study suggests

Children who begin identifying as transgender at a young age tend to retain that identity for several years at least, a new study suggests.

May 4, 2022

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn’t strong evidence in favor of transgender medical treatment for kids.

“In medicine ... the treatment has to be proven safe and effective before we can start recommending it,” Mason said.

Experts say the most rigorous research — studies comparing treated kids with outcomes in untreated kids — would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That’s no change from the group’s previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

• Sex hormones — estrogen or testosterone — starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.

• Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum age wasn’t listed.

• Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Assn. support allowing kids to seek transgender medical treatment, but they don’t offer age-specific guidance.

Dr. Joel Frader , a Northwestern University pediatrician and medical ethicist who advises a gender treatment program at Chicago’s Lurie Children’s Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they’re prone to risk-taking and they take into account long-term consequences of their actions only when they’re much older.

Coleen Williams , a psychologist at Boston Children’s Hospital’s Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

“Medical intervention in any realm is not a one-size-fits-all option,” Williams said.

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July 10, 2024

Texas Supreme Court upholds ban on youth gender transitions. It’s the largest state with such a law

June 28, 2024

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• PMC10063975

Transgender children and young people: how the evidence can point the way forward

Philip graham.

University College, London, UK

Associated Data

Data availability is not applicable to this article as no new data were created or analysed in this study.

The development of gender identity in children from around the age of 3 years is described. Wishes for transgender identity are distinguished from gender-atypical behaviour. Reasons for the recent rise in transgender referrals in the early teen years are discussed. The now widely used protocol developed by the Amsterdam group for assessing transgender children and young people and, where appropriate, offering them puberty blockers, cross-sex hormones and sex reassignment surgery is described. Evidence for the effectiveness of this approach is considered. The competence of young people to give consent to these procedures is discussed. Finally, proposals are made for topics urgently requiring further research.

Children first begin to develop a sense of biological gender at around the age of 2 to 3 years. 1 At this age, they are able to label pictures of boys and girls according to typical presentations of heteronormativity. At 4 years, boys understand that it is the possession of a penis that marks them out as biologically male and girls understand it is the lack of a penis that means they are biologically female. By this age, children have a sense of the stability of biological gender, an understanding that it remains constant with time. From this point up to the age of 6 or 7 years, their judgement of gender in pictures of clothed children is heavily influenced by appearance so that they label boys pictured in dresses as girls and boys with long hair as girls. By 7 years they recognise biological sex as constant and independent of external appearance. 1

By the age of 7 years, therefore, children understand three different concepts related to sex/gender identity: biological sex, self-perceived gender identity and social gender identity. They understand that they and others are biologically male or female, that they and others have a sense of their own gender identity as male or female and that they and others, depending on their appearance and clothing, are usually perceived by others as male or female. As they develop into adolescence and adulthood, people recognise that, with the use of hormones and surgical interventions, some features of biological sex can be changed. Both self-perceived gender identity and social gender identity may also undergo change.

The great majority of young children develop a self-perceived gender identity consonant with their gender assigned at birth, but some, from the age of 3 or 4 years, develop a self-perceived gender identity which is other than that assigned at birth. This sense of another gender identity can be accompanied by a feeling of discomfort or gender dysphoria. There are many autobiographical examples of the first awareness of gender dysphoria. The best known is that written by Jan Morris, who lived as a highly successful male journalist under the name of James Morris until her mid-30s when, following treatment with hormones, she underwent a surgical reconstruction and thereafter lived as a woman. 2 Jan Morris describes very clearly the onset of her gender dysphoria: 2 ‘I was three or perhaps four years old when I realized I had been born into the wrong body and should really be a girl. I remember the moment well, and it is the earliest memory of my life’ (p. 1). Her sense of discomfort with her assigned gender at birth persisted throughout her childhood, adolescence and early adult life. She describes how, when in role as a young man, she used to pray ‘please God make me a girl’ (p. 39). Gender dysphoria persisted throughout her marriage and parenthood. It was only in her late 30s, after she had had gender reassignment surgery, that she felt at ease.

The majority of prepubertal girls and boys have a clear sense of their own gender identity as female or male. This is nearly always consistent with their gender assigned at birth; in some, like Jan Morris, it is not. In a study of adolescents who had been referred to a gender identity clinic in earlier childhood, Steensma et al were able to show that a high proportion of prepubertal children with gender dysphoria did not continue to show such dysphoria after puberty, 3 a finding that had previously been reported by the same group. 4 Further, children who had shown gender-atypical behaviour (see below) without intense gender dysphoria did not generally show gender dysphoria in adolescence. Those with gender dysphoria who had been assigned a female gender at birth were less likely to desist than those assigned a male gender. Those who persisted were much more likely to have a homosexual or bisexual orientation.

A sense of gender identity must be distinguished from the presence of gender-atypical behaviour, which may occur with or without gender dysphoria. Gender-atypical behaviour (boys behaving like girls and having interests generally regarded as feminine and vice versa ) is not uncommon in the general population. In a total population study, using a standardised instrument, Golombok et al were able to identify 112 boys and 113 girls aged 3.5 years who showed gender-atypical behaviour to an extreme degree. 5 This represented about 2.2% of the population studied (S. Golombok, personal communication, 5 Jan 2021). Especially for girls, there was considerable continuity between gender-atypical behaviours at 3.5 years and such behaviour at the age of 13 years. These investigators do not report whether any of the children in their study were referred for gender dysphoria. The prevalence of 2.2% for gender-atypical behaviour needs to be contrasted with the much less frequent prevalence of 1 per 6800 Dutch adolescents aged 12 to 18 years who requested medical help for gender dysphoria. 6

Gender dysphoria and the onset of sexual feelings

Between 9 and 13 years of age, children start to experience sexual feelings arising from their genitalia. This onset of sexual feelings coincides with biological changes known as gonadarche. At this point, as a result of changes in the hypothalamus and pituitary, the gonads begin to secrete the sex hormones, testosterone and oestradiol, in relatively small quantities. This results in a modest growth of hair around the pubes and in the armpits and growth of the penis and breasts respectively. Spontaneous penile erections and clitoral excitement occur. Around 2 years later, positive feedback occurs in the hypothalamo–pituitary–gonadal axis which stimulates the testes to produce much larger amounts of testosterone and the ovaries to secrete more oestradiol, leading to menstruation. These hormonal changes also result in much more intense experience of sexual desire.

In the majority of children, sexual attraction is heterosexual but around 10% of 16- to 44-year-old adults report some previous sexual contact with a member of the same sex. 7 Most of those who experience homosexual attraction are not transgender. Usually, they have not even shown gender-atypical behaviour; they have been typically masculine, if boys, and feminine, if girls. Transgender boys usually, but not always, feel attraction to others of the same natal sex, i.e. they have homosexual feelings, and transgender girls similarly feel attracted by others of the same natal sex. Inevitably, these sexual feelings are often associated with some degree of confusion and uncertainty. For most transgender boys and girls, however, homosexual feelings have the effect of confirming the child in their transgender role: ‘If I'm really a girl, it isn't surprising I'm attracted to boys’, a transgender natal boy might say to himself and vice versa for girls. But some transgender children develop sexual attraction for others of the opposite natal sex, again with the creation of confusion and uncertainty over the transgender role.

Adolescence and gender identity

Adolescence is a social construction, i.e. it is a phase of life defined by society. 8 In Western society, it is regarded as beginning at the onset of biological puberty. Its end is not, however, defined biologically, but usually by a social criterion such as the age at which the individual develops significant autonomy. In practice, most psychologists, clinicians and members of the general public equate adolescence with the teen years, from 13 to 19, although many young people are well into biological puberty by 13 years and will have completed the biological changes of puberty well before 19 years. Recently, Sawyer and colleagues in an influential article have argued for an expanded and more inclusive definition of adolescence corresponding with the longer period of transition from childhood to adulthood now experienced by young people in Western society. They suggest that the period of 10 to 24 years is more consistent with this experience. 9 It is of relevance that there is considerable variation in ages at onset and termination of biological puberty, some young people normally starting at 10 or 11 years old and others not completing puberty until their later teen years. Relatively recent neuroscientific studies have pointed to the fact that rapid biological changes occur in the brain during the teen years, 10 but these are by no means specific to this phase of life. 11

The general public regard various behaviours as characteristic of adolescence. These may be summarised as impulsiveness, a tendency to take risks, moodiness and fractious relationships with parents. The public image of adolescents accords with this view of ‘the typical adolescent’. It is certainly the case that some teenagers show these characteristics, but population studies suggest that they make up no more than about 10–15% of this age group, 12 although they are certainly the most conspicuous. Another important and, in the context of this article, the most relevant feature of adolescence is thought to be self-questioning about identity. Young people of this age are seen as preoccupied with the question ‘Who am I?’, a question relating to all aspects of their identities, including their gender and sexuality. Such self-questioning is not experienced in intense form by most teenagers. The prevalence of ‘identity problems’ was found to be 14.3% in a group of 15- to 18-year-old American high school students 13 and a similar prevalence of ‘identity distress’ was found in a study of Flemish adolescents and young people aged 14–30 years. 14 The considerable increase in exposure of teenagers in the past 10 to 15 years to social media replete with references to gender identity would make it surprising if there had not been at least some increase of such self-questioning and confusion in this area.

