Transgender youth care misconceptions lead physicians, researchers to set the record straight

Medical care for transgender youth has been the focus of legislation across the country in recent years.

Restrictions on access to gender-affirming care for transgender youth have been passed in at least 23 states, many of which have faced legal challenges that argue such bans violate the rights of the youth, their families and their medical providers.

Healthcare providers who specialize in the field of gender-affirming care say misinformation has clouded the general understanding of what it means for transgender minors and their families.

ABC News spoke with physicians and researchers to dive into the most discussed topics surrounding gender-affirming care.

What is gender-affirming care for minors in the U.S.?

Gender-affirming care looks different for every person, says Joshua Safer, an endocrinologist and executive director of the Mount Sinai Center for Transgender Medicine and Surgery.

He says patients, their physicians and their families work together to build a customized and individualized approach to care, meaning not every patient will receive any or every type of gender-affirming medical care option.

"There is no one-size-fits-all approach to care for transgender people or treatment for gender dysphoria," said Kellan Baker, the executive director of the Whitman-Walker Institute, an LGBTQ research organization and care provider.

Baker said the decision to pursue gender-affirming care is often a lengthy process that includes teams of medical care providers and mental health professionals who work with families to talk about their child's experience, their needs, their choices, and more.

"We're talking months of appointments with a mental health specialist. We're talking lots of conversations between providers, parents, and kids," Baker said in an interview. "We are talking about long waitlists because in terms of being able to access these clinicians who actually have experience in working with trans people, this isn't something that happens quickly."

For children who have not reached puberty, there is no medical intervention available, according to care guidelines from the medical organizations Endocrine Society and World Professional Association for Transgender Health.

At this stage, there are no hormonal differences or developments that would prompt the potential for medical intervention, Safer states.

Jack Turban, a child and adolescent psychiatrist and professor of Child and Adolescent Psychiatry at University of California, San Francisco, said health professionals are typically focused on providing education about gender to parents and working to make sure the children have a safe and inclusive environment to explore their gender at this stage.

"The one thing that prepubertal kids might be interested in is a social transition," Turban said in an interview.

He continued, "It could mean trying a new name or new pronoun, or different clothes or different haircut. And the generally accepted consensus in the field for these pre-pubertal kids is that if they want to explore any of those things, that we let them while making sure that they're doing it in a safe, supportive environment."

The World Professional Association for Transgender Health standards of care outline a lengthy and thorough evaluation process to make sure that parents and patients have given informed consent.

"There are some trans people who have physical gender dysphoria and are really distressed by their puberty. There are other trans people who don't and are OK with their bodies," said Turban. "So we always make sure that kids know they don't need to pursue any of these medical interventions."

Puberty blockers, hormone therapy and surgery

When children reach puberty, patients and their providers could consider the use of puberty blockers, which Safer said is a decades-old practice to delay the development of gendered characteristics, including the growth of breasts and facial hair as well as changes in a person's voice.

Safer states that this is not a harmful procedure and has been widely used on children who experience puberty earlier than what is typical.

Once blockers are stopped, puberty continues with little to no proven side effects, according to health professionals.

This delay in puberty allows transgender or questioning children to explore their gender "so that we have time to be more methodical in reviewing the situation with those particular youth, as well as with their parents, and determine what the appropriate course of action would be," said Safer.

He said endocrinologists have been using this particular approach for about 40 years and "have not seen ill effects from doing so."

"This is a well-established, conservative maneuver," said Safer, who wrote the transgender care guidelines for the Endocrine Society.

Hormone therapy also has been used for decades for a variety of cases and can be used for older minors.

The WPATH guidelines recommend a thorough biopsychosocial evaluation prior to initiation of hormone therapy, including a letter from a mental health professional, informed consent from the parents following national laws, and a thorough discussion of the risks and benefits with both patients and parents.

Patients who are given hormone therapy take estrogen or testosterone, based on their gender identity. Changes from hormone therapy occur slowly and are partially reversible, experts explain, such as changes in voice and body hair.

It’s not unusual for patients to stop hormone therapy after some time and decide that they have transitioned as far as they wish, experts told ABC News.

According to the American Academy of Pediatrics, surgery -- such as a mastectomy -- for anyone under 18 is rare and only done on adolescents on a case-by-case basis. It does not come without risk, one medical professional told ABC News, but for those experiencing severe distress in their body, it can be a major source of relief.

What risks do gender-affirming care pose to fertility? How common is regret?

One of the concerns expressed by conservative lawmakers against gender-affirming medical care is that it might render transgender youth sterile.

