In the United States, medical care for transgender and gender-nonconforming people is highly controversial and often divides medical professionals. Multiple reasons drive these differing expert opinions, but one specific question is often the trigger. That question is whether transgender and gender-nonconforming children should begin medical interventions at a young age.
There is no consensus on the best age to start hormone therapy or the long-term risks and benefits. This lack of consensus often leads to heated debates between experts.
One camp believes that transgender and gender-nonconforming children shouldn't receive any medical interventions until they reach adulthood and can make their own informed decisions. These experts are concerned about the potential side effects of gender-affirming treatments and believe that children aren't yet capable of making informed decisions about their bodies.
The opposing camp believes that children experiencing gender dysphoria should be given access to hormone therapy and other appropriate medical interventions as early as possible. They believe that the benefits of early intervention outweigh the risks. They also consider children capable of making these decisions with the help and support of their caregivers and medical professionals.
The matter is controversial and difficult to navigate. As a result, many transgender and gender-nonconforming people have difficulty finding medical care that meets their needs.
What is gender identity?
Gender identity refers to an individual's sense of their own gender. It applies to how they identify internally and how they express this externally. People may use clothing, makeup, and behavior to express their gender identity. A person's gender identity may or may not match the gender they were assigned at birth.
Sex and gender are not the same. Sex is based on genetic and biological factors, such as chromosomes, hormones, and reproductive organs. Female and male are the two primary sexes, although some people are intersex and have features of both.
Gender is a social construct that includes the roles, behaviors, and activities that society associates with a particular sex. In other words, gender is what we make of sex.
What is gender dysphoria?
If someone experiences gender dysphoria, they feel a mismatch between their gender identity and the sex they were assigned at birth. This mismatch can cause significant anxiety, depression, and feelings of isolation. People with gender dysphoria may feel trapped in the wrong body.
Gender dysphoria used to be called "gender identity disorder." But the World Health Organization changed the diagnostic term to "gender dysphoria" in 2018. The change was made to reduce stigma and better reflect the medical consensus that gender dysphoria is not a mental disorder.
What are the treatments for gender dysphoria?
There's no single treatment for gender dysphoria. Instead, the best approach depends on each individual's unique needs and preferences.
Some people may choose to live in their preferred gender role without any medical interventions. Others may elect to undergo hormone therapy, surgery, or both to physically transition to their preferred gender.
Hormone therapy can masculinize or feminize the body. It's usually reversible if a person decides to stop taking hormones. People may also elect to have surgery to remove or alter reproductive organs and breasts or change their bone structure. These surgeries are usually irreversible.
A more recent development in the use of puberty blockers. These medications suppress the production of estrogen or testosterone, pausing the typical bodily changes associated with puberty.
What are the risks and benefits of these treatments?
Gender-affirming hormone therapy and surgery come with both risks and benefits. The decision to undergo these treatments is a personal one that should be made after careful consideration and consultation with medical professionals.
Hormone therapy is generally safe. But like any medical treatment, there are potential risks and side effects. For example, estrogen therapy may increase the risk of blood clots, while testosterone therapy may cause blood thickening, which can cause a stroke or heart attack.
Puberty blockers are a safe way to allow children time and space to consider and settle upon their gender identity. They pause hormone-induced biological changes, like breast growth, vocal cord changes, and changes in physical structure. These changes are irreversible and often distressing to gender-nonconforming or transgender children.
Gender-affirming surgery is also generally safe. But like any surgery, there are potential risks and side effects. These may include pain, bleeding, infection, and scarring.
Despite the potential risks, hormone therapy and surgery can be lifesaving for people with gender dysphoria. They can improve mental health and quality of life.
When is the right time to have gender-affirming therapy?
This is the question that divides the medical community. Some doctors believe transgender children should wait until adulthood to undergo hormone therapy or surgery. They believe that children's bodies and brains are still developing, and they may change their minds about their gender identity as they grow older.
Other expert groups disagree. One example is the World Professional Association for Transgender Health (WPATH), a non-profit promoting evidence-based care, education, and public policy concerning transgender health. WPATH comprises more than 3,000 doctors, scientists, and other health professionals worldwide.
The group has recently lowered its recommended minimum age for starting gender-affirming therapy. They state that hormone therapy could begin at age 14, with surgeries beginning at age 15. They acknowledge the potential risks but say withholding early treatment is unethical and harmful.
Using medications to delay puberty allows for physical development consistent with someone's gender identity. As a result, it reduces gender dysphoria and is associated with better physical and mental health outcomes.
Waiting until after puberty to transition may not be ideal for everyone. Some transgender people feel intense distress at the changes in their bodies during puberty. This distress can lead to anxiety, depression, and thoughts of suicide.
What should doctors consider?
Age is just one factor to be considered. When doctors decide a person's suitability for gender-affirming therapy, they should also consider the severity of the person's gender dysphoria, psychological readiness, overall physical and mental health, and the risks and benefits of hormone therapy and surgery. Another critical factor is the availability of supportive care from family and friends.
Although the division between experts is unlikely to resolve anytime soon, the most crucial thing is that gender-questioning individuals receive the support they need to make informed decisions about every aspect of their care.
Anyone questioning their gender can find help from WPATH. They provide a directory of healthcare providers and helpful resources for trans people.