Teenage presentation of transgender

Clinics serving the adolescent transgender population observed a change in the referral pattern after about 2005. Most notably, the gender identity clinic in Toronto, Canada, reported a dramatic increase in referrals at that time. 15 At the Portman Clinic in London (part of the Tavistock and Portman NHS Trust) referrals increased very significantly from 2009 to 2016. 16 At the Tampere University Hospital, Finland, referrals between 2011 and 2013 far exceeded the number expected from the findings of epidemiological studies. 17 This had not been the case previously. There were two other changes in the referral pattern over this period. First, previously, roughly equal numbers of boys and girls had been referred, whereas the increase was associated with much higher numbers of those who had been assigned female gender at birth. Second, previously, the rates of mental ill health among referred children had been about the same as in the general population, 18 whereas now much higher rates of psychiatric disorder, including autism, were reported. 14 , 16

It is therefore clear that from 2005 in Toronto and a few years later in other centres, the characteristics of patients referred to transgender clinics in their early and mid-teen years changed very significantly. In considering the reasons for this new pattern, Aitken et al 15 suggest that one possibility is that, during this period, societal factors made it easier for gay and lesbian youth and their families to seek clinical care. It could be argued, those authors say, that it became easier for girls to ‘come out’ than boys. It might therefore be easier for girls to opt for a transgender identity. Although there is no evidence to this effect, transgender natal girls who found themselves attracted to girls at puberty might have also found it easier to come out as transgender than hitherto. This implies that the increased presentation at adolescence was of girls who had experienced gender dysphoria since their early years. There is another possibility. It is that girls in their teens who are showing mental health problems for other reasons might, searching for an answer to their identity problems or distress, be influenced by social media to question for the first time their gender identity and to see gender change as an answer to their mental dilemmas. This might be more likely if they had previously shown ‘tomboyish’ behaviour. This possibility has been suggested in considering reasons for an increase in referrals of natal girls to a gender identity service between 2009 and 2016. 15 However, both these possibilities remain hypothetical at present and the reasons for the increase in referrals to transgender clinics is unknown.

Although one should not draw conclusions from a single case, it is of interest that one of the claimants in a judicial review brought about because they felt they had been inappropriately treated with puberty blocking drugs gives an account of her transgender development very much in accord with this second possibility. The claimant described a highly traumatic childhood in which she showed many gender-atypical behaviours: ‘ From the age of 14 she began actively to question her gender identity and started to look at YouTube videos and do research on the internet about gender identity disorder and the transition process’ (para. 78). 19

Although some cases of first presentation of transgender in the early teen years may arise from so-called adolescent identity problems or identity distress, it is likely that others do occur because the young person has been reluctant to come out as transgender beforehand, even though gender dysphoria has been present from the early years. Further, it is well established that such reluctance may persist well into adulthood, so that there are a number of recorded cases of people who have waited until their 30s or 40s to make this decision. 20

There is a need for both quantitative and qualitative research to investigate the early histories of girls referred with gender dysphoria for the first time in adolescence. Such research should include interviewing parents about their children's early years.

Life for children who are transgender from their early years can be challenging. At home, they have to try to communicate how they feel to potentially sceptical parents. At school, they are likely to experience disbelief, mockery and bullying. To cope they need resilient personalities as well as sensitive and understanding parents who are able to explore and talk openly about their children's feelings with acceptance and without trying to influence decisions one way or another. For, as we have seen, although some prepubertal children persist in their transgender identity, in the course of time many will, for reasons we do not understand, desist. 3 It is remarkable that most children who have been transgender from a young age reach adolescence without developing a higher-than-expected rate of significant mental health problems. 17

Many prepubertal children and their parents will benefit from having available a sympathetic counsellor, psychotherapist or other mental health professional. This will allow exploration of the reasons for the presence of gender dysphoria. Material from voluntary organisations such as Mermaids may be helpful, but parents of young children need to monitor this to ensure that their children are not being encouraged to persist, but are just accepted for what they are at the present time. Difficult decisions about changes of name and the use of toilets need to be negotiated with hopefully sympathetic, open-minded teachers.

As puberty approaches, difficult decisions have to be made. The Amsterdam group has been offering transgender adolescents puberty blockers for 30 years, their first case having been treated in 1991. 21 The group has pioneered an approach to assessment and management of gender dysphoria. It has produced a protocol for medical treatment of transgender children and adolescents that has been widely followed, 22 for example in Italy, Canada, the USA and the UK. The protocol is summarised below and in Box 1 :

• Psychological counselling for children and parents starts well before any medical treatment is considered and continues while such intervention is being administered.
• Once Tanner stage 2–3 is reached, and not before, gonadotropin-releasing hormone analogues (GnRHa) are prescribed where there is a clear indication that this is the appropriate course. This medication is given to block pubertal changes, so that the bodily changes rejected by the young person do not occur. Such treatment is only offered to children and young people aged 12 years and older who have intense gender dysphoria and no significant mental health problems. Informed consent by the young person and by the parents is required. The purpose of the use of puberty blockers is to ensure that young people with gender dysphoria do not live through pubertal bodily changes they find abhorrent. Further, the blocking of pubertal changes means that when, as is nearly always the case, transgender adults choose to have at least some degree of gender reassignment surgery, some procedures, particularly bilateral mastectomy for those assigned female gender at birth, will not be necessary.
• With careful assessment and selection, a very small minority of young people prescribed puberty blockers (between 1.4 and 3.5%) change their minds and do not wish to proceed further. 23 For the large majority who do wish to proceed, around the age of 16 years or older, cross-sex hormones are prescribed. For this treatment to be started, the young person must be living in the role of the preferred gender. Again, informed consent by the young person and, preferably, the parents is required.
• At the age of 18 years or older, those (again the great majority) who meet eligibility criteria can begin the process of gender reassignment surgery. Such surgery occurs variably according to the degree and at the pace desired by the individual concerned.

Management of gender dysphoria 22

• Make a full assessment as early as possible
• Follow with supportive counselling throughout childhood and adolescence
• Subsequent interventions should only take place with informed consent, first by parents and then by the young person, with reflection before each phase
• If intense gender dysphoria persists, consider using puberty blockers at Tanner stages 2–3
• Consider use of cross-sex hormones at age 16
• At age 18–19 and subsequently, consider gender reassignment surgery

Effectiveness of treatment

The aims of treatment are twofold:

• to explore with the child or young person with gender dysphoria the reasons for their discomfort with their gender assigned at birth and to consider alternative ways forward, including living in the role of their birth-assigned gender or pursuing medical intervention that will enable them to transition;
• in those who choose to live in their preferred transgender role, to start treatment, pausing for reflection before each step, first with puberty blockers, then with cross-sex hormones and finally with gender reassignment surgery to relieve gender dysphoria.

Among those who opt for medical treatment, the degree of success of intervention is measured by the absence of gender dysphoria and mental health problems and by the presence of psychological well-being. Ideally it would be possible to quote findings from a number of controlled trials of each of the interventions. Given the impracticability of obtaining agreement from children and young people with intense gender dysphoria to participate in controlled trials, the findings from uncontrolled but carefully conducted studies provide the main evidence for effectiveness.

There have now been a number of such uncontrolled studies, in which patients have been followed up to see whether their physical and psychological states have improved or deteriorated after the use of puberty blockers alone 24 – 26 and puberty blockers followed by cross-sex hormones followed by surgery. 27 – 29 The most recently published study of the effects of puberty blockers was reported from the Portman Clinic, London. 30 This study reported on the short-term outcome over 2 years of 44 children and young people aged 12 to 15 years when they started treatment with puberty blockers. Overall, the patient experience was positive. Although there were some children who showed some negative outcomes in mood and quality of relationships with family and friends, the majority showed positive change. There was no change in the rate of parent- or child-rated behaviour problems or risk of self-harm. All adverse effects, when they occurred, were mild. In line with other studies, only 1 of the 44 children and young people treated with puberty blockers did not go on to request cross-sex hormone treatment.

All the studies quoted above have provided valuable information. In all cases, there has been benefit from the interventions for the majority and an absence of significant harm. The most recent critical review of the use of puberty blockers has concluded: ‘Although large long-term studies with diverse and multicultural populations have not been done, the evidence to date supports the finding of few serious adverse outcomes and several potential positive outcomes. This literature suggests the need for transgender youth to be cared for in a manner that not only affirms their gender identities but that also minimises the negative physical and psychological outcomes that could be associated with pubertal development’. 31 In all published cases, the majority has reported benefit from the interventions and an absence of significant harm. Where it has been measured, an improvement in psychological well-being has always been found. It is well established that adults who transition ‘experience fewer psychological problems and interpersonal difficulties as well as a strongly increased life satisfaction’ than before the transition and show no wish to revert to their gender assigned at birth. 32

It should be added that the use of puberty blockers in early adolescence has been strongly criticised. 33 , 34 It has been claimed that there has been undue reliance on an affirmative approach (self-identification) in making a transgender diagnosis, that the complexity of the underlying problems of young people presenting as transgender has been inadequately assessed, that a high proportion of those who are treated with puberty blockers regret that they have received this treatment and that the young people who have been treated have not been capable of giving informed consent to treatment that has such profound implications for their future.

Adverse effects of medical interventions

The effect of puberty blockers is generally, though not universally, regarded as reversible. Their use has been associated with apparently reversible stunting effects on height velocity and bone maturation. 29 , 35 General cautions that have been expressed by clinicians about the possibility of irreversibility, such as those by Professor Butler and Dr de Vries quoted in a judicial review, 19 are no more than one might expect in relation to a large number of interventions in routine use. Caution about possible harm is always an appropriate clinical stance. It should not be taken to mean that the intervention in question should not be used where it is indicated.

There is one undeniable loss that occurs as a result of the use of puberty blockers. The individual does not go through the experience of the ‘normal’ adolescence he or she would have had without their use. However, most transgender young people do not consider this to be a loss or in any way regrettable.

The use of cross-sex hormones exposes the individual to the risk of a metabolic abnormality in about 15% of cases, but the significance of this finding is not clear and it does not seem a contraindication to their use. 36 Further research is required on the nature of possible metabolic abnormalities arising from the use of cross-sex hormones.

