June 15, 2022

Staff Writer, NYT Magazine

Good morning. Doctors who provide gender-affirming care are split on how to evaluate teens.

Tori, 13, told her parents in seventh grade that she didn't want a boy's body.Anne Vetter for The New York Times

A medical frontier

This summer, the World Professional Association for Transgender Health, an international group of health care professionals, plans to release an update to its guidelines for giving care. The guidelines include a chapter on adolescents that is already generating heat from across the political spectrum.

In the decade since the last update, two intersecting forces have transformed the field of transgender health care for preteens and teens. The first is a large rise in the number of teenagers openly identifying as transgender and seeking care. The second is a right-wing backlash in the United States against allowing medical transitions for minors. I spent months reporting about this transformation for a New York Times Magazine cover story that was published online this morning.

As Scott Leibowitz, a child and adolescent psychiatrist who co-led the working group that wrote the adolescent chapter, told me, "Our world, the world of gender care, has exploded."

The debate

Not surprisingly, there is a sharp divide among those who support gender-affirming care — the approach major American medical organizations have adopted for embracing children and teenagers who come out as transgender — and those who oppose medical treatments for minors, including medications that suppress puberty and hormones that change secondary-sex characteristics.

But there is also a divide among gender-affirming providers. It doesn't break down along transgender-cisgender lines — both groups express a range of perspectives. The debate starts with how to evaluate kids who want these treatments.

The research

For transgender adults, the benefits of medical transition are well established and the rate of regret is low. Two studies also show positive long-term results for people who transitioned as teenagers. In 2011, researchers in Amsterdam found a "decrease in behavioral and emotional problems over time" among 70 young patients who received puberty suppressants. Follow-up research showed that five years after going on to hormone treatments as teenagers, the 55 patients who remained in the study had the same or better levels of well-being as a control group of cisgender people their age. None regretted their treatment.

All the young people in the study had a childhood history of gender incongruence and went through a comprehensive diagnostic assessment, to establish the psychological and social context of their gender identity and how it might intersect with other mental-health conditions. That helped prompt Leibowitz and his co-authors to recommend a comprehensive diagnostic assessment (as well as parental consent and other criteria) as they updated the international care guidelines.

Other gender-affirming providers, however, argue that the purpose of an assessment is not to determine the basis of a kid's gender identity. "People are who they say they are," said Colt St. Amand, a clinical psychologist and family-medicine physician at the Mayo Clinic. "So I am less concerned with certainty around identity and more concerned with hearing the person's embodiment goals. Do you want to have a deep voice? Do you want to have breasts?"

The rise

Underlying the debate about assessments is the question of why the number of teenagers in the U.S. who identify as transgender has nearly doubled in recent years.

The authors of the adolescent chapter in the World Professional Association for Transgender Health's Standards of Care said that the increased visibility of trans people in entertainment and the media had played a major — and positive — role in reducing stigma and helping many kids express themselves in ways they might have previously kept buried. But they also wrote about the role of "social influence," absorbed online or peer to peer. During adolescence, the chapter recognizes, peers and culture often affect how kids see themselves and who they want to be.

Some transgender advocates think that bringing up social influence in the context of trans identity is beyond the pale. It "defies reason" to say that "enormous numbers of cisgender-privileged youth are magically transformed by mere social media exposure" to the "most mortally at-risk minority class," the group International Transgender Health, which includes health care professionals, wrote when a draft of the care standards was released in December.

The politics

The backdrop for these debates is a right-wing effort to ban gender-related medical treatment for minors. So far, bans have passed in Arkansas, Arizona, and Alabama and have been proposed this year in about a dozen other states. As with other fraught issues like abortion, America is becoming a split screen. In red states, gender-related care for young people is already rare yet faces legal threats. At clinics that are mostly in progressive metropolitan areas, meanwhile, it's not clear how common comprehensive assessments are. Some families are bewildered by a landscape in which there are no labels for distinguishing one type of therapeutic care from another.

For my Times Magazine story, I interviewed more than 60 clinicians and other experts as well as about two dozen young people seeking care and a similar number of parents. As is often the case in medicine, the question is how to apply existing research for the growing numbers of patients — in this case, teenagers — lining up for care. The intrusion of politics into science makes that more difficult.

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