gender reassignment surgery on minors

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

• Follow Reuters Investigates

Other Reuters investigations

• For Journalists
• News Releases
• Latest Releases
• News Release

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

Media Contacts

Kristin Samuelson

• (847) 491-4888
• Email Kristin
• 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.” 

• Telemedicine
• Healthcare Professionals
• Go to MyChart
• Find a Doctor
• Make an Appointment
• Cancel an Appointment
• Find a Location
• Visit ED or Urgent Care
• Get Driving Directions
• Refill a Prescription
• Contact Children's
• Pay My Bill
• Estimate My Cost
• Apply for Financial Assistance
• Request My Medical Records
• Find Patient Education
• Refer and Manage a Patient

Surgical Gender Affirmation Program

What is gender-affirming surgery.

Surgery that supports a person’s gender identity is called gender-affirming surgery. This term covers a wide range of procedures for people of all genders. Often, it means surgery for a transgender , nonbinary or gender-diverse person to relieve lasting gender dysphoria .

People who choose gender-affirming surgery may have only 1 type of procedure, or they may have many, sometimes over several years. Their choices depend on their gender-related health goals. Each person is unique, and so is their treatment plan.

What age patients does the program treat?

The Surgical Gender Affirmation Program treats teens and young adults. We work closely with patients and families to make decisions about surgery age and timing. Patients must be 18 or older by the time of surgery for gender-affirming genital procedures. For other surgeries, timing depends on many factors, like the patient’s stage of puberty and how surgery fits with the rest of their gender-related healthcare. A typical age is older teens. We treat some patients through age 26 for gender-affirming surgery. Gender-affirming medical care for patients under age 18 requires consent from any parent or guardian that has medical decision-making rights for that patient, unless the patient is an  emancipated minor . 

Genital surgeries for other reasons — such as tumors, differences in sex development (DSDs) or fertility preservation — are offered through other Seattle Children’s programs, like our DSD Program , Urology , Gynecology or Reconstructive Pelvic Medicine .

What’s special about the experience at Seattle Children’s?

Seattle Children’s is the only pediatric academic medical center with fellowship-trained plastic surgeons who provide gender-affirming surgery in our region. We treat teens and young adults who are patients of Seattle Children’s Gender Clinic . We also accept patients who are receiving gender-affirming care through providers outside of Seattle Children’s.

• Our plastic surgeons have special training and experience in gender-affirming surgery for young people, as well as adults. Knowledge and expertise are important to plan and perform these procedures well so patients achieve the results they expect.
• A urologist , dermatologist and gynecologist are part of our team to provide expert advice and treatment in support of patients’ health goals. They work closely with our plastic surgeons.
• Our gender surgery registered nurse also works closely with the doctors. They help with care each step of the way. They know in detail what these surgeries involve, how surgery can affect patients and how to best support a good recovery.
• Everyone on the team specializes in pediatric gender-affirming care . At Seattle Children’s, patients will receive care in a respectful environment from pediatric providers committed to their well-being.
• We follow guidelines of the World Professional Association for Transgender Health (WPATH) and current best practices for young people who want transition-related treatment.
• Our team fully accepts each individual we treat. We meet each patient and family where they are, knowing that surgery is a step in a larger process. Before making a treatment plan, we talk with you in detail about your gender-related health goals, like how your body will look and work after surgery. Knowing these goals allows us to provide the most personalized care.
• We offer complete and accurate information about the range of surgery options, such as different techniques and what to expect during recovery. Our team knows how to explain treatments in ways that match a patient’s age and understanding.
• Our specialized gender-affirmation surgery care coordinator is here to help you throughout the process, starting from the first time you call us. They offer one-on-one help with topics like seeking approval from your insurance company and getting the medical and mental health letters of support that are required.
• Seattle Children’s has many resources to make the experience as smooth as possible, from financial assistance to LGBTQ-friendly spiritual care .
• For patients and their families who travel to Seattle Children’s for gender-affirming surgery, we can help coordinate travel and housing.

What services does the Surgical Gender Affirmation Program offer?

The Surgical Gender Affirmation Program for teens and young adults provides:

• An opportunity to talk with our care coordinator before your first appointment. They will answer questions, help you prepare for an appointment and connect you with our schedulers.
• One or more consultations with surgeons and a gender surgery nurse to talk about your goals and surgery options and to plan the surgery. We will offer to connect you with Seattle Children’s Fertility Preservation Program before surgery if you are interested.
• An opportunity to meet with our mental health therapist before surgery.
• Help after preoperative consultations to get ready for surgery, including working with your insurance company to have surgery approved.
• Complex procedures, including face and neck surgery, top surgery (breast/chest), bottom surgery (genitals) and body contouring.
• Follow-up care after surgery to check and support healing and to smoothly transition back to your usual gender care team.
• Support from a social worker to help arrange transportation and places to stay when you come to Seattle Children’s for care.

Telehealth (virtual) visits may be an option for some of your appointments.

Face and Neck Surgery

Many different procedures can change the shape of the face to look more feminine or masculine. These are sometimes called facial feminization surgery or facial masculinization surgery. They include forehead reduction , forehead contouring or augmentation , brow lift , frontal sinus setback , facial fat grafting , cheek augmentation , nasal surgery ( rhinoplasty ), chin surgery ( genioplasty ), lower jaw surgery ( mandible contouring ) and others.

We use virtual surgical planning (computer modeling) and customized surgical models to guide facial surgeries and to show patients what results to expect. 

This is surgery that can make the Adam’s apple (thyroid cartilage) less visible ( laryngochondroplasty ) or more visible (thyroid cartilage enhancement).

Top Surgery (Breast/Chest)

To increase breast size, surgeons can use implants filled with sterile salt water (saline) or a plastic gel (silicone), or they can use fat taken from another part of the body.

In this procedure, surgeons remove breast tissue to create a natural chest contour that aligns with a patient’s gender identity. One option is to remove the nipple completely and then reattach it in a new position that will look natural (free nipple grafting).

Some people assigned female at birth may feel most affirmed by keeping their breasts but making them smaller.

Bottom Surgery (Genitals)

Surgeons have several options to make a vagina for people who have a penis. In this option, the surgeon removes the penis and testicles . They make a tunnel in front of the rectum and use skin from the penis to line the tunnel. They might use skin from the scrotum or another part of the body, like the thigh. The surgeon also makes inner and outer labia and a new opening for urine. They can use tissue from the penis to make a clitoris . People who may want to have biological children in the future can choose to have their sperm frozen and stored before surgery to remove the testicles.

This is a method to reconstruct a person’s vagina or to make a vagina in a person assigned male at birth. The surgeon makes a vaginal canal using tissue from the lining of the abdomen (peritoneum). Based on the patient’s needs and wishes, the surgeon may also make inner and outer labia and a new opening for urine. For patients with a penis, the surgeon can use tissue from the penis to make a clitoris .

Another way to reconstruct or make a vagina is to use a section of the bowel. Usually, this is not the first choice for gender-affirming surgery, but it may be an important option for someone who wants revision of an earlier surgery (like a penile inversion or peritoneal vaginoplasty). Based on the patient’s needs and wishes, the surgeon may also make inner and outer labia and a new opening for urine. For patients with a penis, they can use tissue from the penis to make a clitoris .

Some people decide to have surgery to make a vagina with a canal that is shorter than typical. This is 1 of many ways that surgery choices depend on the patient’s goals for how their body will look and work after they heal. In minimal-depth vaginoplasty, the surgeon makes a clitoris , inner and outer labia , an opening for urine and an opening of the vagina with a short vaginal canal.

This is surgery to remove 1 or both testicles . Before the surgery, patients may choose to have their sperm frozen and stored so they will have the option to parent biological children later if they want to.

A series of surgeries, done in stages over several months, can make a penis for someone assigned female at birth. The surgeon may make the penis using tissue from the vulva, forearm, thigh or side. Based on the patient’s needs and wishes, the surgeon may also do procedures to make the urethra longer, make a tip for the penis, make the scrotum and add testicle implants, put in an implant to make erections possible and close the opening of the vagina.

For a person with a clitoris and labia , surgeons may be able to use these tissues to make a penis. This is done after the person has been on testosterone therapy, which will make the clitoris larger. Based on the patient’s needs and wishes, the surgeon may also make the urethra longer, make the scrotum and add testicle implants and close the opening of the vagina .

This is surgery to make a tip for the penis or to correct a problem with the tip of the penis. In people who have had surgery to make a penis (phalloplasty), this may make the penis look more like that of a circumcised cisgender male.

This is surgery to make a new scrotum or to correct a problem with the scrotum. In a person without testicles , the surgeon can also add testicle implants.

Other Gender-Affirming Procedures

Procedures like fat grafting and liposuction can be done to shape a person’s body to better match their gender identity.

If the results of gender-affirming surgery do not meet the patient’s needs or goals, our experienced surgeons may be able to offer options to improve the results. We have done surgeries like this for people who had their earlier gender-affirming surgery at other hospitals.

Scheduling an Appointment About Gender-Affirming Surgery

• If you would like a referral to the Surgical Gender Affirmation Program, talk to your gender care provider (the provider who handles your gender-related medical care, such as hormones or menstrual suppression). Patients who are not on hormones or menstrual suppression can be referred by their primary care provider or a medical doctor who knows about their gender care needs.
• If you have a referral, call 206-987-2759 , option 6, to talk about making an appointment. Our care coordinator will call you back to gather information and answer questions before we schedule.
• To schedule an appointment, you will also need to submit at least 1 of the required medical or mental health letters of support from a licensed provider.
• After we receive your referral and at least 1 of the required letters, our schedulers will call you to schedule an appointment.
• If you already have an appointment,  learn more about how to prepare .

Resources for Patients and Families

• Help finding out if your insurance company must cover gender-affirming surgery under state law: Washington State Office of the Insurance Commissioner
• Masculinizing Top Surgery (PDF) ( Spanish )
• Top Surgery Checklist and Resources (PDF) ( Spanish )
• Fertility Preservation Program
• Gender-diverse care resources
• Plastic surgery resources

Contact Plastic Surgery at 206-987-2759 , option 6, to talk with the care coordinator for gender-affirming surgery about an appointment, a second opinion or more information.

Providers, see how to refer a patient . 

Related Links

• Anesthesiology
• Gender Clinic
• Plastic Surgery

Telemedicine at Seattle Children’s

You may be offered a telehealth (virtual) appointment. Learn more .

Paying for Care

Learn about  paying for care at Seattle Children’s, including insurance coverage, billing and financial assistance.

Also in This Section…

• Refer a Patient

Seattle Children’s complies with applicable federal and other civil rights laws and does not discriminate, exclude people or treat them differently based on race, color, religion (creed), sex, gender identity or expression, sexual orientation, national origin (ancestry), age, disability, or any other status protected by applicable federal, state or local law. Financial assistance for medically necessary services is based on family income and hospital resources and is provided to children under age 21 whose primary residence is in Washington, Alaska, Montana or Idaho.

Trans kids’ treatment can start younger, new guidelines say

• Copy Link URL Copied!

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.

More to Read

How California teen Chloe Cole emerged as a leader of the ‘detransition’ movement — and a right-wing icon

July 25, 2024

‘We’ve created medical refugees.’ LGBTQ+ healthcare workers fight for gender-affirming care amid rise in anti-trans laws

July 10, 2024

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

June 28, 2024

More From the Los Angeles Times

Climate & Environment

Fast, wet and furious: How the North American monsoon floods the California desert

Kratom regulations shelved in California amid battle between advocacy groups

Aug. 15, 2024

White House says prescription drug deals will produce billions in savings for taxpayers, seniors

What Elmo — and his human friends — learned by asking Americans about their mental health

The independent source for health policy research, polling, and news.

Youth Access to Gender Affirming Care: The Federal and State Policy Landscape

Lindsey Dawson , Jennifer Kates , and MaryBeth Musumeci Published: Jun 01, 2022

This analysis reflects the policy environment as of June 2020. Our newer tracker , provides a regularly updated overview of state policy restrictions on youth access to gender affirming care.

Numerous states have implemented or considered actions aimed at limiting LGBTQ+ youth access to gender affirming health care. Four states (Alabama, Arkansas, Texas, and Arizona) have recently enacted such restrictions (though the AL, AR, and TX laws all have been temporarily blocked by court rulings) and in 2022, 15 states are considering 25 similar pieces of legislation. At the same time, other states have adopted broad nondiscrimination health protections based on gender identity and sexual orientation. Separately, the Biden administration, which has been working to eliminate barriers and expand access to health care for LGBTQ+ people more generally, has come out against restrictive state policies. This analysis explores the current state and federal policy landscape regarding gender affirming services for youth and the implications of restrictive state laws.

What is the status of state policy restrictions aimed at limiting youth access to gender affirming care?

Four states (Alabama, Arkansas, Texas, and Arizona) recently enacted laws or policies restricting youth access to gender affirming care and, in some cases, imposing penalties on adults facilitating access. Alabama, Arkansas, and Texas have been temporarily blocked from enforcing these laws and policies by court order.