Informed consent

The competence of young people to give informed consent to the use of puberty blockers and cross-sex hormones is currently a matter of great relevance to clinical management. In UK law, 16 years is regarded as the youngest age at which it can be assumed, on the basis of chronological age, that a young person can give informed consent to a medical procedure. Below that age, it is widely accepted that, in considering whether a young person is capable of giving informed consent, the so-called Gillick principle should be applied. This principle, expressed by Lord Scarman in a 1985 House of Lords judgment and repeated in the above-mentioned judicial review, 19 is that ‘as a matter of law the parental right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to […] understand fully what is proposed’. There is a controversy as to whether, because of the unusually complicated issues involved, children under the age of 16 could ever have the cognitive competence to give consent to puberty blockers or cross-sex hormones. This matter was considered in great detail in the judicial review whose judgment was published in December 2020. 19 This court decided that young people under 16 years could not give informed consent to the use of puberty blockers. Further, the court ruled that, even in cases where parents give their informed consent and clinicians are in agreement, an application should be made to the courts for authorisation before a child under 16 years can be administered puberty blockers. However, on appeal, this decision was reversed. The Appeal Court decided that the initial judgment had placed an improper restriction on the Gillick test and that it would not be appropriate for an application to the courts to be required before a child could be administered puberty blockers. 37

There is a need for systematic psychological investigation into the capacity of children and young people to make decisions in this area. Although there is some evidence on the capacity of young people aged 14–16 years to understand medical procedures, there is no evidence relating to the specific question of their understanding of the use of puberty blockers and cross-sex hormones, for example, in comparison with that of older people. Such evidence should be obtained. In the meantime, it would seem reasonable to rely on the findings of Weithorn & Campbell, whose study provides the most relevant data. 38 These investigators looked at 24 individuals in each of four age groups: 9, 14, 18 and 21 years. They tested their competence to make informed treatment decisions in a series of medical dilemmas, involving conditions such as epilepsy, diabetes and psychological problems. The children, adolescents and young adults were given the nature of the problem, treatments options, expected benefits, possible risks and consequences of failure, and then assessed on how much they understood. The 14-year-olds did as well as the 21-year-olds. The 9-year-olds did distinctly less well. Although it is many years since this study was carried out, until more relevant evidence is produced, there is no reason why its findings should not be regarded as highly pertinent.

Conclusions

One can conclude from the evidence that gender dysphoria is a relatively rare but well-defined condition, characterised by a strong desire to be of the gender opposite to that assigned at birth and by an insistence that one is, indeed, of the other gender. Affected transgender individuals are usually aware of its existence by the age of 5 years. Gender dysphoria needs to be distinguished from gender-atypical behaviour, where those assigned male gender at birth showed an interest in activities generally preferred by girls and vice versa . Marked gender-atypical behaviour occurs in around 2–3% of the population, most of whom are not transgender. Further, many children who show gender dysphoria before puberty do not continue to do so during and after pubertal changes occur. However, if gender dysphoria does persist into adolescence, its intensity tends to increase at this time.

From about 2005 until the present, there has been a considerable, perhaps tenfold, increase in the number of children and young people referred to gender identity clinics. This change has been observed not just in the UK, but in Canada, the USA and Finland. These more recent referrals have differed from previous cases in three ways. More recent referrals have been older, often not presenting until the early teen years. Whereas previously referrals were relatively evenly balanced between those assigned male and female gender at birth, there is now a considerable preponderance of those assigned female gender at birth. Further, whereas previously children and young people with transgender did not show high rates of behavioural and emotional disturbance, this is not the case for recent referrals.

The assessment and management of gender dysphoria has been pioneered by a Dutch group based in Amsterdam. This group has laid down a number of principles of management, which have been widely adopted by gender identity clinics in other countries. The effectiveness of this sequence of interventions is now reasonably well established, with good evidence that it relieves gender dysphoria and usually improves psychological well-being. Physical side-effects may occur but as far as can be ascertained at present, not to a degree where possible harm outweighs benefit. There are, however, unresolved issues concerning the capacity of young people with gender dysphoria to give informed consent to the use of puberty blockers.

There are a number of gaps in knowledge requiring urgent attention. First, it is unclear whether the considerable increase in referrals to gender identity clinics in the past 15 years is due to greater willingness of early affected individuals to come out at this age or whether clinics are dealing with a different population with different needs. There is clearly a need for both quantitative and qualitative research to investigate the early histories of those assigned female gender at birth referred with gender dysphoria for the first time in adolescence. Such research should include interviewing parents about their children's early years. Second, although it is reasonably well established that the use of puberty blockers is not accompanied by serious adverse effects, further research is required on the nature of possible metabolic abnormalities arising from the use of cross-sex hormones. Finally, there is a need for research into the capacity of children and young people, compared with older people, to understand the implications of the use of puberty blockers and cross-sex hormones.

About the author

Philip Graham is Emeritus Professor of Child Psychiatry in the Institute of Child Health, University College, London, UK.

Data availability

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Declaration of interest

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Age restriction lifted for gender-affirming surgery in new international guidelines

'Will result in the need for parental consent before doctors would likely perform surgeries'

Media Information

• Release Date: September 16, 2022

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Kristin Samuelson

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• Expert can speak to transgender peoples’ right to bodily autonomy, how guidelines affect insurance coverage, how the U.S. gender regulations compare to other countries, more

CHICAGO --- The World Professional Association for Transgender Health (WPATH) today today announced  its updated Standards of Care and Ethical Guidelines for health professionals. Among the updates is a new suggestion to lift the age restriction for youth seeking gender-affirming surgical treatment, in comparison to previous suggestion of surgery at 17 or older. 

Alithia Zamantakis (she/her), a member of the Institute of Sexual & Gender Minority Health at Northwestern University Feinberg School of Medicine, is available to speak to media about the new guidelines. Contact Kristin Samuelson at [email protected] to schedule an interview.

“Lifting the age restriction will greatly increase access to care for transgender adolescents, but will also result in the need for parental consent for surgeries before doctors would likely perform them,” said Zamantakis, a postdoctoral fellow at Northwestern, who has researched trans youth and resilience. “Additionally, changes in age restriction are not likely to change much in practice in states like Alabama, Arkansas, Texas and Arizona, where gender-affirming care for youth is currently banned.”

Zamantakis also can speak about transgender peoples’ right to bodily autonomy, how guidelines affect insurance coverage and how U.S. gender regulations compare to other countries.

Guidelines are thorough but WPATH ‘still has work to do’

“The systematic reviews conducted as part of the development of the standards of care are fantastic syntheses of the literature on gender-affirming care that should inform doctors' work,” Zamantakis said. “They are used by numerous providers and insurance companies to determine who gets access to care and who does not.

“However, WPATH still has work to do to ensure its standards of care are representative of the needs and experiences of all non-cisgender people and that the standards of care are used to ensure that individuals receive adequate care rather than to gatekeep who gets access to care. WPATH largely has been run by white and/or cisgender individuals. It has only had three transgender presidents thus far, with Marci Bower soon to be the second trans woman president.

“Future iterations of the standards of care must include more stakeholders per committee, greater representation of transgender experts and stakeholders of color, and greater representation of experts and stakeholders outside the U.S.”

Transgender individuals’ right to bodily autonomy

“WPATH does not recommend prior hormone replacement therapy or ‘presenting’ as one's gender for a certain period of time for surgery for nonbinary people, yet it still does for transgender women and men,” Zamantakis said. “The reality is that neither should be requirements for accessing care for people of any gender.

“The recommendation of requiring documentation of persistent gender incongruence is meant to prevent regret. However, it's important to ask who ultimately has the authority to determine whether individuals have the right to make decisions about their bodily autonomy that they may or may not regret? Cisgender women undergo breast augmentation regularly, which is not an entirely reversible procedure, yet they are not required to have proof of documented incongruence. It is assumed that if they regret the surgery, they will learn to cope with the regret or will have an additional surgery. Transgender individuals also deserve the right to bodily autonomy and ultimately to regret the decisions they make if they later do not align with how they experience themselves.” 

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Sex-change treatment for kids on the rise

February 20, 2012 / 8:12 AM EST / AP

CHICAGO - A small but growing number of teens and even younger children who think they were born the wrong sex are getting support from parents and from doctors who give them sex-changing treatments, according to reports in the medical journal Pediatrics.

It's an issue that raises ethical questions, and some experts urge caution in treating children with puberty-blocking drugs and hormones.

An 8-year-old second-grader in Los Angeles is a typical patient. Born a girl, the child announced at 18 months, "I a boy" and has stuck with that belief. The family was shocked but now refers to the child as a boy and is watching for the first signs of puberty to begin treatment, his mother told The Associated Press.

Pediatricians need to know these kids exist and deserve treatment, said Dr. Norman Spack, author of one of three reports published Monday and director of one of the nation's first gender identity medical clinics, at Children's Hospital Boston.

"If you open the doors, these are the kids who come. They're out there. They're in your practices," Spack said in an interview.

Switching gender roles and occasionally pretending to be the opposite sex is common in young children. But these kids are different. They feel certain they were born with the wrong bodies.

Some are labeled with "gender identity disorder," a psychiatric diagnosis. But Spack is among doctors who think that's a misnomer. Emerging research suggests they may have brain differences more similar to the opposite sex.

Spack said by some estimates, 1 in 10,000 children have the condition.

Offering sex-changing treatment to kids younger than 18 raises ethical concerns, and their parents' motives need to be closely examined, said Dr. Margaret Moon, a member of the American Academy of Pediatrics' bioethics committee. She was not involved in any of the reports.

Some kids may get a psychiatric diagnosis when they are just hugely uncomfortable with narrowly defined gender roles; or some may be gay and are coerced into treatment by parents more comfortable with a sex change than having a homosexual child, said Moon, who teaches at the Johns Hopkins Berman Institute of Bioethics.

It's harmful "to have an irreversible treatment too early," Moon said.

Doctors who provide the treatment say withholding it would be more harmful.

These children sometimes resort to self-mutilation to try to change their anatomy; the other two journal reports note that some face verbal and physical abuse and are prone to stress, depression and suicide attempts. Spack said those problems typically disappear in kids who've had treatment and are allowed to live as the opposite sex.

