gender reassignment surgery by age

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Trans kids’ treatment can start younger, new guidelines say

This photo provided by Laura Short shows Eli Bundy on April 15, 2022 at Deception Pass in Washington. In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy hopes to get breast removal surgery next year before college. Bundy, 18, who identifies as nonbinary, supports updated guidance from an international transgender health group that recommends lower ages for some treatments. (Laura Short via AP)

FILE - Dr. David Klein, right, an Air Force Major and chief of adolescent medicine at Fort Belvoir Community Hospital, listens as Amanda Brewer, left, speaks with her daughter, Jenn Brewer, 13, as the teenager has blood drawn during a monthly appointment for monitoring her treatment at the hospital in Fort Belvoir, Va., on Sept. 7, 2016. Brewer is transitioning from male to female. (AP Photo/Jacquelyn Martin, File)

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A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Association for Transgender Health said hormones could be started at age 14, two years earlier than the group’s previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association provided The Associated Press with an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn’t match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group’s standards of care and director of the University of Minnesota Medical School’s human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents’ consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

“Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision,” he said. “That is why we recommend a careful multidisciplinary assessment.”

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment , along with new efforts to prevent or restrict the treatment.

Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of the World Professional Association for Transgender Health last year after voicing concerns about “sloppy” treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn’t always happen.

“They tell me horror stories. They tell me, ‘Our child had 20 minutes with the doctor’” before being offered hormones, she said. “The parents leave with their hair on fire.’’

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association’s new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8% in kids.

Anderson said she’s heard recent estimates suggesting the rate in kids is as high as 1 in 5 — which she strongly disputes. That number likely reflects gender-questioning kids who aren’t good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

“That’s just absolutely cruel,’’ she said.

Dr. Marci Bowers, the transgender health group’s president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been “forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis.’’

Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, North Carolina, resident struggled miserably with gender discomfort before his treatment.

Poulos said he’s glad he was able to get treatment at a young age.

“Transitioning under the roof with your parents so they can go through it with you, that’s really beneficial,’’ he said. “I’m so much happier now.’’

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

“Those decisions are best made by patients and patient families and medical professionals,’’ they said. “It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together.’’

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn’t strong evidence in favor of transgender medical treatment for kids.

“In medicine ... the treatment has to be proven safe and effective before we can start recommending it,’’ Mason said.

Experts say the most rigorous research — studies comparing treated kids with outcomes in untreated kids — would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That’s no change from the group’s previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

—Sex hormones — estrogen or testosterone — starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.

—Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum ag wasn’t listed.

—Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Association support allowing kids to seek transgender medical treatment, but they don’t offer age-specific guidance.

Dr. Joel Frader, a Northwestern University a pediatrician and medical ethicist who advises a gender treatment program at Chicago’s Lurie Children’s Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they’re prone to risk-taking and they take into account long-term consequences of their actions only when they’re much older.

Coleen Williams, a psychologist at Boston Children’s Hospital’s Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

“Medical intervention in any realm is not a one-size-fits-all option,” Williams said.

Follow AP Medical Writer Lindsey Tanner at @LindseyTanner.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

Young Children Do Not Receive Medical Gender Transition Treatment

By Kate Yandell

Posted on May 22, 2023

SciCheck Digest

Families seeking information from a health care provider about a young child’s gender identity may have their questions answered or receive counseling. Some posts share a misleading claim that toddlers are being “transitioned.” To be clear, prepubescent children are not offered transition surgery or drugs.

Some children  identify  with a gender that does not match their sex assigned at birth. These children are referred to as transgender, gender-diverse or gender-expansive. Doctors will listen to children and their family members, offer information, and in some cases connect them with mental health care, if needed.

But for children who have not yet started puberty, there are  no recommended  drugs, surgeries or other gender-transition treatments.

Recent social media  posts   shared  the misleading  claim  that medical institutions in North Carolina are “transitioning toddlers,” which they called an “experimental treatment.” The posts referenced a  blog post  published by the Education First Alliance, a conservative nonprofit in North Carolina that says  many schools are engaging in “ideological indoctrination” of children and need to be reformed.

The group has advocated the passage of a North Carolina bill  to restrict medical gender-transition treatment before age 18. There are now  18 states  that have taken action to restrict  medical transition treatments  for  minors .

A widely shared  article  from the Epoch Times citing the blog post bore the false headline: “‘Transgender’ Toddlers as Young as 2 Undergoing Mutilation/Sterilization by NC Medical System, Journalist Alleges.” The Epoch Times has a history of publishing misleading or false claims. The article on transgender toddlers then disappeared from the website, and the Epoch Times published a new  article  clarifying that young children are not receiving hormone blockers, cross-sex hormones or surgery. 

Representatives from all three North Carolina institutions referenced in the social media posts told us via emailed statements that they do not offer surgeries or other transition treatments to toddlers.

East Carolina University, May 5: ECU Health does not offer gender affirming surgery to minors nor does the health system offer gender affirming transition care to toddlers.

ECU Health elaborated that it does not offer puberty blockers and only offers hormone therapy after puberty “in limited cases,” as recommended in national guidelines and with parental or guardian consent. It also said that it offers interdisciplinary gender-affirming primary care for LGBTQ+ patients, including access to services such as mental health care, nutrition and social work.

“These primary care services are available to any LGBTQ+ patient who needs care. ECU Health does not provide gender-related care to patients 2 to 4 years old or any toddler period,” ECU said.

University of North Carolina, May 12: To be clear: UNC Health does not offer any gender-transitioning care for toddlers. We do not perform any gender care surgical procedures or medical interventions on toddlers. Also, we are not conducting any gender care research or clinical trials involving children. If a toddler’s parent(s) has concerns or questions about their child’s gender, a primary care provider would certainly listen to them, but would never recommend gender treatment for a toddler. Gender surgery can be performed on anyone 18 years old or older .

Duke Health, May 12: Duke Health has provided high-quality, compassionate, and evidence-based gender care to both adolescents and adults for many years. Care decisions are made by patients, families and their providers and are both age-appropriate and adherent to national and international guidelines. Under these professional guidelines and in accordance with accepted medical standards, hormone therapies are explicitly not provided to children prior to puberty and gender-affirming surgeries are, except in exceedingly rare circumstances, only performed after age 18.

Duke and UNC both called the claims that they offer gender-transition care to toddlers false, and ECU referred to the “intentional spreading of dangerous misinformation online.”

Nor do other medical institutions offer gender-affirming drug treatment or surgery to toddlers, clinical psychologist  Christy Olezeski , director of the Yale Pediatric Gender Program, told us, although some may offer support to families of young children or connect them with mental health care. 

The Education First Alliance post also states that a doctor “can see a 2-year-old girl play with a toy truck, and then begin treatment for gender dysphoria.” But simply playing with a certain toy would not meet the criteria for a diagnosis of gender dysphoria, according to the medical diagnostic manual used by health professionals.

“With all kids, we want them to feel comfortable and confident in who they are. We want them to feel comfortable and confident in how they like to express themselves. We want them to be safe,” Olezeski said. “So all of these tenets are taken into consideration when providing care for children. There is no medical care that happens prior to puberty.”

Medical Transition Starts During Adolescence or Later 

The Education First Alliance blog post does not clearly state what it means when it says North Carolina institutions are “transitioning toddlers.” It refers to treatment and hormone therapy without clarifying the age at which it is offered. 

Only in the final section of the piece does it include a quote from a doctor correctly stating that children are not offered surgery or drugs before puberty.

To spell out the reality of the situation: The North Carolina institutions are not providing surgeries or hormone therapy to prepubescent children, nor is this standard practice in any part of the country.

Programs and physicians will have different policies, but widely referenced guidance from the  World Professional Association for Transgender Health  and the  Endocrine Society  lays out recommended care at different ages. 

Drugs that suppress puberty are the first medical treatment that may be offered to a transgender minor, the guidelines say. Children may be offered drugs to suppress puberty beginning when breast buds appear or testicles increase to a certain volume, typically happening between ages 8 to 13 or 9 to 14, respectively.

Generally, someone may start gender-affirming hormone therapy in early adolescence or later, the American Academy for Pediatrics  explains . The Endocrine Society says that adolescents typically have the mental capacity to participate in making an informed decision about gender-affirming hormone therapy by age 16.

Older adolescents who want flat chests may sometimes be able to get surgery to remove their breasts, also known as top surgery, Olezeski said. They sometimes desire to do this before college. Guidelines  do not offer  a  specific age  during adolescence when this type of surgery may be appropriate. Instead, they explain how a care team can assess adolescents on a case-by-case basis.

A previous  version  of the WPATH guidelines did not recommend genital surgery until adulthood, but the most recent version, published in September 2022, is  less specific  about an age limit. Rather, it explains various criteria to determine whether someone who desires surgery should be offered it, including a person’s emotional and cognitive maturity level and whether they have been on hormone therapy for at least a year.

The Endocrine Society similarly offers criteria for when someone might be ready for genital surgery, but specifies that surgeries involving removing the testicles, ovaries or uterus should not happen before age 18.

“Typically any sort of genital-affirming surgeries still are happening at 18 or later,” Olezeski said.

There are no comprehensive statistics on the number of gender-affirming surgeries performed in the U.S., but according to an insurance claims  analysis  from Reuters and Komodo Health Inc., 776 minors with a diagnosis of gender dysphoria had breast removal surgeries and 56 had genital surgeries from 2019 to 2021.

Research Shows Benefits of Affirming Gender Identity

Young children do not get medical transition treatment, but they do have feelings about their gender and can benefit from support from those around them. “Children start to have a sense of their own gender identity between the ages of 2 1/2 to 3 years old,” Olezeski said.

Programs vary in what age groups they serve, she said, but some do support families of preschool-aged children by answering questions or providing mental health care.

Transgender children are at increased risk of some mental health problems, including anxiety and depression. According to the WPATH guidelines, affirming a child’s gender through day-to-day changes — also known as social transition — may have a positive impact on a child’s mental health. Social transition “may look different for every individual,” Olezeski said. Changes could include going by a different name or pronouns or altering one’s attire or hair style.

Two studies of socially transitioned children — including one with kids as young as 3 — have found minimal or no difference in anxiety and depression compared with non-transgender siblings or other children of similar ages.

“Research substantiates that children who are prepubertal and assert an identity of [transgender and gender diverse] know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender and benefit from the same level of social acceptance,” the AAP  guidelines  say, adding that differences in how children identify and express their gender are normal.

Social transitions largely take place outside of medical institutions, led by the child and supported by their family members and others around them. However, a family with questions about their child’s gender or social transition may be able to get information from their pediatrician or another medical provider, Olezeski said.

Although not available everywhere, specialized programs may be particularly prepared to offer care to a gender-diverse child and their family, she said. A child may get a referral to one of these programs from a pediatrician, another specialty physician, a mental health care professional or their school, or a parent may seek out one of these programs.

“We have created a space where parents can come with their youth when they’re young to ask questions about how to best support their child: what to do if they have questions, how to get support, what do we know about the best research in terms of how to allow kids space to explore their identity, to explore how they like to express themselves, and then if they do identify as trans or nonbinary, how to support the parents and the youth in that,” Olezeski said of specialized programs. Parents benefit from the support, and then the children also benefit from support from their parents. 

WPATH  says  that the child should be the one to initiate a social transition by expressing a “strong desire or need” for it after consistently articulating an identity that does not match their sex assigned at birth. A health care provider can then help the family explore benefits and risks. A child simply playing with certain toys, dressing a certain way or enjoying certain activities is not a sign they would benefit from a social transition, the guidelines state.

Previously, assertions children made about their gender were seen as “possibly true” and support was often withheld until an age when identity was believed to become fixed, the AAP guidelines explain. But “more robust and current research suggests that, rather than focusing on who a child will become, valuing them for who they are, even at a young age, fosters secure attachment and resilience, not only for the child but also for the whole family,” the guidelines say.

Mental Health Care Benefits

A gender-diverse child or their family members may benefit from a referral to a psychologist or other mental health professional. However, being transgender or gender-diverse is not in itself a mental health disorder, according to the  American Psychological Association ,  WPATH and other expert groups . These organizations also note that people who are transgender or gender-diverse do not all experience mental health problems or distress about their gender. 

Psychological therapy is not meant to change a child’s gender identity, the WPATH guidelines  say . 

The form of therapy a child or a family might receive will depend on their particular needs, Olezeski said. For instance, a young child might receive play-based therapy, since play is how children “work out different things in their life,” she said. A parent might work on strategies to better support their child.

One mental health diagnosis that some gender-diverse people may receive is  gender dysphoria . There is  disagreement  about how useful such a diagnosis is, and receiving such a diagnosis does not necessarily mean someone will decide to undergo a transition, whether social or medical.

UNC Health told us in an email that a gender dysphoria diagnosis “is rarely used” for children.

Very few gender-expansive kids have dysphoria, the spokesperson said. “ Gender expansion in childhood is not Gender Dysphoria ,” UNC added, attributing the explanation to psychiatric staff (emphasis is UNC’s). “The psychiatric team’s goal is to provide good mental health care and manage safety—this means trying to protect against abuse and bullying and to support families.”

Social media posts incorrectly claim that toddlers are being diagnosed with gender dysphoria based on what toys they play with. One post  said : “Three medical schools in North Carolina are diagnosing TODDLERS who play with stereotypically opposite gender toys as having GENDER DYSPHORIA and are beginning to transition them!!”

There are separate criteria for diagnosing gender dysphoria in adults and adolescents versus children, according to the Diagnostic and Statistical Manual of Mental Disorders. For children to receive this diagnosis, they must meet six of eight criteria for a six-month period and experience “clinically significant distress” or impairment in functioning, according to the diagnostic manual. 

A “strong preference for the toys, games or activities stereotypically used or engaged in by the other gender” is one criterion, but children must also meet other criteria, and expressing a strong desire to be another gender or insisting that they are another gender is required.

“People liking to play with different things or liking to wear a diverse set of clothes does not mean that somebody has gender dysphoria,” Olezeski said. “That just means that kids have a breadth of things that they can play with and ways that they can act and things that they can wear . ”

Editor’s note: SciCheck’s articles providing accurate health information and correcting health misinformation are made possible by a grant from the Robert Wood Johnson Foundation. The foundation has no control over FactCheck.org’s editorial decisions, and the views expressed in our articles do not necessarily reflect the views of the foundation.

Rafferty, Jason. “ Gender-Diverse & Transgender Children .” HealthyChildren.org. Updated 8 Jun 2022.

Coleman, E. et al. “ Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 .” International Journal of Transgender Health. 15 Sep 2022.

Rachmuth, Sloan. “ Transgender Toddlers Treated at Duke, UNC, and ECU .” Education First Alliance. 1 May 2023.

North Carolina General Assembly. “ Senate Bill 639, Youth Health Protection Act .” (as introduced 5 Apr 2023).

Putka, Sophie et al. “ These States Have Banned Youth Gender-Affirming Care .” Medpage Today. Updated 17 May 2023.

Davis, Elliott Jr. “ States That Have Restricted Gender-Affirming Care for Trans Youth in 2023 .” U.S. News & World Report. Updated 17 May 2023.

Montgomery, David and Goodman, J. David. “ Texas Legislature Bans Transgender Medical Care for Children .” New York Times. 17 May 2023.

Ji, Sayer. ‘ Transgender’ Toddlers as Young as 2 Undergoing Mutilation/Sterilization by NC Medical System, Journalist Alleges .” Epoch Times. Internet Archive, Wayback Machine. Archived 6 May 2023.

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McCormick Sanchez, Darlene. “ IN-DEPTH: North Carolina Medical Schools See Children as Young as Toddlers for Gender Dysphoria .” The Epoch Times. 8 May 2023.

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Duke Health spokesperson. Email with FactCheck.org. 12 May 2023.

Olezeski, Christy. Interview with FactCheck.org. 16 May 2023.

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Emmanuel, Mickey and Bokor, Brooke R. “ Tanner Stages .” StatPearls. Updated 11 Dec 2022.

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“ Answers to Your Questions about Transgender People, Gender Identity, and Gender Expression .” American Psychological Association website. 9 Mar 2023.

“ What is Gender Dysphoria ?” American Psychiatric Association website. Updated Aug 2022.

Vanessa Marie | Truth Seeker (indivisible.mama). “ Three medical schools in North Carolina are diagnosing TODDLERS who play with stereotypically opposite gender toys as having GENDER DYSPHORIA and are beginning to transition them!! … ” Instagram. 7 May 2023.

• Introduction
• Conclusions
• Article Information

Error bars represent 95% CIs. GAS indicates gender-affirming surgery.

Percentages are based on the number of procedures divided by number of patients; thus, as some patients underwent multiple procedures the total may be greater than 100%. Error bars represent 95% CIs.

eTable.  ICD-10 and CPT Codes of Gender-Affirming Surgery

eFigure. Percentage of Patients With Codes for Gender Identity Disorder Who Underwent GAS

Data Sharing Statement

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Wright JD , Chen L , Suzuki Y , Matsuo K , Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348

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National Estimates of Gender-Affirming Surgery in the US

• 1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
• 2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

Question   What are the temporal trends in gender-affirming surgery (GAS) in the US?

Findings   In this cohort study of 48 019 patients, GAS increased significantly, nearly tripling from 2016 to 2019. Breast and chest surgery was the most common class of procedures performed overall; genital reconstructive procedures were more common among older individuals.

Meaning   These findings suggest that there will be a greater need for clinicians knowledgeable in the care of transgender individuals with the requisite expertise to perform gender-affirming procedures.

Importance   While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

Objective   To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants   This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures   Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

Results   A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance   Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Gender dysphoria is characterized as an incongruence between an individual’s experienced or expressed gender and the gender that was assigned at birth. 1 Transgender individuals may pursue multiple treatments, including behavioral therapy, hormonal therapy, and gender-affirming surgery (GAS). 2 GAS encompasses a variety of procedures that align an individual patient’s gender identity with their physical appearance. 2 - 4

While numerous surgical interventions can be considered GAS, the procedures have been broadly classified as breast and chest surgical procedures, facial and cosmetic interventions, and genital reconstructive surgery. 2 , 4 Prior studies 2 - 7 have shown that GAS is associated with improved quality of life, high rates of satisfaction, and a reduction in gender dysphoria. Furthermore, some studies have reported that GAS is associated with decreased depression and anxiety. 8 Lastly, the procedures appear to be associated with acceptable morbidity and reasonable rates of perioperative complications. 2 , 4

Given the benefits of GAS, the performance of GAS in the US has increased over time. 9 The increase in GAS is likely due in part to federal and state laws requiring coverage of transition-related care, although actual insurance coverage of specific procedures is variable. 10 , 11 While prior work has shown that the use of inpatient GAS has increased, national estimates of inpatient and outpatient GAS are lacking. 9 This is important as many GAS procedures occur in ambulatory settings. We performed a population-based analysis to examine trends in GAS in the US and explored the temporal trends in the types of GAS performed across age groups.