• Alabama. In April 2022, the Alabama governor signed a bill into law that prevents transgender minors from receiving gender affirming care, including puberty blockers, hormone therapy, and surgical intervention. The bill makes it a felony for any person to “engage in or cause” a transgender minor to receive any of these treatments, punishable by up to 10 years in prison or a fine up to $15,000. The bill additionally states that nurses, counselors, teachers, principals, and other administrative school officials shall not withhold from a minor’s parents or guardian that their child’s “perception of his or her gender or sex is inconsistent with the minor’s sex” assigned at birth and shall not encourage a minor to do so. Shortly after enactment, a federal lawsuit challenging the law was filed by four Alabama families with transgender children, two healthcare providers, and a clergy member. Subsequently, the U.S. Department of Justice (DOJ) joined the case as an additional plaintiff challenging the law. This case has been consolidated with another lawsuit filed by two other Alabama families with transgender children, which raises similar challenges. In May 2022, a federal district court entered a preliminary injunction, blocking enforcement of several sections of the Alabama law while the litigation is pending. Specifically, the preliminary injunction applies to the sections of the law that prohibit puberty blockers and hormone therapy. Other sections of the law remain in effect, including the prohibition on surgical intervention and the prohibition on school officials keeping secret or encouraging or compelling children to keep secret certain gender-identity information from children’s parents. When deciding to grant the preliminary injunction, the district court found that the plaintiffs were substantially likely to succeed on their claim that the sections of the law that prohibit puberty blockers and hormone therapy unconstitutionally violate parents’ fundamental right to autonomy under the 14 th Amendment’s due process clause by prohibiting parents from obtaining medical treatment for their children subject to medically accepted standards. The court also fond that the plaintiffs were substantially likely to succeed on their claim that these sections of the law are unconstitutional sex discrimination in violation of the 14 th Amendment’s equal protection clause because the law denies medically necessary services only to transgender minors, while allowing those services for cisgender minors. Additionally, the court found that the plaintiffs were likely to suffer irreparable harm, in the form of “severe physical and/or psychological harm” and “significant deterioration in their familial relationships and educational performance,” if the law was not blocked. The state has appealed the district court’s decision to the 11 th Circuit.
• Arkansas . In 2021, on override of Governor Hutchinson’s veto, Arkansas lawmakers passed legislation prohibiting gender-affirming treatment for minors, including puberty blockers, hormone therapy, and gender affirming surgery. The law also prohibits medical providers from making referrals to other providers for minors seeking these procedures. Under the law, medical providers offering gender affirming care or providing referrals for such care to minors may be subject to discipline by relevant licensing entities. The legislation additionally includes a prohibition on private insurance coverage of gender affirming services for minors and a prohibition on the use of public funds, including through Medicaid, for coverage of these services for minors. In May 2021, four families of transgender youth and two physicians challenged the Arkansas law in federal court, arguing that the law is illegal sex discrimination under the 14 th Amendment’s equal protection clause. They also argue that the law violates parents’ right to autonomy protected by the 14 th Amendment’s due process clause and violates the families and physicians’ right to free speech under the 1 st Amendment. The U.S. Department of Justice (DOJ) filed a statement of interest in support of the plaintiffs’ motion for a preliminary injunction in the Arkansas case. DOJ  argued that the Arkansas law  violates the Equal Protection Clause of the 14 th Amendment because the state law “singles out transgender minors. . . specifically and discriminatorily den[ies] their access to medically necessary care based solely on their sex assigned at birth.” A preliminary injunction was granted in July 2021, temporarily blocking the state from enforcing the law while the case is pending. The court found that the plaintiffs were likely to succeed on all three of their Constitutional claims, and that the law was not substantially related to the state’s interest in protecting children or regulating physicians’ ethics because the law allows the same medical treatments for cisgender minors. The court also found that the plaintiffs will suffer irreparable physical and psychological harm if the law is not blocked. The court also denied the state’s motion to dismiss the case. The state has appealed both of those decisions to the 8 th Circuit, where a decision is currently pending. A group of 19 states filed an amicus brief in support of the state’s appeal. 1 They argue that states have “broad authority” to regulate gender affirming services, because they allege this area is “fraught with medical uncertainties,” contrary to the evidence from the American Academy of Pediatrics and the American Medical Association on which the lower court relied. Another group of 20 states and the District of Columbia filed an amicus brief in support of the plaintiffs. 2 They argue that they and their residents are economically, physically, and mentally harmed by discrimination against transgender people. They also argue that their states “protect access to gender-affirming healthcare based on well-accepted medical standards” and that Arkansas’ law is unconstitutional sex discrimination and “ignores medical consensus as well as decisions made between doctors and their patients.” Litigation in the case continues in the district court, where the case is scheduled for trial during the week of July 25, 2022.
• Texas . In February 2022, Governor Abbott of Texas issued a directive defining certain gender affirming services for youth as child abuse, and calling for investigation of and penalties for parents who support their children in taking certain medications or undertaking certain procedures, which could include the removal of their children. In addition, under the directive, health care professionals who facilitate access to these services could also face penalties and a range of professionals in the state would be mandated to report known use of the specified gender affirming services. While other states with proposed policies to limit youth access to gender affirming care include penalties for parents who facilitate access to these services (see below), no implemented policy ties the parental role to child abuse as the Texas directive does. In the wake of litigation , a state court entered a temporary injunction preventing the state from enforcing the directive while the case is pending. The court found that the governor acted outside his statutory legal authority in issuing the directive, and the plaintiffs will suffer immediate and irreparable injuries, including loss of employment, deprivation of constitutional rights, and loss of medically necessary care. However, the Texas Supreme Court subsequently modified the temporary injunction, finding that the courts lack authority to prevent enforcement of the directive statewide. Instead, the state is prohibited from enforcing the directive only against the plaintiffs involved in the lawsuit while the case is pending. The case is scheduled for trial on July 11, 2022.
• Arizona . In March 2022, Arizona Governor Ducey signed legislation into law that bans physicians from providing gender-affirming surgical treatment to minors. The legislation does not address hormone therapy or puberty blockers.

In addition, since January 2022 15 states introduced a total of 25 bills that would restrict access to gender-affirming care for youth. Provisions in these bills varied considerably and include those that would:

• criminalize or impose/permit professional disciplinary action (e.g. revoking or suspending licensure) on health professionals providing gender-affirming care to minors, in some cases labeling such services as child abuse
• penalize parents aiding in youth accessing gender-affirming care
• permit individuals to file for damages against providers who violate such laws
• limit insurance coverage or payment for gender affirming services or prohibit the use of state funds for such services

Beyond these policies, states have also passed or considered other policies restricting access, including so called “bathroom bills” which restrict access to bathrooms or locker rooms based on sex assigned at birth, the recent Florida “don’t say gay” bill that would prohibit classroom discussion on sexual orientation or gender identity, and laws that limit transgender students’ access to sports. While these policies are not directly tied to health or health care access, their attempts to limit access to social spaces and services and present non-affirming sentiments could negatively impact LGBTQ+ people’s mental health and well-being. For instance, one recent study found that state laws permitting the denial of services to same-sex couples “are associated with increases in mental distress among sexual minority adults.” In addition, and directly related to health care, Florida recently released non-biding guidance recommending against gender affirming care for youth.

What states have introduced protections related to sexual orientation and gender identity in health care?

Though not specific to youth access to gender affirming care, some states have adopted policies that provide health care protections to LGBTQ+ people, including:

• prohibitions on health insurance discrimination based on sexual orientation and/or
• requirements that state Medicaid programs explicitly cover health services related to gender transition

What is federal policy regarding gender-affirming services?

The Biden administration has taken multiple steps to promote access to health care for LGBTQ+ people and to prohibit discrimination on the basis of sexual orientation and gender identity, including:

• On his first day in office, President Biden signed an executive order directing federal agencies to review existing regulations and policies in order to “prevent and combat discrimination” based on gender identity and sexual orientation. The order states that “people should be able to access healthcare…without being subjected to sex discrimination” and views sex nondiscrimination protections as encompassing sexual orientation and gender identity, following the Supreme Court’s Bostock
• On May 10, 2021, also in light of the Bostock ruling, the Biden Administration announced that the Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) would include gender identity and sexual orientation in its interpretation and enforcement of Section 1557’s prohibition against sex discrimination. Section 1557 of the Affordable Care Act (ACA) contains the law’s primary nondiscrimination provisions, including a prohibition on discrimination on the basis of sex by a range of health care entities and programs that receive federal funding. The May 2021 announcement marked both a reversal of Trump Administration policy, which eliminated gender identity and sex stereotyping from the regulations, and an expansion of Obama Administration policy, which included gender identity and sex stereotyping in the definition of sex discrimination but omitted sexual orientation. Following the  Bostock  ruling, two federal district courts issued nationwide preliminary injunctions, blocking implementation of several provisions of the Trump Administration’s regulations related to Section 1557. Biden Administration implementing regulations on Section 1557 are expected to expand on the May announcement.

In addition to establishing a foundation of nondiscrimination policies for LGBTQ+ people, and participating in the Alabama and Arkansas cases as noted above, the administration has responded specifically to the Texas directive, denouncing it as discriminatory and stating that gender affirming care for youth should be supported as follows:

• Statement from President Biden: The statement from the president states that the administration is “putting the state of Texas on notice that their discriminatory actions put children’s lives at risk. These announcements make clear that rather than weaponizing child protective services against loving families, child welfare agencies should instead expand access to gender-affirming care for transgender children.”
• Statement from Dept. of Health and Human Services (HHS) Sec. Becerra : Becerra’s statement reaffirms “HHS’s commitment to supporting and protecting transgender youth and their parents, caretakers and families” and details action items the administration is taking in response to the Texas directive including those that follow below.
• Following the actions in Texas, HHS’s Administration on Children, Youth and Families issued an Information Memorandum to state child welfare agencies writing that child welfare systems should advance safety and support for LGBTQI+ youth, including though access to gender affirming care.
• Specifically, the guidance states that categorically refusing treatment based on gender identity is prohibited discrimination under Section 1557. The guidance also states that Section 1557’s prohibition against sex-based discrimination is likely violated if a provider reports parents seeking medically necessary gender affirming care for their child to state authorities, if the provider or facility is receiving federal funding. The guidance further states that restricting a provider from providing gender affirming care may violate Section 1557.
• The guidance states that in cases where gender dysphoria qualifies as a disability, restrictions that prevent individuals from receiving medically necessary care based on a diagnosis or perception of gender dysphoria may also violate Section 504 and the ADA.
• It also articulates requirements under the Health Insurance Portability and Accountability Act (HIPAA) that prohibit health plans and providers from disclosing protected health information, such as use of gender affirming physical or mental health care without patient consent, except in limited circumstances.

OCR enforces each of these federal laws, and the guidance states that parents or caregivers who believe their child has been denied health care, including gender affirming care, and health care providers who believe they have been unlawfully restricted from providing such care, may file an administrative complaint for OCR to investigate.

What do major medical societies say about gender affirming services?

Most major U.S. medical associations, including those in the fields of pediatrics, endocrinology, psychiatry, and psychology, have issued statements recognizing the medical necessity and appropriateness of gender affirming care for youth, typically noting harmful effects of denying access to these services. These include statements from the American Medical Association , American Academy of Pediatrics , the Endocrine Society , American Psychological Association , American Psychiatric Association , and the World Professional Association for Transgender Health , among others , which in some cases were specifically issued in response to the Arkansas legislation and Texas directive. Further, 23 medical associations or societies, including those named above, together filed an amicus brief in the case filed against Texas Gov. Abbott opposing the state directive. The brief states that denying gender affirming treatment to adolescents who need them would irreparably harm their health and that enforcing the directive would irreparably harm providers who are forced to choose between potentially facing civil and criminal penalties or endangering their patients. A similar amicus brief was filed in the Arkansas case.

Additionally, the Endocrine Society supports gender affirming care for young people in their clinical practice guidelines , as does the World Professional Association for Transgender Health’s standards of care . Together these guidelines form the standard of care for treatment of gender dysphoria.

What are the implications of access restrictions?

State policies restricting youth access to gender affirming care could have significant health and other implications for LGBTQ+ youth, their parents, health care providers, and, in some cases, other community members:

LGBTQ+ youth : LGBTQ+ youth experience higher rates of depression, anxiety, and suicidality than their non-LGBTQ+ peers. In one CDC study of youth in 10 states and 9 urban school districts, a higher share of transgender students reported suicide risk outcomes across a range of metrics than cisgender students. These include, in the past 12 months: having felt sad or hopeless, considered attempting suicide, made a suicide plan, attempted suicide, or had a suicide attempt treated by a doctor or nurse. Inability to access gender affirming care, such as puberty suppressors and hormone therapy , has been linked to worse mental health outcomes for transgender youth, including with respect to suicidal ideation, potentially exacerbating the already existing disparities. Conversely, access to this care is associated with improved outcomes in these domains. Policies that aim to prohibit or interrupt access to gender affirming care for youth can therefore have negative implications for health in potentially life-threatening ways.

In addition, LGBTQ people report higher rates of negative experiences with medical providers, so creating barriers to gender affirming care could further challenge transgender people’s relationship with the healthcare system.

Finally, with the Texas directive specifically, and in several other states with bills under consideration, youth are vulnerable to secondary trauma, knowing that if they seek such care, their families and providers could be subject to penalties, and, in the case of Texas, children could be separated from their parents.

Parents : In several states with bills under consideration, parents who facilitate access to evidence-based and potentially lifesaving gender affirming services for their children could face penalties. Under the Texas directive, because it is defined as child abuse, parents who facilitate access to gender affirming care for their children, could be subject to penalties, including losing custody of their children. This may place parents in the position of either supporting their children in accessing care supported by medical evidence and facing penalties or denying their children access in an effort not to make their family vulnerable to investigation and potential separation. Each option for parents in this scenario has the potential to be traumatic for the family, and for youth in particular.

Providers: Like parents, providers may be torn between what the medical literature supports is in the best interest of their patients or facing potential sanctions, including violating professional ethics around confidentiality, as in the case of Texas. The American Psychological Association said in a statement that a requirement such as the Texas directive is a violation of both patient confidentiality and professional ethics. Under such circumstances, providers may be forced to decide whether they will provide the highest standard of care for their patients and potentially face sanctions, or obey the state directive but withhold care and potentially violate patient confidentiality and professional ethics. Further, as noted above, the Biden Admiration has stated that HIPAA requirements prohibit providers from disclosing use of gender affirming care without patient consent, except as in narrow circumstances. However, following HIPPA requirements in this case may make providers vulnerable to state sanction under the directive.

Teachers and others : In Texas, in addition to health care providers, other mandated reporters, such as teachers, could also face penalties for failure to report youth known to be accessing gender affirming care. The directive also states that ”there are similar reporting requirements and criminal penalties for members of the general public,” extending the policy’s reach to practically anyone with knowledge of youth accessing these services.

Looking forward

The legal and policy landscape regarding youth access to gender affirming care is shifting across the country, with an increasing number of states seeking to limit such access and impose penalties. Such policies may have significant, negative implications for the health of young people. At the same time, these states are at odds with federal law and policy, and in two recent cases courts have temporarily blocked enforcement of such restrictions. Moving ahead, it will be important to watch how state bills still under consideration unfold and the final outcome of cases in Alabama, Arkansas, and Texas. Decisions in these cases could determine how such policies intersect with existing federal policies — including Section 1557’s prohibition on sex based discrimination in health care, federal disability non-discrimination protections, and HIPAA patient privacy protections — as well as providers’ professional ethics standards.

These states include Alabama, Alaska, Arizona, Georgia, Idaho, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, South Carolina, South Dakota, Tennessee, Texas, Utah, and West Virginia.

← Return to text

These states include California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Carolina, Oregon, Rhode Island, Vermont, and Washington.

Also of Interest

• LGBT+ People’s Health and Experiences Accessing Care
• The Health System Appears To Be Selling LGBT+ People Short
• The Impact of the COVID-19 Pandemic on LGBT+ People’s Mental Health

• Sexual Health
• Feature Stories

What Trans Health Care for Minors Really Means

As of April 2022, two states have passed bills banning gender-affirming care – health care related to a transgender person’s medical transition – for transgender youth, and 20 states are considering laws that would do so. If passed in all these states, more than a third of transgender teens aged 13 to 17 would live in a state that prohibits them from accessing trans health care. But the meaning of gender-affirming care for young people, and what it looks like on the ground, isn’t always clear. The cloud of politics surrounding these bills has obscured the medical reality of how and when trans youth can get the treatments they seek.

Gender-affirming care encompasses nonsurgical treatments like mental health care, puberty blockers, hormone therapy, and reproductive counseling, as well as surgical options like “top” or “bottom” surgery. These treatments can be years-long, incremental processes that may only begin with the approval of parents and health care providers.

The bills banning this kind of care have caused confusion about what gender-affirming care for trans youth actually involves. Some have characterized care like puberty blockers and hormone therapy as child abuse despite the fact that a range of medical associations, including the American Academy of Pediatrics and the American Medical Association, supports them. Some of the bills also present incorrect medical information, like falsely stating that puberty blockers cause infertility (they do not).

In fact, gender-affirming care looks quite different for youth of different ages. Young children – those who have not yet gone through puberty – can’t medically transition. Instead, their transition is entirely social; a gender-expansive child can choose a new name and pronouns, cut their hair, or dress in a different style.

The next step of a child’s transition, if they and their family choose, is to take puberty blockers: medications that essentially press pause on puberty. Puberty blockers have long been given to cisgender children for precocious puberty, a phenomenon which can cause puberty to begin at an unusually young age, such as 7 or 8. As gender-affirming care, puberty blockers are only prescribed to a child once they have begun puberty, which for those assigned female at birth can begin around age 8, or slightly earlier for those who are Black or Hispanic; children assigned male at birth usually hit puberty about 2 years later, according to the Cleveland Clinic .

Physical development in children is measured on what’s called the Tanner Scale, which tracks the progress of puberty from Tanner Stage 1 (prepubescence) to Tanner Stage 5 (sexual maturity). The start of puberty, or Tanner Stage 2, is signaled by breast budding for those assigned female at birth and testicular enlargement for those assigned male at birth, says David Inwards-Breland, MD, MPH, co-director of the Center for Gender Affirming Care at Rady Children's Hospital-San Diego. Some clinics will not offer puberty blockers until a child has reached Tanner Stage 3 or 4, meaning they are only one or two stages away from the end of puberty, according to the Standards of Care (SOC) published by the World Professional Organization for Transgender Health.