Guidelines from the Endocrine Society endorse transgender hormone treatment but say it should not be given before puberty begins. At that point, the guidelines recommend puberty-blocking drugs until age 16, then lifelong sex-changing hormones with monitoring for potential health risks. Mental health professionals should be involved in the process, the guidelines say. The group's members are doctors who treat hormonal conditions.

Those guidelines, along with YouTube videos by sex-changing teens and other media attention, have helped raise awareness about treatment and led more families to seek help, Spack said.

His report details a fourfold increase in patients at the Boston hospital. His Gender Management Service clinic, which opened at the hospital in 2007, averages about 19 patients each year, compared with about four per year treated for gender issues at the hospital in the late 1990s.

The report details 97 girls and boys treated between 1998 and 2010; the youngest was 4 years old. Kids that young and their families get psychological counseling and are monitored until the first signs of puberty emerge, usually around age 11 or 12. Then children are given puberty-blocking drugs, in monthly $1,000 injections or implants imbedded in the arm.

In another Pediatrics report, a Texas doctor says he's also provided sex-changing treatment to an increasing number of children; so has a clinic at Children's Hospital Los Angeles where the 8-year-old is a patient.

The drugs used by the clinics are approved for delaying puberty in kids who start maturing too soon. The drugs' effects are reversible, and Spack said they've caused no complications in his patients. The idea is to give these children time to mature emotionally and make sure they want to proceed with a permanent sex change. Only 1 of the 97 opted out of permanent treatment, Spack said.

Kids will more easily pass as the opposite gender, and require less drastic treatment later, if drug treatment starts early, Spack said. For example, boys switching to girls will develop breasts and girls transitioning to boys will be flat-chested if puberty is blocked and sex-hormones started soon enough, Spack said.

Sex hormones, especially in high doses when used long-term, can have serious side effects, including blood clots and cancer. Spack said he uses low, safer doses but that patients should be monitored.

Gender-reassignment surgery, which may include removing or creating penises, is only done by a handful of U.S. doctors, on patients at least 18 years old, Spack said. His clinic has worked with local surgeons who've done breast removal surgery on girls at age 16, but that surgery can be relatively minor, or avoided, if puberty is halted in time, he said.

The mother of the Los Angeles 8-year-old says he's eager to begin treatment.

When the child was told he could get shots to block breast development, "he was so excited," the mother said.

He also knows he'll eventually be taking testosterone shots for life but surgery right now is uncertain.

The child attends a public school where classmates don't know he is biologically a girl. For that reason, his mother requested anonymity.

She said she explained about having a girl's anatomy but he rejected that, refused to wear dresses, and has insisted on using a boy's name since preschool.

The mother first thought it was a phase, then that her child might be a lesbian, and sought a therapist's help to confirm her suspicion. That's when she first heard the term "gender identity disorder" and learned it's often not something kids outgrow.

Accepting his identity has been difficult for both parents, the woman said. Private schools refused to enroll him as a boy, and the family's pediatrician refused to go along with their request to treat him like a boy. They found a physician who would, Dr. Jo Olson, medical director of a transgender clinic at Children's Hospital Los Angeles.

Olson said the journal reports should help persuade more doctors to offer these kids sex-changing treatment or refer them to specialists who will.

"It would be so nice to move this out of the world of mental health, and into the medical world," Olson said.

More from CBS News

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Mental Health Counseling Transgender-specific counseling can help you manage depression, anxiety, and other conditions that affect your emotional health. It may be needed to confirm a diagnosis of gender dysphoria, which can be an insurance prerequisite for some gender-affirming surgical procedures. We also offer support groups for transgender people ages 40 and older who are in the process of transitioning.

Gender-Affirming Voice Services Our voice therapists and laryngologists offer gender-affirming voice services, including trans-competent voice evaluations and behavioral voice intervention, to transgender and gender-diverse adults and children. In-person and virtual appointments are available. We can help you alter your vocal pitch, intonation, timbre, nonverbal communication style, and more. Our Gender-Affirming Vocal Skills Virtual Group is open to transgender and gender non-conforming adults who want to practice their modified voices in a group setting.

Dermatology Treatments Our dermatologists offer a variety of services designed to help you look and feel your best. These services may not be covered by health insurance. Check with your plan to determine what your out-of-pocket expenses may be.

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Gender Transitioning in Minors

How young is too young.

Posted May 2, 2023 | Reviewed by Michelle Quirk

• Find a therapist who understands gender identity
• While increased awareness of an issue is beneficial, too much emphasis on it when it has become part of the zeitgeist may be harmful.
• Creating blanket laws permitting youth transitioning gives rise to opposing laws meant to prevent gender transitioning.
• Before an attempt is made to come to a legal solution, we need to understand the underlying facts.

When discussing transgender issues in minors, “harm” is understood in precisely opposite ways by those on either side of the debate. Where there are calls for children under the age of 18—the age of legal majority in most U.S. states—to be able to transition, one side argues that “harm” would be preventing minors from doing so, and the other side argues that “harm” would be allowing minors to do so.

Arguments For and Against

One argument for preventing minors from gender transitioning is that they are too young to make that kind of permanent, life-changing decision, and they therefore must wait until they have reached the age of legal majority to make such a decision, with the assumption being that by age 18 they will be prepared and mature enough to make permanent, life-changing decisions.

One counterargument deals with the concept of maturity in an alternative fashion, such that if children don’t transition before puberty , they will in fact develop into biologically mature males or females, which later transitioning will not be able to reverse even with the use of hormones . Another argument is that 18 is an arbitrary age and that decision-making capacity is not significantly less developed in 17-year-olds or 16-year-olds.

A Psychology, Rather Than Legal, Perspective

Instead of immediately brandishing picket signs and legislative pens, we must think about how to approach the issue as it applies to minors. If we consider the question from a psychology perspective rather than a legal perspective, we will be able to evaluate how many individuals actually suffer from gender dysphoria , the age at which decision-making capacity ripens, at what age allowing children to transition might be abusive (the analysis may be different for a 17-year-old and a 7-year-old, for instance), the long-term harms of youth transitioning, and whether something like this emerges in waves in society.

That is, for example, does zeitgeist play a part in the emergence and disappearance of certain disorders simply by virtue of it being widely in the public consciousness? If this is true, how many children are we harming by—to a degree—normalizing gender dysphoria when it’s actually a minority of people who suffer from it?

While increased awareness of an issue is beneficial, too much emphasis on it when it has become part of the zeitgeist may be harmful, such that it may become more difficult for those suffering from gender dysphoria to be taken seriously and get the treatment they need—which may indeed include medical intervention, such as gender reassignment surgery (also referred to as “gender affirmation surgery”).

The Least Harm for the Greatest Number

Assume that the goal is to find a solution that results in the least harm for the greatest number of individuals. If the status quo is that only those who have reached the age of legal majority can make the decisions necessary to facilitate gender transitioning (for reasons that would need to be delineated, such as brain development with regard to decision-making capacity and the percentage of the minor population actually affected by gender dysphoria), the correct immediate step to take in finding the solution that will result in the least harm for the greatest number of individuals may not be reevaluating what laws should exist about preventing or permitting transgender “treatments” for minors—whether that is gender reassignment surgery or otherwise—but what exceptions to the laws should be available to minors.

Perhaps individuals under the age of 18 (the youngest age to which this could apply would need to be discussed) who actually suffer from gender dysphoria rather than experience standard, minor confusion or dissatisfaction with their body would be able to transition sooner—assuming that transitioning is the recommended clinical “treatment” for such a psychological disorder (gender dysphoria is in the Diagnostic and Statistical Manual of Mental Disorders )—if the laws allowed for exceptions in particular cases. Exceptions would be granted, for example, based on the recommendation of trusted psychologists after evaluating the minor, and of doctors after evaluating the child’s medical fitness for a particular course of treatment.

Questions about whether exceptions should be granted for the minor without the consent of the parents would need to be answered. The parents’ involvement would need to be a part of the psychological evaluation of the minor as well: Are the parents unreasonably unsupportive? Supportive but hesitant? Irrational? How does their behavior affect the child’s self-image and perspective on the issue? In addition, there would need to be an evaluation of the long-term effects of transitioning: Aside from long-term physical effects, would the child be mentally capable of thriving in society as a transgender individual? Do the risks outweigh the benefits in this particular case?

Creating blanket laws permitting youth transitioning that do not necessarily apply to the greater population gives rise to opposing laws meant to prevent gender transitioning for all minors, including the small percentage that might actually benefit from such an early transition as determined by medical professionals. This is because lawmakers of the latter persuasion see the harm that is potentially done by large-scale encouragement of youth transitioning where no gender dysphoria exists on a large scale.

Before an attempt is made to come to a legal solution about what path allows for the least harm for the greatest number of individuals, if that is indeed the agreed-upon goal, we need to understand the underlying facts about child psychology, the prevalence of gender dysphoria in minors, and the long-term risks and benefits of transitioning at an early age—and how early is too early from a developmental rather than legal perspective is a key question.

This article draws from ideas discussed in Episodes 6 and 7: “Transitioning Minors” of my Grey Matter video podcast series on Spotify.

Copyright © 2023 Kaitlin Puccio

Kaitlin Puccio, Esq., M.S. , is a lawyer, bioethicist, producer, and host of the "Grey Matter" video podcast. Her work explores and magnifies cultural topics buried at the intersection of philosophy, psychology, politics, bioethics, and law.

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Gender transition treatment minimum age lowered to 14-years-old

Emotional and cognitive maturity will factor in, as well as parental consent, by kelly mcclure.

The World Professional Association for Transgender Health has declared that the minimum age for gender transition treatment can now be lowered to 14, which is two years younger than previously advised. Along with that decrease in the age requirement for hormone treatments, the association has also moved to lower the minimum age for some gender reassignment surgeries to between 15 or 17.