To capture both inpatient and outpatient surgical procedures, we used data from the Nationwide Ambulatory Surgery Sample (NASS) and the National Inpatient Sample (NIS). NASS is an ambulatory surgery database and captures major ambulatory surgical procedures at nearly 2800 hospital-owned facilities from up to 35 states, approximating a 63% to 67% stratified sample of hospital-owned facilities. NIS comprehensively captures approximately 20% of inpatient hospital encounters from all community hospitals across 48 states participating in the Healthcare Cost and Utilization Project (HCUP), covering more than 97% of the US population. Both NIS and NASS contain weights that can be used to produce US population estimates. 12 , 13 Informed consent was waived because data sources contain deidentified data, and the study was deemed exempt by the Columbia University institutional review board. This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We selected patients of all ages with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) diagnosis codes for gender identity disorder or transsexualism ( ICD-10 F64) or a personal history of sex reassignment ( ICD-10 Z87.890) from 2016 to 2020 (eTable in Supplement 1 ). We first examined all hospital (NIS) and ambulatory surgical (NASS) encounters for patients with these codes and then analyzed encounters for GAS within this cohort. GAS was identified using ICD-10 procedure codes and Common Procedural Terminology codes and classified as breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures. 2 , 4 Breast and chest surgical procedures encompassed breast reconstruction, mammoplasty and mastopexy, or nipple reconstruction. Genital reconstructive procedures included any surgical intervention of the male or female genital tract. Other facial and cosmetic procedures included cosmetic facial procedures and other cosmetic procedures including hair removal or transplantation, liposuction, and collagen injections (eTable in Supplement 1 ). Patients might have undergone procedures from multiple different surgical groups. We measured the total number of procedures and the distribution of procedures within each procedural group.

Within the data sets, sex was based on patient self-report. The sex of patients in NIS who underwent inpatient surgery was classified as either male, female, missing, or inconsistent. The inconsistent classification denoted patients who underwent a procedure that was not consistent with the sex recorded on their medical record. Similar to prior analyses, patients in NIS with a sex variable not compatible with the procedure performed were classified as having undergone genital reconstructive surgery (GAS not otherwise specified). 9

Clinical variables in the analysis included patient clinical and demographic factors and hospital characteristics. Demographic characteristics included age at the time of surgery (12 to 18 years, 19 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, 61 to 70 years, and older than 70 years), year of the procedure (2016-2020), and primary insurance coverage (private, Medicare, Medicaid, self-pay, and other). Race and ethnicity were only reported in NIS and were classified as White, Black, Hispanic and other. Race and ethnicity were considered in this study because prior studies have shown an association between race and GAS. The income status captured national quartiles of median household income based of a patient’s zip code and was recorded as less than 25% (low), 26% to 50% (medium-low), 51% to 75% (medium-high), and 76% or more (high). The Elixhauser Comorbidity Index was estimated for each patient based on the codes for common medical comorbidities and weighted for a final score. 14 Patients were classified as 0, 1, 2, or 3 or more. We separately reported coding for HIV and AIDS; substance abuse, including alcohol and drug abuse; and recorded mental health diagnoses, including depression and psychoses. Hospital characteristics included a composite of teaching status and location (rural, urban teaching, and urban nonteaching) and hospital region (Northeast, Midwest, South, and West). Hospital bed sizes were classified as small, medium, and large. The cutoffs were less than 100 (small), 100 to 299 (medium), and 300 or more (large) short-term acute care beds of the facilities from NASS and were varied based on region, urban-rural designation, and teaching status of the hospital from NIS. 8 Patients with missing data were classified as the unknown group and were included in the analysis.

National estimates of the number of GAS procedures among all hospital encounters for patients with gender identity disorder were derived using discharge or encounter weight provided by the databases. 15 The clinical and demographic characteristics of the patients undergoing GAS were reported descriptively. The number of encounters for gender identity disorder, the percentage of GAS procedures among those encounters, and the absolute number of each procedure performed over time were estimated. The difference by age group was examined and tested using Rao-Scott χ 2 test. All hypothesis tests were 2-sided, and P  < .05 was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc).

A total of 48 019 patients who underwent GAS were identified ( Table 1 ). Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged 12 to 18 years. Private insurance coverage was most common in 29 064 patients (60.5%), while 12 127 (25.3%) were Medicaid recipients. Depression was reported in 7192 patients (15.0%). Most patients (42 467 [88.4%]) were treated at urban, teaching hospitals, and there was a disproportionate number of patients in the West (22 037 [45.9%]) and Northeast (12 396 [25.8%]). Within the cohort, 31 668 patients (65.9%) underwent 1 procedure while 13 415 (27.9%) underwent 2 procedures, and the remainder underwent multiple procedures concurrently ( Table 1 ).

The overall number of health system encounters for gender identity disorder rose from 13 855 in 2016 to 38 470 in 2020. Among encounters with a billing code for gender identity disorder, there was a consistent rise in the percentage that were for GAS from 4552 (32.9%) in 2016 to 13 011 (37.1%) in 2019, followed by a decline to 12 818 (33.3%) in 2020 ( Figure 1 and eFigure in Supplement 1 ). Among patients undergoing ambulatory surgical procedures, 37 394 (80.3%) of the surgical procedures included gender-affirming surgical procedures. For those with hospital admissions with gender identity disorder, 10 625 (11.8%) of admissions were for GAS.

Breast and chest procedures were most common and were performed for 27 187 patients (56.6%). Genital reconstruction was performed for 16 872 patients (35.1%), and other facial and cosmetic procedures for 6669 patients (13.9%) ( Table 2 ). The most common individual procedure was breast reconstruction in 21 244 (44.2%), while the most common genital reconstructive procedure was hysterectomy (4489 [9.3%]), followed by orchiectomy (3425 [7.1%]), and vaginoplasty (3381 [7.0%]). Among patients who underwent other facial and cosmetic procedures, liposuction (2945 [6.1%]) was most common, followed by rhinoplasty (2446 [5.1%]) and facial feminizing surgery and chin augmentation (1874 [3.9%]).

The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020 ( Figure 1 ). Similar trends were noted for breast and chest surgical procedures as well as genital surgery, while the rate of other facial and cosmetic procedures increased consistently from 2016 to 2020. The distribution of the individual procedures performed in each class were largely similar across the years of analysis ( Table 3 ).

When stratified by age, patients 19 to 30 years had the greatest number of procedures, 25 099 ( Figure 2 ). There were 10 476 procedures performed in those aged 31 to 40 years and 4359 in those aged 41 to 50 years. Among patients younger than 19 years, 3678 GAS procedures were performed. GAS was less common in those cohorts older than 50 years. Overall, the greatest number of breast and chest surgical procedures, genital surgical procedures, and facial and other cosmetic surgical procedures were performed in patients aged 19 to 30 years.

When stratified by the type of procedure performed, breast and chest procedures made up the greatest percentage of the surgical interventions in younger patients while genital surgical procedures were greater in older patients ( Figure 2 ). Additionally, 3215 patients (87.4%) aged 12 to 18 years underwent GAS and had breast or chest procedures. This decreased to 16 067 patients (64.0%) in those aged 19 to 30 years, 4918 (46.9%) in those aged 31 to 40 years, and 1650 (37.9%) in patients aged 41 to 50 years ( P  < .001). In contrast, 405 patients (11.0%) aged 12 to 18 years underwent genital surgery. The percentage of patients who underwent genital surgery rose sequentially to 4423 (42.2%) in those aged 31 to 40 years, 1546 (52.3%) in those aged 51 to 60 years, and 742 (58.4%) in those aged 61 to 70 years ( P  < .001). The percentage of patients who underwent facial and other cosmetic surgical procedures rose with age from 9.5% in those aged 12 to 18 years to 20.6% in those aged 51 to 60 years, then gradually declined ( P  < .001). Figure 2 displays the absolute number of procedure classes performed by year stratified by age. The greatest magnitude of the decline in 2020 was in younger patients and for breast and chest procedures.

These findings suggest that the number of GAS procedures performed in the US has increased dramatically, nearly tripling from 2016 to 2019. Breast and chest surgery is the most common class of procedure performed while patients are most likely to undergo surgery between the ages of 19 and 30 years. The number of genital surgical procedures performed increased with increasing age.

Consistent with prior studies, we identified a remarkable increase in the number of GAS procedures performed over time. 9 , 16 A prior study examining national estimates of inpatient GAS procedures noted that the absolute number of procedures performed nearly doubled between 2000 to 2005 and from 2006 to 2011. In our analysis, the number of GAS procedures nearly tripled from 2016 to 2020. 9 , 17 Not unexpectedly, a large number of the procedures we captured were performed in the ambulatory setting, highlighting the need to capture both inpatient and outpatient procedures when analyzing data on trends. Like many prior studies, we noted a decrease in the number of procedures performed in 2020, likely reflective of the COVID-19 pandemic. 18 However, the decline in the number of procedures performed between 2019 and 2020 was relatively modest, particularly as these procedures are largely elective.

Analysis of procedure-specific trends by age revealed a number of important findings. First, GAS procedures were most common in patients aged 19 to 30 years. This is in line with prior work that demonstrated that most patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age 7 years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. 19 Our findings were also notable that GAS procedures were relatively uncommon in patients aged 18 years or younger. In our cohort, fewer than 1200 patients in this age group underwent GAS, even in the highest volume years. GAS in adolescents has been the focus of intense debate and led to legislative initiatives to limit access to these procedures in adolescents in several states. 20 , 21

Second, there was a marked difference in the distribution of procedures in the different age groups. Breast and chest procedures were more common in younger patients, while genital surgery was more frequent in older individuals. In our cohort of individuals aged 19 to 30 years, breast and chest procedures were twice as common as genital procedures. Genital surgery gradually increased with advancing age, and these procedures became the most common in patients older than 40 years. A prior study of patients with commercial insurance who underwent GAS noted that the mean age for mastectomy was 28 years, significantly lower than for hysterectomy at age 31 years, vaginoplasty at age 40 years, and orchiectomy at age 37 years. 16 These trends likely reflect the increased complexity of genital surgery compared with breast and chest surgery as well as the definitive nature of removal of the reproductive organs.

This study has limitations. First, there may be under-capture of both transgender individuals and GAS procedures. In both data sets analyzed, gender is based on self-report. NIS specifically makes notation of procedures that are considered inconsistent with a patient’s reported gender (eg, a male patient who underwent oophorectomy). Similar to prior work, we assumed that patients with a code for gender identity disorder or transsexualism along with a surgical procedure classified as inconsistent underwent GAS. 9 Second, we captured procedures commonly reported as GAS procedures; however, it is possible that some of these procedures were performed for other underlying indications or diseases rather than solely for gender affirmation. Third, our trends showed a significant increase in procedures through 2019, with a decline in 2020. The decline in services in 2020 is likely related to COVID-19 service alterations. Additionally, while we comprehensively captured inpatient and ambulatory surgical procedures in large, nationwide data sets, undoubtedly, a small number of procedures were performed in other settings; thus, our estimates may underrepresent the actual number of procedures performed each year in the US.

These data have important implications in providing an understanding of the use of services that can help inform care for transgender populations. The rapid rise in the performance of GAS suggests that there will be a greater need for clinicians knowledgeable in the care of transgender individuals and with the requisite expertise to perform GAS procedures. However, numerous reports have described the political considerations and challenges in the delivery of transgender care. 22 Despite many medical societies recognizing the necessity of gender-affirming care, several states have enacted legislation or policies that restrict gender-affirming care and services, particularly in adolescence. 20 , 21 These regulations are barriers for patients who seek gender-affirming care and provide legal and ethical challenges for clinicians. As the use of GAS increases, delivering equitable gender-affirming care in this complex landscape will remain a public health challenge.

Accepted for Publication: July 15, 2023.

Published: August 23, 2023. doi:10.1001/jamanetworkopen.2023.30348

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Wright JD et al. JAMA Network Open .

Corresponding Author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 4th Floor, New York, NY 10032 ( [email protected] ).

Author Contributions: Dr Wright had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wright, Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wright.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Wright, Chen.

Administrative, technical, or material support: Wright, Suzuki.

Conflict of Interest Disclosures: Dr Wright reported receiving grants from Merck and personal fees from UpToDate outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

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Age restriction lifted for gender-affirming surgery in new international guidelines

'Will result in the need for parental consent before doctors would likely perform surgeries'

Media Information

• Release Date: September 16, 2022

Media Contacts

Kristin Samuelson

• (847) 491-4888
• Email Kristin
• Expert can speak to transgender peoples’ right to bodily autonomy, how guidelines affect insurance coverage, how the U.S. gender regulations compare to other countries, more

CHICAGO --- The World Professional Association for Transgender Health (WPATH) today today announced  its updated Standards of Care and Ethical Guidelines for health professionals. Among the updates is a new suggestion to lift the age restriction for youth seeking gender-affirming surgical treatment, in comparison to previous suggestion of surgery at 17 or older. 

Alithia Zamantakis (she/her), a member of the Institute of Sexual & Gender Minority Health at Northwestern University Feinberg School of Medicine, is available to speak to media about the new guidelines. Contact Kristin Samuelson at [email protected] to schedule an interview.

“Lifting the age restriction will greatly increase access to care for transgender adolescents, but will also result in the need for parental consent for surgeries before doctors would likely perform them,” said Zamantakis, a postdoctoral fellow at Northwestern, who has researched trans youth and resilience. “Additionally, changes in age restriction are not likely to change much in practice in states like Alabama, Arkansas, Texas and Arizona, where gender-affirming care for youth is currently banned.”

Zamantakis also can speak about transgender peoples’ right to bodily autonomy, how guidelines affect insurance coverage and how U.S. gender regulations compare to other countries.

Guidelines are thorough but WPATH ‘still has work to do’

“The systematic reviews conducted as part of the development of the standards of care are fantastic syntheses of the literature on gender-affirming care that should inform doctors' work,” Zamantakis said. “They are used by numerous providers and insurance companies to determine who gets access to care and who does not.

“However, WPATH still has work to do to ensure its standards of care are representative of the needs and experiences of all non-cisgender people and that the standards of care are used to ensure that individuals receive adequate care rather than to gatekeep who gets access to care. WPATH largely has been run by white and/or cisgender individuals. It has only had three transgender presidents thus far, with Marci Bower soon to be the second trans woman president.

“Future iterations of the standards of care must include more stakeholders per committee, greater representation of transgender experts and stakeholders of color, and greater representation of experts and stakeholders outside the U.S.”

Transgender individuals’ right to bodily autonomy

“WPATH does not recommend prior hormone replacement therapy or ‘presenting’ as one's gender for a certain period of time for surgery for nonbinary people, yet it still does for transgender women and men,” Zamantakis said. “The reality is that neither should be requirements for accessing care for people of any gender.

“The recommendation of requiring documentation of persistent gender incongruence is meant to prevent regret. However, it's important to ask who ultimately has the authority to determine whether individuals have the right to make decisions about their bodily autonomy that they may or may not regret? Cisgender women undergo breast augmentation regularly, which is not an entirely reversible procedure, yet they are not required to have proof of documented incongruence. It is assumed that if they regret the surgery, they will learn to cope with the regret or will have an additional surgery. Transgender individuals also deserve the right to bodily autonomy and ultimately to regret the decisions they make if they later do not align with how they experience themselves.” 

I want to transition. How old do you have to be to get HRT? ​​​​

April 24, 2023 2 min read

By Miriam @ Planned Parenthood

If you’re 17 or younger, you need your parent or guardian’s consent to get gender-affirming hormone replacement therapies (HRT) like testosterone and estrogen . However, some states are trying to pass laws blocking people under certain ages from getting HRT, even with parental consent. Contact your nearest Planned Parenthood health center to find out what’s happening in your state. 

For now, you can legally get HRT across the United States on your own if you’re 18+, or with a parent’s consent if you’re under 18. But access isn’t just about the law:

• Some health care providers require both parental consent and a minimum age requirement for people younger than 18. For example, some Planned Parenthood health centers only provide HRT to patients who have parental consent and are at least 16 years old, while others only provide HRT for ages 18+. Other doctors may prescribe hormones to patients who are 12 and up with parental consent.
• You might be required to get a formal diagnosis of gender dysphoria to get gender-affirming care, or to get your care covered by your health insurance plan. The doctors who make these diagnoses factor in your age and how long you have known your gender.

Not all Planned Parenthood health centers provide HRT, but all Planned Parenthood health centers provide a safe and welcoming place for transgender and nonbinary patients of any age. Check with your nearest Planned Parenthood health center to see if they offer gender-affirming health care, and what their policies are around age. If they don’t provide HRT, or have age limits that affect you, they may be able to refer you to other providers in your area.

Tags: Gender-affirming Care , estrogen-based hormone therapy , testosterone , trans health care

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Live Coverage

Trans kids’ treatment can start younger, new guidelines say

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A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Assn. for Transgender Health said hormones could be started at age 14, two years earlier than the group’s previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association, known as WPATH, provided an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn’t match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group’s standards of care and director of the University of Minnesota Medical School’s human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents’ consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

“Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision,” he said. “That is why we recommend a careful multidisciplinary assessment.”

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment , along with new efforts to prevent or restrict the treatment.

World & Nation

A transgender psychologist has helped hundreds of teens transition. But rising numbers have her concerned

Erica Anderson took more than half a century to come out as a woman. Now she works with teens in a rush to transition.

April 12, 2022

Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of WPATH last year after voicing concerns about “sloppy” treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn’t always happen.

“They tell me horror stories. They tell me, ‘Our child had 20 minutes with the doctor’” before being offered hormones, she said. “The parents leave with their hair on fire.”

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association’s new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8% in kids.

Anderson said she’s heard recent estimates suggesting the rate in kids is as high as 1 in 5 — which she strongly disputes. That number probably reflects gender-questioning kids who aren’t good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

“That’s just absolutely cruel,” she said.

Dr. Marci Bowers, the transgender health group’s president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been “forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis.”

Op-Ed: Denying trans youth gender-affirming care is an affront to science and medical ethics

States are pushing anti-trans policies that fly in the face of research and medical expertise.

June 13, 2022

Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, N.C., resident struggled miserably with gender discomfort before his treatment.

Poulos said he’s glad he was able to get treatment at a young age.

“Transitioning under the roof with your parents so they can go through it with you, that’s really beneficial,” he said. “I’m so much happier now.”

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

“Those decisions are best made by patients and patient families and medical professionals,” they said. “It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together.”

Science & Medicine

Early transgender identity in kids tends to endure, study suggests

Children who begin identifying as transgender at a young age tend to retain that identity for several years at least, a new study suggests.

May 4, 2022

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn’t strong evidence in favor of transgender medical treatment for kids.

“In medicine ... the treatment has to be proven safe and effective before we can start recommending it,” Mason said.

Experts say the most rigorous research — studies comparing treated kids with outcomes in untreated kids — would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That’s no change from the group’s previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

• Sex hormones — estrogen or testosterone — starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.

• Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum age wasn’t listed.

• Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Assn. support allowing kids to seek transgender medical treatment, but they don’t offer age-specific guidance.

Dr. Joel Frader , a Northwestern University pediatrician and medical ethicist who advises a gender treatment program at Chicago’s Lurie Children’s Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they’re prone to risk-taking and they take into account long-term consequences of their actions only when they’re much older.

Coleen Williams , a psychologist at Boston Children’s Hospital’s Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

“Medical intervention in any realm is not a one-size-fits-all option,” Williams said.