To be eligible for puberty blockers, a child should have a “long-lasting and intense pattern of gender nonconformity or gender dysphoria,” according to the SOC. (The latest version of the SOC was released in 2012, and an updated edition is expected this spring .) Gender dysphoria is often evaluated by a mental health professional, who may want to see the child and their family for a number of sessions before making a diagnosis.

After taking puberty blockers, which are fully reversible, a child can still undergo their natural puberty, or they may begin to medically transition and eventually undergo gender-affirming hormone treatment with parental consent. The Endocrine Society recommends waiting to prescribe hormones until an adolescent can give informed consent, which is generally recognized as age 16, though it is widely accepted that starting before age 16 is appropriate in many cases. For those assigned female at birth, this would mean taking testosterone, and for those assigned male at birth, estrogen with or without a progestin and an anti-androgen. Hormone treatment is considered “partially reversible” by the SOC because some changes it causes, such as body fat redistribution, are reversible, and others, such as deeping of the voice from testosterone, are permanent.

To receive hormone treatment, a trans child should have “persistent, well-documented gender dysphoria,” according to the SOC, often as determined by a mental health care provider, who will then write a letter of recommendation for the treatment. And although the Endocrine Society recommends waiting until age 16 to start hormones, it recognizes that there may be compelling reasons to begin treatment earlier. In practice, many do receive it before this age. And a draft of the new version of the SOC drops the minimum recommended age for starting hormones to 14.

“It's not totally around age because we tend to do peer-congruent transition,” Inwards-Breland says. In other words, he wants his trans patients to be able to fit in with their peers when they’re going through puberty – and ideally, not be going through puberty late in high school, long after their peers. “Probably the youngest would be around 13,” he says of when he would start a teenager on hormones.

Deciding when an adolescent should begin hormones is a process that should involve the child, their family, and a multidisciplinary team, says Stephanie Roberts, MD, a pediatric endocrinologist at the Gender Multispeciality Service at Boston Children’s Hospital. “We really try to keep it extremely flexible and individualized, and to work with the young person and their family over time to help them meet their [transition] goals.”

The third step sometimes taken as part of gender-affirming treatment is surgery. Some surgeries are options for trans adolescents while others are not. The Endocrine Society recommends that surgery involving the genitals be delayed until a person reaches the age of consent, which is 18 in the United States.

For adolescents who are assigned female at birth, top surgery can be performed to create a flat chest. The Endocrine Society states that there is not enough evidence to set a minimum age for this type of gender-affirming surgery, and the draft of the updated SOC recommends a minimum age of 15. “Usually, for a [person] assigned female at birth, the chest tissue continues to mature until around 14 or 15,” Inwards-Breland says. “What I've seen surgeons do is after 14, they feel more comfortable.” If, though, a person is started on puberty blockers followed by hormone therapy from a relatively early age – around 13 – they will never develop breast tissue and wouldn’t need surgery to remove it.

Although trans youth are technically allowed to receive certain forms of gender-affirming care, in practice, it’s often difficult.

One common barrier is family approval. For minors, parental consent is needed for any form of gender-affirming care, and not all parents are willing to give it. Some parents never give consent; for others, it can take a while to learn about transgender health and get comfortable with letting their child medically transition.

Even parents who want to be supportive can slow things down. When Rose, a transgender girl in California’s Bay Area, came out to her mom, Jessie, around age 15, she became a patient at the gender clinic at Stanford Children’s Health and soon began taking puberty blockers (Jessie asked that their first names only be used due to privacy concerns). Rose wanted to begin hormone therapy shortly thereafter, but Jessie was hesitant. She wanted to make sure she was doing the right thing for her daughter.

“I didn’t know too much about the impact of hormone therapy, and to be frank, I even questioned will she be regretting her choices later and decide this is not what she wanted,” Jessie says. “As a parent, we ask all sorts of questions and try to look at all angles, try to figure out what should we do as a parent to be responsible?”

After receiving education at the clinic and having some tough conversations, Jessie gave her consent and Rose started on hormones about a year later. “The weight of responsibility for the parent, making that decision for their kid, it’s very daunting.”

Another major issue is the availability of pediatric gender clinics. Comprehensive multidisciplinary clinics are rare outside urban areas, Inwards-Breland says. Primary care providers can offer trans health care, but many aren’t experienced in it, particularly for trans youth.

“We still have these deserts where we don't have high-quality transgender health care programs available,” Roberts says. “Now we have more than 50 pediatric transgender health care programs available across the country, but there's still areas where patients and their families may need to travel long distances to access care.”

If a family is able to find a program, they often face long wait times before they can get a foot in the door. Rose’s original wait time was 6 months, and she was lucky to get in after 3, Jessie says. “That’s how she feels: She’s lucky. She’s one of the few lucky ones,” Jessie says.

For those who don’t have access to in-person care, there are telemedicine options. Organizations like Queermed provide remote care to adolescents, including puberty blockers and hormone therapy, in 14 states in the Southeast, where regular care is limited.

Once they’re in, families must navigate insurance coverage, which is inconsistent across public and private plans. “Even if a patient is insured, they may still be underinsured with respect to accessing transgender-related health care,” Roberts says. And insurance appeals can add further delays.

Distrust of the medical system, including fear of discrimination and being misgendered, can also lead trans youth to delay seeking care.

These obstacles are in states where gender-affirming care for trans youth is legal. The barriers introduced by the recent wave of anti-trans legislation in some states make it illegal in some cases for a child to access gender-affirming care. And this onslaught of bills doesn’t seem to be stopping anytime soon.

Top doctors in ,

Find more top doctors on, related links.

• Sexual Health News
• Sexual Health Reference
• Sexual Health Slideshows
• Sexual Health Quizzes
• Sexual Health Videos
• Birth Control
• Erectile Dysfunction
• FDA Drug Trials Snapshot
• HPV/Genital Warts
• Low Testosterone
• Sex & Relationships
• Sex Headaches
• Sex Problems in Men
• Sexual Conditions

• Introduction
• Conclusions
• Article Information

Error bars represent 95% CIs. GAS indicates gender-affirming surgery.

Percentages are based on the number of procedures divided by number of patients; thus, as some patients underwent multiple procedures the total may be greater than 100%. Error bars represent 95% CIs.

eTable.  ICD-10 and CPT Codes of Gender-Affirming Surgery

eFigure. Percentage of Patients With Codes for Gender Identity Disorder Who Underwent GAS

Data Sharing Statement

See More About

Sign up for emails based on your interests, select your interests.

Customize your JAMA Network experience by selecting one or more topics from the list below.

• Academic Medicine
• Acid Base, Electrolytes, Fluids
• Allergy and Clinical Immunology
• American Indian or Alaska Natives
• Anesthesiology
• Anticoagulation
• Art and Images in Psychiatry
• Artificial Intelligence
• Assisted Reproduction
• Bleeding and Transfusion
• Caring for the Critically Ill Patient
• Challenges in Clinical Electrocardiography
• Climate and Health
• Climate Change
• Clinical Challenge
• Clinical Decision Support
• Clinical Implications of Basic Neuroscience
• Clinical Pharmacy and Pharmacology
• Complementary and Alternative Medicine
• Consensus Statements
• Coronavirus (COVID-19)
• Critical Care Medicine
• Cultural Competency
• Dental Medicine
• Dermatology
• Diabetes and Endocrinology
• Diagnostic Test Interpretation
• Drug Development
• Electronic Health Records
• Emergency Medicine
• End of Life, Hospice, Palliative Care
• Environmental Health
• Equity, Diversity, and Inclusion
• Facial Plastic Surgery
• Gastroenterology and Hepatology
• Genetics and Genomics
• Genomics and Precision Health
• Global Health
• Guide to Statistics and Methods
• Hair Disorders
• Health Care Delivery Models
• Health Care Economics, Insurance, Payment
• Health Care Quality
• Health Care Reform
• Health Care Safety
• Health Care Workforce
• Health Disparities
• Health Inequities
• Health Policy
• Health Systems Science
• History of Medicine
• Hypertension
• Images in Neurology
• Implementation Science
• Infectious Diseases
• Innovations in Health Care Delivery
• JAMA Infographic
• Law and Medicine
• Leading Change
• Less is More
• LGBTQIA Medicine
• Lifestyle Behaviors
• Medical Coding
• Medical Devices and Equipment
• Medical Education
• Medical Education and Training
• Medical Journals and Publishing
• Mobile Health and Telemedicine
• Narrative Medicine
• Neuroscience and Psychiatry
• Notable Notes
• Nutrition, Obesity, Exercise
• Obstetrics and Gynecology
• Occupational Health
• Ophthalmology
• Orthopedics
• Otolaryngology
• Pain Medicine
• Palliative Care
• Pathology and Laboratory Medicine
• Patient Care
• Patient Information
• Performance Improvement
• Performance Measures
• Perioperative Care and Consultation
• Pharmacoeconomics
• Pharmacoepidemiology
• Pharmacogenetics
• Pharmacy and Clinical Pharmacology
• Physical Medicine and Rehabilitation
• Physical Therapy
• Physician Leadership
• Population Health
• Primary Care
• Professional Well-being
• Professionalism
• Psychiatry and Behavioral Health
• Public Health
• Pulmonary Medicine
• Regulatory Agencies
• Reproductive Health
• Research, Methods, Statistics
• Resuscitation
• Rheumatology
• Risk Management
• Scientific Discovery and the Future of Medicine
• Shared Decision Making and Communication
• Sleep Medicine
• Sports Medicine
• Stem Cell Transplantation
• Substance Use and Addiction Medicine
• Surgical Innovation
• Surgical Pearls
• Teachable Moment
• Technology and Finance
• The Art of JAMA
• The Arts and Medicine
• The Rational Clinical Examination
• Tobacco and e-Cigarettes
• Translational Medicine
• Trauma and Injury
• Treatment Adherence
• Ultrasonography
• Users' Guide to the Medical Literature
• Vaccination
• Venous Thromboembolism
• Veterans Health
• Women's Health
• Workflow and Process
• Wound Care, Infection, Healing

Get the latest research based on your areas of interest.

Others also liked.

• Download PDF
• X Facebook More LinkedIn

Wright JD , Chen L , Suzuki Y , Matsuo K , Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348

Manage citations:

© 2024

• Permissions

National Estimates of Gender-Affirming Surgery in the US

• 1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
• 2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

Question   What are the temporal trends in gender-affirming surgery (GAS) in the US?

Findings   In this cohort study of 48 019 patients, GAS increased significantly, nearly tripling from 2016 to 2019. Breast and chest surgery was the most common class of procedures performed overall; genital reconstructive procedures were more common among older individuals.

Meaning   These findings suggest that there will be a greater need for clinicians knowledgeable in the care of transgender individuals with the requisite expertise to perform gender-affirming procedures.

Importance   While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

Objective   To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants   This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures   Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

Results   A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance   Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Gender dysphoria is characterized as an incongruence between an individual’s experienced or expressed gender and the gender that was assigned at birth. 1 Transgender individuals may pursue multiple treatments, including behavioral therapy, hormonal therapy, and gender-affirming surgery (GAS). 2 GAS encompasses a variety of procedures that align an individual patient’s gender identity with their physical appearance. 2 - 4

While numerous surgical interventions can be considered GAS, the procedures have been broadly classified as breast and chest surgical procedures, facial and cosmetic interventions, and genital reconstructive surgery. 2 , 4 Prior studies 2 - 7 have shown that GAS is associated with improved quality of life, high rates of satisfaction, and a reduction in gender dysphoria. Furthermore, some studies have reported that GAS is associated with decreased depression and anxiety. 8 Lastly, the procedures appear to be associated with acceptable morbidity and reasonable rates of perioperative complications. 2 , 4

Given the benefits of GAS, the performance of GAS in the US has increased over time. 9 The increase in GAS is likely due in part to federal and state laws requiring coverage of transition-related care, although actual insurance coverage of specific procedures is variable. 10 , 11 While prior work has shown that the use of inpatient GAS has increased, national estimates of inpatient and outpatient GAS are lacking. 9 This is important as many GAS procedures occur in ambulatory settings. We performed a population-based analysis to examine trends in GAS in the US and explored the temporal trends in the types of GAS performed across age groups.

To capture both inpatient and outpatient surgical procedures, we used data from the Nationwide Ambulatory Surgery Sample (NASS) and the National Inpatient Sample (NIS). NASS is an ambulatory surgery database and captures major ambulatory surgical procedures at nearly 2800 hospital-owned facilities from up to 35 states, approximating a 63% to 67% stratified sample of hospital-owned facilities. NIS comprehensively captures approximately 20% of inpatient hospital encounters from all community hospitals across 48 states participating in the Healthcare Cost and Utilization Project (HCUP), covering more than 97% of the US population. Both NIS and NASS contain weights that can be used to produce US population estimates. 12 , 13 Informed consent was waived because data sources contain deidentified data, and the study was deemed exempt by the Columbia University institutional review board. This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We selected patients of all ages with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) diagnosis codes for gender identity disorder or transsexualism ( ICD-10 F64) or a personal history of sex reassignment ( ICD-10 Z87.890) from 2016 to 2020 (eTable in Supplement 1 ). We first examined all hospital (NIS) and ambulatory surgical (NASS) encounters for patients with these codes and then analyzed encounters for GAS within this cohort. GAS was identified using ICD-10 procedure codes and Common Procedural Terminology codes and classified as breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures. 2 , 4 Breast and chest surgical procedures encompassed breast reconstruction, mammoplasty and mastopexy, or nipple reconstruction. Genital reconstructive procedures included any surgical intervention of the male or female genital tract. Other facial and cosmetic procedures included cosmetic facial procedures and other cosmetic procedures including hair removal or transplantation, liposuction, and collagen injections (eTable in Supplement 1 ). Patients might have undergone procedures from multiple different surgical groups. We measured the total number of procedures and the distribution of procedures within each procedural group.

Within the data sets, sex was based on patient self-report. The sex of patients in NIS who underwent inpatient surgery was classified as either male, female, missing, or inconsistent. The inconsistent classification denoted patients who underwent a procedure that was not consistent with the sex recorded on their medical record. Similar to prior analyses, patients in NIS with a sex variable not compatible with the procedure performed were classified as having undergone genital reconstructive surgery (GAS not otherwise specified). 9

Clinical variables in the analysis included patient clinical and demographic factors and hospital characteristics. Demographic characteristics included age at the time of surgery (12 to 18 years, 19 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, 61 to 70 years, and older than 70 years), year of the procedure (2016-2020), and primary insurance coverage (private, Medicare, Medicaid, self-pay, and other). Race and ethnicity were only reported in NIS and were classified as White, Black, Hispanic and other. Race and ethnicity were considered in this study because prior studies have shown an association between race and GAS. The income status captured national quartiles of median household income based of a patient’s zip code and was recorded as less than 25% (low), 26% to 50% (medium-low), 51% to 75% (medium-high), and 76% or more (high). The Elixhauser Comorbidity Index was estimated for each patient based on the codes for common medical comorbidities and weighted for a final score. 14 Patients were classified as 0, 1, 2, or 3 or more. We separately reported coding for HIV and AIDS; substance abuse, including alcohol and drug abuse; and recorded mental health diagnoses, including depression and psychoses. Hospital characteristics included a composite of teaching status and location (rural, urban teaching, and urban nonteaching) and hospital region (Northeast, Midwest, South, and West). Hospital bed sizes were classified as small, medium, and large. The cutoffs were less than 100 (small), 100 to 299 (medium), and 300 or more (large) short-term acute care beds of the facilities from NASS and were varied based on region, urban-rural designation, and teaching status of the hospital from NIS. 8 Patients with missing data were classified as the unknown group and were included in the analysis.

