Florida is the latest state to join the current trend of attempting to restrict gender-affirming care to teens, with new Department of Health guidance stating that “social gender transition should not be a treatment option for children or adolescents” and that” anyone under 18 should not be prescribed puberty blockers or hormone therapy.” Florida’s move follows other states attempting to interfere with how healthcare workers provide evidence-based care to patients. Alabama, for example, just passed a law criminalizing recommending puberty blockers to anyone under 19, a law similar to one Arkansas passed last year.

And in February, the Texas attorney general issued an opinion classifying gender-affirming as “child abuse,” leading the governor to order parents of teens receiving gender-affirming care to be investigated by child protective services. That order is on hold after a lawsuit led a Texas court to block it—but not before multiple Texas child welfare state workers quit and parents began leaving the state for their family’s safety.

Texas and Florida’s actions directly contradict recommendations from all major medical societies with expertise in treating children and adolescents, including the American Academy of Pediatrics, the American Medical Association, the American Psychiatric Association, the American Academy of Child & Adolescent Psychiatry, the American College of Obstetricians and Gynecologists, and the Endocrine Society. The Florida document claims to “clarify” a fact sheet from the US Department of Health and Human Services that, unlike Florida’s DOH guidance, accurately describes gender-affirming care and the evidence base supporting it.  

The trend has led to an outcry from the medical community, who follow the evidence on healthcare for trans and gender-diverse teens and who have strongly opposed state intrusions into the patient-clinician relationship. Appropriate, evidence-based gender-affirming healthcare is a “matter of life and death,” say physicians speaking up about the anti-trans legislation and other state actions.

Amidst all this, it’s important that healthcare providers understand what gender-affirming care is, what it isn’t, and what the evidence says about it.

Review of Definitions

Before discussing gender-affirming care and trans healthcare, it’s important to understand the terminology in this area.

• Sex: An assignment made at birth, usually based on external genital anatomy but sometimes based on gonads, chromosomes, or hormone levels.

• Gender Identity: A person’s sense of being male, female, a combination of these, somewhere between these, or neither of these.

• Gender Expression: How a person expresses their gender identity, such as clothing, hair, behavior, and activities.

• Gender Diverse: A range of gender identities or appearances, including transgender, nonbinary (neither “male” nor “female”), genderqueer, and gender fluid. (Gender diverse replaces “gender nonconforming” because of its negative connotation.)

• Transgender: An adjective (not a noun) that describes someone whose gender identity does not match the sex assigned at birth and remains persistent and consistent over time.

• Cisgender: Describes a person whose gender identity matches the sex assigned at birth.

• Gender Dysphoria: A clinical symptom describing the sense of unease or alienation a person feels toward some or all of their physical characteristics or social roles associated with their sex or assigned gender.

What Is Gender-Affirming Care?

One of the biggest misconceptions about gender-affirming care in children and teens is that it’s all about giving kids hormones and surgeries. In reality, hormone therapy is a small part of gender-affirming care that’s not even provided to most teens, and only adults undergo gender-affirming surgery.  

Contrary to how it’s portrayed by those opposing it, gender-affirming care is a supportive model of healthcare that follows a patient’s lead in determining what services and treatments they may need.” For transgender and nonbinary children and adolescents, early gender-affirming care is crucial to overall health and well-being as it allows the child or adolescent to focus on social transitions and can increase their confidence while navigating the healthcare system,” according to the US HHS.

Gender-affirming care does not always involve medication or hormones; in minors, it rarely involves surgery. In children and teens, the most significant component of gender-affirming care is social, in which a healthcare provider discusses how a child experiences and perceives their gender and how they want to express that.

Examples include:

• Changing their hairstyle.

• Using different gender pronouns (he/she/they) than they’ve used in the past.

• Choosing clothing that they feel suits their gender identity.

• Using restrooms, locker rooms, or similar facilities associated with their gender identity, independent of their sex.

• Going by a different name, nickname, or variation of their name.

• Using binding, stuffing, padding, packing, tucking, or other methods to change one’s outward appearance.

Medical gender-affirming care can also prescribe preteen or teen kids puberty blockers to pause irreversible pubertal changes, such as a boy’s voice becoming deeper or a girl growing breasts. Puberty blockers have been used for decades for many reasons and have shown a strong long-term safety record. They’re also reversible—someone can stop taking them anytime, and puberty resumes as it would.

Less often, gender-affirming care may involve hormone therapy—testosterone or estrogen—in early, middle, or late adolescence, which is partially reversible. This type of care is only offered after extensive counseling and a social transition period. Gender-affirming surgery is available for adults but rarely occurs in those under 18.

Benefits of Gender-Affirming Care

What’s most important to understand about gender-affirming care is that a mountain of evidence shows that providing it benefits children’s and teen’s mental health, and denying it increases the risk of depression, anxiety, and suicidal thoughts and attempts. The National Child Traumatic Stress Network considers gender-affirming “trauma-informed care” in a statement with a helpful list of resources.

For an excellent overview of the “life-saving” science of gender-affirming care in youth, check out this extensive article from Medical News Today.