More to Read

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July 25, 2024

‘We’ve created medical refugees.’ LGBTQ+ healthcare workers fight for gender-affirming care amid rise in anti-trans laws

July 10, 2024

Texas Supreme Court upholds ban on youth gender transitions. It’s the largest state with such a law

June 28, 2024

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• Sexual Health
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What Trans Health Care for Minors Really Means

As of April 2022, two states have passed bills banning gender-affirming care – health care related to a transgender person’s medical transition – for transgender youth, and 20 states are considering laws that would do so. If passed in all these states, more than a third of transgender teens aged 13 to 17 would live in a state that prohibits them from accessing trans health care. But the meaning of gender-affirming care for young people, and what it looks like on the ground, isn’t always clear. The cloud of politics surrounding these bills has obscured the medical reality of how and when trans youth can get the treatments they seek.

Gender-affirming care encompasses nonsurgical treatments like mental health care, puberty blockers, hormone therapy, and reproductive counseling, as well as surgical options like “top” or “bottom” surgery. These treatments can be years-long, incremental processes that may only begin with the approval of parents and health care providers.

The bills banning this kind of care have caused confusion about what gender-affirming care for trans youth actually involves. Some have characterized care like puberty blockers and hormone therapy as child abuse despite the fact that a range of medical associations, including the American Academy of Pediatrics and the American Medical Association, supports them. Some of the bills also present incorrect medical information, like falsely stating that puberty blockers cause infertility (they do not).

In fact, gender-affirming care looks quite different for youth of different ages. Young children – those who have not yet gone through puberty – can’t medically transition. Instead, their transition is entirely social; a gender-expansive child can choose a new name and pronouns, cut their hair, or dress in a different style.

The next step of a child’s transition, if they and their family choose, is to take puberty blockers: medications that essentially press pause on puberty. Puberty blockers have long been given to cisgender children for precocious puberty, a phenomenon which can cause puberty to begin at an unusually young age, such as 7 or 8. As gender-affirming care, puberty blockers are only prescribed to a child once they have begun puberty, which for those assigned female at birth can begin around age 8, or slightly earlier for those who are Black or Hispanic; children assigned male at birth usually hit puberty about 2 years later, according to the Cleveland Clinic .

Physical development in children is measured on what’s called the Tanner Scale, which tracks the progress of puberty from Tanner Stage 1 (prepubescence) to Tanner Stage 5 (sexual maturity). The start of puberty, or Tanner Stage 2, is signaled by breast budding for those assigned female at birth and testicular enlargement for those assigned male at birth, says David Inwards-Breland, MD, MPH, co-director of the Center for Gender Affirming Care at Rady Children's Hospital-San Diego. Some clinics will not offer puberty blockers until a child has reached Tanner Stage 3 or 4, meaning they are only one or two stages away from the end of puberty, according to the Standards of Care (SOC) published by the World Professional Organization for Transgender Health.

To be eligible for puberty blockers, a child should have a “long-lasting and intense pattern of gender nonconformity or gender dysphoria,” according to the SOC. (The latest version of the SOC was released in 2012, and an updated edition is expected this spring .) Gender dysphoria is often evaluated by a mental health professional, who may want to see the child and their family for a number of sessions before making a diagnosis.

After taking puberty blockers, which are fully reversible, a child can still undergo their natural puberty, or they may begin to medically transition and eventually undergo gender-affirming hormone treatment with parental consent. The Endocrine Society recommends waiting to prescribe hormones until an adolescent can give informed consent, which is generally recognized as age 16, though it is widely accepted that starting before age 16 is appropriate in many cases. For those assigned female at birth, this would mean taking testosterone, and for those assigned male at birth, estrogen with or without a progestin and an anti-androgen. Hormone treatment is considered “partially reversible” by the SOC because some changes it causes, such as body fat redistribution, are reversible, and others, such as deeping of the voice from testosterone, are permanent.

To receive hormone treatment, a trans child should have “persistent, well-documented gender dysphoria,” according to the SOC, often as determined by a mental health care provider, who will then write a letter of recommendation for the treatment. And although the Endocrine Society recommends waiting until age 16 to start hormones, it recognizes that there may be compelling reasons to begin treatment earlier. In practice, many do receive it before this age. And a draft of the new version of the SOC drops the minimum recommended age for starting hormones to 14.

“It's not totally around age because we tend to do peer-congruent transition,” Inwards-Breland says. In other words, he wants his trans patients to be able to fit in with their peers when they’re going through puberty – and ideally, not be going through puberty late in high school, long after their peers. “Probably the youngest would be around 13,” he says of when he would start a teenager on hormones.

Deciding when an adolescent should begin hormones is a process that should involve the child, their family, and a multidisciplinary team, says Stephanie Roberts, MD, a pediatric endocrinologist at the Gender Multispeciality Service at Boston Children’s Hospital. “We really try to keep it extremely flexible and individualized, and to work with the young person and their family over time to help them meet their [transition] goals.”

The third step sometimes taken as part of gender-affirming treatment is surgery. Some surgeries are options for trans adolescents while others are not. The Endocrine Society recommends that surgery involving the genitals be delayed until a person reaches the age of consent, which is 18 in the United States.

For adolescents who are assigned female at birth, top surgery can be performed to create a flat chest. The Endocrine Society states that there is not enough evidence to set a minimum age for this type of gender-affirming surgery, and the draft of the updated SOC recommends a minimum age of 15. “Usually, for a [person] assigned female at birth, the chest tissue continues to mature until around 14 or 15,” Inwards-Breland says. “What I've seen surgeons do is after 14, they feel more comfortable.” If, though, a person is started on puberty blockers followed by hormone therapy from a relatively early age – around 13 – they will never develop breast tissue and wouldn’t need surgery to remove it.

Although trans youth are technically allowed to receive certain forms of gender-affirming care, in practice, it’s often difficult.

One common barrier is family approval. For minors, parental consent is needed for any form of gender-affirming care, and not all parents are willing to give it. Some parents never give consent; for others, it can take a while to learn about transgender health and get comfortable with letting their child medically transition.

Even parents who want to be supportive can slow things down. When Rose, a transgender girl in California’s Bay Area, came out to her mom, Jessie, around age 15, she became a patient at the gender clinic at Stanford Children’s Health and soon began taking puberty blockers (Jessie asked that their first names only be used due to privacy concerns). Rose wanted to begin hormone therapy shortly thereafter, but Jessie was hesitant. She wanted to make sure she was doing the right thing for her daughter.

“I didn’t know too much about the impact of hormone therapy, and to be frank, I even questioned will she be regretting her choices later and decide this is not what she wanted,” Jessie says. “As a parent, we ask all sorts of questions and try to look at all angles, try to figure out what should we do as a parent to be responsible?”

After receiving education at the clinic and having some tough conversations, Jessie gave her consent and Rose started on hormones about a year later. “The weight of responsibility for the parent, making that decision for their kid, it’s very daunting.”

Another major issue is the availability of pediatric gender clinics. Comprehensive multidisciplinary clinics are rare outside urban areas, Inwards-Breland says. Primary care providers can offer trans health care, but many aren’t experienced in it, particularly for trans youth.

“We still have these deserts where we don't have high-quality transgender health care programs available,” Roberts says. “Now we have more than 50 pediatric transgender health care programs available across the country, but there's still areas where patients and their families may need to travel long distances to access care.”

If a family is able to find a program, they often face long wait times before they can get a foot in the door. Rose’s original wait time was 6 months, and she was lucky to get in after 3, Jessie says. “That’s how she feels: She’s lucky. She’s one of the few lucky ones,” Jessie says.

For those who don’t have access to in-person care, there are telemedicine options. Organizations like Queermed provide remote care to adolescents, including puberty blockers and hormone therapy, in 14 states in the Southeast, where regular care is limited.

Once they’re in, families must navigate insurance coverage, which is inconsistent across public and private plans. “Even if a patient is insured, they may still be underinsured with respect to accessing transgender-related health care,” Roberts says. And insurance appeals can add further delays.

Distrust of the medical system, including fear of discrimination and being misgendered, can also lead trans youth to delay seeking care.

These obstacles are in states where gender-affirming care for trans youth is legal. The barriers introduced by the recent wave of anti-trans legislation in some states make it illegal in some cases for a child to access gender-affirming care. And this onslaught of bills doesn’t seem to be stopping anytime soon.

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Gender Confirmation Surgery

The University of Michigan Health System offers procedures for surgical gender transition.  Working together, the surgical team of the Comprehensive Gender Services Program, which includes specialists in plastic surgery, urology and gynecology, bring expertise, experience and safety to procedures for our transgender patients.

Access to gender-related surgical procedures for patients is made through the University of Michigan Health System Comprehensive Gender Services Program .

The Comprehensive Gender Services Program adheres to the WPATH Standards of Care , including the requirement for a second-opinion prior to genital sex reassignment.

Available surgeries:

Male-to-Female:  Tracheal Shave  Breast Augmentation  Facial Feminization  Male-to-Female genital sex reassignment

Female-to-Male:  Hysterectomy, oophorectomy, vaginectomy Chest Reconstruction  Female-to-male genital sex reassignment

Sex Reassignment Surgeries (SRS)

At the University of Michigan Health System, we are dedicated to offering the safest proven surgical options for sex reassignment (SRS.)   Because sex reassignment surgery is just one step for transitioning people, the Comprehensive Gender Services Program has access to providers for mental health services, hormone therapy, pelvic floor physiotherapy, and speech therapy.  Surgical procedures are done by a team that includes, as appropriate, gynecologists, urologists, pelvic pain specialists and a reconstructive plastic surgeon. A multi-disciplinary team helps to best protect the health of the patient.

For patients receiving mental health and medical services within the University of Michigan Health System, the UMHS-CGSP will coordinate all care including surgical referrals.  For patients who have prepared for surgery elsewhere, the UMHS-CGSP will help organize the needed records, meet WPATH standards, and coordinate surgical referrals.  Surgical referrals are made through Sara Wiener the Comprehensive Gender Services Program Director.

Male-to-female sex reassignment surgery

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a male-to-female sex reassignment surgery will be offered a penile inversion vaginoplasty with a neurovascular neoclitoris.

During this procedure, a surgeon makes “like become like,” using parts of the original penis to create a sensate neo-vagina. The testicles are removed, a procedure called orchiectomy. The skin from the scrotum is used to make the labia. The erectile tissue of the penis is used to make the neoclitoris. The urethra is preserved and functional.

This procedure provides for aesthetic and functional female genitalia in one 4-5 hour operation.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation. What to Expect: Vaginoplasty at Michigan Medicine .

Female-to-male sex reassignment

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a female-to-male sex reassignment surgery will be offered a phalloplasty, generally using the radial forearm flap method. 

This procedure, which can be done at the same time as a hysterectomy/vaginectomy, creates an aesthetically appropriate phallus and creates a urethera for standing urination.  Construction of a scrotum with testicular implants is done as a second stage.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation.

Individuals who desire surgical procedures who have not been part of the Comprehensive Gender Services Program should contact the program office at (734) 998-2150 or email [email protected] . W e will assist you in obtaining what you need to qualify for surgery.

Putting numbers on the rise in children seeking gender care

By ROBIN RESPAUT and CHAD TERHUNE

Filed Oct. 6, 2022, 11 a.m. GMT

Thousands of children in the United States now openly identify as a gender different from the one they were assigned at birth, their numbers surging amid growing recognition of transgender identity and rights even as they face persistent prejudice and discrimination.

As the number of transgender children has grown, so has their access to gender-affirming care, much of it provided at scores of clinics at major hospitals.

Reliable counts of adolescents receiving gender-affirming treatment have long been guesswork – until now. Reuters worked with health technology company Komodo Health Inc to identify how many youths have sought and received care. The data show that more and more families across the country are grappling with profound questions about what type of care to pursue for their children, placing them at the center of a vitriolic national political debate over what it means to protect youth who identify as transgender.

Diagnoses of youths with gender dysphoria surge

In 2021, about 42,000 children and teens across the United States received a diagnosis of gender dysphoria, nearly triple the number in 2017, according to data Komodo compiled for Reuters. Gender dysphoria is defined as the distress caused by a discrepancy between a person’s gender identity and the one assigned to them at birth.

Overall, the analysis found that at least 121,882 children ages 6 to 17 were diagnosed with gender dysphoria from 2017 through 2021. Reuters found similar trends when it requested state-level data on diagnoses among children covered by Medicaid, the public insurance program for lower-income families.

Gender-affirming care for youths takes several forms, from social recognition of a preferred name and pronouns to medical interventions such as hormone therapy and, sometimes, surgery. A small but increasing number of U.S. children diagnosed with gender dysphoria are choosing medical interventions to express their identity and help alleviate their distress.

These medical treatments don’t begin until the onset of puberty, typically around age 10 or 11.

For children at this age and stage of development, puberty-blocking medications are an option. These drugs, known as GnRH agonists, suppress the release of the sex hormones testosterone and estrogen. The U.S. Food and Drug Administration has approved the drugs to treat prostate cancer, endometriosis and central precocious puberty, but not gender dysphoria. Their off-label use in gender-affirming care, while legal, lacks the support of clinical trials to establish their safety for such treatment.

Over the last five years, there were at least 4,780 adolescents who started on puberty blockers and had a prior gender dysphoria diagnosis.

This tally and others in the Komodo analysis are likely an undercount because they didn’t include treatment that wasn’t covered by insurance and were limited to pediatric patients with a gender dysphoria diagnosis. Practitioners may not log this diagnosis when prescribing treatment.

By suppressing sex hormones, puberty-blocking medications stop the onset of secondary sex characteristics, such as breast development and menstruation in adolescents assigned female at birth. For those assigned male at birth, the drugs inhibit development of a deeper voice and an Adam’s apple and growth of facial and body hair. They also limit growth of genitalia.

Without puberty blockers, such physical changes can cause severe distress in many transgender children. If an adolescent stops the medication, puberty resumes.

The medications are administered as injections, typically every few months, or through an implant under the skin of the upper arm.

After suppressing puberty, a child may pursue hormone treatments to initiate a puberty that aligns with their gender identity. Those for whom the opportunity to block puberty has already passed or who declined the option may also pursue hormone therapy.

At least 14,726 minors started hormone treatment with a prior gender dysphoria diagnosis from 2017 through 2021, according to the Komodo analysis.

Hormones – testosterone for adolescents assigned female at birth and estrogen for those assigned male – promote development of secondary sex characteristics. Adolescents assigned female at birth who take testosterone may notice that fat is redistributed from the hips and thighs to the abdomen. Arms and legs may appear more muscular. The brow and jawline may become more pronounced. Body hair may coarsen and thicken. Teens assigned male at birth who take estrogen may notice the hair on their body softens and thins. Fat may be redistributed from the abdomen to the buttocks and thighs. Their testicles may shrink and sex drive diminish. Some changes from hormone treatment are permanent.

Hormones are taken in a variety of ways: injections, pills, patches and gels. Some minors will continue to take hormones for many years well into adulthood, or they may stop if they achieve the physical traits they want.

Hormone treatment may leave an adolescent infertile, especially if the child also took puberty blockers at an early age. That and other potential side effects are not well-studied, experts say.

The ultimate step in gender-affirming medical treatment is surgery, which is uncommon in patients under age 18. Some children’s hospitals and gender clinics don’t offer surgery to minors, requiring that they be adults before deciding on procedures that are irreversible and carry a heightened risk of complications.

The Komodo analysis of insurance claims found 56 genital surgeries among patients ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021. Among teens, “top surgery” to remove breasts is more common. In the three years ending in 2021, at least 776 mastectomies were performed in the United States on patients ages 13 to 17 with a gender dysphoria diagnosis, according to Komodo’s data analysis of insurance claims. This tally does not include procedures that were paid for out of pocket.

A note on the data

Komodo’s analysis draws on full or partial health insurance claims for about 330 million U.S. patients over the five years from 2017 to 2021, including patients covered by private health plans and public insurance like Medicaid. The data include roughly 40 million patients annually, ages 6 through 17, and comprise health insurance claims that document diagnoses and procedures administered by U.S. clinicians and facilities.

To determine the number of new patients who initiated puberty blockers or hormones, or who received an initial dysphoria diagnosis, Komodo looked back at least one year prior in each patient’s record. For the surgery data, Komodo counted multiple procedures on a single day as one procedure.

For the analysis of pediatric patients initiating puberty blockers or hormones, Komodo searched for patients with a prior gender dysphoria diagnosis. Patients with a diagnosis of central precocious puberty were removed. A total of 17,683 patients, ages 6 through 17, with a prior gender dysphoria diagnosis initiated either puberty blockers or hormones or both during the five-year period. Of these, 4,780 patients had initiated puberty blockers and 14,726 patients had initiated hormone treatment.

Youth in Transition

By Robin Respaut and Chad Terhune

Photo editing: Corrine Perkins

Art direction: John Emerson

Edited by Michele Gershberg and John Blanton

• Follow Reuters Investigates

Other Reuters investigations

Trans kids' treatment can start younger, new guidelines say

A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Association for Transgender Health said hormones could be started at age 14, two years earlier than the group's previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association provided The Associated Press with an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn't match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group's standards of care and director of the University of Minnesota Medical School's human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents' consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

"Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision," he said. "That is why we recommend a careful multidisciplinary assessment."

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment, along with new efforts to prevent or restrict the treatment.

Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of the World Professional Association for Transgender Health last year after voicing concerns about "sloppy" treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn't always happen.

"They tell me horror stories. They tell me, `Our child had 20 minutes with the doctor"' before being offered hormones, she said. "The parents leave with their hair on fire."

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association's new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8 per cent in kids.

Anderson said she's heard recent estimates suggesting the rate in kids is as high as 1 in 5 -- which she strongly disputes. That number likely reflects gender-questioning kids who aren't good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

"That's just absolutely cruel," she said.

Dr. Marci Bowers, the transgender health group's president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been "forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis."

Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, North Carolina, resident struggled miserably with gender discomfort before his treatment.

Poulos said he's glad he was able to get treatment at a young age.

"Transitioning under the roof with your parents so they can go through it with you, that's really beneficial," he said. "I'm so much happier now."

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

"Those decisions are best made by patients and patient families and medical professionals," they said. "It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together."

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn't strong evidence in favor of transgender medical treatment for kids.

"In medicine ... the treatment has to be proven safe and effective before we can start recommending it," Mason said.

Experts say the most rigorous research -- studies comparing treated kids with outcomes in untreated kids -- would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That's no change from the group's previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

• Sex hormones -- estrogen or testosterone -- starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.
• Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum ag wasn't listed.
• Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Association support allowing kids to seek transgender medical treatment, but they don't offer age-specific guidance.

Dr. Joel Frader, a Northwestern University a pediatrician and medical ethicist who advises a gender treatment program at Chicago's Lurie Children's Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they're prone to risk-taking and they take into account long-term consequences of their actions only when they're much older.

Coleen Williams, a psychologist at Boston Children's Hospital's Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

"Medical intervention in any realm is not a one-size-fits-all option," Williams said.

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When Transgender Kids Transition, Medical Risks are Both Known and Unknown

The last couple of years have seen burgeoning awareness in society of what it means to be transgender as an adult. But now doctors, like those at Ann and Robert H. Lurie Children’s Hospital of Chicago, are helping children who identify as transgender negotiate their journey into adulthood.