National estimates of the number of GAS procedures among all hospital encounters for patients with gender identity disorder were derived using discharge or encounter weight provided by the databases. 15 The clinical and demographic characteristics of the patients undergoing GAS were reported descriptively. The number of encounters for gender identity disorder, the percentage of GAS procedures among those encounters, and the absolute number of each procedure performed over time were estimated. The difference by age group was examined and tested using Rao-Scott χ 2 test. All hypothesis tests were 2-sided, and P  < .05 was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc).

A total of 48 019 patients who underwent GAS were identified ( Table 1 ). Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged 12 to 18 years. Private insurance coverage was most common in 29 064 patients (60.5%), while 12 127 (25.3%) were Medicaid recipients. Depression was reported in 7192 patients (15.0%). Most patients (42 467 [88.4%]) were treated at urban, teaching hospitals, and there was a disproportionate number of patients in the West (22 037 [45.9%]) and Northeast (12 396 [25.8%]). Within the cohort, 31 668 patients (65.9%) underwent 1 procedure while 13 415 (27.9%) underwent 2 procedures, and the remainder underwent multiple procedures concurrently ( Table 1 ).

The overall number of health system encounters for gender identity disorder rose from 13 855 in 2016 to 38 470 in 2020. Among encounters with a billing code for gender identity disorder, there was a consistent rise in the percentage that were for GAS from 4552 (32.9%) in 2016 to 13 011 (37.1%) in 2019, followed by a decline to 12 818 (33.3%) in 2020 ( Figure 1 and eFigure in Supplement 1 ). Among patients undergoing ambulatory surgical procedures, 37 394 (80.3%) of the surgical procedures included gender-affirming surgical procedures. For those with hospital admissions with gender identity disorder, 10 625 (11.8%) of admissions were for GAS.

Breast and chest procedures were most common and were performed for 27 187 patients (56.6%). Genital reconstruction was performed for 16 872 patients (35.1%), and other facial and cosmetic procedures for 6669 patients (13.9%) ( Table 2 ). The most common individual procedure was breast reconstruction in 21 244 (44.2%), while the most common genital reconstructive procedure was hysterectomy (4489 [9.3%]), followed by orchiectomy (3425 [7.1%]), and vaginoplasty (3381 [7.0%]). Among patients who underwent other facial and cosmetic procedures, liposuction (2945 [6.1%]) was most common, followed by rhinoplasty (2446 [5.1%]) and facial feminizing surgery and chin augmentation (1874 [3.9%]).

The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020 ( Figure 1 ). Similar trends were noted for breast and chest surgical procedures as well as genital surgery, while the rate of other facial and cosmetic procedures increased consistently from 2016 to 2020. The distribution of the individual procedures performed in each class were largely similar across the years of analysis ( Table 3 ).

When stratified by age, patients 19 to 30 years had the greatest number of procedures, 25 099 ( Figure 2 ). There were 10 476 procedures performed in those aged 31 to 40 years and 4359 in those aged 41 to 50 years. Among patients younger than 19 years, 3678 GAS procedures were performed. GAS was less common in those cohorts older than 50 years. Overall, the greatest number of breast and chest surgical procedures, genital surgical procedures, and facial and other cosmetic surgical procedures were performed in patients aged 19 to 30 years.

When stratified by the type of procedure performed, breast and chest procedures made up the greatest percentage of the surgical interventions in younger patients while genital surgical procedures were greater in older patients ( Figure 2 ). Additionally, 3215 patients (87.4%) aged 12 to 18 years underwent GAS and had breast or chest procedures. This decreased to 16 067 patients (64.0%) in those aged 19 to 30 years, 4918 (46.9%) in those aged 31 to 40 years, and 1650 (37.9%) in patients aged 41 to 50 years ( P  < .001). In contrast, 405 patients (11.0%) aged 12 to 18 years underwent genital surgery. The percentage of patients who underwent genital surgery rose sequentially to 4423 (42.2%) in those aged 31 to 40 years, 1546 (52.3%) in those aged 51 to 60 years, and 742 (58.4%) in those aged 61 to 70 years ( P  < .001). The percentage of patients who underwent facial and other cosmetic surgical procedures rose with age from 9.5% in those aged 12 to 18 years to 20.6% in those aged 51 to 60 years, then gradually declined ( P  < .001). Figure 2 displays the absolute number of procedure classes performed by year stratified by age. The greatest magnitude of the decline in 2020 was in younger patients and for breast and chest procedures.

These findings suggest that the number of GAS procedures performed in the US has increased dramatically, nearly tripling from 2016 to 2019. Breast and chest surgery is the most common class of procedure performed while patients are most likely to undergo surgery between the ages of 19 and 30 years. The number of genital surgical procedures performed increased with increasing age.

Consistent with prior studies, we identified a remarkable increase in the number of GAS procedures performed over time. 9 , 16 A prior study examining national estimates of inpatient GAS procedures noted that the absolute number of procedures performed nearly doubled between 2000 to 2005 and from 2006 to 2011. In our analysis, the number of GAS procedures nearly tripled from 2016 to 2020. 9 , 17 Not unexpectedly, a large number of the procedures we captured were performed in the ambulatory setting, highlighting the need to capture both inpatient and outpatient procedures when analyzing data on trends. Like many prior studies, we noted a decrease in the number of procedures performed in 2020, likely reflective of the COVID-19 pandemic. 18 However, the decline in the number of procedures performed between 2019 and 2020 was relatively modest, particularly as these procedures are largely elective.

Analysis of procedure-specific trends by age revealed a number of important findings. First, GAS procedures were most common in patients aged 19 to 30 years. This is in line with prior work that demonstrated that most patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age 7 years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. 19 Our findings were also notable that GAS procedures were relatively uncommon in patients aged 18 years or younger. In our cohort, fewer than 1200 patients in this age group underwent GAS, even in the highest volume years. GAS in adolescents has been the focus of intense debate and led to legislative initiatives to limit access to these procedures in adolescents in several states. 20 , 21

Second, there was a marked difference in the distribution of procedures in the different age groups. Breast and chest procedures were more common in younger patients, while genital surgery was more frequent in older individuals. In our cohort of individuals aged 19 to 30 years, breast and chest procedures were twice as common as genital procedures. Genital surgery gradually increased with advancing age, and these procedures became the most common in patients older than 40 years. A prior study of patients with commercial insurance who underwent GAS noted that the mean age for mastectomy was 28 years, significantly lower than for hysterectomy at age 31 years, vaginoplasty at age 40 years, and orchiectomy at age 37 years. 16 These trends likely reflect the increased complexity of genital surgery compared with breast and chest surgery as well as the definitive nature of removal of the reproductive organs.

This study has limitations. First, there may be under-capture of both transgender individuals and GAS procedures. In both data sets analyzed, gender is based on self-report. NIS specifically makes notation of procedures that are considered inconsistent with a patient’s reported gender (eg, a male patient who underwent oophorectomy). Similar to prior work, we assumed that patients with a code for gender identity disorder or transsexualism along with a surgical procedure classified as inconsistent underwent GAS. 9 Second, we captured procedures commonly reported as GAS procedures; however, it is possible that some of these procedures were performed for other underlying indications or diseases rather than solely for gender affirmation. Third, our trends showed a significant increase in procedures through 2019, with a decline in 2020. The decline in services in 2020 is likely related to COVID-19 service alterations. Additionally, while we comprehensively captured inpatient and ambulatory surgical procedures in large, nationwide data sets, undoubtedly, a small number of procedures were performed in other settings; thus, our estimates may underrepresent the actual number of procedures performed each year in the US.

These data have important implications in providing an understanding of the use of services that can help inform care for transgender populations. The rapid rise in the performance of GAS suggests that there will be a greater need for clinicians knowledgeable in the care of transgender individuals and with the requisite expertise to perform GAS procedures. However, numerous reports have described the political considerations and challenges in the delivery of transgender care. 22 Despite many medical societies recognizing the necessity of gender-affirming care, several states have enacted legislation or policies that restrict gender-affirming care and services, particularly in adolescence. 20 , 21 These regulations are barriers for patients who seek gender-affirming care and provide legal and ethical challenges for clinicians. As the use of GAS increases, delivering equitable gender-affirming care in this complex landscape will remain a public health challenge.

Accepted for Publication: July 15, 2023.

Published: August 23, 2023. doi:10.1001/jamanetworkopen.2023.30348

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Wright JD et al. JAMA Network Open .

Corresponding Author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 4th Floor, New York, NY 10032 ( [email protected] ).

Author Contributions: Dr Wright had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wright, Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wright.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Wright, Chen.

Administrative, technical, or material support: Wright, Suzuki.

Conflict of Interest Disclosures: Dr Wright reported receiving grants from Merck and personal fees from UpToDate outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

• Register for email alerts with links to free full-text articles
• Access PDFs of free articles
• Manage your interests
• Save searches and receive search alerts

Kate Sosin, The 19th Kate Sosin, The 19th

Leave your feedback

• Copy URL https://www.pbs.org/newshour/health/most-state-bans-on-gender-affirming-care-for-trans-youth-still-allow-controversial-intersex-surgery

Most state bans on gender-affirming care for trans youth still allow controversial intersex surgery

This article was originally published by The 19th on March 23, 2023.

When Georgia lawmakers advanced a bill earlier this month that would ban gender-affirming care for youth, many argued that kids were too young to be making big health care decisions.

“We’re asking that children be 18 years old before they make this decision that will alter their lives forever,” Republican Sen. Carden Summers said, according to an ABC news article.

Summers’ argument is not uncommon. Opponents of trans rights have argued that kids are ill-equipped to decide on gender-related medical interventions. Those arguments largely confuse what gender-affirming health care for youth is.

READ MORE: The fight to end intersex surgeries at a top hospital took a deep toll on activists

Still, Georgia’s bill does not outlaw irreversible gender-related surgeries on all kids. In fact, if the bill becomes law, Georgia will become one of several states to pass laws backing pediatric sex-related surgeries that have been condemned by the United Nations for more than a decade: those for people born intersex.

More than two-thirds of the bills introduced this year that would ban gender-affirming care for transgender youth have specific intersex exemptions. The controversial exemptions allow doctors to assign minors who are born with secondary sex characteristics as “male” or “female” through surgeries, hormones or other interventions.

“So you’re saying that trans kids are too young to consent, but intersex kids aren’t?” asked Bria Brown-King, director of engagement for the intersex rights group InterAct. “How does that make sense?”

Sean Saifa Wall, an intersex scholar and activist, believes that medical interventions for trans kids and intersex kids have become conflated.

“We as a society do not understand the experiences of trans people and trans children,” said Wall. “A lot of trans young people don’t get surgeries until they’re 18. That’s what often happens to intersex young people, but because we don’t understand, we don’t understand neither trans nor intersex experiences, these bills float on by.”

Intersex conditions are common, according to scientists. A 2000 study by Brown University professor Dr. Anne Fausto-Sterling found that 1.7 percent of the population is born intersex. That’s about the same percentage of people born with red hair.

While doctors have operated on intersex minors to assign them “male” or “female” sexes for decades, human rights organizations have long condemned the surgeries on kids as cosmetic, unnecessary and inhumane. That’s because many procedures are done on kids in infancy, without their knowledge or consent.

Intersex adults often only discover they are intersex by accident, they report . Some have grown up being told by doctors or parents that they had painful surgeries because they had cancer . In reality, they learned, the surgeries were done to assign them a binary sex.

In 2013, the United Nations issued a report that called for an end to “genital-normalizing surgery, involuntary sterilization, unethical experimentation, medical display, ‘reparative therapies.’”

“A lot of these things are presented as medical problems that require fixing that are not actually medical problems,” Maddie Moran, director of communications for InterACT, said.

The movement to outlaw intersex surgeries in the United States has made big strides in the last three years. Two prominent hospitals — Chicago’s Lurie Children’s Hospital and Boston Children’s Hospital — have stopped offering pediatric intersex procedures. The Biden administration has also been meeting with intersex advocates to talk about how to end the surgeries nationwide. In the meantime, California, often a leader on LGBTQ+ rights, has introduced a bill to ban pediatric intersex surgeries. The bill has yet to gain enough support to pass.

But as the intersex rights movement becomes more mainstream, it has also become a target. According to InterAct and the National Center for Transgender Equality, more than two-thirds of the bills that target transgender medical care introduced this year (82 out of 120) have carve-outs for pediatric intersex procedures. Those carve-outs have consequences, advocates say:  Some of the first explicit anti-intersex language is being written into law.

“The bills are really authorizing in the law, the practice of performing these unnecessary surgeries,” Moran said. “They are surgeries that are already happening . . . but they are now authorizing that practice in the law, which is the opposite of the direction that we want to be going.”

Wall thinks the bills are not about protecting children at all and said they are really about reinforcing rigid gender ideals and heterosexuality.

“I see the attack on trans people, and I see the mandates to continue doing surgeries on intersex infants and children as a way of crushing bodily autonomy as a way of upholding ‘male’ and ‘female’ as sacred,” he said. “This harm has been really endemic and it’s been long-standing. The scary part about it, though, is when there’s a codifying it into law.”

Support Provided By: Learn more

Educate your inbox

Subscribe to Here’s the Deal, our politics newsletter for analysis you won’t find anywhere else.

Thank you. Please check your inbox to confirm.

• New Hampshire
• North Carolina
• Pennsylvania
• West Virginia
• Online hoaxes
• Coronavirus
• Health Care
• Immigration
• Environment
• Foreign Policy
• Kamala Harris
• Donald Trump
• Mitch McConnell
• Hakeem Jeffries
• Ron DeSantis
• Tucker Carlson
• Sean Hannity
• Rachel Maddow
• PolitiFact Videos
• 2024 Elections
• Mostly True
• Mostly False
• Pants on Fire
• Biden Promise Tracker
• Trump-O-Meter
• Latest Promises
• Our Process
• Who pays for PolitiFact?
• Advertise with Us
• Suggest a Fact-check
• Corrections and Updates
• Newsletters

Stand up for the facts!

Our only agenda is to publish the truth so you can be an informed participant in democracy. We need your help.

I would like to contribute

• Facebook Fact-checks
• Viral image

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. 

Featured Fact-check

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

Read About Our Process

The Principles of the Truth-O-Meter

Our Sources

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

Browse the Truth-O-Meter

More by monique curet.

Support independent fact-checking. Become a member!

• Share full article

Advertisement

Supported by

Biden Officials Pushed to Remove Age Limits for Trans Surgery, Documents Show

Newly released emails from an influential group issuing transgender medical guidelines indicate that U.S. health officials lobbied to remove age minimums for surgery in minors because of concerns over political fallout.

By Azeen Ghorayshi

Health officials in the Biden administration pressed an international group of medical experts to remove age limits for adolescent surgeries from guidelines for care of transgender minors, according to newly unsealed court documents.

Age minimums, officials feared, could fuel growing political opposition to such treatments.

Email excerpts from members of the World Professional Association for Transgender Health recount how staff for Adm. Rachel Levine, assistant secretary for health at the Department of Health and Human Services and herself a transgender woman, urged them to drop the proposed limits from the group’s guidelines and apparently succeeded.

If and when teenagers should be allowed to undergo transgender treatments and surgeries has become a raging debate within the political world. Opponents say teenagers are too young to make such decisions, but supporters including an array of medical experts posit that young people with gender dysphoria face depression and worsening distress if their issues go unaddressed.

In the United States, setting age limits was controversial from the start.

The draft guidelines, released in late 2021, recommended lowering the age minimums to 14 for hormonal treatments, 15 for mastectomies, 16 for breast augmentation or facial surgeries, and 17 for genital surgeries or hysterectomies.

The proposed age limits were eliminated in the final guidelines outlining standards of care , spurring concerns within the international group and with outside experts as to why the age proposals had vanished.

The email excerpts released this week shed light on possible reasons for those guideline changes, and highlight Admiral Levine’s role as a top point person on transgender issues in the Biden administration. The excerpts are legal filings in a federal lawsuit challenging Alabama’s ban on gender-affirming care.

