A huge misconception about gender-affirming care
As a pediatrician who serves youth with gender dysphoria, I think the broader public is wrongly being led to believe the treatments are impulsive or incautious.
Lane was 12 when she told her parents she was a girl. Lane’s birth certificate listed her sex as male and everyone had always assumed she was a boy. Her mother, a clinical psychologist, was frustrated that her parental instincts hadn’t kicked in sooner. Her mother told me that despite her professional background, “I was remarkably clueless about the transgender experience.” She did, however, know that her smart and silly kid was fading away under the specter of male puberty. Lane’s emotional decline was fast, with no quick solution for relief. It took her parents eight months to get their first appointment with a specialized clinic, even after pulling strings with a physician they knew. Still, they were in no rush to pursue treatments until they were fully informed.
As a physician who cares for transgender youth, I have seen this situation play out time and again. Parents move mountains to soothe their children’s distress, and in practice that translates to some of the most measured, thoughtful, and slow-paced decision-making in pediatric health care.
While Lane (which is a pseudonym I’m using to protect her privacy) wasn’t my patient, I met her family and many others through my work in debunking anti-LGBTQ+ misinformation — an unusual niche for a physician and one I wish weren’t needed. But a hostile political climate has led many people far removed from the intimate dynamics in families like Lane’s to worry that a child’s disclosure of gender dysphoria leads to impulsive, irreversible decisions. This is one of many misconceptions that has fueled a cruel crackdown on health care for transgender people.
In sorting through several of these misconceptions, Lane’s parents learned that their daughter’s gender identity was neither an anomaly nor a fad. Their research convinced them that over 90 percent of youth who receive genderaffirming care continue treatments as adults, while regret is vanishingly low. They were reassured to see that the claim that transgender identity spreads through social media hadn’t been replicated by sound research methods. And they failed to see how this could apply to their daughter, who didn’t have a phone or transgender friends.
Moreover, Lane’s parents couldn’t understand how something so painful, that Lane could barely talk about, could be a passing phase. “There was nothing
whimsical or mercurial about this. She knew transition would be hard, and yet it was just . . . true that she was a girl,” her mother recalls. The evidence corroborated their gut feeling — that accepting Lane as her true self was critical for her well-being.
Though eight months of waiting gave them time to recalibrate, they also worried every day about the permanent physical changes of early male puberty. Lane was a beautiful singer and loved her voice, but it was dropping. Would she lose it forever?
During the four hours of their first appointment, they met a psychologist, a physician, and a social worker. Each family member filled out a 30-page packet of questionnaires. Time with a psychologist who understood youth gender dysphoria helped Lane say things aloud that she’d been trying to find words for on her own. She revealed that she had felt like a girl for years before she told her parents. She remembered times where she overcompensated with excessive displays of boyishness because being her authentic self was scary. Delays between knowledge of one’s non-cisgender identity and disclosure are often long, a phenomenon well documented in the literature.
The care team carefully reviewed the results and their impressions: that Lane had what we in the field call a “persistent, insistent, and consistent” gender identity that was different from her sex. But they made no prescriptive medical recommendations. First, they wanted to spend more time getting to know Lane and her family. This followed the clinical practice guidelines from the World Professional Association for Transgender Health and the Endocrine Society. If Lane’s family chose to return, this visit could be the first of many.
The conversation then shifted to her parents’ list of informed questions about puberty-pausing medications. Her doctors explained the process for monitoring bone density, which can be affected by these treatments, and described the rationale behind using this medication for a maximum of two years in Lane’s case. They talked about potential side effects and plans to manage them. At their follow-up a few months later, Lane’s parents opted for a medication called leuprolide, which temporarily pauses puberty and was given at a dosage that would wear off after three months. Lane’s mood didn’t suddenly change for the better, but her body didn’t change for the worse. That stability gave Lane’s parents what they craved — a break for their daughter and more time.