For earlier generations of transgender people, the only way to transition physically was through surgery or taking hormones as adults. However, new medical options are allowing transgender children to start the process of transitioning at younger ages.

But doctors tread carefully, navigating medical interventions that carry risks that are both known and unknown.

PUTTING A PAUSE ON PUBERTY

When someone makes the decision to transition, part of that process can be social — choosing a new name, changing pronouns, wearing different clothes — and part of it can be medical.

One of the more recent medical developments is the use of puberty blockers to treat children who are transgender or gender non-conforming. The medications, which suppress the body’s production of estrogen or testosterone, essentially pause the changes that would occur during puberty.

“That’s really what these pubertal blockers do,” Dr. Rob Garofalo told FRONTLINE. Garofalo is the director of the Lurie Children’s Hospital’s Gender and Sex Development Program. “They allow these families the opportunity to hit a pause button, to prevent natal puberty … until we know that that’s either the right or the wrong direction for their particular child.”

Doctors who use puberty blockers say they allow children who experience gender dysphoria — the feeling that they’re in the wrong body — the time and space to explore and settle on their gender identity. What makes treatment tricky is that there is no test that can tell whether a child experiencing distress about their gender will grow up to be transgender. The handful of studies that do exist suggest that gender dysphoria persists in a minority of children, but they involved very few children and were done mostly abroad.

Puberty blockers have been tested and used for children who start puberty very young — if their bodies start to change before the age of eight or nine. Dr. Courtney Finlayson, a pediatric endocrinologist at Lurie Children’s Hospital, said, “We have a lot of experience in pediatric endocrinology using pubertal blockers. And from all the evidence we have they are generally a very safe medication.”

But their use in treating transgender children is a relatively new practice, first prescribed in the United States by the Gender Management Service at Boston Children’s Hospital in 2007, and recommended in the Endocrine Society’s guidelines for the treatment of transgender people in 2009.

Doctors say the benefit of using puberty blockers is that they block hormone-induced biological changes, such as vocal chord changes, the development of breast tissue or changes in facial structure, that are irreversible and can be especially distressing to children who are gender-non conforming or transgender.

“One of the challenges that’s been faced in the past is that treatment of the transgender population really didn’t start until they were either at least older adolescents or adults,” said Finlayson. “And by that time they’ve had all of the pubertal and physical changes that go along with their … natal sex.”

With the use of puberty blockers, “we’re really starting to some extent from a little bit more of a blank slate,” Finlayson explained. “We don’t have to be erasing or trying to get rid of all these other changes that occurred that they don’t want.”

However, the use of puberty blockers to treat transgender children is what’s considered an “off label” use of the medication — something that hasn’t been approved by the Food and Drug Administration. And doctors say their biggest concern is about how long children stay on the medication, because there isn’t enough research into the effects of stalling puberty at the age when children normally go through it.

The Endocrine Society’s guidelines suggest starting puberty blockers for transgender children when they hit a stage of development known as Tanner stage 2 — usually around 10 or 11 years old for a girl and 11 or 12 years old for a boy. The same guidelines suggest giving cross sex hormones — estrogen for transgender girls and testosterone for transgender boys — at age 16. However, doctors caution that estrogen and testosterone, the hormones that are blocked by these medications, also play a role in a child’s neurological development and bone growth.

“We do know that there is some decrease in bone density during treatment with pubertal suppression,” Finlayson said, adding that initial studies have shown that starting estrogen and testosterone can help regain the bone density. What Finlayson said there isn’t enough research on is whether someone who was on puberty blockers will regain all their bone strength, or if they might be at risk for osteoporosis in the future.

Another area where doctors say there isn’t enough research is the impact that suppressing puberty has on brain development.

“The bottom line is we don’t really know how sex hormones impact any adolescent’s brain development,” Dr. Lisa Simons, a pediatrician at Lurie Children’s, told FRONTLINE. “We know that there’s a lot of brain development between childhood and adulthood, but it’s not clear what’s behind that.” What’s lacking, she said, are specific studies that look at the neurocognitive effects of puberty blockers.

“I wouldn’t use [puberty blockers] if I didn’t think that they were safe, or that the benefits didn’t outweigh the potential risks,” Finlayson said. “But we always have this conversation with families before we start.”

STARTING HORMONES

The stakes are higher for children who want to continue physically transitioning by taking the hormones of their desired gender. Doctors grapple with when to start cross-sex hormones, and they say it really depends on the child’s readiness and stability in their gender identity.

While the Endocrine Society’s guidelines suggest 16, more and more children are starting hormones at 13 or 14 once their doctors, therapists and families have agreed that they are mentally and emotionally prepared. The shift is because of the concerns over the impact that delaying puberty for too long can have on development, physically, emotionally and socially.

The physical changes that hormones bring about are irreversible, making the decision more weighty than taking puberty blockers. Some of the known side effects of hormones include things that might sound familiar: acne and changes in mood. Patients are also warned that they may be at higher risk for heart disease or diabetes later in life. The risk of blood clots increases for those who start estrogen. And the risk for cancer is an unknown, but it is included in the warnings doctors give their patients.

Another potential dilemma facing transgender children, their families and their doctors is this: Taking cross hormones can reduce fertility. And there isn’t enough research to find out of it is reversible or not. So when children make the decision to start taking hormones, they have to consider whether they ever want to have biological children.

“I think it’s really important to talk to these children and families about fertility,” Finlayson says. “I do worry that at that stage in life many of them may not be able to realize how important that would be to them someday.”

It’s an ethical question that each family has to deal with in their own way, because if a child goes from taking puberty blockers to taking hormones, they may no longer have viable eggs or sperm at the age when they decide they would like to have children. They do have the option to start their puberty and delay their treatment in order to store eggs or sperm, but some of them may not want to.

While transgender adults have taken hormones sometimes for years, the generation growing up now is among the first to start taking hormones so young. Since most people who start hormones take them for life, doctors say there also isn’t enough research into the long-term impact of taking estrogen or testosterone for what could end up being 50 to 70 years.

“There are so many unanswered questions around the long-term consequences, and whether your health risk profile really becomes that of a male or female,” Garofalo says. “If we start testosterone today, will you have the cardiac risk profile of a male or female as you grow older? Will you develop breast cancer because we’re administering estrogen?

“I think those are the unanswered questions that really trouble me, and can only be answered with long-term follow-up studies.”

THE COST OF TRANSITIONING

Most of these treatments are still very expensive and often out of reach for people without the help of insurance. The cost of puberty blockers is approximately $1,200 per month for injections and can range from $4,500 to $18,000 for an implant. The least expensive form of estrogen, a pill, can cost anywhere between $4 to $30 a month, according to Simons, while testosterone can be anywhere between $20 to $200 a vial.

“What we’re seeing in the clinic is that whether or not specific insurance plans cover medication or not is completely arbitrary,” Simons said. “It really can’t be predicted very easily.”

“We almost always just expect a denial,” she said.

“Though it is not the only treatment, doctor-supervised medical transition is critically important to aid people in the treatment of gender dysphoria,” Vincent Paolo Villano, the director of communications at the National Center for Transgender Equality, told FRONTLINE. “Access to medical transition is often unobtainable due to cost and insurance discrimination.”

“Transgender people experience twice the rate of unemployment as non-transgender people, which means they often lack insurance to gain access to health care, period,” Villano said. “And even for trans people with insurance, health plans often outright ban coverage of transition-related care, forcing transgender people to pay outrageous out-of-pocket expenses for medically-necessary procedures that are covered without question for non-transgender people.”

But the trend might be changing, with some insurance companies starting to cover the cost of transitioning. The team at Lurie Children’s Hospital says it has seen several cases in recent months that did not require appeals, or covered the medication after the first appeal.

Ultimately, the doctors working in clinics like the one at Lurie Children’s hope to spare transgender children some of the anguish and societal isolation that earlier generations of transgender people went through. But they too would like the answers to the unknown consequences of these medications.

“The stakes are super high, and we don’t have all the answers,” Garofalo says. “Hopefully, there’s going to be more research and some of those unanswered questions, hopefully, will begin to be answered.”

Priyanka Boghani , Digital Editor , FRONTLINE

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Gender transition treatment minimum age lowered to 14-years-old

Emotional and cognitive maturity will factor in, as well as parental consent, by kelly mcclure.

The World Professional Association for Transgender Health has declared that the minimum age for gender transition treatment can now be lowered to 14, which is two years younger than previously advised. Along with that decrease in the age requirement for hormone treatments, the association has also moved to lower the minimum age for some gender reassignment surgeries to between 15 or 17.

While potential risks are present when administering hormone treatments and performing reassignment surgeries on patients within these age brackets, those risks were weighed against those that could come from withholding treatment from someone in need of it.

RELATED:  Trans kids in the U.S. were seeking treatment decades before today's political battles

In a report from AP News in which they detail information shared with them by the association prior to it being published in a medical journal later this year, it's explained that input from a pool of "more than 3,000 doctors, social scientists and others involved in transgender health issues" was used in making the decision to lower these minimum age requirements. A key factor in this decision, according to the association's report, was that lowering these ages would allow for trans youth to go through puberty at the same time as their peers.

Dr. Eli Coleman, chair of the group's standards of care and director of the University of Minnesota Medical School's human sexuality program points out in the AP News report that emotional maturity will also factor in to a case-by-case basis when it comes to any gender transition treatment.

"Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision," Coleman said. "That is why we recommend a careful multidisciplinary assessment."

Want a daily wrap-up of all the news and commentary Salon has to offer? Subscribe to our morning newsletter , Crash Course.

Under the new guidelines, girls will be able to start puberty blockers between the ages of 8 to 13, and two years later for boys, which allows anyone considering gender reassignment to have an expanse of time to decide for themselves whether they'd like to move forward with the next steps in terms of further treatment.

According to AP News the new guidelines also recommend:

—Sex hormones — estrogen or testosterone — starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men. —Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum age wasn't listed. —Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

 "Medical intervention in any realm is not a one-size-fits-all option," Coleen Williams, a psychologist at Boston Children's Hospital's Gender Multi-specialty Service said in response to the new guidelines.

• Why is the right so obsessed with bathroom issues? Behind the new wave of anti-LGBTQ attacks  
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• New York residents can now choose 'X' as their gender on state IDs

Kelly McClure is Salon's Nights and Weekends Editor covering daily news, politics and culture. Her work has been featured in Vulture, The A.V. Club, Vanity Fair, Cosmopolitan, Nylon, Vice, and elsewhere. She is the author of Something is Always Happening Somewhere .

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• Health Check

Florida Gov. Ron DeSantis speaks during a news conference on Aug. 4, 2022, in Tampa. (AP)

Transition-related surgery limited to teens, not 'young kids.' Even then, it's rare

If your time is short.

• We found no examples of "young kids" receiving transition-related surgery. The Florida Department of Health differentiates between children - under 10 -  and adolescents -  between 10 and 18. DeSantis' office provided PolitiFact with two cases involving adolescents.

Florida Gov. Ron DeSantis suspended Hillsborough State Attorney Andrew Warren, in part, for signing a pledge against the criminalization of gender-affirming health care.

Although Florida has not enacted any law prohibiting transgender medical treatment for children, DeSantis cited Warren's pledge not to prosecute doctors who offer these services as evidence of his neglect of duty.

DeSantis has mocked the term "gender-affirming care," which the U.S. Department of Health and Human Services says can include medical, surgical and mental health services for transgender and nonbinary people.

"When you have the 2021 letter saying … no matter what a state declares about protecting child welfare with respect, I mean, you know, they use these euphemisms," DeSantis said at an Aug. 4 press briefing announcing the suspension. "But what it is, is they're literally chopping off the private parts of young kids, and that's wrong."

This isn't the first time DeSantis suggested that "young kids" in the U.S. receive transition-related surgeries. DeSantis criticized these procedures in an Aug. 3 conference : 

"They want to castrate these young boys, that's wrong. We stood up and said, from the health and children's well-being perspective, you don't disfigure 10, 12, 13-year-old kids based on gender dysphoria."

We found no examples of doctors "literally chopping off the private parts of young kids," as DeSantis said. 

"That is not true under any existing medical guidelines," said Dr. Jack Turban, assistant professor of child and adolescent psychiatry at the University of California, San Francisco. "No medical or surgical interventions are considered for prepubertal children."

The governor's office sent PolitiFact two examples of people who received transition-related surgeries in their mid to late teenage years  — one at 15 and one at 17. DeSantis' Florida Department of Health differentiates between children (under 10) and adolescents (10-18). In one case DeSantis provided, an individual from California received masculinizing chest surgery at 15. Under existing California law, an insurer cannot deny coverage for the surgery — which includes double mastectomies —  based on a patient's age alone. 

The procedure is mostly offered to teenagers 15 and older, The New York Times reported. However, we found one report of a 14-year-old who obtained the procedure, and there isn't a consensus on a specific age requirement among medical guidelines.

The other case involved Jazz Jennings, a transgender woman who stars in a reality television show on TLC. Jennings received genital reassignment surgery at 17.

Genital reassignment surgery should be reserved for those 18 and older, according to guidelines for the medical care of transgender patients developed by the Endocrine Society and the World Professional Association for Transgender Health , or WPATH.

Featured Fact-check

C.P. Hoffman, senior policy counsel for the National Center for Transgender Equality, told PolitiFact that cases like Jennings are not common. 

"Even when a minor has parental support for their transition, transition-related surgeries are not typically performed prior to the age of 18," Hoffman said. "While there are some reports of transgender teens between the ages of 16 and 18 receiving transition-related surgical care, these cases are exceedingly rare and based on the specific medical needs of the teen."

The American Academy of Pediatrics recommends what it terms a "gender-affirmative care model" for prepubescent children experiencing gender dysphoria  — distress people may experience because of the discrepancy between their gender identity and the sex assigned to them at birth. Gender-affirmative care is oriented toward understanding and appreciating a child's gender identity rather than providing puberty blockers, hormone therapy or surgery. 

"Before any physical interventions are considered for adolescents, extensive exploration of psychological, family and social issues should be undertaken," the WPATH guideline reads.

The beginning of puberty, which generally occurs between the ages of 10 and 12, is a baseline for medical intervention.

The Endocrine Society recommends against puberty blockers, which suppress the release of testosterone and estrogen during puberty, for prepubescent children. An adolescent can be prescribed the treatment at the onset of puberty.

Hormone therapy can follow the use of puberty blockers, although it isn't typically considered for patients younger than 16 years old, according to the Endocrine Society. 

WPATH recommends that "moving from one stage to another should not occur until there has been adequate time for adolescents and their parents to assimilate fully the effects of earlier interventions."

The association's criteria for initiating surgical treatment include "documentation of persistent gender dysphoria" and the "capacity to make a fully informed decision and to consent for treatment."

Under Florida law , a health care practitioner cannot provide or arrange medical services for a minor without parental consent. And many health insurance providers, including Aetna and Anthem , require a patient seeking genital reassignment surgery to be 18 or older to qualify for coverage.

DeSantis said, "They are literally chopping off the private parts of young kids."

DeSantis' office provided two examples of teenagers who received transition-related surgeries. The Florida Department of Health would define both cases as involving adolescents, and experts say the procedures are rare for minors and aren't typically recommended. There are no examples we could find, or the governor's office provided, of transition-related surgeries for people under the age of 14. 

Medical transitioning is not recommended for prepubescent children, as DeSantis suggested. We rate his claim Mostly False. 

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The Principles of the Truth-O-Meter

Our Sources

Youtube, Governor DeSantis makes a major announcement in Tampa , Aug. 4, 2022

WFLA, Gov. DeSantis announces addiction program to combat overdoses, fentanyl deaths , Aug. 3, 2022

Email interview with Christina Pushaw, DeSantis' press secretary, Aug. 5, 2022

Email interview with C.P. Hoffman, senior policy counsel for the National Center for Transgender Equality, Aug. 5, 2022

Phone interview with Susan Boulware, medical director of the Yale Pediatric Gender Program, Aug. 8, 2022

Email interview with Jack Turban, assistant professor of child and adolescent psychiatry at the University of California, Aug. 4, 2022

Email interview Scott VanDeman, communications coordinator for Florida Chapter of American Academy of Pediatrics, Aug. 5, 2022

The New York Times, DeSantis Suspends Tampa Prosecutor Who Vowed Not to Criminalize Abortion , Aug. 4, 2022

PolitiFact, No, young children cannot take hormones or change their sex , March 5, 2021

PolitiFact, Rep. Mary Miller says White House is encouraging kids to take "castration" drugs, undergo surgeries , April 17, 2022

Endocrine Society, Gender Dysphoria/Gender Incongruence Guideline Resources , Sept. 1, 2017 

World Professional Association for Transgender Health, Standards of Care , 2012 

Tampa Bay Times, DeSantis removes Hillsborough County State Attorney Andrew Warren , Aug. 4, 2022

Fair and Just Prosecution, Trans Criminalization Joint Statemen t, June 2021

Dade County Medical Association, Treating Minors Under Florida's New 'Parental Consent' Law , July 12, 2021

The Washington Post, FAQ: What you need to know about transgender children , Feb. 25, 2022

​​World Health Organization, Adolescent health , assessed Aug. 4, 2022

Office of Population Affairs and U.S. Department of Health and Human Services, Gender-Affirming Care and Young People Guidance , March 2022

American Academy of Pediatrics, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents , Oct.1, 2018

U.S. National Library of Medicine, Medline Plus, " Puberty ," accessed Aug. 5, 2022

Browse the Truth-O-Meter

More by yacob reyes.

Transition-related surgery limited to teens, not 'young kids.' Even then, it's rare

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Treatment - Gender dysphoria

Treatment for gender dysphoria aims to help people live the way they want to, in their preferred gender identity or as non-binary.

What this means will vary from person to person, and is different for children, young people and adults. Waiting times for referral and treatment are currently long.

Treatment for children and young people

If your child may have gender dysphoria, they'll usually be referred to one of the NHS Children and Young People's Gender Services .

Your child or teenager will be seen by a multidisciplinary team including a:

• clinical psychologist
• child psychotherapist
• child and adolescent psychiatrist
• family therapist
• social worker

The team will carry out a detailed assessment, usually over 3 to 6 appointments over a period of several months.

Depending on the results of the assessment, options for children and teenagers include:

• family therapy
• individual child psychotherapy
• parental support or counselling
• group work for young people and their parents
• regular reviews to monitor gender identity development
• referral to a local Children and Young People's Mental Health Service (CYPMHS) for more serious emotional issues

Most treatments offered at this stage are psychological rather than medical. This is because in many cases gender variant behaviour or feelings disappear as children reach puberty.

Hormone therapy in children and young people

Some young people with lasting signs of gender dysphoria who meet strict criteria may be referred to a hormone specialist (consultant endocrinologist). This is in addition to psychological support.

Puberty blockers and gender-affirming hormones

Puberty blockers (gonadotrophin-releasing hormone analogues) are not available to children and young people for gender incongruence or gender dysphoria because there is not enough evidence of safety and clinical effectiveness.

From around the age of 16, young people with a diagnosis of gender incongruence or gender dysphoria who meet various clinical criteria may be given gender-affirming hormones alongside psychosocial and psychological support.