We are having trouble retrieving the article content.

Please enable JavaScript in your browser settings.

Thank you for your patience while we verify access. If you are in Reader mode please exit and  log into  your Times account, or  subscribe  for all of The Times.

Thank you for your patience while we verify access.

Already a subscriber?  Log in .

Want all of The Times?  Subscribe .

• Election 2024
• Entertainment
• Newsletters
• Photography
• AP Buyline Personal Finance
• AP Buyline Shopping
• Press Releases
• Israel-Hamas War
• Russia-Ukraine War
• Global elections
• Asia Pacific
• Latin America
• Middle East
• Delegate Tracker
• AP & Elections
• 2024 Paris Olympic Games
• Auto Racing
• Movie reviews
• Book reviews
• Financial Markets
• Business Highlights
• Financial wellness
• Artificial Intelligence
• Social Media

Toddlers can’t get gender-affirming surgeries, despite claims

FILE - People attend a rally as part of a Transgender Day of Visibility, Friday, March 31, 2023, by the Capitol in Washington. The Associated Press on Friday, April 21, 2023 reported on social media users falsely claiming a map shows the states where it’s possible for a 3-year-old child to receive gender-affirming surgery. (AP Photo/Jacquelyn Martin, File)

• Copy Link copied

CLAIM: Map shows the states where it’s possible for a 3-year-old child to receive gender-affirming surgery.

AP’S ASSESSMENT: False. The map shows which states have passed or are considering anti-transgender laws. Children as young as 3 are not qualified to undergo operations to change their gender, medical experts say. Nationally-recognized medical guidelines recommend patients be at least 15 years old to receive the surgeries, and only then in special circumstances.

THE FACTS: Social media users are sharing a map of the U.S. that purports to show which states are the hardest and which are the easiest to obtain sex change surgery for children as young as 3.

The map shows blue-colored states located mostly along the coasts and the Great Lakes and red-colored states that are mostly in the Midwest and South.

“The dark red states are where it’s hardest to get your 3 year old a sex change operation,” the text above the map claims.

“If you’re thinking about moving this could be helpful,” wrote an Instagram user who shared the map in a post that’s been liked nearly 280,000 times as of Friday. “Get away from the blue.”

But the map is being misrepresented online: it categorizes states according to the type of transgender laws or bills that have been enacted or are under consideration.

Red-colored states are those with the “worst anti-trans laws” while those in blue are the “safest states with protections” for transgender individuals, according to the map’s key, which is visible in small text in the bottom right corner of the image.

Erin Reed, a transgender advocate who developed the map, confirmed to The Associated Press that her graphic is being misrepresented.

She created the “Anti-Trans Legislative Risk” map to track bills moving through state houses across the country, and posted the latest version on her Substack page in March.

“In reality, this is MY map,” Reed later tweeted , sharing a screenshot of the false claim circulating online and adding a large red ‘x’ through it. “It evaluates the risk of anti-trans laws pulling people’s medical care, bans from bathrooms, and more.”

Reed also stressed that sex change operations aren’t permitted on 3 year olds.

“Gender affirming care starts with puberty blockers around age 11-14, and will progress to hormone therapy, with surgeries held off until later,” she wrote in an email to the AP.

Medical experts and LGBTQ advocates agreed, noting that such surgeries aren’t offered until a patient becomes a legal adult, though exceptions are made for minor teens who meet certain criteria.

“The general recommendation is for gender affirming surgeries to be done after age 18 with limited exceptions,” Dr. Michael Irwig, director of transgender medicine at Beth Israel Deaconess Medical Center in Boston, wrote in an email. “The patient should always be of an age where they have adequate maturity including the ability to understand the potential risks and benefits of any treatment.”

The World Professional Association for Transgender Health, a global group that sets standards for medical care of trans youths and adults, recommended last year that hormone treatment start no earlier than 14 years old and surgeries be offered only in rare exceptions in persons as young as 15. Both minimum ages were lower than prior recommendations.

Gender-affirming surgery includes a wide range of procedures, from plastic surgery to change facial features to so-called “top surgery” to change the chest or torso and so-called “bottom surgery” to make changes to genitals.

Teens who are 16 to 17 years old are generally limited to receiving only “top surgeries,” and they must be “consistent and persistent” in their gender identity for years, take gender-affirming hormones for some time and have approvals from both their parents and doctors, according to Aryn Fields, a spokesperson for the Human Rights Campaign, an LGBTQ advocacy group based in Washington, D.C.

“In all cases, gender affirming surgeries are only performed after multiple discussions with both mental health providers and physicians (including endocrinologists and/or surgeons), to determine if surgery is the appropriate course of action,” she wrote in an email.

This is part of AP’s effort to address widely shared misinformation, including work with outside companies and organizations to add factual context to misleading content that is circulating online. Learn more about fact-checking at AP .

• KIRO Opinion
• KTTH Opinion
• KIRO Newsradio 97.3 FM
• Seattle Sports
• 770 KTTH AM
• MyNorthwest News
• MyNorthwest Weather
• MyNorthwest Traffic
• MyNorthwest History
• MyNorthwest Politics
• MyNorthwest Lifestyle
• National News
• Photo Galleries
• Sponsored Stories
• Seattle's Morning News
• Gee and Ursula
• Jack and Spike
• John and Jake

Jason Rantz

• MyNorthwest Blog
• Brock and Salk
• Bump and Stacy
• Wyman and Bob
• The Reset Podcast
• Search the Site
• Earthquake Tracker
• School Closings
• Share Photos With Us
• Advertise With Us
• Contest Rules
• Newsletters
• Contests and Events
• Community Outreach
• X (Twitter)
• KIRO on YouTube
• KTTH on YouTube

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.

Jason Rantz Show

MyNorthwest Video

Video: “Where Kids Should Play, But Addicts Stay” a Poem by Jason Rantz

Jason Rantz likes to take his dog on walks, and he often passes a park where kids can play. Surprise, surprise, underneath a covered structure in the park, there were homeless men smoking weed. Listen to The Jason Rantz Show weekdays from 3 p.m. – 7 p.m. on AM 770 KTTH or on-demand wherever you […]

11 hours ago

Rantz: Hey Seattle media, do you plan on fact-checking Bob Ferguson at some point?

Gubernatorial hopeful Bob Ferguson keeps lying and spinning the truth. Why? Because Seattle media has shown no interest in critical coverage.

Video: All “FIRSTS” Are Bad

Jason thinks the FIRST time you ever do something always sucks. He thinks all FIRSTS are bad, especially the first paycheck you ever receive. You open it up just to see how much money was taken out because of taxes. Jason also has a sex joke that Jake really tried to get him to tell. […]

Video: An Interesting Strategy by Bob Ferguson

Jason talks about Bob Ferguson’s new weird line of attack against Dave Reichert. Listen to The Jason Rantz Show weekdays from 3 p.m. – 7 p.m. on AM 770 KTTH or on-demand wherever you listen to podcasts.

Rantz: ‘Pro-Democracy’ WA Democrats tried to stop Robert F. Kennedy Jr. from ballot access

Washington Democrats claim to fight voter suppression and defend democracy. When it came to Robert F. Kennedy Jr., they did the opposite.

Video: Where to Find Your Mate… Running Clubs!

Some people in Chicago are ditching dating apps to meet at running clubs instead so they can meet their potential mates. Jason thinks it’s just so a person can see if their date is fat, attractive, or can actually run. Jake proposes the idea of a swimming club instead. Listen to the John & Jake […]

Sponsored Articles

Anacortes: The ultimate summer water adventure destination

Anacortes is perfect for relaxation and rejuvenation. With charming shops, delightful dining and a plethora of entertaining activities.

‘Expanding your family:’ Washington Make-A-Wish seeks volunteers amid record numbers

Make-A-Wish Alaska and Washington is on track for a record number of wishes, however, to do that it will need help from volunteers.

Seattle pest control company pioneers ‘rat birth control’ method

Sounds of scratching, gnawing or rustling in your home at night could be signs it could be time to call pest control.

‘Every life matters:’ Nonprofit looks to bolster aid along dangerous stretch of I-90

A local nonprofit is working to protect those driving on I-90 but they can't do it without help from the community.

Isolation to connection: Recognizing the signs to put your seniors into safe care

The transition to a senior living community can be a positive step toward ensuring their safety, health and happiness.

Seattle scholarship celebrates LGBTQ+ community

Founded in 1991, the GSBA Scholarship & Education Fund, with the help of Carter Subaru, has invested almost $6 million in 552 scholars.

Exploring what works, what doesn’t, and why.

Families in states with bans on trans care are finding hope across state lines

• Share on LinkedIn
• Share on Twitter
• Share on Facebook
• Share on WhatsApp
• Share through Email

North Carolina’s House of Representatives debated for only four minutes before casting a final vote to restrict medical treatment for transgender youth. The Senate followed some two hours later, on the evening of August 16, 2023.

Ten miles outside Raleigh, where the legislature was meeting, a 15-year-old theater kid named Leo was preparing for a sleepover with his best friend. Neither he nor his parents were aware of the vote, or of how it would alter the course of his medical care. His endocrinologist, Deanna Adkins, learned about the vote immediately, and knew it would change the way she and her team practiced medicine. They had a new game plan ready, and it was time to roll it out.

Adkins co-founded and directs the Duke Child and Adolescent Gender Care Clinic, one of the oldest facilities of its type in the South. She had been bracing all summer for the legislature to outlaw much of her work, as part of a wave of anti-transgender rights legislation sweeping the nation. In July, Governor Roy Cooper had vetoed House Bill 808, the legislature’s attempt to bar physicians from prescribing hormonal therapies to minors seeking gender transition. In his veto message , he declared, “A doctor’s office is no place for politicians.” It was clear, however, that the lawmakers in the state’s Republican supermajority disagreed and would move to override his veto.

Sign up for Harvard Public Health

Delivered to your inbox weekly.

• Email address By clicking “Subscribe,” you agree to receive email communications from Harvard Public Health.
• Email This field is for validation purposes and should be left unchanged.

The bill exempted some patients who were already in treatment. Knowing this, Adkins and her clinic staff had gone into overdrive. They lengthened their hours. They contacted waiting families and offered them earlier consultations. They referred some of their other patients—Adkins also treats diabetes and other conditions—to different endocrinologists, who stretched their own clinical capacities to accommodate the demand. They asked other therapists to assist with psychosocial assessments. The goal was to accelerate schedules without rushing decisions or compromising safety protocols.

Deanna Adkins, director of the Duke Child and Adolescent Gender Care Clinic, has had to become an advocate for patients.

“We were all exhausted,” says Kristen Russell, the clinical social worker in Adkins’s clinic. “We knew that we only had a certain amount of time, so it was just all hands on deck.”

Some of the parents and teens arrived frightened that long-awaited care was in jeopardy, says Dane Whicker, a Duke University clinical health psychologist who helped with the assessments. The professionals, meanwhile, stayed on task. “You’re sort of in the zone,” he says. “But at the same time, it’s this weird experience.” After all, virtually every major medical association in the United States has opposed bans on minors’ access to gender-affirming care, yet 25 states have passed laws limiting such access. Under the North Carolina bill, any doctor who provided such care would lose their medical license, and could also be sued by former pediatric patients for decades afterward. “What are we doing here?” Whicker recalls thinking. “Especially after so many years, where we’re building the evidence base, we’re growing as a field, the research is there. And then all of a sudden, it’s like going back into the Dark Ages.” 

Adkins’s summertime push to work through her backlog before a potential veto override led her to start treatment for about 25 new patients. Leo and his family thought he would be one of them.

Leo near his home in North Carolina. He says it's been a relief to begin the transition process.

Twelve days before the override vote, Leo and his parents had arrived at Adkins’s clinic in Durham. “I was feeling really hopeful and excited,” he says. He underwent a medical exam and bloodwork to measure his hormone levels. The family met with Adkins and Russell, who detailed the treatment options and answered their questions. “I never felt like they were pushing one way or the other,” says Leo’s father. “That made me really comfortable.”

Russell followed up, four days later, with a two-hour psychosocial assessment, which confirmed that Leo met the diagnostic criteria for gender dysphoria, the persistent and clinically significant distress that some transgender people experience. “It’s not just that they’re uncomfortable in their body,” she says, “but it’s actually impairing their functioning.”

Even though Leo sang and danced his way through childhood—“always living in a Disney musical,” says his mother—he never felt at home in his body. When he was in first grade, Leo wrote a story about a skateboarding penguin, and then panicked when he heard a recording of himself reading it aloud. He had imagined his pitch was deeper; he didn’t want to sound like a girl. He wanted to sound like Zuko, the fire-bending prince from Avatar. He came to hate his voice, and to hate being seen as cute. “I didn’t know what to say or do to make it better,” his mother says. ( Harvard Public Health is not naming the parents or using Leo’s last name to help shield them from harassment.)

Leo and his parents in their kitchen soon after his treatments began.

It took seven more anxious years, and many family conversations, before Leo figured out he was transgender. He cut his hair short, adopted male pronouns, and legally changed his name. He celebrated small victories, like when a lifeguard at the pool called him “buddy.” But he was also entering female adolescence and would soon have a body most would perceive as female. He wanted to start taking testosterone to align his body with his gender identity.

His parents were open-minded, but also trying to make sense of what they were hearing from their only child. Was he really trans? If so, were hormones the best course? There were so many conflicting opinions. “It was scary,” his mother says. “We were alone. We had nobody to talk to.” Leo’s mother had found Adkins’s clinic online, and knew the Duke University Health System’s reputation; the family had had other good experiences with Duke specialists. In late 2022, when Leo was 14, his parents reached out to the clinic. House Bill 808 would be introduced in April 2023.

The bill was not yet law when Russell performed the psychosocial assessment on August 8, or when Leo met with a physical therapist three days later. When the legislation was finally ratified, on August 16, the exemption covered patients who had begun treatment before August 1. It took protracted legal consultations for Adkins and her team to figure out the status of patients who, like Leo, fell into that 16-day hole.

One of several bills on LGBTQ+ issues that were vetoed by North Carolina Governor Roy Cooper and overridden by the state's General Assembly on August 16, 2023. One of the bills banned gender-affirming care for minors.

Hannah Schoenbaum / AP Photo

The limbo felt interminable to Leo. “I had been waiting and waiting and waiting and then waiting more,” Leo says. “I was sick of not even being at the starting point yet.”

That fall, Leo’s parents joined a support group at the clinic, an experience that validated his mother’s conclusion that testosterone was critical to his mental health. In a national survey of 28,000 LGBTQ young people, published in 2023 by the nonprofit Trevor Project, half the transgender and nonbinary respondents had seriously considered suicide within the previous year.  A study of youth treated at Seattle Children’s Gender Clinic revealed that access to hormonal therapies reduced the odds of self-harm or suicidal thoughts by 73 percent. The study, published in 2022, also showed a 60 percent lower chance of depression for those receiving puberty blockers or gender-affirming hormones.

“I would rather have an alive kid on testosterone,” says Leo’s mom, “than a dead kid that’s not on testosterone.”

There was one more safety hurdle before Leo could start taking testosterone: a letter of support from his private therapist. That letter arrived in late November 2023. But the deadline to begin hormonal therapy in North Carolina had passed. If Leo, his parents, and the clinic team still believed he needed testosterone before his 18th birthday, they’d have to find another way.

Adkins is not an activist by nature. “I had a huge fear of the legal system,” she says. “One of the reasons I chose this specialty is that there’s no risky anything. It’s pretty straightforward.” She was drawn to endocrinology because it felt like engineering, her initial undergraduate major. She began practicing at Duke in 2004 and did not intend to treat trans kids until an out-of-town colleague asked her in 2014 to see a patient who lived in North Carolina and needed a hormonal transition.

