Gender-affirming care is medically necessary, evidence-based care that uses a multidisciplinary approach to help a person transition from their assigned gender — the one the person was designated at birth — to their affirmed gender — the gender by which one wants to be known.
By one estimate, more than 58,000 transgender youth 13 and older across the US are facing restricted access or proposals, and could soon lose access to gender-affirming care.
The gold standard of care
Social care for children
This kind of care takes a multidisciplinary approach. Providers work with counselors and the person’s family, as well as the person themselves. They may also work with the child’s school and community.
When someone needs this care really depends on the person. Some children have a sense about their true gender as early as 3 years old, experts say, others as they move into puberty and still others much later.
At the Gender Identity Program at Columbia University Medical Center, Director Melina Wald says, the process usually starts with a phone call. The family speaks with an intake coordinator and completes a brief screening to give an initial assessment of where the child is in their development. Depending on the age of the child, they may also participate.
Next, the clinic schedules the family for a couple of visits with the team’s mental health care professionals. At the first appointment, the team gauges the family’s and child’s needs.
“It’s to really get a better sense of what’s bringing them into the clinic,” Wald said. “We are also looking to understand the child’s understanding of their own gender, gender expression, and a history related to that.”
At Wald’s clinic, after the initial screening and appointments, staffers offer feedback and their clinical impressions to the child and family. They then offer a specific treatment plan tailored for that child, based on who they are, how they identify and where they are developmentally.
“That treatment plan can include individual therapy. It can include parent support. We have an adolescent group for trans and nonbinary teens, and we also have a parent support group run by one of the psychologists on our team,” Wald said.
This part of the care will help with the social transition, said Dr. Madeline Deutsch, medical director of the UCSF Gender Affirming Health Program.
At this point, the child could start using a chosen name and pronoun. They may wear different clothing. This practice helps the young person have the confidence to present in the way that feels more genuine to them, Deutsch said.
“It’s very individualized and usually involves a mix of decision-making by parents and guardians and then maybe other stakeholders, like if the parents are accessing mental health care or if the school becomes involved to kind of help talk things through,” Deutsch said. “Usually, it’s like a no-harm-done thing. So some of it depends on the parent’s level of comfort and the community that they’re living in.”
The physical aspect of care
“That just basically puts everything on pause, and children can be on that for a couple of years without any ill effects, and it’s totally reversible,” Deutsch said. “If it’s stopped, then everything just continues where you left off.”
This part of the process may also include hormone therapy that can lead to gender-affirming physical change, but again, the care plan is flexible, Deutsch said.
“I think one of the big myths out there is that there’s a sense that kids are rushed into decisions related to medical care, like hormone therapy or surgery. That’s just not the case,” Wald said.
Deutsch agreed: “Kids don’t make stuff up about this, wanting to become trans because it’s trendy or something,” she said. “Trans youth and trans people in general do not have access to a hormone vending machine.”
With gender-affirming care, the team of experts will work with the young person and the family throughout the process to decide what treatment is appropriate.
The process can take several years, or it can move faster if a child is in the “throes of puberty” and has been struggling for a long time, Deutsch said. There is still an assessment of what’s needed.
Legal part of care
Legal interventions can include a change in name or gender on a person’s legal documents.
How easy this is, or if it’s even possible, depends on where the person lives. The rules vary by state.
Changes to documents can include a person’s birth certificate, Social Security card, passport or driver’s license.
Why care is necessary
Some critics of the process suggest that children should wait until adulthood to transition, but the American Academy of Pediatrics says this is an outdated approach. It assumes that gender identity is fixed at a certain age, but research shows that it’s healthier to value a child for who they are rather than for what they will become.
Wald says that waiting to transition can create additional psychological distress for a child and can raise a child’s risk of depression, suicidality, self-harm or substance misuse.
“Withholding intervention means that the child is going to go through a puberty that is discordant with their gender identity and would ultimately mean that later, at the age of 18, there would be changes to their body that they would make it even more difficult,” Wald said.
“These children and teens can be incredibly resilient,” Wald said. “With support and access to care, they will thrive and can be just as successful as any kid.”