While potential risks are present when administering hormone treatments and performing reassignment surgeries on patients within these age brackets, those risks were weighed against those that could come from withholding treatment from someone in need of it.

RELATED:  Trans kids in the U.S. were seeking treatment decades before today's political battles

In a report from AP News in which they detail information shared with them by the association prior to it being published in a medical journal later this year, it's explained that input from a pool of "more than 3,000 doctors, social scientists and others involved in transgender health issues" was used in making the decision to lower these minimum age requirements. A key factor in this decision, according to the association's report, was that lowering these ages would allow for trans youth to go through puberty at the same time as their peers.

Dr. Eli Coleman, chair of the group's standards of care and director of the University of Minnesota Medical School's human sexuality program points out in the AP News report that emotional maturity will also factor in to a case-by-case basis when it comes to any gender transition treatment.

"Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision," Coleman said. "That is why we recommend a careful multidisciplinary assessment."

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Under the new guidelines, girls will be able to start puberty blockers between the ages of 8 to 13, and two years later for boys, which allows anyone considering gender reassignment to have an expanse of time to decide for themselves whether they'd like to move forward with the next steps in terms of further treatment.

According to AP News the new guidelines also recommend:

—Sex hormones — estrogen or testosterone — starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men. —Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum age wasn't listed. —Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

 "Medical intervention in any realm is not a one-size-fits-all option," Coleen Williams, a psychologist at Boston Children's Hospital's Gender Multi-specialty Service said in response to the new guidelines.

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Kelly McClure is Salon's Nights and Weekends Editor covering daily news, politics and culture. Her work has been featured in Vulture, The A.V. Club, Vanity Fair, Cosmopolitan, Nylon, Vice, and elsewhere. She is the author of Something is Always Happening Somewhere .

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No, young children cannot take hormones or change their sex

If your time is short.

• Professional medical organizations recommend against puberty blockers for children who have not reached puberty, which typically begins between ages 10 and 12.

• Hormone treatment for feminization or masculinization of the body is typically not considered until patients are at least 16 years old. 

• Gender reassignment surgery is typically only available to those 18 and older in the United States. 

Misinformation about medical treatments for transgender patients has proliferated in recent weeks, as a spate of events brought transgender rights into the spotlight.

The social media backlash was swift following executive actions from President Joe Biden to expand transgender rights, his nomination of a transgender woman for assistant health secretary and the U.S. House of Representatives’ passing of the Equality Act to prohibit discrimation based on sexual orientation and gender identity. 

One Facebook post features an image of a father and son from the comic strip "The Family Circus," with text that reads, "Can I have a cigarette? No, you’re 5. Can I have a beer? No, you’re 5. Can I drive the car? No, you’re 5. Can I take hormones and change my sex? Sure! You know best." 

The onset of puberty is the baseline for medical intervention. Puberty typically occurs between ages 10 and 14 for girls and 12 and 16 for boys. 

Guidelines for the medical care of transgender patients, developed by organizations such as the Endocrine Society and the World Professional Association for Transgender Health, begin with counseling and psychological evaluation by a team of medical professionals before any physical interventions are considered. 

If patients have begun to go through puberty, and they have "demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria," then treatments such as puberty blockers can be considered, according to the standards of care for transgender people by the World Professional Association for Transgender Health. Gender dysphoria refers to distress people may experience as a result of the discrepancy between their gender identity and the sex assigned to them at birth.

Puberty blockers, which suppress the release of testosterone and estrogen during puberty, allow adolescents "more time to explore their gender nonconformity and other developmental issues," and can be used for a few years, the standards of care say. One guideline for giving the medication says parents or guardians must consent to the treatment and also provide support to the youth during the process. 

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If a patient decides to continue transitioning, hormone therapy for feminization or masculinization of the body can follow the use of puberty blockers. But, again, the Endocrine Society’s guidelines say patients should be at least 16 years old to receive hormone treatment, which is partly irreversible. Many hospitals, such as the Duke Health Center for Gender Care for Children and Adolescents , will only offer hormone replacement therapies for adolescents 16 or older.

The World Professional Association for Transgender Health reports that gender dysphoria in childhood "does not inevitably continue into adulthood." One study showed that children who had not yet reached puberty who were referred to clinics for assessment of gender dysphoria had a 12% to 27% persistence rate of gender dysphoria into adulthood. 

By comparison, adolescents with gender dysphoria are much more likely to have it persist into adulthood, the association reports, though no formal studies have been conducted for adolescents.

A cartoon on Facebook implies that a child who is 5 can "take hormones and change my sex." 

The information is unsubstantiated. The guidelines for the medical care of transgender patients, developed by organizations such as the Endocrine Society and the World Professional Association for Transgender Health, do not recommend puberty blockers for children who have not reached puberty; do not recommend hormone treatment for those under 16 years old; and typically restrict genital reassignment surgery to those 18 and older, who also meet other criteria. 

We rate this claim False.

RELATED: What the Equality Act debate gets wrong about gender, sex

RELATED:   Rachel Levine does not support gender confirmation surgery for all children

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Comics Kingdom, " The Family Circus ," accessed March 3, 2021

Endocrine Society, " Gender Dysphoria/Gender Incongruence Guideline Resources ," Sept. 1, 2017

PolitiFact, " Rachel Levine does not support gender confirmation surgery for all children ," March 2, 2021

U.S. National Library of Medicine, Medline Plus, " Puberty ," accessed March 3, 2021

World Professional Association for Transgender Health, " Standards of Care ," 2012

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Trans kids' treatment can start younger, new guidelines say

A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Association for Transgender Health said hormones could be started at age 14, two years earlier than the group's previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association provided The Associated Press with an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn't match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group's standards of care and director of the University of Minnesota Medical School's human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents' consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

"Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision," he said. "That is why we recommend a careful multidisciplinary assessment."

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment, along with new efforts to prevent or restrict the treatment.

Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of the World Professional Association for Transgender Health last year after voicing concerns about "sloppy" treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn't always happen.

"They tell me horror stories. They tell me, `Our child had 20 minutes with the doctor"' before being offered hormones, she said. "The parents leave with their hair on fire."

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association's new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8 per cent in kids.

Anderson said she's heard recent estimates suggesting the rate in kids is as high as 1 in 5 -- which she strongly disputes. That number likely reflects gender-questioning kids who aren't good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

"That's just absolutely cruel," she said.

Dr. Marci Bowers, the transgender health group's president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been "forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis."

Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, North Carolina, resident struggled miserably with gender discomfort before his treatment.

Poulos said he's glad he was able to get treatment at a young age.

"Transitioning under the roof with your parents so they can go through it with you, that's really beneficial," he said. "I'm so much happier now."

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

"Those decisions are best made by patients and patient families and medical professionals," they said. "It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together."

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn't strong evidence in favor of transgender medical treatment for kids.

"In medicine ... the treatment has to be proven safe and effective before we can start recommending it," Mason said.

Experts say the most rigorous research -- studies comparing treated kids with outcomes in untreated kids -- would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That's no change from the group's previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

• Sex hormones -- estrogen or testosterone -- starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.
• Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum ag wasn't listed.
• Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Association support allowing kids to seek transgender medical treatment, but they don't offer age-specific guidance.

Dr. Joel Frader, a Northwestern University a pediatrician and medical ethicist who advises a gender treatment program at Chicago's Lurie Children's Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they're prone to risk-taking and they take into account long-term consequences of their actions only when they're much older.

Coleen Williams, a psychologist at Boston Children's Hospital's Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

"Medical intervention in any realm is not a one-size-fits-all option," Williams said.

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JASON RANTZ

Rantz: WA laws now allow teen gender reassignment surgery without parental consent

Jan 10, 2022, 6:00 PM | Updated: Feb 10, 2023, 8:17 am

L.G.B.T. activists and their supporters rally in support of transgender people on the steps of New York City Hall in 2018. (File photo by Drew Angerer/Getty Images)

(File photo by Drew Angerer/Getty Images)

BY JASON RANTZ

AM 770 KTTH host

Washington state now appears to allow minors to undergo life-changing gender reassignment surgery without parental consent.

Under a new law, health insurers must cover “gender-affirming” care, including surgical treatments that were previously denied coverage. Democrats rejected a proposal to apply the new law to patients over 18 years old.

It’s one in a series of new laws that, taken together, allow children as young as 13 years old to make serious health care decisions. The consequences are immense.

Another law making it easier for minors to transition without parental guidance

Last year, via SB 5889 , Washington Democrats forced insurers to cover gender dysphoria treatment and gender-affirming care for minors between 13 and 17, without parental consent. It mandates that insurers deal directly with the patient without requiring the policyholder’s authorization.

It builds on SB 5904 , which provides outpatient mental health treatment without parental consent for the same age group.

All communication must go directly to the patient. The insurer may not disclose the patient’s medical information to outside parties, like the policyholder, unless given permission. The policyholder, in this case, is the parent.

The standard of care for gender dysphoria in youth is outlined by the World Professional Association for Transgender Health (WPATH). It includes everything from puberty-blocking hormones and speech therapy, to laser hair removal and counseling on binding. But it also asks doctors to affirm the choice of some to undergo surgical procedures to help them match their gender identity.

For some transgender patients, WPATH says, “relief from gender dysphoria cannot be achieved without modification of their primary and/or secondary sex characteristics to establish greater congruence with their gender identity.”

“Mental health professionals should not impose a binary view of gender. They should give ample room for clients to explore different options for gender expression. Hormonal or surgical interventions are appropriate for some adolescents, but not for others,” WPATH notes.

Technical update on language downplays the seriousness of law

The new law is just a minor update to technical terminology on the surface. But it’s much more than that.

SB 5313 bans an insurance provider from categorically rejecting cosmetic, gender-affirming treatments when deemed medically necessary by a health care provider and when prescribed to a patient, consistent with their gender identity.

