gender identity reassignment therapy

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• Gender dysphoria

Your health care provider might make a diagnosis of gender dysphoria based on:

• Behavioral health evaluation. Your provider will evaluate you to confirm the presence of gender dysphoria and document how prejudice and discrimination due to your gender identity (minority stress factors) impact your mental health. Your provider will also ask about the degree of support you have from family, chosen family and peers.
• DSM-5. Your mental health professional may use the criteria for gender dysphoria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Gender dysphoria is different from simply not conforming to stereotypical gender role behavior. It involves feelings of distress due to a strong, pervasive desire to be another gender.

Some adolescents might express their feelings of gender dysphoria to their parents or a health care provider. Others might instead show symptoms of a mood disorder, anxiety or depression. Or they might experience social or academic problems.

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Treatment can help people who have gender dysphoria explore their gender identity and find the gender role that feels comfortable for them, easing distress. However, treatment should be individualized. What might help one person might not help another.

Treatment options might include changes in gender expression and role, hormone therapy, surgery, and behavioral therapy.

If you have gender dysphoria, seek help from a doctor who has expertise in the care of gender-diverse people.

When coming up with a treatment plan, your provider will screen you for mental health concerns that might need to be addressed, such as depression or anxiety. Failing to treat these concerns can make it more difficult to explore your gender identity and ease gender dysphoria.

Changes in gender expression and role

This might involve living part time or full time in another gender role that is consistent with your gender identity.

Medical treatment

Medical treatment of gender dysphoria might include:

• Hormone therapy, such as feminizing hormone therapy or masculinizing hormone therapy
• Surgery, such as feminizing surgery or masculinizing surgery to change the chest, external genitalia, internal genitalia, facial features and body contour

Some people use hormone therapy to seek maximum feminization or masculinization. Others might find relief from gender dysphoria by using hormones to minimize secondary sex characteristics, such as breasts and facial hair.

Treatments are based on your goals and an evaluation of the risks and benefits of medication use. Treatments may also be based on the presence of any other conditions and consideration of your social and economic issues. Many people also find that surgery is necessary to relieve their gender dysphoria.

The World Professional Association for Transgender Health provides the following criteria for hormonal and surgical treatment of gender dysphoria:

• Persistent, well-documented gender dysphoria.
• Capacity to make a fully informed decision and consent to treatment.
• Legal age in a person's country or, if younger, following the standard of care for children and adolescents.
• If significant medical or mental concerns are present, they must be reasonably well controlled.

Additional criteria apply to some surgical procedures.

A pre-treatment medical evaluation is done by a doctor with experience and expertise in transgender care before hormonal and surgical treatment of gender dysphoria. This can help rule out or address medical conditions that might affect these treatments This evaluation may include:

• A personal and family medical history
• A physical exam
• Assessment of the need for age- and sex-appropriate screenings
• Identification and management of tobacco use and drug and alcohol misuse
• Testing for HIV and other sexually transmitted infections, along with treatment, if necessary
• Assessment of desire for fertility preservation and referral as needed for sperm, egg, embryo or ovarian tissue cryopreservation
• Documentation of history of potentially harmful treatment approaches, such as unprescribed hormone use, industrial-strength silicone injections or self-surgeries

Behavioral health treatment

This treatment aims to improve your psychological well-being, quality of life and self-fulfillment. Behavioral therapy isn't intended to alter your gender identity. Instead, therapy can help you explore gender concerns and find ways to lessen gender dysphoria.

The goal of behavioral health treatment is to help you feel comfortable with how you express your gender identity, enabling success in relationships, education and work. Therapy can also address any other mental health concerns.

Therapy might include individual, couples, family and group counseling to help you:

• Explore and integrate your gender identity
• Accept yourself
• Address the mental and emotional impacts of the stress that results from experiencing prejudice and discrimination because of your gender identity (minority stress)
• Build a support network
• Develop a plan to address social and legal issues related to your transition and coming out to loved ones, friends, colleagues and other close contacts
• Become comfortable expressing your gender identity
• Explore healthy sexuality in the context of gender transition
• Make decisions about your medical treatment options
• Increase your well-being and quality of life

Therapy might be helpful during many stages of your life.

