Gender-affirming care is safe, effective, and life-saving care for trans and gender-diverse youth. Of the more than 300,000 high school-aged transgender youth in the United States today, 35% live in states that have passed bans on gender-affirming care. Gender-affirming care includes mental health and non-medical services. Legislative actions typically focus on the medical and surgical aspects of care: puberty blockers, hormone replacement therapy, and gender-affirming surgery (which is rarely approved for adolescents under 18). The legislatures of 23 states have banned these treatments despite overwhelming support for gender-affirming care in the medical and scientific community.
Leading medical researchers and organizations confirm that gender-affirming care has significant positive outcomes for trans youth. A 2022 study published in JAMA Network Open found that having access to hormones and puberty blockers for youth ages 13 to 20 was associated with 60% lower odds of moderate to severe depression and 73% lower odds of self-harm or suicidal thoughts compared to youth who did not receive these medications over 12 months. Medical professional organizations, including the Endocrine Society, the World Professional Association for Transgender Health, and the American Academy of Pediatrics, are consistent in their standards and recommendations for medical care for trans youth who desire it –and vocal in their opposition to these bans. We might ask, as parents in one study did, “Why [has] transgender health care now become a political issue when other medical decisions are typically left up to medical experts and patients”?
Conservative legislators and organizations continue to push for bans and propagate misleading information about gender-affirming care. Why generate fear of and stigmatize trans youth, their families, and the physicians who treat them?
Some, including contributors to this syllabus, argue it’s an effort by the Right to “uphold white supremacy, normative gender, and heterosexuality” (Barcelos) and because transphobia is more acceptable in broad society, it can be used as a gateway to power for extremists (Branstetter).
This microsyllabus provides an introductory look at gender-affirming care and the legislative movement to ban it. It includes the voices of physicians, lawyers, and researchers, but also trans advocates, youth, and their families. It examines the arguments and motivations of legislators and organizations working to ban the care and invites you to compare that to the evidence-based findings highlighted in the rest of the microsyllabus.
Medical Research
Transgender and Gender Diverse Children and Adolescents, Endocrine Society, January 24, 2022.
This webpage is an important starting point in understanding the issue of gender-affirming care for transgender and gender-divergent youth. The Endocrine Society developed the 2017 Clinical Practice Guidelines for Gender-Dysphoric/Gender-Incongruent Persons; these guidelines are supported and followed by major medical organizations, including the American Medical Association, the American Academy of Pediatrics, the American Psychiatric Association, and the American Academy of Child and Adolescent Psychiatry. This reference provides simple definitions for important terms, including gender identity, gender diversity, and gender dysphoria. It provides evidence-based descriptions of the different types of gender-affirming care and their outcomes. For example, adolescents do not begin puberty blockers until the onset of puberty, and the transition to hormone replacement therapy is undertaken with teenagers only after a qualified mental health professional confirms gender dysphoria and emotional and cognitive maturity for informed consent. In contrast to the language in legislative bans, the Endocrine Society makes clear that all gender-affirming care is accompanied by thorough mental health evaluations and discussions of risks and benefits with young people and their families.
Janet Y. Lee and Stephen M. Rosenthal, Gender-Affirming Care of Transgender and Gender-Diverse Youth: Current Concepts, Annual Review of Medicine, Vol. 74, 107-116, January 2023.
This article provides a meta-review of 25 years of published research about the clinical outcomes of gender-affirming care for transgender and gender-diverse (TGD) youth. The authors conclude that current care practices “demonstrate the clearly beneficial—even lifesaving—mental health impact of gender-affirming medical care in TGD youth.”
They also examine the potential adverse impacts of puberty blockers and hormone therapy on bone density, growth, neurocognitive development, and fertility, risks that are often exaggerated in legislative discussions around bans. The authors acknowledge some level of risk but also point to the need for more research to optimize medical care for TGD youth.
