What the science says about trans kids and medical care

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Trans Kids 360 OVERVIEW

Heather Crawford came home from work one day in October 2019 and found her 12-year-old child, Cass, unconscious on a bed. Cass had swallowed more than 60 pills, including a prescription antidepressant. There was a note written in blue glitter pen.

“I’m sorry. I just couldn’t take it any more. I want this. Life is too strong and I’m too weak. Don’t be too sad. It’s just me,” wrote Cass, who had come out as nonbinary that summer. “Now you can get a normal child who isn’t a complete fuck-up. I love you. Never forget that. I don’t belong here. This is better.”

“I know that gender-affirming care saves children’s lives because I almost had to learn the other lesson,” said Crawford, who at first rejected her child’s assertion of a nonbinary identity and new name.

Texas, where the Crawfords live, has gone a step further, by classifying gender-affirming therapies as a form of child abuse, even though these therapies are endorsed by major medical groups. Plenty of research demonstrates benefits of access to this care — including improved mental health — and suggests that the earlier it’s accessed, with developmentally appropriate timing, the better. Evidence also shows that interfering with access can cause immeasurable and irreparable harm, including increased risk for significant mental health problems.

Despite this, in late February, Republican Texas Gov. Greg Abbott wrote a letter instructing employees of the state’s Department of Family and Protective Services (DFPS) to prosecute parents whose minor children had undergone gender-affirming therapies. The letter also asserted that mandated reporters such as teachers and doctors, and even regular citizens, were also obligated to turn parents in for child abuse.

Trans Kids 360 THESIS

Thesis

Gender-affirming therapy for trans children has become the front line of a raging culture war. These tactics are counter to current medical guidelines and practices based on decades of research, and they rely on claims that scientific evidence does not support. Battles are being fought on many fronts, but families in states like Texas are under siege, targeted by state agencies weaponized by the government and facing an uncertain future for their families and their children’s lives. The national and international trends suggest an association of these actions with growing authoritarianism, according to the American Civil Liberties Union.

Medicine Lens

Gender-affirming care is standard of care

The recommendations for transgender and nonbinary children range from social affirmation of their identity to medical interventions involving hormones and, in some cases, surgery to the chest area to remove breast tissue.

The affirmation begins with a series of conversations, said Scott Hadland, chief of the division of adolescent and young adult medicine at Massachusetts General Hospital for Children and Harvard Medical School. “The interventions that many people think of when they think of gender-affirming care, specifically hormones and surgeries, are much later in this trajectory and not even interventions that many kids end up desiring,” he said.

“When I’m talking to a [younger] child, what I’m trying to figure out is what is their conception of their gender, and how did they develop that concept,” said Frey-Vogel. “What feels stressful, and how do we decrease stress and increase a sense of well-being with an alignment with body and identity?”

Puberty blockade and later gender-affirming hormone therapy with either estrogen or testosterone are options for older trans kids. Puberty-suppressing hormones have been used since the 1980s for children with extremely early puberty. For transgender children, AAP’s policy statement says that these reversible treatments are appropriate as a bridge up to age 16 years to prevent development of features that can be distressing. If these hormones are stopped, gonadally driven puberty resumes.

For adolescents, who overwhelmingly tend to have persistent gender identities, the conversations change. “We go through a lot of detail what about what’s reversible and what’s not, and effects on fertility, and what’s best to do to meet those goals,” said Frey-Vogel.

More permanent surgical changes are almost always delayed to the late teens, at the earliest, and then only with mental health support. “Genital surgery is almost never done before age 18, and gonadectomy [removal of ovaries or testes] is almost never done in the under 18,” said Benjamin Park, a research fellow in the plastic surgery department at Vanderbilt University School of Medicine, who works with gender-diverse patients. There are other reasons for these surgeries, he noted, including being intersex or having a congenital anomaly that needs to be addressed.

Mental Health Lens

Evidence shows benefits from treatment — and the cost of denial

Gender-affirming care lifts the mental health burden for trans children, reducing their risks for depression, anxiety and suicide attempts. The vast majority of adolescents who receive this care — from affirmation of pronouns to hormone therapies to “top surgery” — do not regret it.

Crawford’s family knows far too well the costs of denying a transgender or nonbinary child’s gender identity. Before that horrible day in October 2019 when Cass attempted suicide, they had disclosed in a letter from summer camp that they were nonbinary. Heather Crawford described it as a “regular letter” from camp, “but at the bottom, in tiny letters written upside down, it said, ‘I am nonbinary and I want you to call me Cass.’”

Her reaction, she said, was “about as bad a reaction [could be] short of kicking them out of the house.” She didn’t know what nonbinary meant and tried to tell Cass that they were “going through a phase” and were “confused.” Crawford recalled saying, “I’m going to call you by the name I gave you because that is your name.” After that, “things got pretty uncomfortable and pretty rocky in our house. I knew something was wrong, but I didn’t know how to fix it.”

