Across the country, Republican lawmakers have introduced legislation that restricts transgender health care for minors.
At least eight states have passed laws or policies restricting this care, and 23 more state legislatures are considering similar legislation of their own.
Medical experts say that understanding transgender identities, gender dysphoria and how gender-affirming treatments work is key to understanding the impact these bans may have on patients.
"When it becomes too political, it becomes more about paying attention to very short sentences, but not paying attention to nuance” said Dr. Hussein Abdul-Latif, a pediatric endocrinologist at the Children’s Hospital of Alabama with a special focus on gender care.
“And that's unfortunate, because this is not something that is very simple.”
Why do people undergo gender-affirming care?
Gender-affirming care can help treat gender dysphoria, which refers to the stress of being in a body that doesn’t feel like one’s own, according to the Diagnostic and Statistical Manual, Fifth Edition, which provides up-to-date information on mental health conditions.
People experiencing gender dysphoria may feel that their physical body does not match their inner sense of who they are or that they do not desire the gender identity typically associated with their assigned sex at birth.
This can cause distress, depression and anxiety, according to medical experts. However, being transgender is not a mental illness.
“There's not a blood test, there's not an MRI we can do to determine who's … dealing with dysphoria,” said Dr. Andrew Goodman, the medical director for Callen-Lorde, a community health center in Manhattan that specializes in LGBTQ health care. “We have to listen to people, and to trust them and what they're telling us.”
A national survey in 2015 by The National Center for Transgender Equality reported that of the more than 27,000 trans Americans who responded, 38% of them knew they were trans before 5 years old, and 60% knew they were trans before 10.
Is gender diversity a new concept?
No. There is documentation of gender diverse individuals in a wide range of cultures around the world throughout history, dating back centuries.
Medical treatment for gender dysphoria, as it’s known today, was introduced in the early to mid-1900s in Germany.
Modern gender-affirming care is based on “decades of clinical experience and research and, therefore, they are not considered experimental, cosmetic or for convenience,” per the World Professional Association for Transgender Health standards of care.
What is gender-affirming care?
Gender-affirming care is about supporting someone’s identity, said Dr. Goodman. It helps align their physical appearance with their gender identity, and can include puberty blockers, hormone medications, and surgery.
Trans individuals often transition socially — by changing their name and pronouns, or dressing differently — before beginning any medications.
“I look for the need, the crisis… when the dysphoria really starts to intensify,” said Dr. Goodman, who explained this can be when a trans youth starts seeing puberty-related changes in their body.
Puberty blockers are used in people who have not started or completed puberty. Pausing puberty allows children to explore their gender identity without the growth of permanent sex characteristics, Dr. Abdul-Latif explained.
Puberty blockers mimic the body’s natural hormone, called GnRH, which suppresses the release of testosterone for biological males or estrogen for biological females, according to the U.S. Department of Health and Human Services.
These are typically offered during the early stages of puberty, according to the Endocrine Society treatment guidelines. This stage of puberty can be determined by changes in the body such as enlargement in the testicles or breast bud formation. The average age for this developmental stage is 11-12 years old for biological males and 10-11 for biological females.
If these are stopped, a child will resume undergoing puberty with little to no proven side effects, according to medical experts ABC News spoke with.
Once kids are in the later stages of puberty, typically around the age of 15, they are no longer a candidate for puberty blockers and would transition to hormone therapy, explains Dr. Abdul-Latif. They are directly given estrogen or testosterone, based on their gender identity.
Changes from hormone therapy occur slowly and are less reversible, he explains, such as changes in voice and body hair.
The World Professional Association for Transgender Health 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 in accordance with national laws, and a thorough discussion of the risks and benefits with both patients and parents.
It’s not unusual for patients to stop hormone therapy and decide that they have transitioned as far as they wish, according to Abdul-Latif.
“A very important idea that I share with them is that they can change their mind anytime they want to, even when they start hormone therapy or puberty blockers,” Abdul-Latif said. “That is important for me to make sure that they are not continuing because of fearing that they will disappoint me. I certainly would not be disappointed. I'm there to serve them.”
According to the American Academy of Pediatrics, gender-affirming surgery is only done on adolescents on a case-by-case basis. It does not come without risk, said Goodman, but for those experiencing severe distress with their body, such care can be a major source of relief.
Surgeries include the removal of breast tissue, creating the appearance of breast tissue, or reconstructing of genitalia.
Is gender-affirming care safe?
All medications, surgeries or vaccines come with some kind of risk and gender-affirming care is no different, according to physicians. However, knowing the risks and benefits of treatment – and of not treating a condition – can help families make an informed decision.
“I never phrase the conversation [with patients] as this is totally benign…there are risks here. But the thing that we're really considering is are these risks worth taking on because of the benefits? Because of the misery of dysphoria, because of how much it might be holding you back?” Goodman said.
“I can point to dozens of cases in my own practice where those risks absolutely were worth the benefits. We have made people's lives tremendously better because we started hormones when they were at a young age.”
There is evidence of a slight reduction in bone mineral density for those on estrogen therapy for male to female transition. Dr. Abdul-Latif says he warns patients of this risk beforehand and if patients start to develop pain or weakness, dosing can be adjusted to lessen the effects.
Early research 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.
Those receiving hormone therapy need routine lab monitoring and may require medication to manage their cholesterol.
Oral estrogen has been shown to increase risk of blood clots. When Dr. Abdul-Latif starts a patient on this medication, he strongly encourages patients not to smoke cigarettes as that can further increase risk of blood clots. Depending on the situation, he may switch to a non-oral form of estrogen as it carries less risk.
Estrogen therapy can decrease sperm count, so Dr. Abdul-Latif recommends trans women freeze their sperm before starting therapy. The long term effects of testosterone on fertility are still being studied, however this is discussed in detail before starting hormone therapy.
But those potential risks are often outweighed by the benefits.
Major national medical associations, including the American Academy of Pediatrics, the American Medical Association, the American Academy of Child and Adolescent Psychiatry, and over 20 more agree that gender-affirming care is safe, effective, beneficial, and medically necessary.
Transgender youth are more likely to experience anxiety, depressed mood and suicidal ideation and attempts, often due to gender-related discrimination and gender dysphoria.
Gender-affirming hormone therapy has been proven to improve the mental health of transgender adolescents and teenagers, according to a recent study in the New England Journal of Medicine.
It’s rare for people to reverse a transition after undergoing gender affirming care, according to research published in the journal LGBT Health. Research found that those who reverse their transition often do so because of pressures from family and social stigma.
Rates of regret for gender affirmation surgery are extremely low — research shows they hover around 1%. Rates of regret for knee and hip surgeries are significantly higher, studies show.
Ultimately, said Goodman, every trans child should be addressed individually.
“This is a purely medical decision between parents and families and physicians,” said Dr. Abdul-Latif. “It does not need interference and added pressure on a family that is already under pressure.”