A behavioral health evaluation may not be required before receiving hormonal and surgical treatment of gender dysphoria, but it can play an important role when making decisions about treatment options. This evaluation might assess:

• Gender identity and dysphoria
• Impact of gender identity in work, school, home and social environments, including issues related to discrimination, abuse and minority stress
• Mood or other mental health concerns
• Risk-taking behaviors and self-harm
• Substance misuse
• Sexual health concerns
• Social support from family, friends and peers — a protective factor against developing depression, suicidal thoughts, suicide attempts, anxiety or high-risk behaviors
• Goals, risks and expectations of treatment and trajectory of care

Other steps

Other ways to ease gender dysphoria might include use of:

• Peer support groups
• Voice and communication therapy to develop vocal characteristics matching your experienced or expressed gender
• Hair removal or transplantation
• Genital tucking
• Breast binding
• Breast padding
• Aesthetic services, such as makeup application or wardrobe consultation
• Legal services, such as advanced directives, living wills or legal documentation
• Social and community services to deal with workplace issues, minority stress or parenting issues

More Information

Gender dysphoria care at Mayo Clinic

• Pubertal blockers
• Feminizing hormone therapy
• Feminizing surgery
• Gender-affirming (transgender) voice therapy and surgery
• Masculinizing hormone therapy
• Masculinizing surgery

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Coping and support

Gender dysphoria can be lessened by supportive environments and knowledge about treatment to reduce the difference between your inner gender identity and sex assigned at birth.

Social support from family, friends and peers can be a protective factor against developing depression, suicidal thoughts, suicide attempts, anxiety or high-risk behaviors.

Other options for support include:

• Mental health care. You might see a mental health professional to explore your gender, talk about relationship issues, or talk about any anxiety or depression you're experiencing.
• Support groups. Talking to other transgender or gender-diverse people can help you feel less alone. Some community or LGBTQ centers have support groups. Or you might look online.
• Prioritizing self-care. Get plenty of sleep. Eat well and exercise. Make time to relax and do the activities you enjoy.
• Meditation or prayer. You might find comfort and support in your spirituality or faith communities.
• Getting involved. Give back to your community by volunteering, including at LGBTQ organizations.

Preparing for your appointment

You may start by seeing your primary care provider. Or you may be referred to a behavioral health professional.

Here's some information to help you get ready for your appointment.

What you can do

Before your appointment, make a list of:

• Your symptoms , including any that seem unrelated to the reason for your appointment
• Key personal information , including major stresses, recent life changes and family medical history
• All medications, vitamins or other supplements you take, including the doses
• Questions to ask your health care provider
• Ferrando CA. Comprehensive Care of the Transgender Patient. Elsevier; 2020. https://www.clinicalkey.com. Accessed Nov. 8, 2021.
• Hana T, et al. Transgender health in medical education. Bulletin of the World Health Organization. 2021; doi:10.2471/BLT.19.249086.
• Kliegman RM, et al. Gender and sexual identity. In: Nelson Textbook of Pediatrics. 21st ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Nov. 8, 2021.
• Ferri FF. Transgender and gender diverse patients, primary care. In: Ferri's Clinical Advisor 2022. Elsevier; 2022. https://www.clinicalkey.com. Accessed Nov. 8, 2021.
• Gender dysphoria. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed Nov. 8, 2021.
• Keuroghlian AS, et al., eds. Nonmedical, nonsurgical gender affirmation. In: Transgender and Gender Diverse Health Care: The Fenway Guide. McGraw Hill; 2022. https://accessmedicine.mhmedical.com. Accessed Nov. 8, 2021.
• Coleman E, et al. Surgery. In: Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People. Version 7. World Professional Association for Transgender Health; 2012. https://www.wpath.org/publications/soc. Accessed Nov. 3, 2021.

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Effective Treatments for Gender Dysphoria: Goals and Techniques

Reviewed by Laura Angers, LPC · November 27, 2020 ·

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Here's a look at gender dysphoria treatment and how it can help.

Assigned Gender Vs. Expressed And Experienced Gender

Before looking at the definition of gender dysphoria, it helps if you know what assigned and experienced gender is.