Cass, who is now 15, said they’d sent the note hoping that it would arrive home before they did so that their parents “could have time and process.” It got there first. Their parents’ reaction “hurt a lot.”

After Cass’ suicide attempt, Crawford and her husband got them to the emergency room where the preteen was in a precarious state, on the verge of a strokelike syndrome. It took about 12 agonizing hours to stabilize them.

“The very first thing they said when they woke up was ‘I’m sorry,’” said Crawford. “At that point, I came to the very hard and fast conclusion that I had done something very wrong that my 12-and-a-half-year-old would rather die than go on living the way they had. That was really a turning point.”

The family immediately started using Cass’ chosen name and correct pronouns. Cass underwent weeks of inpatient mental health treatment followed by intensive outpatient care. They now are attending a brick-and-mortar high school after a stint of home schooling.

The 2021 Trevor Project survey showed that 52 percent of transgender and nonbinary youth had considered attempting suicide in the past year, compared with 32 percent among LGBTQ respondents who were cisgender. It found similar patterns for generalized anxiety disorder and depression.

Gender-affirming treatment “is lifesaving treatment,” said Frey-Vogel. With the fusillade of political efforts to prevent access to these treatments for transgender children, “I really worry that there will be increased suicide rates,” she added.

“Put simply: These policies will kill,” said Hadland.

Politics Lens

Big actions against a small population

“You can see the creep into care for adults, with some states having bills that criminalize care up to age 21 or banning state funding for care including at state hospitals at any age,” said Chase Strangio, deputy director for trans justice with the American Civil Liberties Union’s LGBTQ and HIV Project. “The justification starts with ‘we are protecting minors,’ then it actually goes up to 19, up to 21, up to 25. It’s not about age, and it’s not about minors. It’s to stop people from being trans altogether.”

The Texas policy has already left a mark, regardless. Children undergoing bloodwork for starting puberty blockers have found their doctors suddenly cutting off all contact or declining to proceed, devastating them and their families.

Texas parent L.R., whose initials are being used to protect their identity, was an immediate target of the state DFPS following Abbott’s February letter to the agency. L.R. described being in the shower when an agent banged on the door and advised them that DFPS had received “multiple reports of genital mutilation, hormone abuse, physical abuse against your child.”

The hitch, or so it seemed, was that L.R.’s child was an adult, having turned 18 the preceding month. That wasn’t enough to stop the DFPS. They insisted that because L.R.’s job involved contact with people who are elderly or disabled, the agency could still retroactively investigate them for child abuse. Agency representatives contacted L.R.’s workplace, a co-worker and their adult son at his out-of-state college.

The upshot is that L.R. and their son had to lawyer up to deal with it all. “I am not sleeping. I can barely eat. My stomach hurts,” L.R. said. “I know I didn’t do anything wrong.”

“What’s different about [the Texas policy] is that it weaponizes the state control apparatus of child protective services in a way that’s not just extralegal but is also outside the normal realm of oversight,” said Khadijah Silver, director of communications at the Transgender Legal Defense and Education Fund. “This basically is like a very efficient eradication of process between accusation and punishment for deigning to love your child and to try to give them the care that you know is medically necessary for them.”

As part of that eradication, DFPS employees were instructed not to follow the agency’s usual processes. One former employee testified in a court hearing that staff were ordered to investigate every call claiming child abuse because of gender-affirming care. That instruction was against the usual agency practice of prioritizing calls based on apparent imminent danger to the child. Case workers also had been advised not to put specifics about the cases in writing, an unprecedented directive. The employee had left the agency after six years because of Abbott’s order.

Strangio said that this kind of resistance from inside institutions is telling. “Within the agency, there is a lot of resistance. People don’t want to be investigating these cases, by and large,” he said.

International Lens

A red flag for fascism

These patterns, along with the loud anti-trans drumbeats in countries like Hungary and in the U.K., exemplify a “loose alignment in the rise of far-right governments with the rise of these policies,” said Strangio. “There are different strains of far-right government, but all of them have this orientation toward an anti-trans discourse and rhetoric.” The purpose, said Strangio, is to use scapegoating and narratives of fear to consolidate the power of their base.

In the end, “you can’t extricate these efforts from the efforts to ban trans people from bathrooms and sports,” said Strangio. He added that these attempts all triangulate on a claim “that ‘it is harmful to be trans, and we are going to stop you.’ Which they simply cannot do.”

Trans Kids 360 CONCLUSION

Opponents of gender-affirming care for trans and nonbinary kids and teens often claim that these therapies harm children. But extensive research endorsed by major U.S. medical groups finds the exact opposite conclusion: Gender-affirming care improves the health of trans and nonbinary children and teens, reducing their otherwise significant risk of severe mental health problems and suicide.