These hormones cause some irreversible changes, such as:

• breast development (caused by taking oestrogen)
• breaking or deepening of the voice (caused by taking testosterone)

Long-term gender-affirming hormone treatment may cause temporary or even permanent infertility.

However, as gender-affirming hormones affect people differently, they should not be considered a reliable form of contraception.

There is some uncertainty about the risks of long-term gender-affirming hormone treatment.

Children, young people and their families are strongly discouraged from getting puberty blockers or gender-affirming hormones from unregulated sources or online providers that are not regulated by UK regulatory bodies.

Transition to adult gender identity services

Young people aged 17 or older may be seen in an adult gender identity clinic or be referred to one from a children and young people's gender service.

By this age, a teenager and the clinic team may be more confident about confirming a diagnosis of gender dysphoria. If desired, steps can be taken to more permanent treatments that fit with the chosen gender identity or as non-binary.

Treatment for adults

Adults who think they may have gender dysphoria should be referred to a gender dysphoria clinic (GDC).

Find an NHS gender dysphoria clinic in England .

GDCs have a multidisciplinary team of healthcare professionals, who offer ongoing assessments, treatments, support and advice, including:

• psychological support, such as counselling
• cross-sex hormone therapy
• speech and language therapy (voice therapy) to help you sound more typical of your gender identity

For some people, support and advice from the clinic are all they need to feel comfortable with their gender identity. Others will need more extensive treatment.

Hormone therapy for adults

The aim of hormone therapy is to make you more comfortable with yourself, both in terms of physical appearance and how you feel. The hormones usually need to be taken for the rest of your life, even if you have gender surgery.

It's important to remember that hormone therapy is only one of the treatments for gender dysphoria. Others include voice therapy and psychological support. The decision to have hormone therapy will be taken after a discussion between you and your clinic team.

In general, people wanting masculinisation usually take testosterone and people after feminisation usually take oestrogen.

Both usually have the additional effect of suppressing the release of "unwanted" hormones from the testes or ovaries.

Whatever hormone therapy is used, it can take several months for hormone therapy to be effective, which can be frustrating.

It's also important to remember what it cannot change, such as your height or how wide or narrow your shoulders are.

The effectiveness of hormone therapy is also limited by factors unique to the individual (such as genetic factors) that cannot be overcome simply by adjusting the dose.

Find out how to save money on prescriptions for hormone therapy medicines with a prescription prepayment certificate .

Risks of hormone therapy

There is some uncertainty about the risks of long-term cross-sex hormone treatment. The clinic will discuss these with you and the importance of regular monitoring blood tests with your GP.

The most common risks or side effects include:

• blood clots
• weight gain
• dyslipidaemia (abnormal levels of fat in the blood)
• elevated liver enzymes
• polycythaemia (high concentration of red blood cells)
• hair loss or balding (androgenic alopecia)

There are other risks if you're taking hormones bought over the internet or from unregulated sources. It's strongly recommended you avoid these.

Long-term cross-sex hormone treatment may also lead, eventually, to infertility, even if treatment is stopped.

The GP can help you with advice about gamete storage. This is the harvesting and storing of eggs or sperm for your future use.

Gamete storage is sometimes available on the NHS. It cannot be provided by the gender dysphoria clinic.

Read more about fertility preservation on the HFEA website.

Surgery for adults

Some people may decide to have surgery to permanently alter body parts associated with their biological sex.

Based on the recommendations of doctors at the gender dysphoria clinic, you will be referred to a surgeon outside the clinic who is an expert in this type of surgery.

In addition to you having socially transitioned to your preferred gender identity for at least a year before a referral is made for gender surgery, it is also advisable to:

• lose weight if you are overweight (BMI of 25 or over)
• have taken cross-sex hormones for some surgical procedures

It's also important that any long-term conditions, such as diabetes or high blood pressure, are well controlled.

Surgery for trans men

Common chest procedures for trans men (trans-masculine people) include:

• removal of both breasts (bilateral mastectomy) and associated chest reconstruction
• nipple repositioning
• dermal implant and tattoo

Gender surgery for trans men includes:

• construction of a penis (phalloplasty or metoidioplasty)
• construction of a scrotum (scrotoplasty) and testicular implants
• a penile implant

Removal of the womb (hysterectomy) and the ovaries and fallopian tubes (salpingo-oophorectomy) may also be considered.

Surgery for trans women

Gender surgery for trans women includes:

• removal of the testes (orchidectomy)
• removal of the penis (penectomy)
• construction of a vagina (vaginoplasty)
• construction of a vulva (vulvoplasty)
• construction of a clitoris (clitoroplasty)

Breast implants for trans women (trans-feminine people) are not routinely available on the NHS.

Facial feminisation surgery and hair transplants are not routinely available on the NHS.

As with all surgical procedures there can be complications. Your surgeon should discuss the risks and limitations of surgery with you before you consent to the procedure.

Life after transition

Whether you've had hormone therapy alone or combined with surgery, the aim is that you no longer have gender dysphoria and feel at ease with your identity.

Your health needs are the same as anyone else's with a few exceptions:

• you'll need lifelong monitoring of your hormone levels by your GP
• you'll still need contraception if you are sexually active and have not yet had any gender surgery
• you'll need to let your optician and dentist know if you're on hormone therapy as this may affect your treatment
• you may not be called for screening tests as you've changed your name on medical records – ask your GP to notify you for cervical and breast screening if you're a trans man with a cervix or breast tissue
• trans-feminine people with breast tissue (and registered with a GP as female) are routinely invited for breast screening from the ages of 50 up to 71

Find out more about screening for trans and non-binary people on GOV.UK.

NHS guidelines for gender dysphoria

NHS England has published what are known as service specifications that describe how clinical and medical care is offered to people with gender dysphoria:

• Non-surgical interventions for adults
• Surgical interventions for adults
• Interim service specification for specialist gender incongruence services for children and young people

Review of gender identity services

NHS England has commissioned an independent review of gender identity services for children and young people. The review will advise on any changes needed to the service specifications for children and young people.

Page last reviewed: 28 May 2020 Next review due: 28 May 2023

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Gender affirming surgery

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Gender affirming surgery refers to a variety of procedures that some people may use to affirm their gender.

• There are many different gender affirming surgeries and procedures.
• Gender affirmation might also include social affirmation, legal affirmation or medical affirmation.
• Everyone affirms their gender in different ways, and that may or may not include surgery.

What is gender affirmation?

Gender affirmation is the process you go through when you start to live as the gender with which you identify.

Gender affirmation might include:

• social affirmation — such as changing your name, pronouns, hair or clothing
• legal affirmation — such as changing your legal name or gender
• medical affirmation — which can include puberty blockers, hormones or surgery

Read more about gender incongruence and gender affirming care.

What is gender affirming surgery?

Surgery is just one option for gender affirming care. This includes top and bottom surgeries, as well as other surgeries like facial feminisation surgery.

All trans and gender diverse people are unique. You can choose to affirm your gender in a way that feels right for you.

This article talks more about gender affirming surgery.

What happens during gender affirming surgery?

Gender affirming surgery is usually done in adulthood.

There are many different gender affirming surgeries and procedures. They may include making changes to your:

• other body parts

Not everyone with gender incongruence has surgery.

Male to female surgeries

For people assumed male at birth, feminising surgeries may include:

• Breast/chest surgery — augmentation with insertion of breast implants.
• Facial feminisation — changing the shape of the lips, eyes or nose.
• Voice surgery — shortening the vocal cords for a higher, more feminine voice.
• Tracheal shave — reducing the size of the 'Adam's apple'.
• Lipofillers or liposuction, to achieve a more feminine shape.

Bottom surgery (genital reconfiguration surgery) involves changes to the genitals. This was previously known as 'sex reassignment surgery' or 'gender confirmation surgery'. The name change shows that your genitals don't define your sex or gender.

Feminising bottom surgery may involve a mixture of the following procedures:

• Removing the testicles (orchiectomy).
• Removing and reshaping tissue from the penis to make a vulva (penectomy) — this includes creating external labia or lips, and a clitoris (vulvoplasty).
• Shortening the urethra (tube that you urinate from).
• Creating a vaginal canal (vaginoplasty) — some people choose to skip this.

After vaginoplasty surgery, you need to use vaginal dilators to maintain the shape of your vaginal canal.

Female to male surgeries

For people assumed female at birth, masculinising surgeries may include:

• Breast/chest surgery to create a male chest.
• Lipofillers and liposuction to achieve a more masculine shape.
• Pectoral implants.

Masculinising bottom surgery may involve a mixture of the following procedures:

• Hysterectomy and ovariectomy — removal of your uterus (womb) and ovaries.
• Removal of the vagina (vaginectomy).
• Creation of a penis, which may include metoidioplasty or phalloplasty.

Metoidioplasty involves making a small penis using tissue from the clitoris after it is enlarged by testosterone hormone therapy.

Phalloplasty uses tissue from your body to make a penis. This tissue usually comes from your arm, thigh or back. Phalloplasty is a multi-stage process.

You may choose to have urethral lengthening, so that you can urinate from the tip of your new penis. This can happen about 6 months after your first surgery.

The final stage of surgery involves testicle implants and a device that may help you to have an erection.

Is gender affirming surgery right for me?

Choosing to undergo any surgery is a big decision. Everyone affirms their gender in different ways, and that may or may not include surgery.

Surgery is permanent, so you need to make sure it's the right choice for you. Doing your own research and talking with experts will help you decide what's best for you. Surgery doesn't make you more or less trans.

When can I have gender affirming surgery?

Before you can get gender affirming surgery, you need to meet certain criteria. You need to:

• have a history of gender dysphoria (for 6 months or more)
• have the ability to make a fully informed decision
• be over the age of 16 years for top surgery, or 18 years for bottom surgery (some surgeons will provide surgery to younger people in specific situations)
• ensure that any physical or mental health conditions you have are well managed

You will also need letters of support from a mental health professional before having gender affirming surgery. The letter needs to state that surgery is:

• appropriate for you
• likely to help affirm your gender
• likely to reduce any gender dysphoria that you have

For top surgery, one letter is needed. For bottom surgery, 2 letters are needed.

For bottom surgery, you are also required to have 'lived as your current gender' for 12 months. This means that you have socially transitioned.

If you are taking gender affirming hormones, you should do this for at least 12 months before having surgery. This is to allow any significant body changes to occur before surgery.

What questions should I ask my doctor before surgery?

It's important to talk about the pros and cons of any surgery with your doctor. It's a good idea to ask to see pictures of how other people look before and after surgery.

Questions to ask your surgeon include:

• Am I a good candidate for the procedure?
• What different surgical techniques are recommended for me?
• How long will the recovery period be?
• What are the possible risks and complications?
• Where will you perform the surgery?

ASK YOUR DOCTOR — Preparing for an appointment? Use the Question Builder for general tips on what to ask your GP or specialist.

What should I expect after surgery?

Surgical recovery can be long and uncomfortable. Your surgeon will be able to give you more information on what you can expect after each surgery.

You may want to ask:

• How long will I spend in hospital?
• When can I shower?
• Will I need any special dressings or surgical garments?
• When do I need to return for follow-up care?

Make sure you do everything your doctor tells you and go to all follow-up appointments. This will help you get the best results from your surgery. Some people may need another surgery to get the best results.

Most people who have surgery are happy with their results and feel more comfortable in their bodies. But some people are disappointed with the results or find that their gender dysphoria is not fully resolved.

Make sure you discuss any difficult feelings with your doctor or psychologist.

Complications from gender affirming surgery

Having surgery is a big deal. Even if you've been looking forward to it and are happy with the result, it can still be quite confronting. It might take some time to get used to your new body.

However, research suggests that very few people who have gender affirming surgery regret their decision.

Talk to your doctor or psychologist if you are feeling any distress after surgery.

How much will gender affirming surgery cost?

Gender affirming surgery can be very expensive. It can cost between $20,000 to more than $100,000, depending on which procedures you need.

Your surgeon will be able to tell you how much surgery will cost. There may be extra costs for:

• specialist visits before and after surgery
• surgeon and anaesthetist fees
• hospital and theatre costs
• any other products or services you need

The costs of some procedures may be covered by Medicare. You should ask your surgeon what Medicare item numbers they use. You can check the Medicare rebate at MBS Online .

Unfortunately, most gender affirming surgery in Australia is done privately. If you have private health insurance , it's important to check with your health fund about:

• what is covered
• what your out-of-pocket costs will be

Legal affirmation

Changing your gender on your passport, licence, Medicare card or birth certificate all require separate processes. These processes can vary between states and territories.

In some states and territories, you must have gender affirmation surgery to change the gender marker on your birth certificate.

You are legally protected from discrimination on the grounds of sexual orientation, gender identity or intersex status by the Sex Discrimination Act . Visit the Australian Government Attorney-General's Department for more details.

Resources and support

The Australian Professional Association for Trans Health (AusPATH) lists healthcare professionals who are committed to strengthening the health, rights and wellbeing of all trans people.

TransHub has information about gender affirming surgery and updating your gender marker on identity documents

The Gender Centre (NSW) offers resources and support.

You can also call the healthdirect helpline on 1800 022 222 (known as NURSE-ON-CALL in Victoria). A registered nurse is available to speak with 24 hours a day, 7 days a week.

Learn more here about the development and quality assurance of healthdirect content .

Last reviewed: May 2024

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More people are getting gender-affirming care, under attack in many states. Few are kids

The number of people seeking gender-affirming surgeries such as breast and chest operations or genital reconstruction nearly tripled during the three years before the coronavirus pandemic, a new study shows.

The study tracked more than 48,000 patients who had operations in hospitals and same-day surgery centers from 2016 through 2020, the most recent data available. The number of patients getting these operations nearly tripled from 4,552 in 2016 to 13,011 in 2019, before decreasing slightly in 2020 amid the coronavirus restrictions that postponed or halted many types of non-emergency operations, according to the study published Wednesday in JAMA Network Open .

Gender-affirming surgeries were most popular with young adults; more than 25,000 people ages 19 to 30 received these procedures. Fewer than 8% of patients − a total of 3,678 − were 12- to 18-year-olds, a group scrutinized by lawmakers pursuing restrictions mainly in conservative states .

Banned: Gender-affirming care for minors no longer allowed in North Carolina

Insurance coverage, awareness, satisfaction drive gender operations

Dr. Jason D. Wright, the study's lead author and an associate professor of gynecologic oncology at Columbia University, said the purpose of the study was to get an accurate count on such operations at hospitals and outpatient surgery centers.

The researchers sifted through databases to find people diagnosed with gender identity disorder , transsexualism or a personal history of sex reassignment. From there, researchers tracked whether those patients sought a range of gender-affirming surgeries.

More than half of the people in the study had breast and chest procedures, making it the most common type of gender-affirming operation. More than 1 in 3 people received genital reconstruction − a category that included any surgical intervention of the male or female genital tract. Others sought facial and cosmetic procedures such as hair removal, hair transplants, liposuction and collagen injections.

Gender-affirming surgeries are becoming more common as insurers offer more robust coverage. About 3 in 5 patients were covered by a private insurance plan, and 1 in 4 had Medicaid, the government health insurance plan for low-income and disabled residents.

People are also more aware these surgeries are available, Wright said.

"More patients have had access to these procedures," Wright said. "Not only are most of these procedures very safe from a complication standpoint, but they're also associated with favorable outcomes with relatively high rates of patient satisfaction."

Proud purple to angry red: These Florida residents feel unwelcome in 'new' Florida

22 states restrict gender-affirming care for minors

Last week, North Carolina Republican state lawmakers overrode Democratic Gov. Roy Cooper’s veto and passed legislation barring surgical gender-transition procedures to anyone under 18, with some exceptions. The legislation, which takes effect immediately, also prohibits medical professionals from providing hormone therapy puberty-blocking drugs.

Minors who had begun treatment before Aug. 1 may continue receiving that care if their doctors deem it medically necessary and their parents consent.

Louisiana, Texas, Missouri, Florida and Nebraska are among states that passed legislation restricting gender-reassignment operations among minors or limiting other gender-affirming care. In all, 22 states have restrictions on gender-affirming operations or related care for transgender minors.

"These are happening in conservative, Republican-led states. The language being used to promote the policies is around protection," said Lindsey Dawson, associate director of HIV policy and director of LGBTQ+ health policy for KFF, a nonpartisan health foundation. "But really, the policies target gender-diverse young people and aim to restrict providers from delivering what is widely considered best-practice medical care."

Wright said the study provides data on how frequently gender-affirming surgeries are performed and requested − important information for doctors to consider when discussing care with patients.

"More patients are asking for information about these services," Wright said. "As these procedures become more common, we need to have the expertise to care for transgender populations who are interested in surgery."

Contributing: The Associated Press

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Transgender children and young people: how the evidence can point the way forward

Philip graham.

University College, London, UK

Associated Data

Data availability is not applicable to this article as no new data were created or analysed in this study.

The development of gender identity in children from around the age of 3 years is described. Wishes for transgender identity are distinguished from gender-atypical behaviour. Reasons for the recent rise in transgender referrals in the early teen years are discussed. The now widely used protocol developed by the Amsterdam group for assessing transgender children and young people and, where appropriate, offering them puberty blockers, cross-sex hormones and sex reassignment surgery is described. Evidence for the effectiveness of this approach is considered. The competence of young people to give consent to these procedures is discussed. Finally, proposals are made for topics urgently requiring further research.

Children first begin to develop a sense of biological gender at around the age of 2 to 3 years. 1 At this age, they are able to label pictures of boys and girls according to typical presentations of heteronormativity. At 4 years, boys understand that it is the possession of a penis that marks them out as biologically male and girls understand it is the lack of a penis that means they are biologically female. By this age, children have a sense of the stability of biological gender, an understanding that it remains constant with time. From this point up to the age of 6 or 7 years, their judgement of gender in pictures of clothed children is heavily influenced by appearance so that they label boys pictured in dresses as girls and boys with long hair as girls. By 7 years they recognise biological sex as constant and independent of external appearance. 1

By the age of 7 years, therefore, children understand three different concepts related to sex/gender identity: biological sex, self-perceived gender identity and social gender identity. They understand that they and others are biologically male or female, that they and others have a sense of their own gender identity as male or female and that they and others, depending on their appearance and clothing, are usually perceived by others as male or female. As they develop into adolescence and adulthood, people recognise that, with the use of hormones and surgical interventions, some features of biological sex can be changed. Both self-perceived gender identity and social gender identity may also undergo change.

The great majority of young children develop a self-perceived gender identity consonant with their gender assigned at birth, but some, from the age of 3 or 4 years, develop a self-perceived gender identity which is other than that assigned at birth. This sense of another gender identity can be accompanied by a feeling of discomfort or gender dysphoria. There are many autobiographical examples of the first awareness of gender dysphoria. The best known is that written by Jan Morris, who lived as a highly successful male journalist under the name of James Morris until her mid-30s when, following treatment with hormones, she underwent a surgical reconstruction and thereafter lived as a woman. 2 Jan Morris describes very clearly the onset of her gender dysphoria: 2 ‘I was three or perhaps four years old when I realized I had been born into the wrong body and should really be a girl. I remember the moment well, and it is the earliest memory of my life’ (p. 1). Her sense of discomfort with her assigned gender at birth persisted throughout her childhood, adolescence and early adult life. She describes how, when in role as a young man, she used to pray ‘please God make me a girl’ (p. 39). Gender dysphoria persisted throughout her marriage and parenthood. It was only in her late 30s, after she had had gender reassignment surgery, that she felt at ease.