Since then, Adkins has seen about 700 patients with gender dysphoria. And in the current political climate, she understands that advocacy is part of her job. When North Carolina first tried to restrict pediatric gender-affirming care in 2021 with legislation similar to House Bill 808, she spoke out publicly against the effort.

That same year, Arkansas became the first state to ban such care. Adkins signed on as a medical expert in the lawsuit seeking to overturn the measure. On the witness stand in 2022, she laid out the professional consensus in the United States: Gender dysphoria, untreated, puts patients at risk for depression, self-harm, and suicidality. Some teens, she testified, can’t afford to delay treatment until adulthood: “I lost a patient to suicide because they did not make it to their second visit.”

Adkins told the Arkansas court that each of her patients goes through a robust assessment that covers their medical history, family dynamics, and educational issues, along with mental-health concerns like eating disorders, depression, and trauma. Then her team works with the family to develop an individualized care plan. That plan occasionally means pausing puberty until a younger patient can clarify their gender identity, so they don’t have to worry about unwanted physical changes like breast development or the deepening of their voice. More often, though not always, it means prescribing gender-affirming hormones for older adolescents. She explained to the court, “If you align the body with the identity . . . it can decrease their depression, their anxiety, their dysphoria.”

A federal judge cited Adkins’ testimony when he blocked the Arkansas law in June 2023. The case is now under appeal . (In total, the courts have fully or partly blocked similar laws in four states; the other 21 are in effect.) This summer, the U.S. Supreme Court announced it would review the legality of state bans on gender-affirming care for minors, taking up a case from Tennessee. The justices are likely to hear arguments before the end of the year.

The Arkansas ruling came as North Carolina’s legislature was considering House Bill 808, which banned the prescription of both puberty blockers and gender-affirming hormones for minors. It also outlawed pediatric surgery related to gender transition like chest reconstruction, which minors rarely receive and Adkins’s clinic doesn’t offer.

Adkins had hoped the Arkansas ruling would deter her own state’s legislators, but the bill kept barreling forward, and the debate in North Carolina grew particularly contentious: One group made repeated false claims that Duke was transitioning two-year-olds.

One sponsor, Republican State Representative Ken Fontenot, compared gender-affirming care to 20th-century experiments like the Tuskegee Study , in which 399 Black men infected with syphilis went untreated for 40 years. “We as a nation have been at the forefront of medical blunders time and time again, and this is no different,” he said during a floor debate.

Adkins didn’t respond publicly; she says she no longer felt safe visiting the legislature. Boston Children’s Hospital, home of the nation’s first pediatric gender clinic, had received a series of bomb threats , and its doctors were being menaced online. In North Carolina, anti-trans activists had focused their attention on Adkins and Whicker, the psychologist. “There were a lot of death threats,” says Whicker. “You can only see images of yourself going through a wood chipper, á la Fargo , so many times.”

In the clinic, Adkins began to exercise more caution. “We have heard, within our groups, that they’re sending in patients who aren’t really patients to try and record us saying something that looks bad,” she says. In the past, Adkins trusted every patient at their word, within reason. Now, she says, “our little antennae are up” for odd behaviors that might signal an infiltrator.

As House Bill 808 headed toward ratification, Adkins understood that accelerating her schedule would not help everyone. One of her patients would eventually challenge the new law in federal court, but that lawsuit is pending. Those who missed the cutoff needed an immediate, creative solution—an interstate solution. That was the course Leo and his family would have to follow.

Transgender North Carolinians and their supporters in the North Carolina House in May 2023, demanding to speak to a bill banning gender-affirming care for minors. Public comments were not allowed.

Hannah Schoenbaum / AP photo

House Bill 808, it turned out, doesn’t prohibit all care for trans kids. It doesn’t ban intake exams or services like voice therapy, physical therapy, counseling, and pastoral care. Physicians are still allowed to communicate about patient care with their peers outside North Carolina.

So Adkins looked north to Virginia, where pediatric gender-affirming care remains legal. She and the clinic’s fellow talked with colleagues at three Virginia hospitals and developed a hybrid model that would minimize travel. Patients would first come to Duke, where clinic personnel would assess their readiness, lay out the options, and direct them to locally available services like voice therapy. Then the information would be sent to a Virginia physician, who would verify the patient’s eligibility. The family would cross the state line for an appointment with the prescribing doctor and would pick up the medication at a Virginia pharmacy. Duke would do ongoing monitoring.

About 18 of Adkins’s patients, including Leo, now use this interstate solution. One Virginia physician (not Leo’s) told me that the system is working reasonably well. “We’re very lucky with North Carolina,” she says. “[Patients] have already met with Dr. Adkins . . . and it’s very clear that the family has gotten some education, and then we can pick up where they left off. So that is very nice.”

But only a limited number of Virginia doctors do this work, she says, and they’re overwhelmed by medical refugees from nearby states. They also fear that collaborating with doctors in those states will attract hostile attention, particularly because Virginia does not have a shield law protecting transgender health care.

“There’s so [much] behind-the-scenes scrutiny of our logistical process to make sure that we’re protecting ourselves,” she says. “All of us are constantly worried: Is my medical license going to be at stake? Is our institution protected? There’s just this constant concern that we’re going to be attacked.” Because of that concern, Harvard Public Health agreed not to name her or the institution.

That concern has a realistic basis. As a result of the legislative wave, almost 40 percent of the nation’s transgender youth— 1.4 percent of 13- to 17-year-olds identify as trans, though not all of them pursue medical transition—live in states that restrict access, according to KFF. Some clinics, like Vanderbilt University’s in Nashville, have shut down entirely. Doctors at Washington University in St. Louis stopped prescribing hormones and puberty blockers to pediatric patients, even those exempt from the ban, saying that Missouri’s law exposed them to “ untenable ” legal liability. Texas’s only clinic, at Children’s Medical Center in Dallas, closed under pressure from the governor even before the state passed a ban .

The resulting crisis has triggered a response that extends beyond any one hospital system. A nationwide network of professionals and nonprofits now helps trans youth and their families navigate the patchwork system. One key player is the Asheville, North Carolina-based Campaign for Southern Equality, which in 2023 launched an emergency project for families whose states have outlawed gender-affirming care.

As the access map began to shrink, the Campaign built a referral network of providers in safe states who offer care to patients living in restricted ones. Now, when parents reach out, navigators help them think through their options and offer them $500 renewable grants for travel and, in some situations, clinical costs. Since March 2023, the Campaign has distributed more than $500,000 in such grants.

Depending on where a patient lives, traveling to a safe state might entail more than crossing a border. If you live in Alabama, for example, your closest option might be Illinois. For some of those patients, the Campaign partners with Elevated Access, a nonprofit that uses volunteer pilots to fly families to their appointments in small aircraft. (Elevated Access does this for abortion care, too.)

“Getting them there is only part of it,” says Allison Scott, the Campaign’s director of impact and innovation. “How are we going to make sure that they can actually afford it?” At a few clinics, the Campaign has set up care funds to help defray the cost of treatment.

In North Carolina, House Bill 808 complicates payment for patients covered by the exemption because it prohibits the use of state funds for their treatment. Puberty blockers, for example, can cost tens of thousands of dollars, putting them out of reach for families enrolled in Medicaid. At Duke, the hospital absorbed the cost of some patients’ care, deeming it lifesaving. In addition, Adkins has switched some hormone users to less expensive delivery systems, like estrogen pills instead of injections.

Overall, though, Scott says trans children and their families are “getting pummeled” by the bans. And the ripple effects extend to states where the care remains legal. Wait times are growing longer. Providers have seen escalating malpractice premiums and even insurance-coverage denials . Transportation logistics have grown trickier as restrictions spread.

Scott takes comfort in the response from health professionals in safe states.

“We used to have to hunt these clinics down,” she says. “We are getting more providers now, throughout the country, who are reaching out to us, going, ‘Hey, we have capacity. What can we do to help?’ There’s a huge joy component in this because we’re seeing people stepping up to the challenge. They are not going to let these families and these kids have to stand in this alone.”

Leo, now 16, and his mother drove four hours to their first appointment with a Virginia endocrinologist in January 2024. They came home with 30 small tubes of testosterone gel and then repeated the process in April. One of those $500 grants from the Campaign for Southern Equality helped pay for their travel.

Leo now has access to hormone treatments.

Leo demonstrating how he applies the testosterone.

He has not noticed any physical changes yet, but just beginning the transition gives Leo reassurance. “When things are stressful for me, it helps just knowing at least I’m starting it already. No matter what, most of those problems are going to be going away soon,” he says. “I’ve just got to be patient.”

His parents view him as less anxious. “Prior to the testosterone, he was hyper-fixated on the frustration and the injustice,” says his mother. But since January, “he’s just more at peace. He doesn’t seem as concerned with how he presents: If he gets misgendered, he knows it’s temporary.” Leo today feels confident enough to wear his curly hair long again. He’s even shed his aversion to the color pink. “He’s more comfortable leaning into all sides of himself,” his mother says.

Leo is fortunate compared to many trans teens. His parents have professional jobs, and his mother can take time off for overnight medical trips. They have been unfailingly supportive, as have other adults in Leo’s life. Plus, he has only one state line to cross. “It sucks that we have to do it at all, because it’s a big hassle,” he says. “But at the very least . . . we’re not in a deep, deep South area.”

On both Virginia trips, snafus at the pharmacy delayed their return home. “It’s anxiety-ridden, because I know I have to leave there with testosterone,” his mother says. “We’ve done all that work: taking off school and paying all that money for gas and the hotel, and me taking off work. And then to be, at that last moment, in that pharmacy where we’re so close to being done and going home. Both times have been extremely stressful. And it’s like, well, what do we do next?”

These out-of-state trips, she understands, are part of raising a trans teen in 2024. “The truth is,” she says, “I would travel wherever I needed to.”

Lead image: Leo in the woods near his home in North Carolina in June.

