America’s leading child doctors are continuing to back transgender healthcare services for minors under 18 – despite concerns about long-term risks.
The influential American Academy of Pediatrics (AAP) voted to stand by its 2018 guidance that supports access to counseling, hormone therapy, puberty blockers, and occasionally surgery.
But the AAP has commissioned a systematic review of those treatments, which are becoming increasingly common because of the sharp rise in gender dysphoria diagnoses among minors.
The decision to keep recommending the pharmaceutical interventions puts the US at odds with other countries like the UK and Sweden, which have also commissioned systematic reviews but have paused puberty blockers, hormone drugs and surgery until those reviews are concluded.
The AAP’s move comes as trans youth issues have become a culture war flashpoint, with 19 US states banning or severely restricting under-18s from accessing the drugs.
Access to gender-affirming care in the US has been heavily restricted or banned in 20 states. Many also have bills under consideration to further limit access to care
The above map from a study published in JAMA shows the median travel time to the nearest gender-affirming clinic before various states enacted restrictions on medical care for transgender youth.
The above map from a study published in JAMA shows the median travel time to the nearest gender-affirming clinic after various states enacted restrictions on medical care for transgender youth
The AAP’s 16 members, who represent a collective 67,000 pediatricians, all expressed confidence in the evidence available showing the clinical benefits of gender-affirming care for trans youth.
They concluded that children should still have access to ‘comprehensive, gender-affirming, and developmentally appropriate health care.’
This type of gender-affirming care typically starts with robust social support including the use of preferred pronouns and psychological counseling, which can sometimes lead to the decision to start certain clinical interventions like puberty blockers. These temporarily halt the development of secondary sex characteristics, giving youth more time to explore their gender identity without undergoing irreversible changes.
Doctors may also consider prescribing hormone replacement therapy, which entails giving cross-sex hormones to promote the development of physical characteristics consistent with the individual’s gender identity.
For instance, testosterone injections for trans boys who were born girls can help deepen the voice and increase muscle mass.
In rare cases, doctors may recommend that the person undergo surgery such as a double mastectomy, also known as top surgery, to help them feel better attuned to their gender identity.
Surgeries among under-18s are uncommon but totally irreversible.
This is typically seen as the final step toward transitioning only after other therapies such as hormones have been used.
The AAP’s 2018 policy statement regarding surgeries said: ‘These changes are irreversible.
‘Although current protocols typically reserve surgical interventions for adults, they are occasionally pursued during adolescence on a case-by-case basis, considering the necessity and benefit to the adolescent’s overall health and often including multidisciplinary input from medical, mental health, and surgical providers as well as from the adolescent and family.’
The AAP’s decision to stick by the 2018 policy reaffirms the group’s belief that gender-affirming care is evidence-based and even life-saving in some cases.
Pointing to several studies, including Government-run research, the group said ‘56% of youth who identified as transgender reported previous suicidal ideation, and 31% reported a previous suicide attempt, compared with 20% and 11% among matched youth who identified as cisgender, respectively.’
At the same time, transition care does not solve the problem every time. There have been many anecdotes of trans people in the US and aboad who underwent treatment such as hormone therapies or top surgeries as minors only to regret it later.
Some people, such as now-25-year-old Laura Becker from Wisconsin, have gone so far as to detransition. Ms Becker was referred for top surgery at 19, just seven months after being prescribed hormone-warping drugs to make her more masculine. Becker said the surgery is her ‘biggest regret’.
Luka Hein, another detransitioner, was prescribed hormone treatments to transition from female to male at 15 and was just 16 when she had her breasts removed.
The Minnesotan was a young teenager when she became unsure of her true gender, but thinks doctors were too quick to nudge her in the direction of surgery and did not take her mental health issues into account.
Mark Del Monte, the chief executive of the AAP told the New York Times: ‘The board has confidence that the existing evidence is such that the current policy is appropriate.
Laura Becker (left) began testosterone treatments at 19 to transition from female to male (pictured right). Doctors pressed ahead with her mastectomy even though she told them she was feeling suicidal
Luka Hein is speaking out about how she feels she was rushed into surgery at a young age and doctors did not take into account her poor mental state
‘At the same time, the board recognized that additional detail would be helpful here.’
The AAP’s vote comes less than two months after the UK’s National Health Service upended its system for youth gender-affirming care system by limiting the use of puberty-suppressing drugs to youth in clinical trials only.
That decision followed an independent review which found ‘there is not enough evidence to support their safety or clinical effectiveness as a routinely available treatment.’
In the US, children’s access to gender-affirming care has been extremely curtailed as more states enact restrictions or all-out bans on types of care services.
As of May 2023, 20 states have enacted legislation, executive actions, or other policies that restrict or ban healthcare for transgender youths, and more than 100 additional bills are under consideration.
All of the states are Republican or Republican-leaning, and all but one voted for former President Donald Trump in the 2020 election.
Up until the wave of state bans began in 2020 and 2021, there were no restrictions at the federal level for access to these treatments.
But a white-hot culture war sparked by rising stars on the right such as Florida Gov and GOP Presidential candidate Ron DeSantis is ongoing.
Still, there is compelling evidence to show that trans youth are more susceptible to mental health issues when their dysphoria goes unaddressed, with one study showing as many as 56 percent of trans youth experience suicidal thoughts, while 31 percent reported having attempted suicide.
According to the AAP: ‘[The risk for mental illness] is believed to be multifactorial, stemming from an internal conflict between one’s appearance and identity, limited availability of mental health services, low access to health care providers with expertise in caring for youth who identify as TGD, discrimination, stigma, and social rejection.’
Prescribing forms of gender-affirming care, even social measures such as calling a trans person by their preferred new name or pronouns, can have immeasurable benefits for a child’s emotional wellbeing.