Gender-Affirming Care for Trans Youth
By Jamie Santa Cruz
Social Work Today
Vol. 23 No. 1 P. 12

What Social Workers Need to Know

The last few years have seen fierce public debate around whether transgender adolescents should have access to gender-affirming medical care. Multiple states recently have moved to provide greater protection to trans people and increase access to medical care for gender transitions. Many states now cover gender transitions under Medicaid, and some also require private insurers to do so.1

However, many Americans oppose offering gender-affirming medical care to minors,1 and several states—including Alabama, Arkansas, Arizona, and Florida—have recently passed laws banning the prescription of puberty blockers, cross-sex hormones, and gender-affirming surgery to people under 18. The governor of Texas recently went so far as to tell state health agencies that providing gender-affirming medical treatments to trans minors should be classified as child abuse.1

Unfortunately, the highly politicized debates around medical transitions for minors have obscured the profound complexity surrounding the treatment of trans youth. Here’s what social workers need to know about trans teens, the value of gender-affirming care, and what they can do to help gender-diverse teens access the care they need.

The Percentage of Trans Youth Is Increasing—Rapidly
The number of adolescents who identify as trans is rising sharply in the United States. As of 2022, about 1.4% of American youth aged 13 to 17 identify as trans,2 which is double the percentage just five years earlier.3 The rate varies from state to state, ranging from 3% of youth in New York identifying as trans to 0.6% in Wyoming. 2 Significantly, trans identification is increasing among youth but not adults, who identify as trans at much lower rates.2

What’s Driving the Increase?
One obvious factor is changing social attitudes. “American society has become more accepting of sexual and gender minorities,” says Erica Anderson, PhD, a clinical psychologist in private practice in Oakland, California, and former president of US Professional Association for Transgender Health. That means it’s easier for trans teens to come out of the closet without suffering crippling stigma.

But the full story is likely more complicated. Historically, most trans teens who sought care at gender clinics had a long history of gender incongruence, often extending back to childhood. However, some gender experts have reported that they’re seeing an increase in the number of adolescents who started to experience gender incongruence only recently, in adolescence.4-7 Neuroimaging studies and genetic studies suggest that biological factors influence gender identity in many trans individuals.8 However, psychosocial factors are also known to influence gender identity,9 and these factors may be playing a role in the current rapid rise in teens who identify as trans.10,11

“Adolescents are at a point in development where social factors significantly impact psychological and emotional wellbeing,” says Scott Leibowitz, MD, a child and adolescent psychiatrist and colead author of the World Professional Association for Transgender Health guidelines for the treatment of transgender adolescents. Peers, online influences, and other elements of culture can affect how teens understand themselves and what groups they want to be identified with, he explains. In an age in which teens are able—and frequently encouraged—to explore gender more deeply than in the past, it’s not surprising that more are claiming gender identities they might not have claimed in the past.

It’s Not Clear How Many Trans Teens May Change Their Minds
Several recent studies have found that children and youth who identify as trans usually don’t change their minds as they grow older. A study published last year by the Trans Youth Project tracked 317 trans children in the United States and Canada and found that almost 93% of the children continued to identify as transgender five years later.12 Among those who retransitioned to their gender assigned at birth, almost all did so before the age of 10. Similarly, Dutch researchers tracked 720 trans teens who had started taking puberty suppressants before age 18 and found that 98% of the teens continued to use gender-affirming hormones after turning 18.13 These findings suggest that teens who identify as trans are unlikely to change their minds.

That said, nearly all the existing research on the persistence of trans identity has focused on children and adolescents who began experiencing gender incongruence in childhood. Very little is known about the rate of persistence in youth who only started experiencing gender incongruence in adolescence.11

Experts also caution that the population of youth who identify as trans now is quite different from that of earlier generations, so much so that earlier data on the persistence of trans identity might not apply. A decade ago, most children and adolescents referred to gender clinics were assigned male at birth, but that has evolved rapidly, and the ratio now favors assigned females.14 In addition, there’s been a rise in the number of adolescents who identify as nonbinary rather than as male or female.15

“Gender is something that is constantly evolving in terms of how we think about it and how kids express it,” Leibowitz says. “The way that kids were expressing their gender in 2012 is very different than how they are expressing it now, and we should be embracing that change, not rejecting it.”