Up until this law, gender reassignment surgery and other procedures like facial reconstruction or laser hair removal were considered cosmetic by health insurance companies. Due to its classification as cosmetic, health insurers did not usually cover the procedures, even when doctors medically recommended them.

The bill was signed into law by Governor Jay Inslee in 2021 and went into effect on Jan. 1, 2022.

Is this about bigotry?

The bill’s sponsor, State Senator Marko Liias (D-Lynnwood), argued at the time of its passage that it was in response to other states banning treatment for minors. He labeled the bans as “transphobic.”

“I am proud that our state is sort of standing up to this hysteria sweeping the country of intolerance and hatred of trans people,” Liias told Crosscut. “We are going the opposite direction saying that, here, people are welcome and we support them.”

But the direction that Liias is going means cutting parents out of the decision-making process, allowing a child to alter their body permanently.

It’s also a curious move since Washington law bans minors from using tanning beds . Lawmakers, including Liias, voted for that ban to protect children from the harmful effects of UV rays. Now Democrats allow your child to go through feminizing hormone therapy and some surgical procedures independently.

One Senate Republican supported the bill, and all House Republicans rejected it.

Liias finally weighs in with an evasive response

Initially, Liias did not respond to multiple requests for comment.

Instead, the Senate Democratic Caucus spokesperson sent a statement arguing “there is not a specific mention of gender affirming care in statute.” She argues that means gender reassignment surgery would still need parental consent.

But SB 5889 mentions explicitly “gender dysphoria” and “gender affirming care.” And Liias’ bill covers “gender affirming” surgical procedures.

When asked to clarify their statement with the language in the bills, the spokesperson did not respond. But at the behest of the Senate Democratic Caucus, Liias finally responded.

I asked Liias if he supports gender reassignment surgery for minors either with or without parental consent. He would not answer directly but implied he supports it with or without parental consent.

“There is not a short or simple answer on what care is appropriate for which individuals. In short, I support the ability of all trans people to access medically necessary care. Medical providers use established standards of care in consultation with patients and their caregivers as appropriate,” Liias wrote in an email to the Jason Rantz Show on KTTH.

He linked to the American Academy of Pediatrics with an example of pediatric care guidelines. It does offer guidance to avoid surgery, such as “pubertal suppression in children.”

But it also notes that the process of gender affirmation may include: “‘top’ surgery (to create a male-typical chest shape or enhance breasts); ‘bottom’ surgery (surgery on genitals or reproductive organs); facial feminization and other procedures.”

“I don’t believe that lawmakers or insurance companies should make determinations of what care is appropriate, that decision is best left with our health agencies, medical professionals and patients,” Liias says, failing to mention parents.

Republicans saw this coming

Republicans argue the current laws do not require parental consent for these surgical procedures if the patient is between 13 and 18, assuming a patient is able to find a willing doctor.

“This is wrong — 13-year-olds are not mature enough to make gender reversal surgery decisions and need parental support during this time,” State Representative Michele Caldier (R-Port Orchard) told the Jason Rantz Show on KTTH. “The same legislators who pushed the age of purchase of tobacco products from age 18 to 21, now claim 13-year-olds are able to make the solo decision whether to get their trachea shaved or a mastectomy.”

“I am a foster parent who takes in hard-to-place teens. These kids need my help for simple day-to-day tasks. I couldn’t imagine them making life-changing decisions without my support or their parent’s support,” Caldier added.

The direct intent of SB 5313 wasn’t to offer surgical treatment to minors. But combined with previously passed legislation, it’s now possible.

Republican lawmakers saw this coming. It’s why they saw only one defector.

State Senator Phil Fortunado (R-Auburn) attempted to amend SB 5313. His amendment inserted language that would deny gender-affirming treatment to patients under 18. But Democrats, who have control of the legislature, rejected it.

On the House side, Caldier tried to at least tighten the language.

Instead of blanket support of cosmetic gender-affirming treatment, Caldier wanted a slightly higher bar to be met. Procedures would only be covered “if the treatment or services will improve the overall mental health of the enrollee.”

Again, Democrats rejected it.

This isn’t about trans rights

Many Democrats who support this kind of legislation try to silence critics by labeling them transphobic and intolerant. It’s a cheap and disingenuous attempt to shut down reasonable opposition.

Parents have the biggest role to play in the well-being of their children. But progressive lawmakers and activists pretend parents are abusive if they dare to question their kid’s position that they’re transgender.

No, 13-year-olds aren’t mature enough at that age to determine they can handle a gender reassignment surgery.

Unfortunately, unless a parent immediately and unquestionably accepts their kid’s feelings at the time, the Left deems them to be unfit parents. And they believe that if a child even suspects their parents might say no to a life-altering surgery, the child should have the right to move forward on their own.

It’s an easy position for politicians or activists to take when they don’t have to deal with the consequences the way a child and his or her family would.

This isn’t responsible lawmaking, either

Will there be a rush of 13-year-olds getting gender reassignment surgery without parental consent as a result of this law? No. But this is another step Democrats are taking to redefine gender. And, in time, teenage gender reassignment surgeries could become more frequent.

There are endless stories of people regretting their transitions . They felt betrayed by doctors who refused to question their decisions, eager to appear supportive rather than inform them of the consequences. When outlets tell these stories, progressive activists scream claims of bigotry.

There are also clear examples of children shutting out parents who are supportive.

Most teens go through a phase of being untrusting of parents or wanting to keep something private — issues much less sensitive or serious than gender reassignment surgery.

Breaking the bond between child and parent

These laws intentionally disconnect a parent and child. When did breaking up a family connection lead to societal benefits?

The legislature could have easily created a carve-out for minors who have a legitimate reason to keep some treatment private from abusive parents. But they chose not to. This isn’t about the child, it’s about a greater political movement. And these children are being used to forward it.

Teens who question their gender identity deserve our support and compassion. I can’t imagine what it’s like to have that particular feeling. But I certainly know what teenage years feel like as someone who is gay. It can be awkward and isolating even when you do have someone to talk to.

These Democrat laws do not serve these children. They’re being deprived of the support they’re owed by adults using them to make political statements. Having gender identity conversations with loving parents, however awkward, is better than letting an activist politician push teens down a path they’re certainly not ready to handle on their own.

Listen to the Jason Rantz Show weekday afternoons from 3–6 pm on KTTH 770 AM (HD Radio 97.3 FM HD-Channel 3). Subscribe to the podcast here . Follow  @JasonRantz   on   Twitter,    Instagram , and  Facebook . Check back frequently for more news and analysis.

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Children with gender dysphoria no longer have to seek court approval to undergo surgery

The Family Court has decided it will no longer intervene in cases where children with gender dysphoria have the permission of their parents and treating doctors to undergo surgery.

The ruling has cleared the way for one teenager who is transitioning from female to male to undergo a double mastectomy as a treatment for gender dysphoria.

It also means parents who agree with the treatment will not be subject to the expense, stress and possible delay of going to court.

The ruling builds on an earlier decision, in a separate case last year.

In that case, the Full Court determined it had no role in determining whether a child diagnosed with gender dysphoria should begin stage two — non-surgical treatment.

Stage two treatment involves the use of either oestrogen to feminise the body in those who have a female gender identity, or the use of testosterone to masculinise the body in those who have a male gender identity.

In the latest case, the 16-year-old given the pseudonym Matthew was born genetically female but identifies as a male.

His parents asked the court to find he is competent to consent to stage three — surgical treatment.

The court found its consent was not necessary, because his doctors and parents agreed he suffered gender dysphoria, that the surgery was therapeutic and Matthew was competent to decide whether to have the treatment.

The court heard evidence from a doctor who said the treatment could be life-saving.

He said the effect of denying the treatment to Matthew "would likely be extreme distress, low mood and the potential for worsening suicidal ideation".

Another doctor told the court the surgery often had "immediate and profound therapeutic benefit".

"The individual is able to wear clothing that is congruent with their gender, has much less fear of being misgendered as a female or having their transgender status unwantedly discovered by others, and can move freely and participate in a broad range of desired social and sporting activities."

Children in state care and those whose parents object to their hormone treatment will still have to go to court.

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In the Operating Room During Gender Reassignment Surgery

Behind the scenes with identical twin Emmie Smith during her medical transition.

Before August 30, 2016, getting stitches at age seven was the most time Emmie Smith had ever spent in a hospital.

That morning, she swapped her plaid shirt and jean shorts for a gown, tucked her hair into a cap, and prepared for surgery to conform her anatomy to the gender she already identified with: woman. In the operating room with her was National Geographic photographer Lynn Johnson. She and Emmie hoped they could demystify the procedure by documenting it, close-up and unflinching. “It was stressful and scary at times, but it almost created a mission other than just recovery,” Emmie says. “We were making something together.”

It had been a year and a half since Emmie had first come out as a transgender woman on Facebook. Telling her family and friends had been an enormous relief. “I’m not sure I could have taken another few years of being closeted,” she says.

Still, it was a challenging time for her family. Her mother, Reverend Kate Malin, is a prominent figure in their Massachusetts town, and her identical twin sons Caleb and Walker were familiar fixtures at her Episcopal church. A month after Walker came out as Emmie, Malin stepped out from behind her pulpit and walked into the aisle. Halfway through her sermon she decided it was time to address the change in her family.

“As most of you know, Bruce and I have three children,” she began. “Caleb and Walker, who are 17, and 13-year-old Owen. Walker’s new name is Emerson, and she prefers Emmie or Em. She’s wearing feminine clothing and makeup and will likely continue to move in the direction of a more feminized body.”

Follow Emmie's transition in pictures

Kate nervously revealed her struggle to the attentive New England crowd. “I feel broken much of the time,” she confessed. “I’ve wanted to run away, and I’ve prayed for this child that I would gladly die for, guilty for how much I miss the person I thought was Walker and everything I thought might be.”