Republish this article

<h1>Families in states with bans on trans care are finding hope across state lines</h1> <p>“I would rather have an alive kid on testosterone than a dead kid that’s not," says one North Carolina mom.</p> <p>Written by Barry Yeoman</p> <p>This <a rel="canonical" href="https://harvardpublichealth.org/policy-practice/keeping-gender-affirming-care-accessible-after-u-s-state-bans/">article</a> originally appeared in<a href="https://harvardpublichealth.org/">Harvard Public Health magazine</a>. Subscribe to their <a href="https://harvardpublichealth.org/subscribe/">newsletter</a>.</p> <p class="has-drop-cap">North Carolina’s House of Representatives debated for only four minutes before casting a final vote to restrict medical treatment for transgender youth. The Senate followed some two hours later, on the evening of August 16, 2023.</p> <p>Ten miles outside Raleigh, where the legislature was meeting, a 15-year-old theater kid named Leo was preparing for a sleepover with his best friend. Neither he nor his parents were aware of the vote, or of how it would alter the course of his medical care. His endocrinologist, Deanna Adkins, learned about the vote immediately, and knew it would change the way she and her team practiced medicine. They had a new game plan ready, and it was time to roll it out.</p> <p>Adkins co-founded and directs the Duke Child and Adolescent Gender Care Clinic, one of the oldest facilities of its type in the South. She had been bracing all summer for the legislature to outlaw much of her work, as part of a wave of anti-transgender rights legislation sweeping the nation. In July, Governor Roy Cooper had vetoed House Bill 808, the legislature’s attempt to bar physicians from prescribing hormonal therapies to minors seeking gender transition. In his <a href="https://webservices.ncleg.gov/ViewBillDocument/2023/6811/0/H808-BD-NBC-11125" target="_blank" rel="noreferrer noopener">veto message</a>, he declared, “A doctor’s office is no place for politicians.” It was clear, however, that the lawmakers in the state’s Republican supermajority disagreed and would move to override his veto.</p> <p>The bill exempted some patients who were already in treatment. Knowing this, Adkins and her clinic staff had gone into overdrive. They lengthened their hours. They contacted waiting families and offered them earlier consultations. They referred some of their other patients—Adkins also treats diabetes and other conditions—to different endocrinologists, who stretched their own clinical capacities to accommodate the demand. They asked other therapists to assist with psychosocial assessments. The goal was to accelerate schedules without rushing decisions or compromising safety protocols.</p> <p>“We were all exhausted,” says Kristen Russell, the clinical social worker in Adkins’s clinic. “We knew that we only had a certain amount of time, so it was just all hands on deck.”</p> <p>Some of the parents and teens arrived frightened that long-awaited care was in jeopardy, says Dane Whicker, a Duke University clinical health psychologist who helped with the assessments. The professionals, meanwhile, stayed on task. “You're sort of in the zone,” he says. “But at the same time, it’s this weird experience.” After all, virtually every major medical association in the United States has opposed bans on minors' access to gender-affirming care, yet <a href="https://www.kff.org/other/dashboard/gender-affirming-care-policy-tracker/" target="_blank" rel="noreferrer noopener">25 states</a> have passed laws limiting such access. Under the North Carolina bill, any doctor who provided such care would lose their medical license, and could also be sued by former pediatric patients for decades afterward. “What are we doing here?” Whicker recalls thinking. “Especially after so many years, where we’re building the evidence base, we’re growing as a field, the research is there. And then all of a sudden, it's like going back into the Dark Ages.”&nbsp;</p> <p>Adkins’s summertime push to work through her backlog before a potential veto override led her to start treatment for about 25 new patients. Leo and his family thought he would be one of them.</p> <p>Twelve days before the override vote, Leo and his parents had arrived at Adkins’s clinic in Durham. “I was feeling really hopeful and excited,” he says. He underwent a medical exam and bloodwork to measure his hormone levels. The family met with Adkins and Russell, who detailed the treatment options and answered their questions. “I never felt like they were pushing one way or the other,” says Leo’s father. “That made me really comfortable.”</p> <p>Russell followed up, four days later, with a two-hour psychosocial assessment, which confirmed that Leo met the diagnostic criteria for gender dysphoria, the persistent and clinically significant distress that some transgender people experience. “It’s not just that they’re uncomfortable in their body,” she says, “but it’s actually impairing their functioning.”</p> <p>Even though Leo sang and danced his way through childhood—“always living in a Disney musical,” says his mother—he never felt at home in his body. When he was in first grade, Leo wrote a story about a skateboarding penguin, and then panicked when he heard a recording of himself reading it aloud. He had imagined his pitch was deeper; he didn’t want to sound like a girl. He wanted to sound like Zuko, the fire-bending prince from <em>Avatar. </em>He came to hate his voice, and to hate being seen as cute. “I didn't know what to say or do to make it better,” his mother says. (<em>Harvard Public Health</em> is not naming the parents or using Leo’s last name to help shield them from harassment.)</p> <p>It took seven more anxious years, and many family conversations, before Leo figured out he was transgender. He cut his hair short, adopted male pronouns, and legally changed his name. He celebrated small victories, like when a lifeguard at the pool called him “buddy.” But he was also entering female adolescence and would soon have a body most would perceive as female. He wanted to start taking testosterone to align his body with his gender identity.</p> <p>His parents were open-minded, but also trying to make sense of what they were hearing from their only child. Was he really trans? If so, were hormones the best course? There were so many conflicting opinions. “It was scary,” his mother says. “We were alone. We had nobody to talk to.” Leo’s mother had found Adkins’s clinic online, and knew the Duke University Health System’s reputation; the family had had other good experiences with Duke specialists. In late 2022, when Leo was 14, his parents reached out to the clinic. House Bill 808 would be introduced in April 2023.</p> <p>The bill was not yet law when Russell performed the psychosocial assessment on August 8, or when Leo met with a physical therapist three days later. When the legislation was finally ratified, on August 16, the exemption covered patients who had begun treatment before August 1. It took protracted legal consultations for Adkins and her team to figure out the status of patients who, like Leo, fell into that 16-day hole.</p> <p>The limbo felt interminable to Leo. “I had been waiting and waiting and waiting and then waiting more,” Leo says. “I was sick of not even being at the starting point yet.”</p> <p>That fall, Leo’s parents joined a support group at the clinic, an experience that validated his mother’s conclusion that testosterone was critical to his mental health. In a <a href="https://www.thetrevorproject.org/survey-2023/assets/static/05_TREVOR05_2023survey.pdf" target="_blank" rel="noreferrer noopener">national survey</a> of 28,000 LGBTQ young people, published in 2023 by the nonprofit Trevor Project, half the transgender and nonbinary respondents had seriously considered suicide within the previous year.&nbsp;<a href="https://epi.washington.edu/news/gender-affirming-hormones-and-puberty-blockers-improve-mental-health-in-transgender-youth" target="_blank" rel="noreferrer noopener">A study of youth</a> treated at Seattle Children’s Gender Clinic revealed that access to hormonal therapies reduced the odds of self-harm or suicidal thoughts by 73 percent. The study, published in 2022, also showed a 60 percent lower chance of depression for those receiving puberty blockers or gender-affirming hormones.</p> <p>“I would rather have an alive kid on testosterone,” says Leo’s mom, “than a dead kid that’s not on testosterone.”</p> <p>There was one more safety hurdle before Leo could start taking testosterone: a letter of support from his private therapist. That letter arrived in late November 2023. But the deadline to begin hormonal therapy in North Carolina had passed. If Leo, his parents, and the clinic team still believed he needed testosterone before his 18th birthday, they’d have to find another way.</p> <p>Adkins is not an activist by nature. “I had a huge fear of the legal system,” she says. “One of the reasons I chose this specialty is that there’s no risky anything. It’s pretty straightforward.” She was drawn to endocrinology because it felt like engineering, her initial undergraduate major. She began practicing at Duke in 2004 and did not intend to treat trans kids until an out-of-town colleague asked her in 2014 to see a patient who lived in North Carolina and needed a hormonal transition.</p> <p>Since then, Adkins has seen about 700 patients with gender dysphoria. And in the current political climate, she understands that advocacy is part of her job. When North Carolina first tried to restrict pediatric gender-affirming care in 2021 with legislation similar to House Bill 808, she <a href="https://www.wral.com/story/top-transgender-doctor-warns-teen-treatment-ban-could-be-deadly/19618762/" target="_blank" rel="noreferrer noopener">spoke out</a> publicly against the effort.</p> <p>That same year, Arkansas became the first state to ban such care. Adkins signed on as a medical expert in the lawsuit seeking to overturn the measure. On the witness stand in 2022, she laid out the professional consensus in the United States: Gender dysphoria, untreated, puts patients at risk for depression, self-harm, and suicidality. Some teens, she testified, can’t afford to delay treatment until adulthood: “I lost a patient to suicide because they did not make it to their second visit.”</p> <p>Adkins told the Arkansas court that each of her patients goes through a robust assessment that covers their medical history, family dynamics, and educational issues, along with mental-health concerns like eating disorders, depression, and trauma. Then her team works with the family to develop an individualized care plan. That plan occasionally means pausing puberty until a younger patient can clarify their gender identity, so they don’t have to worry about unwanted physical changes like breast development or the deepening of their voice. More often, though not always, it means prescribing gender-affirming hormones for older adolescents. She explained to the court, “If you align the body with the identity . . . it can decrease their depression, their anxiety, their dysphoria.”</p> <p>A federal judge <a href="https://npr.brightspotcdn.com/39/60/c0ca02924b6cb8443da60f6c1ce3/ruling.pdf" target="_blank" rel="noreferrer noopener">cited</a> Adkins’ testimony when he <a href="https://www.npr.org/2023/06/20/1183344228/arkansas-2021-gender-affirming-care-ban-transgender-blocked" target="_blank" rel="noreferrer noopener">blocked</a> the Arkansas law in June 2023. The case is now under <a href="https://apnews.com/article/transgender-gender-affirming-care-arkansas-court-c299aa1db823fdeda5b1e0b457a7a9b5" target="_blank" rel="noreferrer noopener">appeal</a>. (In total, the courts have fully or partly blocked similar laws in four states; the other 21 are in effect.) This summer, the U.S. Supreme Court <a href="https://www.reuters.com/legal/us-supreme-court-hear-challenge-ban-transgender-care-minors-2024-06-24/" target="_blank" rel="noreferrer noopener">announced</a> it would review the legality of state bans on gender-affirming care for minors, taking up a case from Tennessee. The justices are likely to hear arguments before the end of the year.</p> <p>The Arkansas ruling came as North Carolina’s legislature was considering House Bill 808, which banned the prescription of both puberty blockers and gender-affirming hormones for minors. It also outlawed pediatric surgery related to gender transition like chest reconstruction, which minors rarely receive and Adkins’s clinic doesn’t offer.</p> <p>Adkins had hoped the Arkansas ruling would deter her own state’s legislators, but the bill kept barreling forward, and the debate in North Carolina grew particularly contentious: One group made repeated <a href="https://apnews.com/article/fact-check-transgender-unc-duke-644667457768" target="_blank" rel="noreferrer noopener">false claims</a> that Duke was transitioning two-year-olds.</p> <p>One sponsor, Republican State Representative Ken Fontenot, <a href="https://www.carolinajournal.com/opinion/weve-been-here-before-on-compassionate-experimental-medical-treatments/" target="_blank" rel="noreferrer noopener">compared</a> gender-affirming care to 20th-century experiments like the <a href="https://www.cdc.gov/tuskegee/timeline.htm" target="_blank" rel="noreferrer noopener">Tuskegee Study</a>, in which 399 Black men infected with syphilis went untreated for 40 years. “We as a nation have been at the forefront of medical blunders time and time again, and this is no different,” he said during a floor debate.</p> <p>Adkins didn’t respond publicly; she says she no longer felt safe visiting the legislature. Boston Children’s Hospital, home of the nation’s first pediatric gender clinic, had received a series of <a href="https://www.boston.com/news/crime/2022/11/16/boston-childrens-hospital-bomb-threat-gems-program-gender-multiservices-anti-trans/" target="_blank" rel="noreferrer noopener">bomb threats</a>, and its doctors were being <a href="https://www.boston.com/news/local-news/2022/08/17/boston-childrens-hospital-inundated-by-harassment-campaign-over-trans-health-services/" target="_blank" rel="noreferrer noopener">menaced</a> online. In North Carolina, anti-trans activists had focused their attention on Adkins and Whicker, the psychologist. “There were a lot of death threats,” says Whicker. “You can only see images of yourself going through a wood chipper, á la <em>Fargo</em>, so many times.”</p> <p>In the clinic, Adkins began to exercise more caution. “We have heard, within our groups, that they’re sending in patients who aren’t really patients to try and record us saying something that looks bad,” she says. In the past, Adkins trusted every patient at their word, within reason. Now, she says, “our little antennae are up” for odd behaviors that might signal an infiltrator.</p> <p>As House Bill 808 headed toward ratification, Adkins understood that accelerating her schedule would not help everyone. One of her patients would eventually challenge the new law in federal court, but that lawsuit is pending. Those who missed the cutoff needed an immediate, creative solution—an interstate solution. That was the course Leo and his family would have to follow.<a id="_msocom_1"></a></p> <p>House Bill 808, it turned out, doesn’t prohibit <em>all</em> care for trans kids. It doesn’t ban intake exams or services like voice therapy, physical therapy, counseling, and pastoral care. Physicians are still allowed to communicate about patient care with their peers outside North Carolina.</p> <p>So Adkins looked north to Virginia, where pediatric gender-affirming care remains legal. She and the clinic’s fellow talked with colleagues at three Virginia hospitals and developed a hybrid model that would minimize travel. Patients would first come to Duke, where clinic personnel would assess their readiness, lay out the options, and direct them to locally available services like voice therapy. Then the information would be sent to a Virginia physician, who would verify the patient’s eligibility. The family would cross the state line for an appointment with the prescribing doctor and would pick up the medication at a Virginia pharmacy. Duke would do ongoing monitoring.</p> <p>About 18 of Adkins’s patients, including Leo, now use this interstate solution. One Virginia physician (not Leo’s) told me that the system is working reasonably well. “We’re very lucky with North Carolina,” she says. “[Patients] have already met with Dr. Adkins . . . and it’s very clear that the family has gotten some education, and then we can pick up where they left off. So that is very nice.”</p> <p>But only a limited number of Virginia doctors do this work, she says, and they’re overwhelmed by medical refugees from nearby states. They also fear that collaborating with doctors in those states will attract hostile attention, particularly because Virginia does not have a <a href="https://www.lgbtmap.org/equality-maps/healthcare/trans_shield_laws" target="_blank" rel="noreferrer noopener">shield law</a> protecting transgender health care.</p> <p>“There’s so [much] behind-the-scenes scrutiny of our logistical process to make sure that we’re protecting ourselves,” she says. “All of us are constantly worried: Is my medical license going to be at stake? Is our institution protected? There’s just this constant concern that we’re going to be attacked.” Because of that concern, <em>Harvard Public Health</em> agreed not to name her or the institution.</p> <p>That concern has a realistic basis. As a result of the legislative wave, almost 40 percent of the nation’s transgender youth—<a href="https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/" target="_blank" rel="noreferrer noopener">1.4 percent</a> of 13- to 17-year-olds identify as trans, though not all of them pursue medical transition—live in states that restrict access, according to KFF. Some clinics, like Vanderbilt University’s in Nashville, have <a href="https://www.nashvillepost.com/business/health_care/vumc-ceases-operations-at-pediatric-transgender-clinic/article_a9de70ee-0adc-11ee-904f-a70409ef95c6.html" target="_blank" rel="noreferrer noopener">shut down</a> entirely. Doctors at Washington University in St. Louis stopped prescribing hormones and puberty blockers to pediatric patients, even those exempt from the ban, saying that Missouri’s law exposed them to “<a href="https://source.wustl.edu/2023/09/statement-on-washington-university-transgender-centehttps:/source.wustl.edu/2023/09/statement-on-washington-university-transgender-center/" target="_blank" rel="noreferrer noopener">untenable</a>” legal liability. Texas’s only clinic, at Children’s Medical Center in Dallas, closed<a href="https://www.nytimes.com/2022/03/08/health/texas-transgender-clinic-genecis-abbott.html?unlocked_article_code=1.uE0.kx0n.I9lB7ocg1qUf&amp;smid=url-share" target="_blank" rel="noreferrer noopener"> under pressure</a> from the governor even before the state passed a ban<em>.</em></p> <p>The resulting crisis has triggered a response that extends beyond any one hospital system. A nationwide network of professionals and nonprofits now helps trans youth and their families navigate the patchwork system. One key player is the Asheville, North Carolina-based Campaign for Southern Equality, which in 2023 launched an <a href="https://southernequality.org/tyep/">emergency project</a> for families whose states have outlawed gender-affirming care.</p> <p>As the access map began to shrink, the Campaign built a referral network of providers in safe states who offer care to patients living in restricted ones. Now, when parents reach out, navigators help them think through their options and offer them $500 renewable grants for travel and, in some situations, clinical costs. Since March 2023, the Campaign has distributed more than $500,000 in such grants.</p> <p>Depending on where a patient lives, traveling to a safe state might entail more than crossing a border. If you live in Alabama, for example, your closest option might be Illinois. For some of those patients, the Campaign partners with Elevated Access, a nonprofit that uses volunteer pilots to fly families to their appointments in small aircraft. (Elevated Access does this for abortion care, too.)</p> <p>“Getting them there is only part of it,” says Allison Scott, the Campaign’s director of impact and innovation. “How are we going to make sure that they can actually afford it?” At a few clinics, the Campaign has set up care funds to help defray the cost of treatment.</p> <p>In North Carolina, House Bill 808 complicates payment for patients covered by the exemption because it prohibits the use of state funds for their treatment. Puberty blockers, for example, can cost tens of thousands of dollars, putting them out of reach for families enrolled in Medicaid. At Duke, the hospital absorbed the cost of some patients’ care, deeming it lifesaving. In addition, Adkins has switched some hormone users to less expensive delivery systems, like estrogen pills instead of injections.</p> <p>Overall, though, Scott says trans children and their families are “getting pummeled” by the bans. And the ripple effects extend to states where the care remains legal. Wait times are growing longer. Providers have seen <a href="https://www.pbs.org/newshour/health/rising-malpractice-premiums-push-small-clinics-away-from-gender-affirming-care-for-minors" target="_blank" rel="noreferrer noopener">escalating</a> malpractice premiums and even insurance-coverage <a href="https://www.texastribune.org/2022/03/22/texas-transgender-teenagers-medical-care/" target="_blank" rel="noreferrer noopener">denials</a>.&nbsp;Transportation logistics have grown trickier as restrictions spread.</p> <p>Scott takes comfort in the response from health professionals in safe states.</p> <p>“We used to have to hunt these clinics down,” she says. “We are getting more providers now, throughout the country, who are reaching out to us, going, ‘Hey, we have capacity. What can we do to help?’ There's a huge joy component in this because we're seeing people stepping up to the challenge. They are not going to let these families and these kids have to stand in this alone.”</p> <p>Leo, now 16, and his mother drove four hours to their first appointment with a Virginia endocrinologist in January 2024. They came home with 30 small tubes of testosterone gel and then repeated the process in April. One of those $500 grants from the Campaign for Southern Equality helped pay for their travel.</p> <p>He has not noticed any physical changes yet, but just beginning the transition gives Leo reassurance. “When things are stressful for me, it helps just knowing at least I’m starting it already. No matter what, most of those problems are going to be going away soon,” he says. “I’ve just got to be patient.”</p> <p>His parents view him as less anxious. “Prior to the testosterone, he was hyper-fixated on the frustration and the injustice,” says his mother. But since January, “he's just more at peace. He doesn't seem as concerned with how he presents: If he gets misgendered, he knows it’s temporary.” Leo today feels confident enough to wear his curly hair long again. He’s even shed his aversion to the color pink. “He’s more comfortable leaning into all sides of himself,” his mother says.</p> <p>Leo is fortunate compared to many trans teens. His parents have professional jobs, and his mother can take time off for overnight medical trips. They have been unfailingly supportive, as have other adults in Leo’s life. Plus, he has only one state line to cross. “It sucks that we have to do it at all, because it’s a big hassle,” he says. “But at the very least . . . we’re not in a deep, deep South area.”</p> <p>On both Virginia trips, snafus at the pharmacy delayed their return home. “It’s anxiety-ridden, because I know I <em>have</em> to leave there with testosterone,” his mother says. “We’ve done all that work: taking off school and paying all that money for gas and the hotel, and me taking off work. And then to be, at that last moment, in that pharmacy where we’re so close to being done and going home. Both times have been extremely stressful. And it’s like, well, what do we do next?”</p> <p class="is-style-default t-has-endmark t-has-endmark">These out-of-state trips, she understands, are part of raising a trans teen in 2024. “The truth is,” she says, “I would travel wherever I needed to.”</p> <script async src="https://www.googletagmanager.com/gtag/js?id=G-S1L5BS4DJN"></script> <script> window.dataLayer = window.dataLayer || []; if (typeof gtag !== "function") {function gtag(){dataLayer.push(arguments);}} gtag('js', new Date()); gtag('config', 'G-S1L5BS4DJN'); </script> Copied! Copy HTML

Republishing guidelines

We’re happy to know you’re interested in republishing one of our stories. Please follow the guidelines below, adapted from other sites, primarily ProPublica’s Steal Our Stories guidelines (we didn’t steal all of its republishing guidelines, but we stole a lot of them). We also borrowed from Undark and KFF Health News .

Timeframe: Most stories and opinion pieces on our site can be republished within 90 days of posting. An article is available for republishing if our “Republish” button appears next to the story. We follow the Creative Commons noncommercial no-derivatives license .