The majority of prepubertal girls and boys have a clear sense of their own gender identity as female or male. This is nearly always consistent with their gender assigned at birth; in some, like Jan Morris, it is not. In a study of adolescents who had been referred to a gender identity clinic in earlier childhood, Steensma et al were able to show that a high proportion of prepubertal children with gender dysphoria did not continue to show such dysphoria after puberty, 3 a finding that had previously been reported by the same group. 4 Further, children who had shown gender-atypical behaviour (see below) without intense gender dysphoria did not generally show gender dysphoria in adolescence. Those with gender dysphoria who had been assigned a female gender at birth were less likely to desist than those assigned a male gender. Those who persisted were much more likely to have a homosexual or bisexual orientation.

A sense of gender identity must be distinguished from the presence of gender-atypical behaviour, which may occur with or without gender dysphoria. Gender-atypical behaviour (boys behaving like girls and having interests generally regarded as feminine and vice versa ) is not uncommon in the general population. In a total population study, using a standardised instrument, Golombok et al were able to identify 112 boys and 113 girls aged 3.5 years who showed gender-atypical behaviour to an extreme degree. 5 This represented about 2.2% of the population studied (S. Golombok, personal communication, 5 Jan 2021). Especially for girls, there was considerable continuity between gender-atypical behaviours at 3.5 years and such behaviour at the age of 13 years. These investigators do not report whether any of the children in their study were referred for gender dysphoria. The prevalence of 2.2% for gender-atypical behaviour needs to be contrasted with the much less frequent prevalence of 1 per 6800 Dutch adolescents aged 12 to 18 years who requested medical help for gender dysphoria. 6

Gender dysphoria and the onset of sexual feelings

Between 9 and 13 years of age, children start to experience sexual feelings arising from their genitalia. This onset of sexual feelings coincides with biological changes known as gonadarche. At this point, as a result of changes in the hypothalamus and pituitary, the gonads begin to secrete the sex hormones, testosterone and oestradiol, in relatively small quantities. This results in a modest growth of hair around the pubes and in the armpits and growth of the penis and breasts respectively. Spontaneous penile erections and clitoral excitement occur. Around 2 years later, positive feedback occurs in the hypothalamo–pituitary–gonadal axis which stimulates the testes to produce much larger amounts of testosterone and the ovaries to secrete more oestradiol, leading to menstruation. These hormonal changes also result in much more intense experience of sexual desire.

In the majority of children, sexual attraction is heterosexual but around 10% of 16- to 44-year-old adults report some previous sexual contact with a member of the same sex. 7 Most of those who experience homosexual attraction are not transgender. Usually, they have not even shown gender-atypical behaviour; they have been typically masculine, if boys, and feminine, if girls. Transgender boys usually, but not always, feel attraction to others of the same natal sex, i.e. they have homosexual feelings, and transgender girls similarly feel attracted by others of the same natal sex. Inevitably, these sexual feelings are often associated with some degree of confusion and uncertainty. For most transgender boys and girls, however, homosexual feelings have the effect of confirming the child in their transgender role: ‘If I'm really a girl, it isn't surprising I'm attracted to boys’, a transgender natal boy might say to himself and vice versa for girls. But some transgender children develop sexual attraction for others of the opposite natal sex, again with the creation of confusion and uncertainty over the transgender role.

Adolescence and gender identity

Adolescence is a social construction, i.e. it is a phase of life defined by society. 8 In Western society, it is regarded as beginning at the onset of biological puberty. Its end is not, however, defined biologically, but usually by a social criterion such as the age at which the individual develops significant autonomy. In practice, most psychologists, clinicians and members of the general public equate adolescence with the teen years, from 13 to 19, although many young people are well into biological puberty by 13 years and will have completed the biological changes of puberty well before 19 years. Recently, Sawyer and colleagues in an influential article have argued for an expanded and more inclusive definition of adolescence corresponding with the longer period of transition from childhood to adulthood now experienced by young people in Western society. They suggest that the period of 10 to 24 years is more consistent with this experience. 9 It is of relevance that there is considerable variation in ages at onset and termination of biological puberty, some young people normally starting at 10 or 11 years old and others not completing puberty until their later teen years. Relatively recent neuroscientific studies have pointed to the fact that rapid biological changes occur in the brain during the teen years, 10 but these are by no means specific to this phase of life. 11

The general public regard various behaviours as characteristic of adolescence. These may be summarised as impulsiveness, a tendency to take risks, moodiness and fractious relationships with parents. The public image of adolescents accords with this view of ‘the typical adolescent’. It is certainly the case that some teenagers show these characteristics, but population studies suggest that they make up no more than about 10–15% of this age group, 12 although they are certainly the most conspicuous. Another important and, in the context of this article, the most relevant feature of adolescence is thought to be self-questioning about identity. Young people of this age are seen as preoccupied with the question ‘Who am I?’, a question relating to all aspects of their identities, including their gender and sexuality. Such self-questioning is not experienced in intense form by most teenagers. The prevalence of ‘identity problems’ was found to be 14.3% in a group of 15- to 18-year-old American high school students 13 and a similar prevalence of ‘identity distress’ was found in a study of Flemish adolescents and young people aged 14–30 years. 14 The considerable increase in exposure of teenagers in the past 10 to 15 years to social media replete with references to gender identity would make it surprising if there had not been at least some increase of such self-questioning and confusion in this area.

Teenage presentation of transgender

Clinics serving the adolescent transgender population observed a change in the referral pattern after about 2005. Most notably, the gender identity clinic in Toronto, Canada, reported a dramatic increase in referrals at that time. 15 At the Portman Clinic in London (part of the Tavistock and Portman NHS Trust) referrals increased very significantly from 2009 to 2016. 16 At the Tampere University Hospital, Finland, referrals between 2011 and 2013 far exceeded the number expected from the findings of epidemiological studies. 17 This had not been the case previously. There were two other changes in the referral pattern over this period. First, previously, roughly equal numbers of boys and girls had been referred, whereas the increase was associated with much higher numbers of those who had been assigned female gender at birth. Second, previously, the rates of mental ill health among referred children had been about the same as in the general population, 18 whereas now much higher rates of psychiatric disorder, including autism, were reported. 14 , 16

It is therefore clear that from 2005 in Toronto and a few years later in other centres, the characteristics of patients referred to transgender clinics in their early and mid-teen years changed very significantly. In considering the reasons for this new pattern, Aitken et al 15 suggest that one possibility is that, during this period, societal factors made it easier for gay and lesbian youth and their families to seek clinical care. It could be argued, those authors say, that it became easier for girls to ‘come out’ than boys. It might therefore be easier for girls to opt for a transgender identity. Although there is no evidence to this effect, transgender natal girls who found themselves attracted to girls at puberty might have also found it easier to come out as transgender than hitherto. This implies that the increased presentation at adolescence was of girls who had experienced gender dysphoria since their early years. There is another possibility. It is that girls in their teens who are showing mental health problems for other reasons might, searching for an answer to their identity problems or distress, be influenced by social media to question for the first time their gender identity and to see gender change as an answer to their mental dilemmas. This might be more likely if they had previously shown ‘tomboyish’ behaviour. This possibility has been suggested in considering reasons for an increase in referrals of natal girls to a gender identity service between 2009 and 2016. 15 However, both these possibilities remain hypothetical at present and the reasons for the increase in referrals to transgender clinics is unknown.

Although one should not draw conclusions from a single case, it is of interest that one of the claimants in a judicial review brought about because they felt they had been inappropriately treated with puberty blocking drugs gives an account of her transgender development very much in accord with this second possibility. The claimant described a highly traumatic childhood in which she showed many gender-atypical behaviours: ‘ From the age of 14 she began actively to question her gender identity and started to look at YouTube videos and do research on the internet about gender identity disorder and the transition process’ (para. 78). 19

Although some cases of first presentation of transgender in the early teen years may arise from so-called adolescent identity problems or identity distress, it is likely that others do occur because the young person has been reluctant to come out as transgender beforehand, even though gender dysphoria has been present from the early years. Further, it is well established that such reluctance may persist well into adulthood, so that there are a number of recorded cases of people who have waited until their 30s or 40s to make this decision. 20

There is a need for both quantitative and qualitative research to investigate the early histories of girls referred with gender dysphoria for the first time in adolescence. Such research should include interviewing parents about their children's early years.

Life for children who are transgender from their early years can be challenging. At home, they have to try to communicate how they feel to potentially sceptical parents. At school, they are likely to experience disbelief, mockery and bullying. To cope they need resilient personalities as well as sensitive and understanding parents who are able to explore and talk openly about their children's feelings with acceptance and without trying to influence decisions one way or another. For, as we have seen, although some prepubertal children persist in their transgender identity, in the course of time many will, for reasons we do not understand, desist. 3 It is remarkable that most children who have been transgender from a young age reach adolescence without developing a higher-than-expected rate of significant mental health problems. 17

Many prepubertal children and their parents will benefit from having available a sympathetic counsellor, psychotherapist or other mental health professional. This will allow exploration of the reasons for the presence of gender dysphoria. Material from voluntary organisations such as Mermaids may be helpful, but parents of young children need to monitor this to ensure that their children are not being encouraged to persist, but are just accepted for what they are at the present time. Difficult decisions about changes of name and the use of toilets need to be negotiated with hopefully sympathetic, open-minded teachers.

As puberty approaches, difficult decisions have to be made. The Amsterdam group has been offering transgender adolescents puberty blockers for 30 years, their first case having been treated in 1991. 21 The group has pioneered an approach to assessment and management of gender dysphoria. It has produced a protocol for medical treatment of transgender children and adolescents that has been widely followed, 22 for example in Italy, Canada, the USA and the UK. The protocol is summarised below and in Box 1 :

• Psychological counselling for children and parents starts well before any medical treatment is considered and continues while such intervention is being administered.
• Once Tanner stage 2–3 is reached, and not before, gonadotropin-releasing hormone analogues (GnRHa) are prescribed where there is a clear indication that this is the appropriate course. This medication is given to block pubertal changes, so that the bodily changes rejected by the young person do not occur. Such treatment is only offered to children and young people aged 12 years and older who have intense gender dysphoria and no significant mental health problems. Informed consent by the young person and by the parents is required. The purpose of the use of puberty blockers is to ensure that young people with gender dysphoria do not live through pubertal bodily changes they find abhorrent. Further, the blocking of pubertal changes means that when, as is nearly always the case, transgender adults choose to have at least some degree of gender reassignment surgery, some procedures, particularly bilateral mastectomy for those assigned female gender at birth, will not be necessary.
• With careful assessment and selection, a very small minority of young people prescribed puberty blockers (between 1.4 and 3.5%) change their minds and do not wish to proceed further. 23 For the large majority who do wish to proceed, around the age of 16 years or older, cross-sex hormones are prescribed. For this treatment to be started, the young person must be living in the role of the preferred gender. Again, informed consent by the young person and, preferably, the parents is required.
• At the age of 18 years or older, those (again the great majority) who meet eligibility criteria can begin the process of gender reassignment surgery. Such surgery occurs variably according to the degree and at the pace desired by the individual concerned.

Management of gender dysphoria 22

• Make a full assessment as early as possible
• Follow with supportive counselling throughout childhood and adolescence
• Subsequent interventions should only take place with informed consent, first by parents and then by the young person, with reflection before each phase
• If intense gender dysphoria persists, consider using puberty blockers at Tanner stages 2–3
• Consider use of cross-sex hormones at age 16
• At age 18–19 and subsequently, consider gender reassignment surgery

Effectiveness of treatment

The aims of treatment are twofold:

• to explore with the child or young person with gender dysphoria the reasons for their discomfort with their gender assigned at birth and to consider alternative ways forward, including living in the role of their birth-assigned gender or pursuing medical intervention that will enable them to transition;
• in those who choose to live in their preferred transgender role, to start treatment, pausing for reflection before each step, first with puberty blockers, then with cross-sex hormones and finally with gender reassignment surgery to relieve gender dysphoria.

Among those who opt for medical treatment, the degree of success of intervention is measured by the absence of gender dysphoria and mental health problems and by the presence of psychological well-being. Ideally it would be possible to quote findings from a number of controlled trials of each of the interventions. Given the impracticability of obtaining agreement from children and young people with intense gender dysphoria to participate in controlled trials, the findings from uncontrolled but carefully conducted studies provide the main evidence for effectiveness.

There have now been a number of such uncontrolled studies, in which patients have been followed up to see whether their physical and psychological states have improved or deteriorated after the use of puberty blockers alone 24 – 26 and puberty blockers followed by cross-sex hormones followed by surgery. 27 – 29 The most recently published study of the effects of puberty blockers was reported from the Portman Clinic, London. 30 This study reported on the short-term outcome over 2 years of 44 children and young people aged 12 to 15 years when they started treatment with puberty blockers. Overall, the patient experience was positive. Although there were some children who showed some negative outcomes in mood and quality of relationships with family and friends, the majority showed positive change. There was no change in the rate of parent- or child-rated behaviour problems or risk of self-harm. All adverse effects, when they occurred, were mild. In line with other studies, only 1 of the 44 children and young people treated with puberty blockers did not go on to request cross-sex hormone treatment.

All the studies quoted above have provided valuable information. In all cases, there has been benefit from the interventions for the majority and an absence of significant harm. The most recent critical review of the use of puberty blockers has concluded: ‘Although large long-term studies with diverse and multicultural populations have not been done, the evidence to date supports the finding of few serious adverse outcomes and several potential positive outcomes. This literature suggests the need for transgender youth to be cared for in a manner that not only affirms their gender identities but that also minimises the negative physical and psychological outcomes that could be associated with pubertal development’. 31 In all published cases, the majority has reported benefit from the interventions and an absence of significant harm. Where it has been measured, an improvement in psychological well-being has always been found. It is well established that adults who transition ‘experience fewer psychological problems and interpersonal difficulties as well as a strongly increased life satisfaction’ than before the transition and show no wish to revert to their gender assigned at birth. 32

It should be added that the use of puberty blockers in early adolescence has been strongly criticised. 33 , 34 It has been claimed that there has been undue reliance on an affirmative approach (self-identification) in making a transgender diagnosis, that the complexity of the underlying problems of young people presenting as transgender has been inadequately assessed, that a high proportion of those who are treated with puberty blockers regret that they have received this treatment and that the young people who have been treated have not been capable of giving informed consent to treatment that has such profound implications for their future.

Adverse effects of medical interventions

The effect of puberty blockers is generally, though not universally, regarded as reversible. Their use has been associated with apparently reversible stunting effects on height velocity and bone maturation. 29 , 35 General cautions that have been expressed by clinicians about the possibility of irreversibility, such as those by Professor Butler and Dr de Vries quoted in a judicial review, 19 are no more than one might expect in relation to a large number of interventions in routine use. Caution about possible harm is always an appropriate clinical stance. It should not be taken to mean that the intervention in question should not be used where it is indicated.

There is one undeniable loss that occurs as a result of the use of puberty blockers. The individual does not go through the experience of the ‘normal’ adolescence he or she would have had without their use. However, most transgender young people do not consider this to be a loss or in any way regrettable.

The use of cross-sex hormones exposes the individual to the risk of a metabolic abnormality in about 15% of cases, but the significance of this finding is not clear and it does not seem a contraindication to their use. 36 Further research is required on the nature of possible metabolic abnormalities arising from the use of cross-sex hormones.

Informed consent

The competence of young people to give informed consent to the use of puberty blockers and cross-sex hormones is currently a matter of great relevance to clinical management. In UK law, 16 years is regarded as the youngest age at which it can be assumed, on the basis of chronological age, that a young person can give informed consent to a medical procedure. Below that age, it is widely accepted that, in considering whether a young person is capable of giving informed consent, the so-called Gillick principle should be applied. This principle, expressed by Lord Scarman in a 1985 House of Lords judgment and repeated in the above-mentioned judicial review, 19 is that ‘as a matter of law the parental right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to […] understand fully what is proposed’. There is a controversy as to whether, because of the unusually complicated issues involved, children under the age of 16 could ever have the cognitive competence to give consent to puberty blockers or cross-sex hormones. This matter was considered in great detail in the judicial review whose judgment was published in December 2020. 19 This court decided that young people under 16 years could not give informed consent to the use of puberty blockers. Further, the court ruled that, even in cases where parents give their informed consent and clinicians are in agreement, an application should be made to the courts for authorisation before a child under 16 years can be administered puberty blockers. However, on appeal, this decision was reversed. The Appeal Court decided that the initial judgment had placed an improper restriction on the Gillick test and that it would not be appropriate for an application to the courts to be required before a child could be administered puberty blockers. 37

There is a need for systematic psychological investigation into the capacity of children and young people to make decisions in this area. Although there is some evidence on the capacity of young people aged 14–16 years to understand medical procedures, there is no evidence relating to the specific question of their understanding of the use of puberty blockers and cross-sex hormones, for example, in comparison with that of older people. Such evidence should be obtained. In the meantime, it would seem reasonable to rely on the findings of Weithorn & Campbell, whose study provides the most relevant data. 38 These investigators looked at 24 individuals in each of four age groups: 9, 14, 18 and 21 years. They tested their competence to make informed treatment decisions in a series of medical dilemmas, involving conditions such as epilepsy, diabetes and psychological problems. The children, adolescents and young adults were given the nature of the problem, treatments options, expected benefits, possible risks and consequences of failure, and then assessed on how much they understood. The 14-year-olds did as well as the 21-year-olds. The 9-year-olds did distinctly less well. Although it is many years since this study was carried out, until more relevant evidence is produced, there is no reason why its findings should not be regarded as highly pertinent.

Conclusions

One can conclude from the evidence that gender dysphoria is a relatively rare but well-defined condition, characterised by a strong desire to be of the gender opposite to that assigned at birth and by an insistence that one is, indeed, of the other gender. Affected transgender individuals are usually aware of its existence by the age of 5 years. Gender dysphoria needs to be distinguished from gender-atypical behaviour, where those assigned male gender at birth showed an interest in activities generally preferred by girls and vice versa . Marked gender-atypical behaviour occurs in around 2–3% of the population, most of whom are not transgender. Further, many children who show gender dysphoria before puberty do not continue to do so during and after pubertal changes occur. However, if gender dysphoria does persist into adolescence, its intensity tends to increase at this time.

From about 2005 until the present, there has been a considerable, perhaps tenfold, increase in the number of children and young people referred to gender identity clinics. This change has been observed not just in the UK, but in Canada, the USA and Finland. These more recent referrals have differed from previous cases in three ways. More recent referrals have been older, often not presenting until the early teen years. Whereas previously referrals were relatively evenly balanced between those assigned male and female gender at birth, there is now a considerable preponderance of those assigned female gender at birth. Further, whereas previously children and young people with transgender did not show high rates of behavioural and emotional disturbance, this is not the case for recent referrals.