The takeaway for social workers, according to Leibowitz, is to avoid making assumptions about what the future will look like for any given transgender teen and to consider each one as an individual. “Even if the rates [of persistence] were 99%, technically the family I have in front of me could fall into the 1% anyway. So it doesn’t matter what the statistics say or what the rates of persistence are; it matters more what the needs of the young person in front of us are,” Leibowitz says.

Gender-Affirming Care Has Crucial Benefits for Some Trans Adolescents, Though Not All
Research suggests that gender-affirming medical treatments (particularly puberty blockers and hormone therapy) have important positive impacts on transgender adolescents in terms of psychological functioning.16,17

One 2020 study comparing trans youth to cisgender peers found that the trans youth had lower psychological function than did the cisgender teens at the start of the study before they had started puberty suppressants. Once they started on puberty suppressants, however, the trans teens demonstrated similar or better psychological function compared with their cisgender peers.18 Similarly, several recent studies have found that trans adolescents taking puberty blockers and hormone therapy had lower odds of depression, anxiety, and suicidality than did those not receiving gender-affirming treatment.19,20 In addition, a large study of trans adults found that those who had received gender-affirming hormones starting in adolescence were less likely to have considered suicide in the past year than those who had started receiving gender-affirming hormones only as adults.21

A critical caveat, however: the studies showing the value of gender-affirming care for adolescents have focused almost exclusively on teens who first started experiencing gender incongruence in childhood.11 “We don’t have any research on this current group, on this larger group that only started presenting in adolescence,” says Anderson, who is herself transgender.

It’s also worth noting that the long-term health effects of gender-affirming medical treatment aren’t clear. There is some concern that puberty blockers may compromise bone health, influence growth and adult height, and alter brain development, in addition to compromising fertility.11,22

Because of the lack of evidence surrounding widespread use of gender-affirming medical treatments and because of the potentially serious consequences of overusing such treatments, several European countries—including Sweden, Finland, and most recently, the United Kingdom—have recently moved toward more caution about offering them to adolescents.23,24 Both Leibowitz and Anderson support this impulse toward caution, stressing the need for highly individualized care based on a careful evaluation of each teen’s specific context and unique needs. It’s important, they say, to ask questions like these:

• Is this teen gender questioning or gender distressed? According to Anderson, some young people experience an incongruence between their felt gender and their sex assigned at birth and feel marked distress over it, while others are exploring gender and may experience incongruence without true distress. “One size does not fit all,” she says. If an adolescent is distressed, “that begs for more intervention.” On the other hand, if teens are gender questioning without marked distress, “why medicalize them?”

• How well does this teen know themselves? Gender-affirming medical treatments are safer for adolescents who have a strong self-understanding, Leibowitz says. “If a kid is gender diverse in their expression or identity for a really long time, they’re more informed than if a kid experiences gender diverse expression or identity more recently,” he explains. Similarly, adolescents with stable mental health are more grounded than adolescents who have unaddressed psychiatric concerns or other factors in their lives that could impair their decision-making ability.

One of the complexities of treating transgender adolescents is that many do have factors that might impair self-knowledge and decision-making ability. To begin with, trans teens are much more likely than their cisgender peers to suffer from anxiety, eating disorders, depression, self-harm behaviors, and suicidal ideation.25 They’re also more likely to be on the autism spectrum, and many have also experienced trauma of one kind or another, including sexual assault or bullying.25

Some of the mental health conditions that co-occur with transgender identification may be caused either by gender incongruence or by the social stigma associated with it, and these mental health conditions may be improved with gender-affirming treatment. Thus, according to Anderson, it’s unreasonable to deny teens gender-affirming treatment solely on the grounds that they have co-occurring mental health conditions.

At the same time, Anderson adds, the presence of mental health conditions makes it more difficult to accurately diagnose gender incongruence and determine the best treatment plan. Indeed, a recent survey of 237 individuals who retransitioned to their assigned sex found that 70% did so because they ultimately realized their gender incongruence was related to other issues.26 It is, therefore, essential, according to Anderson, to carefully evaluate and treat co-occurring mental health concerns prior to launching into gender-affirming medical treatment. This is especially true in the case of teens who start experiencing gender incongruence relatively late (in adolescence rather than childhood) since teens in this category appear to have worse mental health than those who start presenting at younger ages.11,27

Why Access to Gender-Affirming Care for Adolescents Remains Critical
While medical treatments may not be appropriate for all trans youth, Anderson and Leibowitz both argue it’s essential that such treatments be available. More specifically, gender-affirming care should be available to teens while they are still adolescents—not just when they become adults.