After the sermon, the congregation engulfed her in a hug. Then they moved to offer words of support to the sandy-haired 17-year-old sitting in the pews. In the first of many awkward mistakes the family would later laugh about, it was Caleb—Emmie’s identical twin.

After that sermon, a “new normal” set in. On a Saturday night soon after, they had their first “out” outing. Kate took Emmie—whose hair was still short and chest was flat—to buy a prom dress at David’s Bridal. She feared someone would point or laugh, but the crowds of brides and bridesmaids in the dressing room offered only compliments.

Though she hadn’t initially considered surgery, after a couple of months Emmie had grown frustrated by the tucking and taping required to fit into women’s clothes. That fall, her senior year of high school, she decided to do it.

But waking up after the operation, Emmie felt none of the immediate relief she’d expected. In the recovery room her earbuds played a soothing loop of Bon Iver and Simon and Garfunkel, but it didn’t drown out her disappointment and fear. In retrospect, she thought, hadn’t life before been OK?

It wasn’t until months later, when she was home and could walk and sit again, that Emmie knew she’d made the right choice. “If you’re not living freely that’s time wasted, and I felt my time was wasted pretending to be a boy,” she says. “It was the best decision in my life.”

Now, halfway through a gap year, she’s applying to college theater programs. It’s strange, she says, knowing that her future classmates may watch Johnson’s film and learn the most intimate details of her life. She’s hopeful that her participation will evolve the public’s understanding of gender reassignment surgery. “It’s not science fiction or mythology,” Emmie says. “It’s what happens to women just trying to be at peace with themselves and their bodies.”

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Mental Health of Transgender Youth Following Gender Identity Milestones by Level of Family Support

• 1 Department of Economics, Southern Oregon University, Ashland, Oregon
• 2 RAND Corporation, Arlington, Virginia
• 3 Department of Labor Studies and Employment Relations, Rutgers University, Piscataway, New Jersey
• 4 Division of Health Policy and Administration, University of Illinois at Chicago, Chicago, Illinois
• Viewpoint Moving Beyond Statements to Protect Transgender Youth Melissa Santos, PhD; William T. Zempsky, MD, MPH; Jim Shmerling, DHA JAMA

Question   How are gender identity milestones, such as first feeling one’s gender was different or first telling someone that they are transgender, associated with the mental health of transgender youth and how does the level of family support moderate these associations?

Findings   In this study, initiating a gender identity milestone was associated with a higher risk of suicide attempt and running away from home among transgender youth who live in unsupportive families, whereas supportive family environments mitigate these risks.

Meaning   These findings highlight the critical role of family support in maintaining healthy family environments and reducing the likelihood of transgender youth attempting suicide or leaving their homes during identity development.

Importance   Transgender youth are at an elevated risk for adverse mental health outcomes compared with their cisgender peers. Identifying opportunities for intervention is a priority.

Objective   To estimate differences in the association between gender identity milestones and mental health outcomes among transgender youth, stratified by level of family support.

Design, Settings, and Participants   This retrospective cohort study compares changes in mental health outcomes among transgender youth who initiate gender identity milestones compared with those who initiate the same milestones 1 year later, stratified by level of family support, using the 2015 US Transgender Survey. The analytic samples included 18 303 transgender adults aged 18 and older who had initiated at least 1 gender identity milestone between ages 4 and 18 years.

Exposure   Four gender identity milestones: feeling one’s gender was different, thinking of oneself as transgender, telling another that one is transgender, and living full-time in one’s gender identity, stratified by 3 levels of family support: supportive, neutral, and adverse.

Main Outcomes   Age at first suicide attempt and at running away.

Results   Study participants included 18 303 transgender adults (10 288 [56.2%] assigned female at birth; 14 777 [80.7%] White). Initiating a gender identity milestone was associated with a higher risk of suicide attempt and running away from home among transgender youth. This finding was driven by children who live in unsupportive families. For example, thinking of oneself as transgender was associated with a meaningful increase in the overall probability of attempting suicide among those in either adverse families (estimate = 1.75 percentage points; 95% CI, 0.47-3.03) or neutral families (estimate = 1.39 percentage points; 95% CI, 0.72-2.05). Among youth living with supportive families, there were no statistically significant associations between gender identity milestones and adverse mental health outcomes and 95% CIs generally ruled out any meaningful associations.

Conclusion   These results demonstrate that without a supportive family environment, gender identity development increases the risk of transgender youth attempting suicide or running away from home. Social services and community resources to establish supportive relationships between transgender children and their parents are essential.

Read More About

Campbell T , Mann S , Rodgers YVDM , Tran NM. Mental Health of Transgender Youth Following Gender Identity Milestones by Level of Family Support. JAMA Pediatr. Published online July 15, 2024. doi:10.1001/jamapediatrics.2024.2035

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© 2024

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California bans school rules requiring parents notification of child's pronoun change

The Associated Press

Parents, students, and staff of Chino Valley Unified School District hold up signs in favor of protecting LGBTQ+ policies at Don Antonio Lugo High School, in Chino, Calif., in June 2023. California Gov. Gavin Newsom signed a law Monday barring school districts from passing policies that require schools to notify parents if their child asks to change their gender identification. Anjali Sharif-Paul/The Orange County Register/AP hide caption

SACRAMENTO, Calif. — California became the first U.S. state to bar school districts from requiring staff to notify parents of their child's gender identification change under a law signed Monday by Gov. Gavin Newsom.

The law bans school rules requiring teachers and other staff to disclose a student's gender identity or sexual orientation to any other person without the child's permission. Proponents of the legislation say it will help protect LGBTQ+ students who live in unwelcoming households. But opponents say it will hinder schools' ability to be more transparent with parents.

The legislation comes amid a nationwide debate over local school districts and the rights of parents and LGBTQ+ students.

"This law helps keep children safe while protecting the critical role of parents," Brandon Richards, a spokesperson for Newsom, said in a statement. "It protects the child-parent relationship by preventing politicians and school staff from inappropriately intervening in family matters and attempting to control if, when, and how families have deeply personal conversations."

A San Francisco store is shipping LGBTQ+ books to places where they are banned

The new law comes after several school districts in California passed policies requiring that parents be notified if a child requests to change their gender identification. That led to pushback by Democratic state officials, who say students have a right to privacy.

But Jonathan Zachreson, an advocate in California who supports the so-called parental notification policies, opposes the law and said telling parents about a student's request to change their gender identification is "critical to the well-being of children and for maintaining that trust between schools and parents."

States across the country have sought to impose bans on gender-affirming care, bar transgender athletes from girls' and women's sports, and require schools to out trans and nonbinary students to their parents. Some lawmakers in other states have introduced bills with broad language requiring that parents are told of any changes to their child's emotional health or well-being.

Transgender bathroom bills are back, gaining traction after past boycotts

The California law led to heated debate in the state Legislature. LGBTQ+ lawmakers have shared stories about how it was difficult for them to decide when to come out to their families, arguing that transgender students should be able to share that part of their identity on their own terms. State Assemblymember Bill Essayli, a Republican representing part of Riverside County, is an outspoken opponent of the law. He has criticized Democratic leaders for preventing a bill he introduced last year — that would have required parents to be told of their child's gender identification change — from receiving a hearing.

In Northern California, the Anderson Union High School District board approved a parental notification policy last year. But the teachers union recommended that teachers not enforce the rule while the union is involved in a labor dispute with the district over the policy, said Shaye Stephens, an English teacher and president of the teachers association at the district.

The notification policies put teachers in an unfair position, Stephens said.

"It's kind of a lose-lose situation for teachers and administrators or anybody that's being asked to do this. I don't think it's safe for students," she said. "I do not think that we are the right people to be having those conversations with a parent or a guardian."

Musk says estranged child's gender-affirming care sparked fight against 'woke mind virus'

Tesla CEO Elon Musk said his estranged transgender daughter was "killed" by the "woke mind virus" after he was tricked into agreeing to gender-affirming care procedures .

In an interview with psychologist and conservative commentator Dr. Jordan Peterson , the X owner called gender-reassignment surgery "child mutilation and sterilization." He then discussed his 20-year-old child Vivian Jenna Wilson , who he said underwent the procedures during the pandemic.

"I was essentially tricked into signing documents for one of my older boys," Musk told Peterson in a Daily Wire interview during which he referred to his child by their deadname. "This was really before I had any understanding of what was going on, and we had COVID going on, so there was a lot of confusion and I was told (Musk's child) might commit suicide."

The SpaceX founder claimed the process is done to children "who are far below the age of consent" and said he agreed with Peterson's belief that anyone who promotes the practice should go to prison.

"I was tricked into doing this," Musk said. "I lost my son, essentially. They call it 'deadnaming' for a reason. The reason they call it ‘deadnaming’ is because your son is dead."

Musk went on to say that the experience set him on a mission.

"I vowed to destroy the woke mind virus after that," Musk said. "And we’re making some progress."

Twitter AI: Elon Musk is quietly using your tweets to train his chatbot. Here’s how to opt out.

Vivian Jenna Wilson cut ties with father in 2022

Wilson was legally granted her name and gender change at age 18 at the Santa Monica courthouse in California on June 22, 2022.

She said the name change was due to gender identity and an apparent dislike of Musk, according to a petition filed on April 18, 2022, in Los Angeles County Superior Court.

"I no longer live with or wish to be related to my biological father in any way, shape or form," Wilson wrote in the petition.

Wilson's mother is Justine Wilson, a Canadian author who divorced Musk in 2008; the couple shares six children.

Musk called 'woke mind virus' threat to modern civilization

Musk has previously criticized what he calls "woke mind virus"  in a December 2021 interview with conservative outlet The Babylon Bee, where said called it "a world without humor"  and "arguably one of the greatest threats to modern civilization."

Musk announced his intent to buy Twitter for $44 billion on April 25, 2022 , and closed the deal about six months later . He promised to restore "free speech" on the platform and has increased his conservative political commentary since the purchase.