The assessment and management of gender dysphoria has been pioneered by a Dutch group based in Amsterdam. This group has laid down a number of principles of management, which have been widely adopted by gender identity clinics in other countries. The effectiveness of this sequence of interventions is now reasonably well established, with good evidence that it relieves gender dysphoria and usually improves psychological well-being. Physical side-effects may occur but as far as can be ascertained at present, not to a degree where possible harm outweighs benefit. There are, however, unresolved issues concerning the capacity of young people with gender dysphoria to give informed consent to the use of puberty blockers.

There are a number of gaps in knowledge requiring urgent attention. First, it is unclear whether the considerable increase in referrals to gender identity clinics in the past 15 years is due to greater willingness of early affected individuals to come out at this age or whether clinics are dealing with a different population with different needs. There is clearly a need for both quantitative and qualitative research to investigate the early histories of those assigned female gender at birth referred with gender dysphoria for the first time in adolescence. Such research should include interviewing parents about their children's early years. Second, although it is reasonably well established that the use of puberty blockers is not accompanied by serious adverse effects, further research is required on the nature of possible metabolic abnormalities arising from the use of cross-sex hormones. Finally, there is a need for research into the capacity of children and young people, compared with older people, to understand the implications of the use of puberty blockers and cross-sex hormones.

About the author

Philip Graham is Emeritus Professor of Child Psychiatry in the Institute of Child Health, University College, London, UK.

Data availability

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Declaration of interest

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Lydia Polgreen

The Strange Report Fueling the War on Trans Kids

By Lydia Polgreen

Opinion Columnist

I n its upcoming term, the Supreme Court will once again hear a case that involves a highly contentious question that lies at the heart of personal liberty: Who should decide what medical care a person receives? Should it be patients and their families, supported by doctors and other clinicians, using guidelines developed by the leading experts in the field based on the most current scientific knowledge and treatment practice? Or does the Constitution permit lawmakers to place themselves, and courts, in the middle of some of the most complex and intimate decisions people will make in their lives?

The case, United States v. Skrmetti , has been brought by the Biden administration to challenge a ban in Tennessee on gender-affirming care for adolescents that all major American medical organizations support. Tennessee is one of some two dozen states that have passed laws limiting gender-affirming care for young people. The appeal argues that these bans are an unconstitutional form of sex discrimination: They forbid long-used treatments for transgender adolescents that are also given to children who are not transgender for different reasons.

The Tennessee law, called the Protecting Children From Gender Mutilation Act, prohibits the use of puberty-blocking medications for transgender adolescents, for example, but permits them for children who go into puberty at an early age. It bans the use of sex hormones like testosterone in transgender adolescents but allows it for other health issues, such as for children assigned male at birth. It bans gender-affirming surgeries for transgender adolescents — such surgeries are extremely rare — but allows similar surgical procedures that affirm the sex a child is assigned at birth, even on infants who are intersex.

The Supreme Court ruled in 2020 — somewhat surprisingly given its conservative majority — that differential treatment of transgender and gay people is impermissible under civil rights law. “It is impossible,” Justice Neil Gorsuch wrote in his decision in that landmark employment discrimination case, “to discriminate against a person for being homosexual or transgender without discriminating against that individual based on sex.” Lawyers seeking to overturn gender-affirming-care bans will urge the court to follow the logic of that ruling and declare the Tennessee law and others like it unconstitutional.

Lawyers arguing in favor of these bans have taken a sharply different approach. In a striking echo of the arguments used to challenge medical abortion, they have asserted , against the consensus of the mainstream medical science, that the standard treatments for transgender children are not based in evidence and represent a grave risk to the health and well-being of young people.

This argument has been floating around conservative circles in the United States for some time, and some European government health care systems have embraced it, too, with some limiting access to gender-affirming care for young people, citing doubts about the evidence supporting it. The argument has been supercharged in recent months by an unlikely ally on the other side of the Atlantic Ocean: the British pediatrician Hilary Cass.

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• Open access
• Published: 19 August 2024

Discontinuing hormonal gender reassignment: a nationwide register study

• Riittakerttu Kaltiala   ORCID: orcid.org/0000-0002-2783-3892 1 ,
• Mika Helminen 2 ,
• Timo Holttinen 3 &
• Katinka Tuisku 4  

BMC Psychiatry volume  24 , Article number:  566 ( 2024 ) Cite this article

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With increasing numbers of people seeking medical gender reassignment, the scientific community has become increasingly aware of the issue of detransitioning from social, hormonal or even surgical gender reassignment (GR). This study aimed to assess the proportion of patients who discontinued their established hormonal gender transition and the risk factors for discontinuation.

A nationwide register-based follow-up was conducted. Data were analysed via cross-tabulations with chi-square statistics and t tests/ANOVAs. Multivariate analyses were performed via Cox regression, which accounts for differences in follow-up times.

Of the 1,359 subjects who had undergone hormonal GR in Finland from 1996 to 2019, 7.9% discontinued their established hormonal treatment during an average follow-up of 8.5 years. The risk for discontinuing hormonal GR was greater among later cohorts. The hazard ratio was 2.7 (95% confidence interval 1.1–6.1) among those who had accessed gender identity services from 2013 to 2019 compared with those who had come to contact from 1996 to 2005. Discontinuing also appeared to be emerging earlier among those who had entered the process in later years.

Conclusions

The risk of discontinuing established medical GR has increased alongside the increase in the number of patients seeking and proceeding to medical GR. The threshold to initiate medical GR may have lowered, resulting in a greater risk of unbalanced treatment decisions.

Trial registration number (TRN)

Not applicable (the paper does not present a clinical trial).

Peer Review reports

In gender medicine, transition refers to people with sex-discordant gender identities making changes in their lives to live in their experienced gender, socially (appearance, name, personal pronouns), juridically (identity documents) or medically (hormonal and surgical medical interventions that modify secondary sex characteristics ) . Detransition refers to people aborting their initiated transition and reversing it, totally or partially, to live in a sex-accordant role by reversing the abovementioned steps of transition.

Recent decades have witnessed an exponential increase in those seeking medical interventions to support their transition (medical gender reassignment, GR), with an increasing share of younger individuals of the female sex [ 1 , 2 ]. Psychiatric morbidity among people who contact specialized gender identity services (GISs) has increased simultaneously [ 2 , 3 ] and is particularly pronounced among the youngest age groups [ 4 ].

It has long been assumed that very few patients embarking on medical GR regret their choice and seek to reverse it. From the 1970s to the 2010s, estimates of those regretting their initiated GR were only in the region of 2% [ 5 , 6 ]. However, more recent research suggests that alongside the increase in the number of people accessing medical gender reassignment, reversing the initiated transition seems to be increasing [ 7 ]. In recent samples, 20–30% of those who initiated hormonal GR discontinued hormonal treatment in four to five years [ 8 , 9 ]. It is possible that some patients discontinue hormonal treatment because they have reached their transition goals. Some changes, such as lowering of the voice, can be reached with relatively short hormonal treatments and are permanent, while maintaining some other changes require permanent treatment.

People abandoning their gender transition have reported various reasons for doing so, such as coming to terms with their natal sex, concerns about medical complications, attributing gender dysphoria to reasons other than gender identity, such as trauma or mental disorders, finding that the transition did not alleviate distress, struggles with sexual orientation and discrimination [ 10 , 11 ]. More importantly, those who have detransitioned have repeatedly reported that before their embarking on medical GR, insufficient attention was given to their mental health and psychosocial problems, which, in retrospect, they believed played a major role in their desire to transition. They have expressed concerns that assessments for medical gender reassignment were too superficial, with no search for explanations for their distress beyond an assumed stable sex-discordant identity requiring transition. [ 10 , 11 ]. This contradicts calls to lower the threshold for medical gender reassignment [ 12 , 13 ]. Several recent national guidelines and recommendations [ 4 , 14 , 15 ], however, emphasize the appropriate treatment of psychiatric comorbidities and associated difficulties as well as a psychosocial intervention facilitating identity exploration as first-line interventions for gender dysphoria before considering medical interventions, particularly for young people.

In Finland, gender identity assessments potentially leading to medical GR interventions are conducted at two of the country’s five university hospitals. Services for legal adults (> 18 years) have been available since the early 1990s [ 16 ] and became available to minors in 2011 [ 17 ]. The national guidelines require minors presenting with feelings of gender dysphoria to first undergo psychosocial intervention to support identity exploration and to receive appropriate treatment for any severe mental disorders [ 14 ], after which they can proceed to the centralized GIS, where diagnostic assessments are carried out by specialized mental health teams. Both GISs have separate diagnostic teams for minors and for adults. Hormonal GR interventions are initiated at the same hospitals in gynecological outpatient clinics, and after stabilization, hormonal treatment is transferred to services in the patients’ places of residence. Genital surgeries with gender identity indication are nationally centralized to one university hospital and require recommendations from both nationally centralized diagnostic GIS units. Psychiatric treatment for any concomitant mental health condition is provided at the specialized secondary care or primary health care facility in the patient’s place of residence. Until 2022, diagnostic assessments at the nationally centralized GIS were also a prerequisite for registered sex change, but since 3 April 2023, legal adults have been granted legal GR on the basis solely of their own request. Medical GR remains nationally centralized and is available case-by-case after a comprehensive diagnostic assessment by a multidisciplinary mental health team, as outlined in the national guidelines [ 14 , 18 , 19 ].

An important ethical principle in all medicine is to not harm. A more severe or life-threatening condition may justify greater risks in its treatment. In medical gender reassignment, hormonal and surgical interventions are performed on physically healthy bodies. If the patient subsequently regrets the changes brought by the treatments, not to mention undesired side effects, this can be considered harmful. As in other Western countries, alongside the vastly increasing number of referrals to the GIS, increasing numbers of younger people with increasingly common psychiatric needs have initiated medical GR in Finland [ 2 ]. This may be followed by increasing numbers of people who later feel otherwise about their medical GR. On the other hand, the purpose of the nationally centralized and comprehensive assessment before medical GR is to ensure reasoned treatment decisions and satisfactory patient outcomes, avoiding possible regrets. This may counteract the risks related to the more complex presentations among those seeking medical GR. Those abandoning their gender transitions have repeatedly claimed that the distress accompanying their situation is not appropriately addressed [ 20 ]. It is crucial to take seriously the desire to reverse medical GR and to ascertain its likelihood and predictors to target medical GR safely and provide appropriate services for those opting out of treatment that has resulted in irreversible changes in a healthy pretreatment body. In the present study, we referred to national registry data to determine which patients are likely to discontinue hormonal GR. More specifically, we asked:

How commonly did people who proceeded to hormonal GR after assessment in the nationally centralized GIS from 1996 to 2019 discontinue their established hormonal GR?

What are the predictors of discontinuation in terms of age, age at admission to the GIS, direction of transition, surgical treatment, psychiatric treatment needs and cohort effects?

Has the risk of discontinuing hormonal GR changed over time?

Design and setting

A register-based follow-up study was conducted using information held in health care registers in Finland. These comprehensive and reliable national registers can be used to study large patient groups and collate information from different registers (on an individual level) via the unique personal identity code assigned to each permanent resident of Finland. Register data can be applied for research purposes from the Finnish Social and Health Data Permit Authority Findata and Statistics Finland. Data extraction, linkages and pseudonymization are carried out by these authorities, and researchers are allotted a special secure connection for pseudonymized data only. Analyses producing unduly precise information potentially enabling a person to be identified must be amended to ensure the anonymity of the persons included. The present study obtained ethical approval from the ethics committee of Tampere University Hospital (R20040R) and relevant permissions from Findata (THL/5188/14.02.00/2020) and Statistics Finland (TK/1016/07.03.00/2020). In accordance with Articles 6e and 9i and j of Regulation (EU) 2016/679 of the European Parliament and of the Council [ 21 ], no individual informed consent was needed.

A personal identity code is assigned at birth (or upon obtaining Finnish citizenship). This indicates sex (male or female). Legal sex change entails a new identity code. People are listed in the national registers according to their currently valid personal identity code. This code serves to retrieve data from various registers (including earlier data under the original identity code). Researchers cannot obtain information about identity code changes (changes in juridical sex). Researchers using the data never see the actual identity codes.

Data extraction

Subjects referred to either of the two nationally centralized GISs were identified from the hospital databases of Tampere and Helsinki University Hospitals. The first contact with a diagnostic team in either of the two GISs was recorded as the index date. The Finnish Social and Health Data Permit Authority Findata combined the lists from the two hospitals. A total of 3,665 individuals were identified as having contacted the nationally centralized gender identity units between 1996 and 2019. Of these, 1,359 had initialized and embarked on feminizing or masculinizing hormonal treatment (see below, next paragraph) and formed the subjects of the present study.

The register of the Social Insurance Institution of Finland (KELA), with information on prescription medications purchased and information on reimbursement, was used to obtain information on hormonal GR in the clinical GD group. Persons diagnosed with F64.0 (since 2020, also F64.8) in the nationally centralized gender identity units are entitled to special reimbursement (code 121) for their hormonal treatment, as are patients suffering from specified endocrine disorders. In the treatment of gender dysphoria, special reimbursement is available when hormonal treatment has continued for more than a year. The data on prescription medications were collected up to the end of 2021.

The Care Register for Health Care [ 22 ] was used for information on all treatment contacts to specialist-level psychiatric services from 1994 to 2022. The register, which has been in operation since 1994, includes all outpatient and inpatient contacts with specialist-level health services in Finland. For all contacts, admission and discharge dates were extracted. The Care Register for Health Care was further used to provide information on gender reassignment surgeries.

The Population Register provided information on those deceased and their dates of death.

Discontinuing hormonal GR

Subjects entitled to special reimbursement for hormonal treatments were considered to have discontinued their hormonal GR if they had purchased no hormones for more than 12 months before the end of the data collection or, if deceased, for 12 months or more before their death, or if they had been purchasing specially reimbursed feminizing hormones but had later switched to masculinizing hormones, or vice versa. To obtain reimbursements for prescription medications from the Social Insurance Institution of Finland (KELA), these medications can be purchased for only three months at a time. Thus, not purchasing them for over a year means that they are most likely not being taken. The last date of purchase of the originally prescribed hormonal GR medication was recorded. Patients who discontinue hormonal GR may require birth-sex accordant hormonal replacement to detransition after gonad removal or if their natural hormone production does not resume. For subjects whose specially reimbursed hormone treatment had changed from masculinizing to feminizing or vice versa, the last date of purchase of the originally initiated type of hormonal GR was recorded.

Types and durations of hormonal GR

In the analyses, hormonal GR was divided into feminizing and masculinizing. The duration of hormonal GR with special reimbursement was calculated in months from the dates of first and last/latest purchase of the originally initiated masculinizing/feminizing hormones.

Time variables

The subject’s year of birth was used in the analyses as a continuous variable. The year of initial contact with the GIS (index year) was categorized into intake cohorts with the first contact with the GIS in 1996–2005 vs. 2006–2012 vs. 2013‒2019. As the inclusion period did not fall into three even periods, the first period, with a clearly lower case load, was extended.

Age at first contact with the GIS (index date) was calculated from the dates of index contact and birth. Age in years was used in bivariate analyses as a continuous variable. In multivariable analyses, age was divided into adolescent (up to 22 years old) and adult (23+) at index contact.

Gender reassignment surgeries

The gender reassignment surgeries recorded were genital surgery (vaginoplasty, phalloplasty/metoidioplasty) and chest masculinization.

Specialist-level psychiatric treatment contact

Specialist-level psychiatric treatment contacts other than those related to gender identity assessment were recorded. Having received specialist-level psychiatric treatment was used in the analyses as a comprehensive dichotomous variable (yes/no). Furthermore, having specialist-level psychiatric treatment contact before entering the GIS (yes/no) was used, as was having specialist-level psychiatric treatment two or more years after entering the GIS (yes/no).

Statistical analyses.

Bivariate associations between discontinuing hormonal GR and the explanatory variables were studied via cross-tabulations with chi-square statistics (Fisher’s exact test where appropriate) and the Mantel‒Haenszel test for categorical variables and t tests and ANOVA for continuous variables. Multivariate associations were studied via Cox regression, accounting for differences in follow-up times. Discontinuing hormonal GR was entered as the dependent variable. The independent variables entered were (1) direction of hormonal treatment (masculinizing/feminizing), year of birth and index year cohort; (2) GR surgeries; (3) age at first entering the GIS (adolescent vs. adult); and (4) and, finally, having received specialist-level psychiatric treatment (yes/no). Hazard ratios (HRs) with 95% confidence intervals are given. The cut-off for statistical significance was considered p  < 0.05.

There were 1,359 people who, after having been assessed in the nationally centralized GIS, had purchased masculinizing or feminizing hormones with a special reimbursement code. The mean (sd) age of the participants on admission to the GIS was 25.6 (9.3) years, and 49.1% of them were under 23 years of age. In total, 467 (34.4%) had received feminizing treatment, and 892 (65.6%) had received masculinizing treatment. At index contact with the GIS, those who subsequently initiated feminizing GR were older than those who proceeded to masculinizing GR (29.7 (11.1) vs. 23.4 (7.3) years, p  < 0.001). The mean (sd) duration of hormonal GR was 62.0 (57.0) months, with a median of 44.5 months, with no difference between masculinizing and feminizing treatments. Genital surgeries were more commonly performed on those who had proceeded to feminizing treatment (46.7% vs. 14.9%, p  < 0.001). Among those on masculinizing treatment, 41.5% had undergone chest masculinization. Among all patients proceeding to hormonal GR, 57.4% had ever had treatment contact with specialist-level psychiatric care.

A total of 107 subjects (7.9% of those who had started hormonal GR and obtained special reimbursement for it) had not been purchasing GR hormones for at least a year before the end of data collection (or before the subject died) or had changed from feminizing GR to masculinizing treatment, or vice versa. These were considered to have discontinued hormonal GR. Among those who had obtained feminizing GR, 10.5% had discontinued hormonal treatment, and among those who had obtained masculinizing GR, 6.5% ( p  = 0.004). Those who discontinued hormonal GR were slightly older at the index contact and at their latest purchase of specially reimbursed hormones than those who continued hormonal GR. The two groups had used hormonal GR for comparable periods. Those who discontinued and those who stayed on hormonal GR had comparable specialist-level psychiatric treatment contacts. (Table  1 )

Those who discontinued and those who continued hormonal GR had equally common specialist-level psychiatric treatment contact before contacting the GIS (15.3% vs. 17.8%, p  = 0.5) as well as two or more years after entering the GIS (59.9% vs. 57.0%, p  = 0.2).

Changes across intake cohorts

The basic characteristics of the subjects changed across intake cohorts. The mean (sd) age among those who had contacted the GIS from 1996 to 2005 and subsequently proceeded to hormonal GR was 31.1 (7.9); from 2006 to 2012, it was 25.7 (9.3); from 2013 to 2019, it was 24.8 (9.2) years ( p  < 0.001); and the proportion of adolescents (< 23-year-olds) was 13.7% vs. 48.9% vs. 53.6% ( p  < 0.001). The proportion of those seeking change towards masculinity increased, and the same change was observed among those discontinuing hormonal GR. The proportion of those with specialist-level psychiatric treatment contacts fluctuated between cohorts among those continuing hormonal GR but remained unchanged among those who discontinued it (Table  1 ).