Diana M. Tordoff, MPH; Jonathon W. Wanta, MD; Arin Collin, BA, Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care, JAMA Network Open. 5(2), February 25, 2022.
This study examined mental health outcomes for 103 transgender and nonbinary (TNB) youth after 12 months of gender-affirming care. Gender-affirming medical interventions were associated with lower odds of depression and suicidality over a time frame of one year. It also draws attention to the social determinants of mental health, pointing out that “high levels of social rejection, such as a lack of support from parents and bullying, and increased stigma and discrimination” can lead to poor mental health outcomes. The authors call upon “medical systems and insurance providers to decrease barriers and expand access to gender-affirming care.”
Katherine L. Kraschel, Alexander Chen, Jack L. Turban, and Glenn Cohen, Legislation restricting gender-affirming care for transgender youth: Politics eclipse healthcare,Cell Reports Medicine Vol. 3 Issue 8, August 16, 2022.
At the time this commentary was written, bills had been introduced in 25 U.S. states to restrict access to gender-affirming medical care for minors. The article brings together the evidence-based guidelines for gender-affirming care for transgender adolescents and its positive outcomes with a legal analysis of how proposed legislation to limit access to this medical care violates rights and can be legally challenged. According to the authors, the laws “violate the rights of transgender minors under the 14th Amendment’s Equal Protection Clause… interfere with the fundamental rights of parents to direct the care, custody, and control of their children under the 14th Amendment’s Due Process Clause… and likely violate the Equal Protection rights of physicians who provide gender-affirming care to transgender patients by treating them worse than physicians who provide other types of medically accepted care.” This argument bridges the medical and legal arguments for gender-affirming care, helpful for countering anti-trans legislation.
Abby Walch, Caroline Davidge-Pitts, Joshua D Safer, Ximena Lopez, Vin Tangpricha, Sean J Iwamoto, Proper Care of Transgender and Gender Diverse Persons in the Setting of Proposed Discrimination: A Policy Perspective, The Journal of Clinical Endocrinology & Metabolism, 106 (2), February 2021, 305–308.
This article provides a policy critique of bans on gender-affirming care by medical experts. The authors confirm that policies banning gender-affirming care run counter to evidence-based standards of care. Of unique value is their attention to the use of erroneous information in anti-trans proposals. For instance, they discuss a ballot question from a 2020 Texas Republican Party primary that reads: “Texas should ban chemical castration, puberty blockers, cross-sex hormones and genital mutilation surgery on all minor children for transition purposes, given that Texas children as young as three (3) are being transitioned from their biological sex to the opposite sex.” As the authors argue, “‘Chemical castration’ and ‘genital mutilation’ are not part of gender-affirming care for minors,” and the wording is meant to cause alarm. The deliberate misrepresentation of medical care is effective, as “94.57% of the electors supported the measure.” The authors condemn the politicization of gender-affirming care and argue for health policy guided by health experts.
Advocacy and Activism
David H. Thompson, Brian W. Barnes, John D. Ramer, The Justice for Adolescent and Child Transitioners Act, Do No Harm.
This white paper provides a useful perspective on the arguments of proponents of gender-affirming care bans. This white paper was commissioned by the organization, Do No Harm, which defines itself as “a diverse group of physicians, healthcare professionals, medical students, patients, and policymakers united by a moral mission: Protect healthcare from a radical, divisive, and discriminatory ideology.” Supposedly emanating from a medical organization, the paper was written by Washington, D.C. law firm Cooper & Kirk and serves as a template for state legislators to pursue gender-affirming care bans. The paper’s arguments against care include:
- There is no reliable scientific or medical evidence to justify the use of these treatments;
- The benefits of gender-affirming care treatments do not outweigh the risks;
- Minors and their parents are not adequately informed of the risks before treatments are administered.
The other medical sources in this microsyllabus dispute the arguments presented in this white paper.
