Gender-Affirming Medical Care: What It Is and Why It Can Be Lifesaving

Gender-affirming care is any treatment that helps a transgender, nonbinary, intersex, or gender-nonconforming person. Gender is not the same as sex. Sex refers to the biological sex organs you're born with. Gender refers to the social characteristics and roles a person identifies with.

Unfortunately, tailoring medical care to a person's gender identity has become rather controversial. In the United States, for example, some states outright ban best-practice medical and surgical care for LGBTQ+ youth. However, such bans can actually have a harmful effect on this population.

While some forms of gender-affirming care entail hormone therapy or surgery, not all do. Here's a closer look at what gender-affirming care actually involves, why it is important, and how to access it.

What Is Gender-Affirming Medical Care?

Gender-affirming medical care provides medical, surgical, mental health, and nonmedical services to transgender and nonbinary people. Professionals specializing in gender-affirming care provide a judgment-free environment to help patients explore their gender identity.

There are a lot of misconceptions involving gender-affirming care. These misconceptions may, in large part, be due to a narrative that's been woven by anti-transgender care activists. This narrative often involves a variety of false assumptions regarding the process of gender-affirming care.

The main goal of gender-affirming care is to help patients be comfortable with their gender identity and not try to "fix" it.

Myth: Rapid-Onset Gender Dysphoria

One of the biggest misunderstandings in gender-affirming medical care is a phenomenon called rapid-onset gender dysphoria (ROGD). ROGD dates back to 2016 and describes an alleged epidemic of youth coming out as trans "out of the blue" due to social contagion and mental illness.

Some people cite ROGD as a reason for being against gender-affirming care. However, scientific evidence does not back up ROGD as a real phenomenon. ROGD took off as a concept after the results of a single online survey were published.

Scientifically speaking, there were two major problems with the online survey on ROGD: the sampling method and the target population. Convenience sampling is prone to bias. This means the results of that study may not accurately reflect what's really going on. Also, the survey would have had more scientific clout if it would have studied ROGD from the perspective of adolescents instead of parents.

Gender dysphoria, however, is a real diagnosis according to the "Diagnostic and Statistic Manual of Mental Disorders, Fifth Edition, Text Revision," commonly referred to as DSM-5-TR. Gender dysphoria is when a person's gender identity does not align with the assigned sex, causing significant impairment and distress.

The definition of gender dysphoria is not all-encompassing, however. Not all transgender patients experience gender dysphoria, and not all patients with gender dysphoria are transgender.

Psychotherapy

Another popular misconception is that gender-affirming care only involves hormone therapy or surgery. To set the record straight, there are many forms of gender-affirming care. This care is tailored to each individual's wants and needs from psychotherapy to surgery.

Gender-affirming care can include a safe space through therapy with patients and their families to process and understand the transition. Patients may also opt for psychoeducation on gender and sexuality.

This is an individualized process. People can start off in counseling with a social worker or a psychologist and later make a decision to include an endocrinologist on their team for medical treatment. For those who do decide to medically transition, there are options such as gender-affirming hormone therapy and genital reconstruction.

It's also important to remember that not all transgender patients want hormone therapy or surgery. Gender identity does not necessarily correlate with gender expression. Just because someone identifies as a certain gender does not mean that the person has to act or dress in accordance with that gender.

Puberty Blockers

Puberty blockers are certain hormones that effectively delay puberty. These drugs can be used only during puberty, and their effects are reversible. Puberty blockers can help younger people in considerable distress about body changes.

Specifically, gonadotropin-releasing hormone (GnRH) agonist therapy is used to suppress puberty hormones. This therapy has a long history of use in medicine to help people with early puberty. The treatment is generally considered safe, with no reported significant side effects.

These types of medications can give young people time to explore their identity before permanent changes set in. Some adolescents who chose to use this option go on to receive further gender-affirming therapy, while others do not.

Hormone Replacement Therapy

Hormone therapy involves the use of steroid and/or gonadotropin therapy to inhibit or enhance the effects of the sex hormones, namely androgens or estrogens. Testosterone is arguably the most well-known of the androgens.

Testosterone therapy can stop menstruation, increase body and facial hair, change fat distribution, and more. In contrast, estrogen therapy can encourage breast growth, increase body fat, slow facial and body hair growth, and decrease testicular size.

Patients in early adolescence and onward are eligible for hormone therapy. The effects of this treatment are partially reversible.

Hormone therapy is not without its risks, however. One of the potential side effects is loss of bone density. The dose has to be just right because sex hormones are important in maintaining bone health. While less conclusive, other evidence suggests that cross-sex hormone therapy can affect cardiovascular health as well. Medical monitoring is needed for anyone on hormone therapy.

Gender-Affirming Surgeries

Gender-affirming surgeries are another option for people who want to medically transition. However, it's a misconception to think that everyone seeks surgery. Not everyone with a gender different from the sex assigned to them at birth wants to undergo surgery. In fact, only very few patients decide to have full gender-affirming surgery.

Surgical options include facial surgery, top surgery, and bottom surgery specific to the respective gender. The goal of facial surgery is to make the face appear more like the desired gender. Transfeminine top surgery aims to give the breasts a more feminine shape and size, while transmasculine top surgery involves removing breast tissue to create a less feminine-appearing chest. Bottom surgery encompasses reconstructing the genitalia.

Gender-affirming surgery is irreversible. Before making this decision, patients need to be absolutely certain this is the right choice after having reviewed the risks and benefits. Typically, these surgeries are used in adults but may be used on a case-by-case basis in adolescents.