One reason for this is that gender-affirming treatment may be more effective in adolescence. Once a teenager has developed secondary sex characteristics—such as a prominent Adam’s apple, tall stature, and deep voice for men, and breast tissue for women—it’s difficult or impossible to alter those characteristics later.

But another reason is that treatment in adolescence allows the physical maturation of trans teenagers to occur in sync with their emotional and psychological maturation. “When different development processes are aligned as closely as possible, young people, both cis and trans, do better over the course of their lives,” Leibowitz says. “When there are gaps [in different aspects of development] is when there are higher risks of psychopathology.”

According to Leibowitz, disconnects in development can occur in cisgender youth, such as in the case of a teenager who enters puberty very late (age 16 or 17) or in the case of adolescents on the autism spectrum whose intellectual development is far ahead of their social and emotional development. But they can also occur in the case of trans youth who are prohibited from pursuing medical care to bring their physical development into harmony with their psychological understanding of their own gender identity. To avoid this kind of disconnect and the psychosocial difficulties associated with it, Leibowitz says, it is best not to delay gender-affirming treatment more than necessary for adolescents who are clear candidates.

What Social Workers Can Do
Social workers have a key role to play in supporting trans teens, connecting them to other resources, and advocating for legal protections that will promote their wellbeing. Here are the top steps social workers should take in the current environment of intense political polarization around gender-affirming care:

1. Seek resources before you need them.
“Get educated on these issues,” says Kristie Seelman, PhD, MSW, an associate professor and director of the Bachelor of Social Work Program in the School of Social Work at Georgia State University. “Read first-person accounts from transgender youth and their parents about care they need and their experiences trying to access it. Read books, blogs, watch videos. Educate yourself.”

It’s important to take these steps today, even if you don’t currently have any trans clients. “Just recognize that the next person who comes through the door could be trans. Or might come out as trans six months down the road,” says Meg Paceley, an associate professor in the School of Social Welfare at the University of Kansas in Lawrence. “So find your resources before the need arises. Make sure you are prepared to practice competently.”

2. Promote affirming spaces for trans youth.
Regardless of whether trans teens continue to identify as trans for the rest of their lives or not, they need to know they are accepted and affirmed and that they have space and support to develop their identities, whatever those turn out to be. “Even having just one supportive/affirming person reduces suicide risk by 40%,” Paceley says, citing recent research from The Trevor Project.28

Social workers can provide affirmation on an individual level, Paceley says, but it’s equally important to work at a system level. The idea is not just to be an affirming person but to create affirming and accepting spaces. Two simple ways to do this: advocate within your institution for gender-affirming bathrooms and for forms that offer more options for gender than just male/female. “Advocating for a gender-inclusive bathroom can signal, ‘we thought of you,’” Paceley says. Similarly, “if our forms don’t just say male/female, it shows, ‘we thought of you.’”

Also: educate other professionals in the office, such as front-desk staff and those who cover billing. “It’s great if a therapist is affirming, that’s great, but the front desk staff matters,” Paceley says. “Do they know to check people’s chosen name and pronouns and use them correctly?”

3. Treat all trans youth as individuals. Recognize that they come from different contexts and will have different needs.
Some may have a relatively fixed gender identity that has been consistent since childhood; others may still be in a more fluid process of gender identity development. Some may be experiencing distress over their gender, others may not. Some may benefit from gender-affirming medical care; others won’t need it.

4. Advocate for access to gender-affirming care for adolescents.
It’s extremely important not to rush transgender teens into medical treatment since such treatments may have life-altering impacts and some teens are unlikely to benefit. But it is also critical that such care be available to teens who need it, and social workers have a critical role to play in advocacy.

“Research where local elected officials stand on these issues,” Seelman says. “This topic is very on the radar politically. A lot of people in Congress, senators, state legislators are making public statements on this topic. Share your personal perspective with them as a voter.”

Ultimately, Anderson says, it all comes down to making sure the right care is available to the right person. “I don’t want kids to be subjected to treatment needlessly—whether psychotherapy or medical treatment,” she says. “But I don’t want them to be denied it if they need it.”

— Jamie Santa Cruz is a writer in Parker, Colorado.

References
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