Medical professionals and studies say denying or delaying care comes with significant damage to mental health.
by Blaise Mesa
Iridescent Riffel wishes she could have started gender-affirming treatment when she was younger.
Riffel, a transgender Kansan, said she wasn’t in a welcoming home, so she delayed her transition until she felt more safe. She went through an unwanted puberty while she waited.
“I didn’t really want to grow facial hair,” she said. “A lot of the changes to my body I did not want.”
Once puberty hits and secondary sexual characteristics begin to emerge — things like a deeper male voice and facial hair, or breasts for women — an opportunity for a transgender person to grow into the body that matches their identity begins to slip away.
Physicians and research suggest proposals like those in Kansas that bar gender-affirming care for minors pose long-term dangers for mental and physical health — while at least stalling that process with puberty blockers keeps options open.
The process of gender transition
Gender-affirming care can take a variety of forms, but bills advancing in legislatures across the country usually target puberty blockers, hormone treatment and surgeries.
Puberty blockers act like a pause button on adolescence. Take the puberty blockers away and the body picks up where it left off.
Hormone treatments suggest a more deliberate approach. Broadly speaking, estrogen will make a person more physically feminine, and testosterone brings out classically masculine characteristics. The effects can largely be reversed depending on whether the hormone treatments began before or after puberty.
Gender-affirming care is rising but still highly rare among minors. A Reuters report said that of about 50 million Americans between 6-17 years old, 42,167 sought gender-affirming care in 2021.
Surgery is even more rare. Fewer than 300 U.S. minors had top surgery, or breast removal, in 2021. With help from Komodo Health Inc., Reuters identified fewer than 60 genital surgeries in minors in the country in a three-year period ending in 2021.
Those medical interventions can come years into gender-affirming care, said Dr. Michelle Forcier, a professor of pediatrics at The Warren Alpert Medical School of Brown University.
Medical professionals stress that it’s hard to generalize the care of transgender patients.
But they say that physicians approach cases carefully, starting with talking to a patient, and can include seeking therapeutic consultation.
Talking to a doctor about gender dysphoria doesn’t guarantee a prescription for puberty blockers or hormones quickly, Forcier said. Some children spend years simply living as the gender they identify with — wearing clothes or answering to a name traditionally associated with boys or girls — before they’re given any medication.
And hormone treatment is a multistep process. It starts with puberty blockers, which the Mayo Clinic sees as completely reversible.
Puberty blockers aren’t designed to give boys estrogen or girls testosterone. Puberty blockers have been approved for medical use for decades and are often used to treat premature puberties in children.
Children who have a premature puberty take blockers, get off blockers and eventually have a normal puberty. The science behind that is uncontested.
A child is given a puberty blocker — gonadotropin-releasing hormone (GnRH) temporarily stops the production of sex hormones such as estrogen or testosterone — and time to live as the gender that matches their identity. If that child is happy with the results, hormone treatments follow. If the child is unhappy with the experience, then they are taken off puberty blockers and resume the puberty of their gender assigned at birth.
The next step could involve testosterone or estrogen, which are partially reversible.
Patients on estrogen will develop breast tissue, which would need surgery to remove if a patient decided to detransition. Patients on testosterone could develop a deeper voice or more body hair. Forcier said the medications work slowly — over months and years — which gives someone time to react to the changes.
“If and when they are ready, if and when parents are ready, and if or when it is appropriate (for) their age and social situation,” she said in an email, “a patient on blockers may be introduced to the idea of puberty hormones such as testosterone or estradiol.”
It is possible this process ends with gender-affirming surgery, but that is extremely rare with children.
Patients typically spend years living in a gender that matches their identity before surgery, and sometimes before hormone treatments.
An Associated Press article reviewed 27 studies involving about 8,000 transgender people who had gender-affirming surgery. The article found that 1% of people on average had regret.
Another report published in The Lancet, a British peer-reviewed journal, found that 98% of the 720 people who started gender-affirming care in the study continued with the treatment for future visits. Yet another study of 385 patients found that only two patients permanently discontinued gender-affirming care. Patients in that study were getting treatment for an average of four years.
Delaying transition linked to mental health issues
Mental health issues are a major consequence of delaying someone’s transition. Stress, depression and other behavioral health issues can also be tied to joint pains, high blood pressure, sleep issues and stomach problems, studies show.
A study of 104 transgender and nonbinary youth between 13 and 20 years old found that gender-affirming care brings a 60% drop in moderate or severe depression. Those young people were also 73% less likely to be suicidal.
Experts say that’s because the way puberty changes someone’s physiology can bring them closer to, or further from, the gender they identify with.
Having a deeper or higher voice, a hairier or smoother chest, and wider or thinner shoulders can keep someone from feeling comfortable with themselves. Hormone treatments can prevent that. But if the proposed bill passes, transgender Kansans will be stuck going through a puberty that makes them uncomfortable, doctors and transgender Kansans told The Beacon.
“How would you feel, (for example) a self-identifying woman, if your chest was covered in hair?” said Dr. Meredithe McNamara, an assistant professor of pediatrics at the Yale School of Medicine. “It would feel foreign. It would feel so uncomfortable. It’d be kind of torturous.”
McNamara said psychological therapy alone isn’t enough to ease the mental strain transgender people go through. She said therapy, while important, should be just one part of a treatment plan. Delaying care until someone is an adult can mean that patient needs surgery to truly feel better, doctors and transgender Kansans told The Beacon.
“Less surgery is healthier,” Dr. Joshua Safer, the executive director of the Center for Transgender Medicine and Surgery at Mount Sinai Health System, said in an email. “There (is) data that those who come to attention at younger ages and receive treatment sooner, do better from a mental health perspective.”
Kansas lawmakers consider gender-affirming care ban, again
One bill passed out of the Kansas House fell four votes short of a veto-proof majority, though four Republican lawmakers were not present for the vote. The bill bans hormones and surgery for minors, and it opens doctors up to disciplinary action if they provide this type of care.
House and Senate lawmakers are working through the specifics of the bill, so it isn’t clear how much it’ll might change before it reaches Democratic Gov. Laura Kelly’s desk.
She is all but guaranteed to veto it, as she has done with past proposals she deemed anti-transgender.
This isn’t the first time a ban on gender-affirming care has gained favor in the Kansas Statehouse. It continues to reappear because lawmakers worry children don’t understand the consequences of their decisions and say the medical treatment is unproven.
Dr. Paul Bauer, a Shawnee pediatrician, said minors are having surgery to remove healthy genitals without understanding the long-term consequences, though the number of surgeries on minors is extremely small.
Kansas hospitals couldn’t provide the number of surgeries for minors. It’s highly specialized and not available at every hospital.
That doesn’t cool concerns from critics, like Bauer.
“These procedures harm the children and the families they claim to help,” he wrote in testimony to lawmakers. “These procedures keep children who are wrestling with questions about who they are from resolving those questions.”
Doctors like Forcier completely disagree.
“None of this is fast,” she said. “To deny available, safe, effective care for political purposes is a terrible tragedy.”
This article was republished here with the permission of: The Beacon