Earlier this month, Musk said he fully endorsed former President Donald Trump after the attempted assassination at a Pennsylvania rally on July 13.

Gender-affirming care is a valid, science-backed method

Gender-affirming care  is a  valid, science-backed method  of medicine that saves lives for people who require care while navigating their gender identity. Gender-affirming care can range from talk or hormone therapy to  surgical intervention .

Some experts claim that that  gender-affirming care  should be viewed like other forms of medicine where methods of treatment can be debated and discussed rather than the validity of it's need.

"In any medical field, we're continuously improving the care, changing the care, developing new  guidelines , developing research," Dr. Ximena Lopez, a pediatric endocrinologist in California, previously told USA TODAY. "So it should not be a surprise that it's the same in gender care."

Transgender adults  make up less than 2% of the U.S. population with about 5% of young adults identifying as  transgender  or nonbinary.

"We need to take a step back from acknowledging yes, they might have side effects, but that's why they're not done so flippantly," Dr. Ramiz Kseri , assistant professor in the department of clinical sciences at Florida State University College of Medicine, previously told USA TODAY. "That's why there is conversation about it, there is discussion, in terms of which outcomes are desired, and which outcomes are not desired."

Contributing: Natalie Neysa Alund, Jessica Guynn and David Oliver, USA TODA Y

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The Debate Over Gender-Affirming Care

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To the Editor:

Re “ U.S. Gender Care Is Ignoring Science ,” by Pamela Paul (column, July 14):

I appreciated the depth and thoughtfulness of Ms. Paul’s column. But as the mother of a trans daughter, I question her conclusion that the evidence is against gender-affirming care, given the confusing mix of information, research, opinion and anecdotes swirling around the issue.

My child told us clearly she was a girl a few days shy of her fourth birthday, and she has been clear about her gender identity ever since. We have been through years of family counseling, and she has continued with an individual counselor as well. We have tried to be careful, not make assumptions in either direction and listen well. Now 10, she has expressed to me and my husband extreme distress at the idea of going through puberty as a boy.

Since we live in a state that does not allow puberty blockers, we have begun the process of trying to find her care elsewhere. Despite sharing the concerns that Ms. Paul lists and shouldering the expense and exhaustion of having to go out of state, what is clear to me as a parent is that forcing my daughter to wait until she had fully developed as a male before being able to access medical interventions would be cruel. Every day for her would be an agony.

And in a country where transgender people of color are disproportionately targeted as victims of violent crimes, forcing her to look like a man who is dressed as a woman could result in serious harm.

I understand and agree with much of what Ms. Paul says. But I wonder why we can’t allow for more nuance. Is the medical system unable to handle differentiating care? Why must we outlaw medical interventions that for a small minority are quite literally lifesaving? Why can’t we put into place reasonable safeguards to protect the many so that the few can still access the care that they need?

Name Withheld San Antonio The writer requested anonymity to protect the privacy of her child.

Thank you for publishing this article! Pamela Paul reflects the views of so many who are afraid to say it out loud.

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Two female boxers meet Paris Olympics rules after gender test issue at world championships, IOC says

This photo shows a view from the Eiffel Tower ahead of the 2024 Summer Olympics, Monday, July 22, 2024, in Paris, France. (AP Photo/Natacha Pisarenko)

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PARIS (AP) — Two female boxers at the Paris Olympics who were disqualified at the 2023 world championships after being judged to have failed gender eligibility tests have complied with all rules to fight at the games, the IOC said Monday.

Lin Yu-ting of Taiwan and Imane Khelif of Algeria are competing at their second Summer Games. Both finished outside the medals at the Tokyo Olympics held in 2021.

“All athletes participating in the boxing tournament of the Olympic Games Paris 2024 comply with the competition’s eligibility and entry regulations, as well as all applicable medical regulations,” the International Olympic Committee said in a statement.

The 28-year-old Lin is a two-time worlds gold medalist and the 25-year-old Khelif won a silver at the 2022 tournament.

Both were removed from their competitions in New Delhi last year at the world championships, run by the International Boxing Association which has been banished from Olympic boxing since before the Tokyo Games.

The different status of Lin and Khelif at the Olympics and worlds is fallout from the years-long dispute between the IOC and the Russian-led IBA over alleged failures of governance and integrity, plus reliance on funding from state energy firm Gazprom.

The IOC has appointed officials to run boxing at two straight Summer Games and acknowledged Monday the tournament rules for Paris are “descended from” those in place eight years ago at the Rio de Janeiro Olympics.

Boxing officials picked to run Paris qualifying and finals tournaments tried “to restrict amendments to minimize the impact on athletes’ preparation and guaranteeing consistency between Olympic Games,” the IOC said.

The IOC-run database of about 10,700 athletes competing in Paris detailed both boxers’ experiences at the 2023 worlds.

Khelif was disqualified “just hours before her gold medal showdown” against a Chinese opponent “after her elevated levels of testosterone failed to meet the eligibility criteria.”

Paris Olympics

• The men’s Olympic triathlon has been postponed over Seine water quality concerns. Read more here .
• Take a look at everything else to watch on Day 4.
• See AP’s top photos from the 2024 Paris Olympics here .
• See the Olympic schedule of events and follow all of AP’s coverage of the Summer Games .
• Here is a link to the Olympic medal tracker .
• Want more? Sign up for our daily Postcards from Paris newsletter.

Lin “was stripped of her bronze medal (by the IBA) after failing to meet eligibility requirements based on the results of a biochemical test,” the IOC database stated.

On Thursday, Khelif will fight Italy’s Angela Carini in the 66-kilogram category at the North Paris Arena. Lin, who got a first-round bye as the top seed in the 57-kilogram category, will have her opening bout Friday in the round of 16.

Medal bouts in boxing at Paris will be staged at the Roland Garros tennis venue.

AP Summer Olympics: https://apnews.com/hub/2024-paris-olympic-games

How Kamala Harris fares against Trump in the 2024 polls

With President Joe Biden exiting the 2024 presidential race, Vice President Kamala Harris now becomes the overwhelming front-runner to be the Democratic Party’s presidential nominee.

Harris’ biggest challenge lies further ahead, though: She   has been polling   the same as Biden — or just slightly better — against Republican nominee Donald Trump, according to multiple surveys taken before Biden withdrew from the 2024 contest.

And Biden was running behind Trump in many national and battleground-state polls — which precipitated the president’s withdrawal.

In  NBC News’ latest national poll , conducted more than a week after Biden’s dismal debate performance but before the assassination attempt on Trump, both the president and Harris trailed Trump by 2-point margins among registered voters, though the actual percentages for each candidate were slightly different. Trump led Biden 45%-43%, while he took 47% to Harris’ 45% in their matchup. Both ballot tests fell within the poll’s margin of error.

Similarly, a post-debate  national Fox News poll  found Trump ahead by 1 point against both Biden (Trump 49%, Biden 48%) and Harris (Trump 49%, Harris 48%) among registered voters.

But other polls have shown Harris slightly outperforming Biden by 1 or 2 points — though, critically, still trailing Trump at this point in some key matchups.

A  national CBS News/YouGov poll  of likely voters conducted after the assassination attempt found Trump leading Biden by 5 points among likely voters, 52% to 47%, while it showed Harris trailing by 3 points, 51% to 48%.

And in  New York Times/Siena College battleground polls  of Pennsylvania and Virginia, Harris performed 2 points better than Biden did among likely voters in these two states.

Importantly, all of these results are within each poll’s margin of error — and so is the difference between Biden’s and Harris’ numbers. Also important: It’s possible these numbers could change after the news of Biden’s exit from the 2024 race. But for the moment, Biden’s numbers and Harris’ numbers look quite similar.

Where Harris runs stronger — and weaker — than Biden

While the recent NBC News poll found Biden and Harris running 2 points behind Trump nationally, the survey found some  important differences among demographic groups .

For one thing, Harris slightly outperformed Biden among Black voters, leading Trump among this demographic by 64 points (78% to 14%). That compares with Biden’s 57-point lead among Black voters (69%-12%).

 On the other hand, the NBC News poll showed Trump doing slightly better among white voters when matched up with Harris instead of Biden, leading her by 16 points among these voters, compared with his 14-point advantage here against Biden.

Among other demographics — by age, by gender, among Latino voters — there was almost no difference between Biden or Harris.

Indeed, the biggest differences between Biden and Harris in the poll went well beyond demographics.

Among the roughly one-quarter of Republican registered voters in the poll who said they were unsatisfied with Trump as the GOP’s nominee, Trump ran ahead of Biden by 46 points, 63%-17%. But when Trump’s opponent was Harris, more of these dissatisfied GOP voters flocked to Trump. The Republican’s lead with that group grew to 57 points, 73%-16%.

Meanwhile, the voters who preferred a third-party candidate in the poll’s multicandidate ballot test seemed more open to Harris coming in as a fresh face in the 2024 race.

Trump and Biden were virtually tied with these third-party-interested   voters in a head-to-head matchup. Trump took   32% and   Biden took   31%, with a plurality declining to make a two-way choice, saying they were undecided, would pick another candidate, or something else.

But when Harris was the choice against Trump, more of those respondents made a pick in the two-way ballot test. The vice president went ahead of Trump among these “other” voters, 46% to 39%, suggesting a higher upside with voters currently   considering a third-party candidate.

Biden, Harris and Trump have almost equal positive-negative scores

The NBC News poll also  showed  Biden, Harris and Trump with almost equal positive-negative scores with the electorate.

• Trump: 38% positive, 53% negative (-15 net rating)
• Biden: 36% positive, 53% negative (-17 net rating)
• Harris: 32% positive, 50% negative (-18 net rating)

That said, while Harris had a slightly lower positive score in the poll, 15% of voters said they’re “neutral” about her, compared with just 11% who are neutral on Biden.

That suggests an opportunity for Harris to grow — or fall — with this sliver of voters in the middle.

Mark Murray is a senior political editor at NBC News.