When republishing a Harvard Public Health story, please follow these rules and use the required acknowledgments:

• Do not edit our stories, except to reflect changes in time (for instance, “last week” may replace “yesterday”), make style updates (we use serial commas; you may choose not to), and location (we spell out state names; you may choose not to).
• Include the author’s byline.
• Include text at the top of the story that says, “This article was originally published by Harvard Public Health . You must link the words “Harvard Public Health” to the story’s original/canonical URL.
• You must preserve the links in our stories, including our newsletter sign-up language and link.
• You must use our analytics tag: a single pixel and a snippet of HTML code that allows us to monitor our story’s traffic on your site. If you utilize our “Republish” link, the code will be automatically appended at the end of the article. It occupies minimal space and will be enclosed within a standard <script> tag.
• You must set the canonical link to the original Harvard Public Health URL or otherwise ensure that canonical tags are properly implemented to indicate that HPH is the original source of the content. For more information about canonical metadata,  click here .

Packaging: Feel free to use our headline and deck or to craft your own headlines, subheads, and other material.

Art: You may republish editorial cartoons and photographs on stories with the “Republish” button. For illustrations or articles without the “Republish” button, please reach out to [email protected] .

Exceptions: Stories that do not include a Republish button are either exclusive to us or governed by another collaborative agreement. Please reach out directly to the author, photographer, illustrator, or other named contributor for permission to reprint work that does not include our Republish button. Please do the same for stories published more than 90 days previously. If you have any questions, contact us at [email protected] .

Translations: If you would like to translate our story into another language, please contact us first at [email protected] .

Ads: It’s okay to put our stories on pages with ads, but not ads specifically sold against our stories. You can’t state or imply that donations to your organization support Harvard Public Health .

Responsibilities and restrictions: You have no rights to sell, license, syndicate, or otherwise represent yourself as the authorized owner of our material to any third parties. This means that you cannot actively publish or submit our work for syndication to third-party platforms or apps like Apple News or Google News. Harvard Public Health recognizes that publishers cannot fully control when certain third parties aggregate or crawl content from publishers’ own sites.

You may not republish our material wholesale or automatically; you need to select stories to be republished individually.

You may not use our work to populate a website designed to improve rankings on search engines or solely to gain revenue from network-based advertisements.

Any website on which our stories appear must include a prominent and effective way to contact the editorial team at the publication.

Social media:  If your publication shares republished stories on social media, we welcome a tag. We are @PublicHealthMag on  X ,  Threads , and  Instagram , and Harvard Public Health magazine on  Facebook  and  LinkedIn .

Questions: If you have other questions, email us at [email protected] .

More in Policy & Practice

NYC is working to help residents live longer, healthier lives

Can California’s health care providers help solve homelessness?

Unhoused  shows us the public health crisis under our noses

• News and Features
• Conferences
• Clinical Tools
• Special Collections

Gender-Affirming Surgery Rare Among Transgender Children in US

In 2019, no transgender and gender diverse (TGD) children aged 12 years and younger underwent gender-affirming procedures in the United States (US). These findings were published in JAMA Network Open .

Gender-affirming health care procedures are aimed at aligning one’s physical appearance with their gender identity for TGD individuals. However, these procedures can also include breast reduction for cisgender men and boys with gynecomastia.

Recent US legislative efforts have attempted to restrict gender-affirming health care to TGD individuals. Although supporters of these legislations often site concerns about TGD children, the number of TGD children undergoing gender-affirming procedures is expected to be low.

Investigators from the Harvard T.H. Chan School of Public Health conducted a cross-sectional study sourcing data from the Inovalon Insights database. Among a cohort of 47,437,919 adults and 22,827,194 children and adolescents, the rates of gender-affirming procedures in 2019 were assessed on the basis of gender and age. Surgery for other indications, such as cancer or injury, were excluded from the analysis.

Among children and adolescents, 16.8% were aged 15 to 17 years, 11.9% were aged 13 to 14 years, and 71.3% were aged 12 years and younger.

The rate of gender-affirming surgery among TGD individuals was 5.3 per 100,000 adults, 2.1 per 100,000 adolescents aged 15 to 17 years, 0.1 per 100,000 adolescents aged 13 to 14 years, and 0 among children aged 12 years and younger.

Most gender-affirming procedures were chest-related among adults (59.7%) and children and adolescents (96.4%). Of all gender-affirming breast reductions among adults and children/adolescents, 80% were performed on cisgender men and 97% were performed on cisgender boys.

The major limitation of this study was the reliance on diagnostic coding, which may have resulted in misidentification of the clinical justification for TGD or cisgender identities, and the exclusion of patients without insurance and patients who self-paid for gender-affirming surgery.

The study authors concluded that “these findings suggest that concerns around high rates of gender-affirming surgery use, specifically among TGD minors, may be unwarranted. Low use by TGD people likely reflects adherence to stringent standards of gender-affirming care.”

References:

Dai D, Charlton BM, Boskey ER, et al. Prevalence of gender-affirming surgical procedures among minors and adults in the US. JAMA Netw Open . Published online June 27, 2024. doi:10.1001/jamanetworkopen.2024.18814

Picked For You

Latest News

Want to read more?

Please login or register first to view this content.

Login Register

Connection denied by Geolocation Setting.

Reason: Blocked country: Russia

The connection was denied because this country is blocked in the Geolocation settings.

Please contact your administrator for assistance.

Ohio judge rules ban on health care for transgender minors can take effect, appeal expected

A Franklin County judge ruled Tuesday that Ohio's ban on gender-affirming care for transgender minors can take effect immediately.

Franklin County Court of Common Pleas Judge Michael Holbrook rescinded an earlier restraining order temporarily blocking the law , which also bans transgender girls from participating in female sports. The American Civil Liberties Union of Ohio plans to appeal the decision.

Holbrook, a Republican, ruled that Ohio's new ban doesn't violate the Ohio Constitution's health care freedom amendment or an Ohio law requiring legislation be limited to a single subject.

"The court finds the health care ban reasonably limits parents' rights to make decisions about their children's medical care consistent with the state’s deeply rooted legitimate interest in the regulation of medical profession and medical treatments," Holbrook wrote in his order.

The Ohio law prevents doctors from prescribing hormones, puberty blockers or gender reassignment surgery for patients under 18.

The American Civil Liberties Union of Ohio sued the state on behalf of two Ohio transgender girls and their families, saying the law violates their right to choose their health care under the Ohio Constitution. Holbrook  temporarily blocked the law  in April.

The ACLU of Ohio argued that puberty blockers and hormone therapy are safe and effective approaches for treating gender dysphoria. Gender dysphoria refers to the distress a person feels when their gender identity does not match their assigned sex. 

The Ohio Attorney General's Office argued that gender dysphoria should be addressed solely through mental health interventions.

Ohio Attorney General Dave Yost applauded Holbrook's decision. 

"This case has always been about the legislature’s authority to enact a law to protect our children from making irreversible medical and surgical decisions about their bodies," Yost spokeswoman Bethany McCorkle said. "The law doesn’t say 'no' forever; it simply says 'not now’ while the child is still growing."

Freda Levenson, legal director at the ACLU of Ohio, called the decision devastating and a genuine setback.

“This loss is not just devastating for our brave clients, but for the many transgender youth and their families across the state who require this critical, life-saving health care," she said in a statement. "While this decision by the court is a genuine setback, it is not the end of the road in our fight to secure the constitutional rights of transgender youth, as well as  all Ohioans’ right to bodily autonomy."

Read the decision here:

Ruling on transgender healthcare bill by Jessie Balmert on Scribd

Erin Glynn is a reporter for the USA TODAY Network Ohio Bureau, which serves the Columbus Dispatch, Cincinnati Enquirer, Akron Beacon Journal and 18 other affiliated news organizations across Ohio.

• Today's news
• Reviews and deals
• Climate change
• 2024 election
• Newsletters
• Fall allergies
• Health news
• Mental health
• Sexual health
• Family health
• So mini ways
• Unapologetically
• Buying guides

Entertainment

• How to Watch
• My watchlist
• Stock market
• Biden economy
• Personal finance
• Stocks: most active
• Stocks: gainers
• Stocks: losers
• Trending tickers
• World indices
• US Treasury bonds
• Top mutual funds
• Highest open interest
• Highest implied volatility
• Currency converter
• Basic materials
• Communication services
• Consumer cyclical
• Consumer defensive
• Financial services
• Industrials
• Real estate
• Mutual funds
• Credit cards
• Balance transfer cards
• Cash back cards
• Rewards cards
• Travel cards
• Online checking
• High-yield savings
• Money market
• Home equity loan
• Personal loans
• Student loans
• Options pit
• Fantasy football
• Pro Pick 'Em
• College Pick 'Em
• Fantasy baseball
• Fantasy hockey
• Fantasy basketball
• Download the app
• Daily fantasy
• Scores and schedules
• GameChannel
• World Baseball Classic
• Premier League
• CONCACAF League
• Champions League
• Motorsports
• Horse racing

New on Yahoo

• Privacy Dashboard

NC Democrat challenges ads on gender-affirming surgery for kids. What’s the reality?

A Democratic candidate in a battleground district that could be key to political control in North Carolina is pushing back against advertisements by opponents calling him a “quack liberal” and saying he supports “sex-change surgery,” also known as gender-affirming surgery.

Democratic candidate Dr. David Hill — a pediatrician — issued a “cease-and-desist” letter on Tuesday to Sen. Michael Lee and the North Carolina Senate Majority Fund, regarding claims they made about him in TV ads and mailers. The Senate Majority Fund is a special committee that helps fund Republican state Senate candidates.

Hill says the ads are full of false claims, but Lee and the committee are standing by the ads.

The Dowling Firm, a law firm representing Lee and the Senate Majority Fund, replied on Thursday to the cease-and-desist letter, citing statements made by Hill in podcasts and other instances as backing for language used in its advertisements.

“We are not sure how else Dr. Hill would like the public to understand such statements. Admittedly, the list of liberal politicians who have abandoned their support for sex-change surgeries for minors is growing, and Dr. Hill may now wish to disavow his prior endorsements of comprehensive gender-affirming care for minors,” says the letter shared by Lee with The News & Observer.

Barring Hill publicly declaring his stance, the letter says, “Senator Lee and the North Carolina Senate Majority Fund will continue to inform voters of Dr. Hill’s support of sex-change surgeries for children.

“Senator Lee strongly disagrees with Dr. Hill’s views on gender. The Senator is free to express his opinion that Dr. Hill’s radical views are wrong and, in doing so, point out that Dr. Hill’s self-promotion as a doctor does not make him an authority on gender issues,” says the letter.

In addition to gender-affirming surgeries, the ads allude to debates over transgender girls in sports and minors changing their pronouns without parental permission. Asked by The N&O about Hill’s positions on those issues, campaign manager Nehemiah Curnock sent a written statement from Hill that said he believed “in families’ and patients’ ability to make the best decisions for themselves without interference from the government.”

“Michael Lee is lying to voters about my beliefs and the type of care I provide. I’m the doctor you come to when your child is sick or hurt. I’m the doctor called into your delivery room when your newborn is having an emergency. That is what I do every day, and that is why parents trust me to care for their kids. I’m running to make sure that North Carolinians can get the care they need without lawyers and politicians joining them in their most private and critical healthcare decisions,” he said.

As the Nov. 5 election nears, advertising is growing —and Senate District 7, which includes parts of Wilmington, will likely see a lot more of it, considering it’s been targeted by Democrats and Republicans alike as a key district to win.

Here’s a look at what the ads say, what the candidates argue, and the evidence we could find about their claims.

Mail ad details

The cease-and-desist letter sent by law firm Womble Bond Dickinson on behalf of Hill on Tuesday cites an ad running on TV and more sent by mail, including a mailer that says that Hill “strongly supports sex-change surgeries for kids.”

“That statement is false,” says the letter shared by Curnock.

Curnock also shared a photo of the mailer on support for gender-affirming surgeries. The picture of the mailer does not show who paid for it, but Curnock said Hill’s lawyers confirmed that the mailer was paid for and approved by Lee’s committee.

The mailer quotes a blog post by Hill from July 1, 2021, but the letter from Republicans’ lawyers said that post was not the source for Hill’s position on surgery.

“To the contrary, the blog post was cited as the source for Dr. Hill’s quote that belittles parents who disagree with his liberal ideology,” says the letter.

“The mailer did not include a citation to Dr. Hill’s advocacy for sex-change surgery for minors because his support for such procedures seems without question,” says the letter.

It then references Hill having held leadership roles with the American Academy of Pediatrics and cites that during Hill’s leadership tenure the AAP published a policy statement recommending transgender youth have access to “comprehensive, gender-affirming” healthcare.

That document supports gender-affirming surgery for teens on a “case-by-case” basis. The letter cites various other sources.

The blog cited in the mailer appears to be the post written by Hill titled “ Yes, I Just Changed Your Baby’s Diaper ,” which hones in on why changing a dirty diaper has helped him as a pediatrician to diagnose various ailments a baby may have and allows him to inspect the baby’s genitalia.

Hill writes that some people are born with ambiguous genitalia, combinations of sex chromosomes beyond XY and XX, and “It may take weeks or months before gender is assigned in consultation with the family, endocrinologists, and psychologists.”

“What happens when these babies grow older and want to play school sports? Or must pick a public restroom to use? Or choose pronouns that someone else isn’t sure applies to them? Without even beginning to address the very real and very serious issue of gender dysphoria,” he wrote.

“When you hear someone assert that gender is either one thing or another, and they’re ready to pass laws to police how gender is treated, you can bet that they don’t understand the basics of endocrinology, genetics, or physical and psychological development. And I’ll bet they haven’t changed tens of thousands of diapers,“ he wrote.

‘Quack liberal’ TV ad

The letter also cites a television advertisement that calls Hill a “quack liberal.”

“They say doctors know best, but not David Hill. He’s a liberal, a radical, too extreme,” says the TV ad, which says it was paid for by Lee’s campaign committee.

“Let children change their gender with puberty blockers and other life altering treatments? Dr. David says yes. Let school kids change their name, their pronouns without their parents permission? Dr. David says yes. Let biological boys, men compete in women’s sports? Dr. David says yes. Dr. David Hill. He doesn’t know best. He’s just a quack liberal,” says the TV ad.

Hill’s campaign took issue with the insinuation that he was not fit to practice medicine, saying “that epithet, as you undoubtedly know, is typically reserved for medical practitioners who are ignorant, misinformed, or dishonest.”

On the use of the word “quack,” Lee’s attorney’s letter says “the advertisement is devoid of a single factual statement regarding Dr. Hill’s medical practice, much less a factual statement about his honesty or competency as a pediatrician.” The word “quack” is used to describe Hill’s “liberal views,” the letter says.

On the TV ad, Curnock said “the claims do not represent Dr. Hill’s views or his future priorities as a legislator” and “we believe that they have taken many things out of context and exaggerated many claims.”

Lee has also faced attack ads. Hill’s campaign has aired an ad against Lee saying he is “just another anti-abortion extremist,” citing Lee’s vote in favor of the GOP’s Senate Bill 20, which banned abortions after 12 weeks of pregnancy, with some exceptions.

The TV ad also cites the 2021 blog, as well as a podcast in which Hill participated and “public school forum, 24” as sources it used to back statements.

The GOP last year in North Carolina passed several laws aimed at the LGBTQ+ community, including one titled the Parents’ Bill of Rights that would ban curriculum on gender identity, sexual activity or sexuality from being taught in elementary school and that would require schools to notify parents if their children change their names or pronouns.

It also included one limiting gender-affirming treatment for transgender minors and another barring transgender females from playing in sports aligning with their gender identity. Lee voted in favor of these three bills during the final Senate floor vote.

Under the Dome

Get the latest news about North Carolina politics from The News & Observer's award-winning team. Get the free digest sent to your inbox by signing up here .