Your assigned gender is the gender you were proclaimed to be at birth. Perhaps a doctor or midwife looked at you and told your parents whether you were a boy or girl. Or maybe your parents made that determination themselves. They treated you as that gender as you grew up. They probably dressed you in the typical clothes for that gender, encouraged you to behave as that gender, and discouraged you from participating in the usual activities of the other gender.

Your experienced or expressed gender is the gender you feel inside. It's aligned with the gender roles that feel right to you. And it's the gender that society associates with the types of behavior that you feel natural doing. When you and others accept your experienced and expressed gender, you can feel comfortable in your skin.

Gender Dysphoria Definition

Gender dysphoria can happen when there's a mismatch between the gender you were assigned at birth and your own experiences of gender. Your body parts may indicate that you're male or female, but you feel strongly that you're the opposite. The dysphoria part refers to a sense of discontent or unhappiness with your biological gender and the gender roles you're expected to conform to in society. The dysphoria definition emphasizes the distress caused by the mismatch between assigned gender and experienced gender.

Gender Dysphoria Vs. Gender Identity Disorder

In the past, transgender people were often diagnosed with a gender identity disorder. But psychology experts realized that this diagnosis could be harmful. It suggests that it's your gender identity that's the problem. It seems to say that if you don't identify with your assigned gender, there's something wrong with you. And, gender identity disorder gives the impression that you need to think, feel, and behave as society expects you to because of your assigned gender.

That's why the DSM 5 changed the name and criteria for diagnosis. Now, the term used is gender dysphoria. What's the difference? The phrase "gender dysphoria" recognizes that the real problem is the distress you feel about the mismatch. Part of the distress may come from ideas you and your family have about gender you or they think you should be. Also, you and they may be uncomfortable with how you express gender. Another part of the discontent might be because of the social stigma attached to being transgender. In any case, the new term recognizes that your gender identity isn't a problem.

Is Gender Dysphoria A Mental Illness?

As defined in the Diagnostic and Statistical Manual, the  DSM-5, gender dysphoria  is listed among all the recognized mental disorders. After all, the purpose of the manual is to guide the diagnosis of mental conditions.

However, the label "disorder" was eliminated in this version of the DSM to reduce the stigma of having that diagnosis. And in the sense that mental illness indicates an abnormal way of thinking, feeling, or behaving, gender dysphoria really can't be considered a mental illness.

Again, it's important to remember that it's the distress or dysphoric experience of being transgender, making it a mental problem. If you're transgender but have no dysphoric feelings, thoughts, or behaviors about it, you don't have dysphoria.

DSM Gender Dysphoria Criteria

The DSM 5 lists specific criteria for gender dysphoria to help mental health professionals recognize and diagnose this condition. Receiving this diagnosis means that two things are true. First, your assigned gender is different from the gender you experience and express. Second, you have distress about that and may even have problems functioning because of it.

Furthermore, you must have at least two of the following symptoms, and they must last for at least six months.

• There's a significant difference between your experienced gender and your primary or secondary sex characteristics.
• You strongly wish you could eliminate your current primary and secondary sex characteristics.
• You have a deep desire to have the primary or secondary characteristics of another gender.
• You strongly want to be the other gender.
• You want others to treat you as the other gender.
• You feel confident that you behave and react the same as people of the other gender usually do.

Gender Dysphoria Treatment

Treatment for gender dysphoria  is designed to help you deal with or overcome your dysphoric experience of gender. It can consist of various types of individual or group therapy. This treatment won't change who you are. It has different goals and outcomes you may not expect.

Goals Of Treatment

The goals of treatment for gender dysphoria all have to do with coming to terms with your gender. Here is a brief list of some of the goals you might work towards psychological treatment for gender dysphoria.

• Explore Your Gender Identity – Maybe you don't know what your gender identity is. You might have had conflicting feelings or experiences related to gender. In therapy, you have the freedom to question your assigned gender without any requirement to change or not change your gender identity. And, you can explore what it means to you to be male or female.
• Accept Yourself As The Gender You Feel Inside – With society pushing you to behave as your assigned gender, it might be hard to accept yourself for who you are inside. You may criticize yourself constantly or feel like a failure when you don't conform to others' wants. Before you can deal with their disapproval, you have to learn to love yourself like your gender. Therapy can help you come to terms with the mismatch and even boost your self-esteem.
• Deal With Family And Society's Expectations. It can be disheartening when those around you expect you to behave differently than you do. Even if you don't express the gender you feel inside, knowing that others expect you to can be very upsetting. But as you learn to deal with their disapproval, you can begin to feel more confident in being who you are.
• Learn How To Handle Bullying  – Often, transgender people are the targets of bullies. It's a common experience to be hurt physically or emotionally by people who don't understand gender differences. So, knowing how to deal with situations where you're being bullied can make your life easier and less distressing.