2022 National Survey on LGBTQ Youth Mental Health, The Trevor Project, 2022.
The Trevor Project, a nonprofit focused on ending suicide among LGBTQ young people, surveyed 34,000 racially-diverse, LGBTQ youth across the United States. The results demonstrate the serious mental health issues faced by gender-diverse youth, with two-thirds of transgender and nonbinary youth reporting symptoms of depression and more than 50% considering suicide. The survey examines the causes of poor mental health, including obstacles to accessing mental health care, discrimination, and experiences of physical threats and/or harm. The survey demonstrates a mental health crisis but also shows that when youth are supported, they can thrive. “Very simple things — like support from family and friends, seeing LGBTQ representation in media, and having your gender expression and pronouns respected — can have such a positive impact on the mental health of an LGBTQ young person,” Amit Paley, Executive Director, The Trevor Project.
Map: Attacks on Gender Affirming Care by State, Human Rights Campaign Foundation, September 9, 2023.
This map provides a visual representation of the scale of the current attack on transgender and gender-diverse youth and their right to receive gender-affirming care. The map shows that 22 U.S. states, almost half, have passed bans on gender-affirming care, which impacts at least 35% of the estimated 300,000 high school-aged (ages 13-17) transgender youth in the United States today. That number grows to 45% if you include states where legislation banning gender-affirming care has been introduced.
Gender Justice Virtual Briefing Survey: Defending Transgender Kids in North Dakota, Gender Justice, September 27, 2023.
Gender Justice is a Minnesota nonprofit legal and policy advocacy organization with a mission to advance gender equity through the law; it often represents individuals in legal cases brought under federal and state civil rights statutes. The organization recently announced a lawsuit on behalf of three North Dakota families and a pediatrician to block North Dakota’s ban on essential healthcare for transgender youth. In this briefing, the state director and lead attorney discuss details of the case and the strategies they plan to use to protect the rights and freedom of those they represent. This is a helpful resource to understand how legislation banning gender-affirming care is being challenged in the courts.
Chris Barcelos, “Gendered Racial Projects: Anti-Trans, Anti-CRT, and Anti-Abortion Legislation” Gender Policy Report. July 14, 2022.
This article deftly connects the rapid increase of anti-trans legislation to that of anti-abortion and anti-critical race theory movements. Barcelos writes, “Bringing these punitive public policies into the same frame illustrates how they are part of a gendered racial project to promote policies that uphold white supremacy, normative gender, and heterosexuality.” Barcelos outline the similarities of these campaigns, including the goals of disenfranchising and denying bodily autonomy to marginalized people already struggling under the weight of social exclusion, and their leadership: far-right organizations and white nationalists who want to “preserve white, heterosexual childhood innocence” while criminalizing and punishing youth of color, queer, and transgender youth. By making these connections, Barcelos encourages activists to engage in collective action.
Mattew Sitman & Sam Adler-Bell (Hosts), Know Your Enemy. The Anti-Trans Agenda (with Gillian Branstetter) (No. 51). (3/20/2022). Simplecast.
Gillian Branstetter, press secretary for the National Women’s Law Center, contextualizes the rise of state legislative attacks on trans people and trans youth. Along with the hosts, Branstetter analyzes the motives and goals of the conservative legislators and organizations that are backing them.
She points to the 2020 Supreme Court decision in Bostock v. Clayton County, which found that prohibiting discrimination in the workplace on the basis of sex includes sexual orientation and gender identity, as a flashpoint for many conservative groups working to strip away LGBTQIA+ rights. After that, more than 100 anti-trans and anti-LGBTQ bills flooded state legislatures.
As to the goals of these legislators and groups, Branstetter points to fear, “They’re afraid that the existence of trans people poses an existential threat to their broader effort to enforce a strict gender binary and the complementary roles that come with it.” Like Barcelos, Branstetter advances an intersectional analysis –noting that anti-abortion and white nationalist groups are also involved in anti-trans movements.