Multivariable analyses

The hazard ratio (HR) for discontinuing hormonal GR was greater among those in the latest intake cohort (2013–2019) as compared to those in the earliest cohort (1996–2005) when the type of hormonal GR (masculinizing vs. feminizing) and year of birth were accounted for (Table  2 Model 1) and when surgical GR (Table  2 Model 2), age at index admission (adolescent vs. adult) (Table  2 Model 3) and, finally, specialist-level psychiatric treatment contact (Table  2 Model 4) were added. Genital surgeries were associated with a decreased HR for the discontinuation of hormonal GR. Earlier year of birth was very slightly but statistically significantly associated with increased HR for discontinuing hormonal GR in the first models but levelled out in subsequent models.

Confirmatory analyses

Because the oldest individuals in the sample may have discontinued hormonal GR due to reaching the age of natural decline in hormonal levels, the final model was repeated among individuals younger than 60 at the end of data collection, but this did not change the findings.

A further confirmatory analysis was carried out using data from those subjects whose index contact was before 2018 because of the rather short follow-up times among those who had started their gender identity assessments in 2018 or 2019. This caused no changes to the findings presented in Table  2 .

Changes in the discontinuation of hormonal GR over time

Survival curves for the three index date cohorts suggested that the discontinuation of hormonal GR emerged in a shorter time from the earliest to the latest intake cohort (Fig.  1 ). To explore this further, discontinuation within two years of obtaining special reimbursement for hormonal GR was scrutinized among those with index dates before 2018. Among the two earlier intake cohorts (combined due to small cell frequencies in the original categories), 1.3% of those who had started hormonal GR discontinued it within two years; among the latest intake cohort, 2.9% ( p  = 0.06).

Time (in years)* to discontinuing hormonal gender reassignment in the different intake cohorts (1 = 1996–2005, 2 = 2006–2012, 3 = 2013–2019). *modeled by Cox regression

In this nationally representative register study covering subjects proceeding to hormonal GR over three decades, 7.9% discontinued their established hormonal GR. The risk for discontinuing hormonal GR was greater in the latest intake cohort (2013–2019) than in the earliest cohort (1996–2005). Genital surgeries were associated with a decreased risk of discontinuing hormonal GR. Over the decades, the time to discontinuation grew shorter.

The proportion of those who discontinued treatment was smaller than that reported in the most comparable study [ 9 ] from the USA, where almost one-third of adolescents and young adults discontinued their hormonal GR within four years. The relatively low discontinuation rate in our study may be due to the comprehensive assessment in the nationally centralized GIS before initiating hormonal treatments. When severe psychiatric comorbidities are present, great care is taken in considering physical interventions [ 2 , 14 , 17 ]. The proportion of those who discontinued their established hormonal GR was nevertheless manifold compared with earlier reports of proportions regretting medical transition among samples who had initiated their treatments between the 1960s and 2010s [ 5 , 6 ]. However, both of those reports focused on actively expressed regrets, and in the latter study [ 6 ], the proportion lost to follow-up—with later development thus unknown—was high. The proportion discontinuing their established hormonal GR in the present study was comparable to the proportion defined as detransitioners (those who discontinued treatment and reverted to living in their original gender role) in a register-based study of 175 subjects initially assessed in 2017–18 in the UK [ 7 ]. However, in that UK study, a clearly greater additional share of the studied group also subsequently disengaged from the treatments or did not adhere to their treatment plan. In a study evaluating the situation of people diagnosed with GD in a specified GP practice population [ 8 ] and, as noted, in a register study in the USA [ 9 ], much greater shares discontinued their medical GR. Direct comparisons among these studies are not feasible because of their different focuses and methodologies. However, together with the most recent studies, our study suggests that discontinuing hormonal GR is a significant phenomenon in gender medicine, and studies reporting the experiences of detransitioners [ 10 , 11 ] suggest that it is often related to profound psychological distress.

In multivariate models accounting for differences in follow-up times and for changes in patient characteristics across intake cohorts, the risk of discontinuing hormonal GR was almost threefold among those patients who had contacted the GIS from 2013 to 2019 compared with those who had contacted the GIS from 1996 to 2005. Our findings also suggest that the time to discontinuation of hormonal GR may have shortened among the later patients; however, in the latest intake cohort, more discontinuations may still emerge, and this will eventually affect the final conclusions about the average time to discontinuation. The proportion of subjects who discontinued after short use, a maximum of two years of specially reimbursed medication use, nevertheless appeared to have increased. (This will mean a maximum of three years of total use, given the rules on special reimbursement). Over the whole study period, the number of people seeking GR increased manifoldly [ 2 ], as did the number of subjects proceeding to hormonal GR. Alongside with this, the risk of discontinuing established medical GR has also increased. The populations seeking medical GR may have changed in a way that limits positive treatment outcomes. It is already known that subjects currently seeking medical GR are, unlike earlier, predominantly birth-registered females, who are younger than before and present with more psychiatric comorbidities than before [ 1 , 2 , 3 , 20 ]. These observations may suggest that an increasing share of GD patients actually do not present with achieved, consolidated identity [ 20 , 23 ]. In particular, medical transition early in terms of identity development may increase the risk of unbalanced treatment decisions, and this risk appears to have increased towards the present day, with detransitioning as the next step. Greater attention to gender identity issues and GR in the media and social media as well as assertive advocacy for medical GR may play a role in these developments [ 20 , 24 , 25 ].

Somewhat unexpectedly, the need for specialist-level psychiatric care did not differentiate those who continued and those who discontinued hormonal GR. Approximately one in six of the patients who had started hormonal GR, both those who later discontinued and those who continued the treatment, had needed specialist-level psychiatric treatment before embarking on gender identity assessments. This number was clearly less than that of all patients who were in contact with the GIS [ 2 ]. It is expected that the two groups would be comparable at the time of the decision to initiate medical GR and suffer fewer psychiatric comorbidities than those who could not start medical GR. However, psychiatric treatment needs increased vastly after the index contact with the GIS in both groups who proceeded to medical GR, those who subsequently discontinued it and those who continued on hormonal GR. A more detailed analysis of the nature of psychiatric needs and subsequent identity struggles is needed to better understand the discontinuation of medical GR in the future. According to the multivariable analyses, the risk for discontinuing hormonal GR did not differ between those who had initially contacted the GIS during adolescence (< 23 years) and those who had contacted in adulthood. This may be due to assessments being particularly cautious with younger patients, whereas with middle-aged subjects, self-determination may be accorded greater significance.

Having undergone genital surgeries was predictive of a decreased risk of discontinuing hormonal treatments. This may be due to strict treatment protocols requiring psychological stability as part of eligibility for genital surgeries. A recommendation letter is required from both the nationally centralized GIS for gender surgeries to ensure both the patient’s capacity to consent and that their psychological and psychosocial resources will suffice to recover from major surgery.

Methodological considerations.

A strength of the present study is the use of nationwide registry data over three decades. The registers are comprehensive since treatment providers are required by law to report to them all the information on which this study relies. The subjects were identified in the databases of the hospitals where the nationally centralized GISs operate, thereby ensuring the reliability of sampling. The long inclusion period made it possible to analyse changes over time. A limitation is that only subjects who had obtained the special reimbursement code for their hormonal GR were included. There may be subjects who discontinued hormonal GR before their entitlement to special reimbursement (which can take place after a year), and their number is not known. Another limitation is that registers include no information on the reasons for discontinuing hormonal GR. Given the ample publicly funded health services and the special reimbursement for hormonal GR, financial problems are an unlikely reason. Further changes in identity, medical complications or concerns over them, not being helped by GR or social reasons, may contribute [ 10 , 11 , 20 ]. It is also possible that some achieved their goals and therefore discontinued, although this seems implausible in the case of discontinuation after many years. A more profound understanding of the reasons for discontinuing medical GR will require studies using information elicited directly from patients. A further limitation is that regarding the need for psychiatric treatment, this research focused on specialist-level service contacts reflecting severe psychiatric needs. Mild to moderate mental disorders are treated in primary health care. Thus, the need for psychiatric treatment was likely somewhat underestimated in the present study. A limitation is that the possible use of hormonal GR through unofficial routes was not addressed. Publicly funded medical GR interventions are possible only through nationally centralized gender identity services. Obtaining hormonal GR via unofficial routes would likely be related to medical GR not being considered timely in the official treatment route. This finding may suggest that the discontinuation of hormonal GR can be more common among those who obtain hormones unofficially. We combined minors (< 18 at intake to the GIS) and late adolescents (18–22-year-olds at intake) because before 2011, minors entered the assessments only occasionally. Brain development, personality development and identity consolidation continue well beyond the age of reaching legal adulthood [ 23 , 26 , 27 , 28 , 29 , 30 ]. Finally, discontinuing hormonal GR, desisting from identifying in a sex-discordant way, detransitioning and regretting medical GR are concepts referring partly to the same phenomenon but not totally overlapping [ 20 ]. A register-based study cannot reach these nuances.

Discontinuing established medical GR appears to be less common in Finland than reported elsewhere. This is likely due to careful, comprehensive assessment before initiating physical treatments. The risk of discontinuing established medical GR has nevertheless increased alongside increases in the number of patients seeking and proceeding to medical GR. In later intake cohorts, discontinuation also appears to emerge earlier. The threshold to initiate medical GR may have decreased, resulting in greater risks of suboptimal decisions. More research is needed on practically all aspects of detransitioning from medical GR.

Data availability

The authors are not allowed to give the data to any party. Information about how to apply Finnish register data for research purposes can be found in www.findata.fi.

Abbreviations

• Gender dysphoria

Gender identity service

Hazard ratio

Confidence interval

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This research has received funding from the Wihuri Foundation and the Suomen Kulttuurirahasto. The funders had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.

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Riittakerttu Kaltiala

Tays Research Services, Wellbeing Services County of Pirkanmaa, Tampere University, Faculty of Social Sciences, Tampere, Finland

Mika Helminen

Department of Adolescent Psychiatry, Tampere University Hospital, Tampere, Finland

Timo Holttinen

Department of Psychiatry, Helsinki University Hospital, Helsinki, Finland

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RK, MH, TH and KT all contributed substantially to the design of the work; TH and RK curated the data; RK performed the analyses; MH consulted in statistical analyses; RK, MH, TH and KT interpreted the results; RK had the main responsibility of drafting the manuscript; MH, TH and KT participated in drafting the manuscript and approved the version submitted. All the authors have agreed both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. All the authors reviewed and approved the manuscript.

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Correspondence to Riittakerttu Kaltiala .

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The present study obtained ethical approval from the ethics committee of Tampere University Hospital (R20040R) and relevant permissions from Findata (THL/5188/14.02.00/2020) and Statistics Finland (TK/1016/07.03.00/2020). In accordance with Articles 6e and 9i and j of Regulation (EU) 2016/679 of the European Parliament and of the Council [ 21 ], individual informed consent of each registrar was not needed.

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Kaltiala, R., Helminen, M., Holttinen, T. et al. Discontinuing hormonal gender reassignment: a nationwide register study. BMC Psychiatry 24 , 566 (2024). https://doi.org/10.1186/s12888-024-06005-6

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Received : 13 June 2024

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Published : 19 August 2024

DOI : https://doi.org/10.1186/s12888-024-06005-6

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China man awaiting sex reassignment surgery sues hospital over forced electroshock therapy

• Live-streamer who posts videos wearing make-up and women’s clothing says he only went to hospital to keep parents happy

A man in China who is awaiting gender reassignment surgery has sued a hospital for 80,000 yuan (US$11,000) claiming he was forced to undergo electroshock therapy.

Linger, 27, is a live-streamer from Hebei province in northern China, who posts videos of himself online wearing make-up and women’s clothing.

He told Hongxing News that, although his biological sex is male, he has preferred the company of girls since childhood and, upon starting university, realised he identified as a woman.

Linger began taking oestrogen, one of the main female sex hormones. His facial hair became sparse, his voice softened, and he grew his hair long.

He has been saving money he made from live-streaming for years, hoping to undergo gender reassignment surgery.

Studies show that around four million people in China identify as transgender.

However, changing gender on official documents such as identity cards is only permitted after undergoing reassignment surgery.

The country’s strict standards require parental consent, and the procedure costs at least 150,000 yuan (US$21,000).

But Linger’s parents could not accept their son’s transition, which led to many arguments.

Traditional Chinese beliefs hold that the body is a gift from one’s parents and that gender is innate and should not be changed. Otherwise, it is considered disrespectful to parents.

Linger told Hongxing News that, to avoid further family conflict, he agreed to go to Jiulongshan Hospital in 2022 at his parents’ request.

He knew it was a psychiatric hospital, but he did not think he had a mental illness.

However, he did not expect the doctor to diagnose him with an “anxiety disorder” and “ego-dystonic sexual orientation”, which is a mental disorder that describes a conflict between a person’s desired and actual sexual orientation.

He was then stripped of his phone by medical staff and forcibly hospitalised for 97 days, according to Hongxing News.

“After being admitted to the hospital, I was tied to the bed with ropes, and many doctors controlled my body and administered electroshock therapy for days,” Linger said.

This year, Linger filed a lawsuit against the hospital for human rights violations, seeking 80,000 yuan in compensation.

On August 13, the hospital stated during the trial that they had “done nothing wrong”.

They argued that the purpose of electroshock was to control the emotions of psychiatric patients and enhance their self-awareness.

In China, being transgender is not classified as a mental illness.

Pan Bailin, a plastic surgeon in Beijing, said that using electroconvulsive therapy to try and reverse gender identity was not scientific.

“Transgender people are not mentally ill. They can alleviate their gender anxiety through psychological counselling, hormone therapy and voice training,” Pan said.

The hospital claimed that Linger’s mother had signed a consent form.

Chinese law allows for the involuntary hospitalisation of patients with mental disorders in specific cases, such as when they have shown, or are at risk of, self-harm or endangering others.

Legal experts contend that if these criteria are unmet, forced hospitalisation is unjustified.

Linger’s case is still being heard in court.

Missouri quietly made it much harder to change gender marker on driver’s licenses

The Missouri Department of Revenue used to allow the signature of a physician, therapist or social worker before approving the change of a gender designation. Now, it requires residents to provide either documentation of gender reassignment surgery, or a court order.

It became much harder this month for Missourians to change the gender marker on their driver’s licenses following a quiet change by the state Department of Revenue.

The department, which issues state driver’s licenses, switched from requiring the signature of a physician, therapist or social worker to approve a change in gender designation to mandating documentation of gender reassignment surgery or a court order.

The shift happened earlier this month, though it was not announced publicly by the department. The Wayback Machine , which archives web pages, shows the gender designation change request form requiring physician signoff, known as Form 5532, was available Aug. 6. The next day, the web page with the form was offline.

A spokesperson for the Department of Revenue told The Independent in a statement that “Form 5532 is no longer needed.”

“Customers are required to provide either medical documentation that they have undergone gender reassignment surgery or a court order declaring gender designation to obtain a driver license or non-driver ID card denoting gender other than their biological gender assigned at birth.”

According to the Movement Advanced Project , which maps states’ policies affecting LGBTQ residents, Missouri is one of 10 states with this policy. Just three states do not allow residents to change their gender markers.

PROMO, Missouri’s largest LGBTQ advocacy organization, reached out to the department after hearing that people could no longer make changes to their identification using Form 5532 and heard that “an incident” spurred the move, said executive director Katy Erker-Lynch.

The policy change took place soon after controversy erupted earlier this month over a transgender woman who used the women’s locker rooms at a private gym in Ellisville.

Elected officials held a press conference outside the gym Aug. 2, and Missouri Attorney General Andrew Bailey announced an investigation into the incident the same day.

State Rep. Justin Sparks, a Republican from Wildwood, spoke to reporters at the press conference about the Department of Revenue’s policy. He said on a radio appearance that the transgender woman “displayed a state ID describing (herself) as female.”

“We are going to get to the bottom of what happened in the Department of Revenue and that form they issued several years ago,” he said. “It was inappropriate and in my opinion, it is not legal.”

Later that evening, in a live broadcast via Facebook, he told followers that he had been in contact with the department.

“I have assurances from the Department of Revenue that they are going to change their policies and their form,” he said, promising to follow up with the department.

The form had been in place since 2016.

“It seems the mere mention and threat of a potential investigation into the policies and practices of the Department of Revenue caused Director (Wayne) Wallingford to end a policy that worked to help people,” Erker-Lynch said. “This decision reflects a state and state departments run by fear and intimidation — not a state run to serve its residents.”

PROMO is gathering stories of those who are struggling to change their gender marker on their state identification, calling the campaign “The ID for Me .”

Sparks did not respond to a request for comment.

This story was originally published by the Missouri Independent.

St. Louis LGBTQ group says Missouri’s abrupt ID policy changes harm trans people

St. Louis-area LGBTQ+ advocacy groups want to know why the Missouri Department of Revenue suddenly changed its policy for someone to change the gender listed on a driver’s license or a nondriver identification card.

Leaders with the statewide gender equality group PROMO said the policy change is alarming and poses challenges to trans and nonbinary people who want to get their name or gender changed on identifying documents.

“What concerns me the most is that this decision is an attempt to stop recognizing people, trans people, gender-expansive people, nonbinary people in public and civic life,” said Katy Erker-Lynch, PROMO’s executive director.

PROMO leaders were alerted about the policy change when residents complained that the Missouri Department of Motor Vehicles offices no longer accepted Form 5532, the Gender Designation Change Request Form. The form was implemented in 2016 after the state's Department of Motor Vehicles and Revenue received an “F” from national human rights and LGBTQ+ advocacy groups on the state’s processes to change a person’s gender.

St. Louis Public Radio asked the department why it abruptly changed its policy, and a spokesperson said that Form 5532 is no longer required and that customers must provide medical documentation showing they have undergone gender-reassignment surgery or a court order declaring gender designation to obtain a license or ID.

When PROMO leaders asked the Department of Revenue about the new policy, they were told the change was made after an unspecified incident. PROMO assumes the form change is connected to the potential investigation by the Missouri attorney general’s office after a trans woman used a women’s locker room in an Ellisville fitness center.

Erker-Lynch said she worries that the attorney general will politicize the investigation during this election year and try to disenfranchise some voters.

“It is no business of the State of Missouri if someone has had surgery or not, but it is the role and responsibility of the state to protect us to make sure that we can engage in our day-to-day functions,” Erker-Lynch said. “This is a huge hindrance for folks who are already disenfranchised voters and who are more vulnerable to harm and to discrimination.”

PROMO created the ID For Me campaign for residents to report problems with changing their gender on identifying documents with the group.

The Metro Trans Umbrella Group, a local social service organization that supports trans and queer people, has not received any complaints. However, June Choate, the group’s executive director, said this policy change makes it extremely hard for trans or nonbinary people to obtain a license because it is costly to have gender reassignment surgery and people who are transitioning without a gender-affirming ID could lose access to daily liberties.

“That makes it very hard, especially when we're talking about certain accesses, like bathrooms or other things, where, if your ID can’t say the sex that you are trying to be representative in," Choate said. "If it doesn't say what it needs to be said, it can bring a lot of harm to folks.”