In favor of a gender-affirming care ban in Ohio, state Rep. Gary Click said on the House floor: "We also look to infertility as another issue that comes up with this. We look at children who are unable to enjoy the pleasures of sex later in life because of these drugs, these hormones that they are taking do a lot of damage to these kids."

Professionals have not seen fertility issues in people who temporarily use puberty blockers.

Safer, who wrote the guidelines for the Endocrine Society, states that hormone therapy does not make transgender people permanently sterilized; however, it does reduce fertility.

"If we're talking about a transgender boy -- so female to male -- somebody who has ovaries, testosterone will cause them not to ovulate. In fact, that's part of the goal. However, there isn't any evidence that any harm comes to those ovaries," said Safer.

This means there is potential for transgender boys to still get pregnant.

"For transgender girls, male to female, if you knock your testosterone levels down … that will cut spermatogenesis, that is sperm growth, and that will really decrease fertility," said Safer. "But even that is not absolute."

The gender-affirming care guidelines from the World Professional Association for Transgender Health and the Endocrine Society state that physicians should thoroughly warn patients about the potential for reduced fertility before administering hormone therapy.

Safer said patients of both treatments are also cautioned that they need to be careful if they're engaging in sexual activity because of the ongoing possibility of getting pregnant or causing pregnancy.

Lawmakers in support of gender-affirming care bans also expressed concerns about potential side effects -- including bone density cardiovascular health, and more.

Research has show that there is some potential for gender-affirming care to impact other parts of a patient's health.

There is evidence of a slight reduction in bone mineral density for those on estrogen therapy, a study in the The Journal of Clinical Endocrinology & Metabolism shows.

Early research from JAMA Pediatrics shows that testosterone therapy might increase cholesterol levels. However, a study published by the American Heart Association has not demonstrated any evidence of increased cardiovascular risk. And oral estrogen has been shown to increase risk of blood clots, according to research from the Thrombosis Research journal.

However, physicians have told ABC News that all medications, surgeries or vaccines come with some kind of risk and knowing both the risks and benefits of treatment – and of not treating a condition – can help families make an informed decision.

Legislators also have said they have concerns about people who regret accessing gender-affirming care.

Click argued: "We have a number of kids who have started on this progress. As they grow up, they look back at themselves and they say, 'How did adults let me make this decision?'"

Medical experts do not deny that some patients have later "detransitioned" or regretted their care -- however, research shows that rates of regret for gender affirmation surgery are extremely low, hovering around 1%.

Rates of regret for knee and hip surgeries are significantly higher, studies show -- 17.1% and 4.8% respectively.

"That doesn't mean that it isn't important to make sure that everyone can get the care that they need and that they're getting it in safe, high quality care environments, but [gender-affirming care bans] are the opposite of that," Baker said.

Are gender-affirming care procedures "experimental"?

Gender-affirming care is not experimental, according to physicians and psychologists interviewed by ABC News.

The first-of-its-kind gender care clinic at Johns Hopkins Hospital in Maryland opened in the 1960s, using similar procedures still used today, according to new research published by the American College of Physicians.

Major national medical associations, including the American Academy of Pediatrics, the American Medical Association, the American Academy of Child and Adolescent Psychiatry, and more than 20 others agree that gender-affirming care is safe, effective, beneficial, and medically necessary.

What states have banned gender-affirming care?

The 23 states that have restricted gender-affirming care, according to the Human Rights Campaign includes: Montana, Idaho, North Dakota, South Dakota, Nebraska, Iowa, Utah, Arizona, Texas, Oklahoma, Louisiana, Mississippi, Missouri, Iowa, Alabama, Florida, Georgia, North Carolina, West Virginia, Kentucky, Indiana, Ohio, Arkansas and Tennessee.

However, several states have had their policies blocked in legal challenges.

Impact of transgender care bans

Some physicians and LGBTQ advocates are concerned about the impact such bans can have on the mental and physical well-being of transgender youth.

Often because of gender-related discrimination and gender dysphoria, transgender youth are more likely to experience anxiety, depressed mood, and suicidal ideation and attempts, according to the Centers for Disease Control and Prevention.

Hormone therapy can improve the mental health of transgender adolescents and teenagers, a recent study in the New England Journal of Medicine found.

Ash Orr of the National Center for Transgender Equality, now 33, said they've felt this improvement firsthand, saying they felt "trapped in my own body" and feel freer with gender-affirming care.

"I've already noticed such a massive shift in my mental health because I am now in the body that was meant to be mine," said Orr in an interview. "I am happy to be in this body. I'm happy to be able to present more masculine and truly I know that sounds kind of cliché, but access to gender for me was life saving."

ABC News Mary Kekatos contributed to this report.