Unfortunately, many hormone therapy and surgical treatment options may only be available if the patient has been diagnosed with gender dysphoria according to the DSM-5-TR criteria. As noted above, some people with a gender identity incongruent with the assigned sex at birth do not meet these criteria.

Also, legal and insurance hurdles can complicate access to hormone therapy and gender-affirming surgery. In some cases, healthcare providers can assist patients in cutting through the red tape of bureaucracy. Sadly, the number of attempted suicides in people without access to gender-affirming surgery is rather high.

Benefits of Gender-Affirming Care

Time and time again, research has shown that gender-affirming medical care is incredibly important for the health and well-being of transgender children. It is critical, lifesaving care. Rejection, depression, suicide, homelessness, and other negative outcomes can occur when support is lacking.

A December 2021 study from The Trevor Project, for instance, found gender-affirming hormone therapy was linked to a 40% lower risk of depression and suicide attempts over a one-year period. This large study included a total of 34,759 lesbian, gay, bisexual, transgender, queer, and questioning youth aged 13–24 years.

Seattle Children's Hospital and the University of Washington also looked at how gender-affirming care affects youth. The results of their joint study found a 60% reduction in depression and a 73% reduction in suicidality in transgender and nonbinary adolescents in their first year of gender-affirming hormone care.

Gender-affirming care is key to achieving better health outcomes. It has been shown to improve quality of life while reducing rates of suicidal ideation and suicide attempts. It can also build self-esteem.

For those seeking it, hormone therapy improves the quality of life for transgender patients. It can also have positive effects on sexual function and mood. Moreover, it may even help reduce physiological stress and lower levels of the stress hormone cortisol.

The evidence clearly shows the benefits of gender-affirming care. By acknowledging gender identity in health care, providers can make a big difference in the lives of LGBTQ+ patients.

Gender-Affirming Care in the U.S.

Attitudes toward gender-affirming medical care in the U.S. vary widely. Treatments like hormone therapy may be difficult to access for many patients and families because few clinics and medical providers offer them. Several states even prevent people from receiving appropriate care.

As of March 2023, 30 states in the U.S. restrict access to gender-affirming care or are considering laws that would do so. Under these laws, healthcare providers, and sometimes families, can be penalized for providing or seeking out this care for minors. Some of the bans being considered in 2023 would even restrict access to care for people up to the age of 26 years.

In Alabama and Idaho, providing best-practice medical care to transgender youth can actually be considered a felony charge. The Idaho bill will not go into effect until January 2024, however.

Utah passed similar legislation. In January 2023, the governor signed into law a bill that bans gender-affirming health care for transgender people under the age of 18 years.

Texas takes things a step further. As of March 2023, the Texas Legislature is considering numerous bills to prevent youth from receiving gender-affirming care. What's more, one of the bills proposes expanding the definition of child abuse to include providing puberty blockers or cross-sex hormone therapy to youth as part of gender-affirming care.

Not all states share these same views. Many have expanded their laws to protect people's right to seek gender-affirming care. Gender clinics are available in some, but not all states. According to the Human Rights Campaign, there are more clinical care programs for transgender and gender-expansive youth along the northeastern region than in the central and southern regions of the U.S.

Transgender people living in rural areas may be some of the most negatively affected. Their options for gender-affirming care and employment are often limited. A 2015 U.S. Transgender Survey found that compared to the general population, rural transgender people are more than two times—and transgender people of color are more than four times—as likely to be unemployed and living in poverty, even those with a college degree.

Telehealth has helped somewhat in bridging the gap in rural areas, but the benefits are limited by the number of licensed professionals within a state who can prescribe treatment.

Is a Prescription Required for Gender-Affirming Care?

If you do have access to gender-affirming care, you do not need a prescription for nonmedical services such as therapy. However, all gender-affirming medical treatments require a prescription. This includes puberty blockers, cross-sex hormone therapy, and surgery.

Gender-affirming care is only accessible when a child is in puberty or after, not before. There are no medical interventions for young people before they start to have changes to their bodies from puberty. Additionally, some clinics have different approaches surrounding the type of treatment a person is eligible to receive.

Additional Resources

Multiple organizations stand in support of access to gender-affirming care. The American Academy of Family Physicians recognizes diversity in gender identity and expression as a "normal part of the human existence." The American Academy of Pediatrics and the American American College of Obstetricians likewise voice their support for gender-affirming care.

Here are some of the websites and organizations that can provide more information about gender-affirming care:

• American Psychiatric Association
• American Medical Association
• Human Rights Campaign
• The Trevor Project
• World Professional Association For Transgender Health

The key message is that there is scientifically-backed evidence supporting the physical and mental health benefits of gender-affirming care. Gender-affirming care provides critical, lifesaving treatment. It starts with listening and can take many forms afterward.

It should also be mentioned that everyone should still follow recommended screening guidelines throughout their lives. People with a prostate should continue to get prostate exams. Breast exams and mammograms are also recommended if these organs/tissues have not been surgically removed.

A Quick Review

Gender-affirming care is medical care provided to the LGBTQ+ community supporting the patient's gender identity. It comes in many forms, including medical, mental health, surgical, and nonmedical services. Having access to gender-affirming care can be lifesaving.

Support is crucial and can take many forms. Healthcare providers, family, friends, and peers can make a big difference in improving health outcomes, especially in youth. Compassion, understanding, and support can go a long way.