A patient of mine named Max, on the other hand, knew he was a boy since kindergarten. There was no
The decisions on whether, when, and how to pursue medical interventions are slow-moving, rigorous, and individualized.
coming-out moment — his gender identity had long been supported by his family and community. But puberty came faster than his parents anticipated. He developed an eating disorder shortly after his first menstrual period, which slowed his breast development and halted menses, but he didn’t realize he was restricting calories so much that his heart rate had become dangerously slow. This is what brought him into my care. As he overcame this eating disorder, a hard-won victory that saved his life, the dreaded physical change of puberty took hold. But it happened as he was surrounded by people who cared about him. A daily birth control pill suppressed menstruation and spared him a physical experience that was particularly distressing. He worked with a therapist weekly, and his parents joined once a month.
Two years after recovering from anorexia, Max was 17 and felt like testosterone was now the right path. His parents wondered if he should have started sooner, because it would have spared their son a few years of dysphoria about his feminine frame, high voice, and dewy skin. But when he looks back on this time, Max (also a pseudonym) says he would have been afraid to be cast in male social stereotypes before he understood how to navigate them. He didn’t see any men around him who expressed the tender masculinity with which he so strongly identifies. He says, “I’m a guy, but I’m not one of the guys.” He has a knack for procuring quirky vintage clothes, and he decorates his Afro with daisy barrettes. He writes poetry about the natural world that expresses his grief about climate change, and he adorns his handwritten work with sketches of birds. His parents are divorced but show up together at our appointments because they say “He’s the best thing we’ve done.”
With a privileged view into the lives of transgender youth, I know that no two of their stories are the same. Lane and Max evince this clearly. One identifies as a girl; the other identifies as a boy. One spoke up about her gender identity when puberty hit, and the other expressed it for as long as he had the right language. Lane’s parents were hit with a ton of bricks, while Max’s parents always knew who their son was. Their expectations of gender-affirming care are shaped by their different talents, goals, and worldviews: Lane wants to sing in a voice that sounds like her own, while Max wants to pursue life as a different kind of man from what he thinks society expects him to be.
Lane’s and Max’s stories do, however, have one thing in common that I see universally in the care of transgender youth: The decisions on whether, when, and how to pursue medical interventions are slow-moving, rigorous, and individualized.
Lane’s parents moved slowly for three reasons. First, they were compelled to wait because care is incredibly difficult to obtain. Over 25 percent of trans youth now live a full day’s drive away from a gender clinic, and waiting lists for this time-sensitive care range from a few months to a few years. Second, Lane’s parents also needed time to gather information and come to terms with the fact that there was no medical decision that would take their family back to a time when their daughter’s gender dysphoria didn’t exist. And third, the medical team that cared for Lane followed clinical practice guidelines that prescribe a thorough, multidisciplinary assessment process. Max’s years-long path toward testosterone was slowed at first by the medical instability caused by his eating disorder and then by his desire to fully clarify what he wanted out of gender-affirming care.
Nationwide data on youth gender treatments show that the careful approaches I see in my practice are the norm. Although the number of youths diagnosed with gender dysphoria has been increasing in recent years, the proportion of them who receive medically affirming care appears to be roughly the same. In 2017, 4 percent of those aged 6-17 with this diagnosis received pubertypausing medications; in 2021 the figure was 3 percent, according to an analysis by Reuters. Thirteen percent with this diagnosis received hormones in 2017; in 2021 the figure was 10 percent.
When I tell my patients that “the best is yet to come,” I do so with caution because their stories increasingly have something else in common — the threat of political interference. Twenty-three states have now banned the care that helped bring Lane’s and Max’s bodies into alignment with their true selves. The benefits of genderaffirming care have drawn more transgender youth into the light only to generate public fear and scrutiny. I may despair at this societal bait and switch, but my patients carry on. They adjust their college application strategies to avoid half the country and build protective communities. The truth is that politicization and public scrutiny make this care harder to obtain but don’t make it any less effective. They also don’t change who Lane, Max, or any transgender person is.