• Express Your Dysphoric Feelings In A safe, Non-Judgmental Environment – One goal of therapy is to support you. This therapy aspect is often critical because so many transgender people face disapproval and are even shunned by their family and society; having a place to express yourself freely can be invaluable.
• Explore Options For Expressing And Living Your Gender Identity –Your therapist can provide information and educational materials about the ways you might choose to approach gender incongruence. They can offer info on topics like living as the other gender, getting gender reassignment surgery, and each option's psychological challenges. They can also support you as you talk through your reactions to each of these solutions.
• Manage The Coming Out Process – If you decide to let others know that you're transgender, you may be afraid of what will happen. And indeed, you may face numerous challenges during this crucial period. A counselor allows you to express yourself and helps you deal with your fears. They can offer insights about what to expect and offer support during this time.
• Help With Living According To Your True Gender Identity –If you have gender reassignment treatment, you'll probably spend some time living as the other gender before making the transition. Even if you don't intend to make a medical transition, you might decide to live in a way that's congruent with your gender identity. This change may involve many practical dilemmas and adjust to societal attitudes about how you choose to live. A therapist can help you cope with and manage your new living situation.
• Deal With Gender Reassignment – At some point, you may decide to make a physical transition to your experienced gender. If you do, therapy can help you deal with any mixed feelings or fears you have about changing your gender through medical procedures.

Treatment Methods

Many of the same treatment methods are used for gender dysphoria as for many other mental problems. The difference is that the subjects you deal with in therapy will be different. But the techniques used may be about the same.

The exception, of course, is gender reassignment. Medical treatment for gender dysphoria usually consists of the triadic treatment model. The triadic treatment has three parts: living as your true gender identity, taking hormones, and getting surgery to change your sex characteristics.

As for psychotherapy methods, your counselor may help you using a variety of techniques and therapy types. These include:

• Individual counseling
• Couples, family, or group therapy
• Educational counseling
• Coping skills development
• Insight therapy

"Do I Have Gender Dysphoria?"

You might be well aware there's a mismatch between your assigned gender and your experienced gender. Or perhaps you're only questioning whether you have gender identity issues. Even if you are sure of your gender identity, though, you may not be sure that it's causing you significant distress.

One way to find out is to take a  gender dysphoria test . An online screening test for gender dysphoria is a confidential and objective assessment of your symptoms. It isn't a diagnosis, but it can reveal the need to explore the possibility further. Suppose the results show you probably have this condition. In that case, you can then consider working with a mental health professional to resolve your gender issues.

Gender dysphoria is a condition that can cause significant distress. The first step to relieving your fears or discomfort is to find out if you have the symptoms of gender dysphoria. If you do, you can move on to seeking mental health help for diagnosis and treatment.

In the end, whatever your gender identity, you can learn many ways to deal with the feelings that come with it. With the best treatment for you, you can learn to accept your inner gender identity and live the life that matches your gender experience.

Frequently Asked Questions (FAQs)

What is the most effective treatment for gender dysphoria? How do you cure gender dysphoria? What happens if you don't treat gender dysphoria? What medications are used for gender dysphoria? Can gender dysphoria go away? Can gender dysphoria be caused by trauma? At what age is gender dysphoria most common? How do you shower with dysphoria? What are the signs of gender dysphoria? Can you self-diagnose gender dysphoria?

Find out if you have Gender Dysphoria

Take this mental health test. It's quick, free, and you'll get your confidential results instantly.

Mental health conditions are real, common, and treatable. If you or someone you know thinks you are suffering from gender dysphoria then take this quick online test or click to learn more about the condition.

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Psychotherapy Bulletin

Practice Recommendations for Psychotherapy With Gender Diverse Clients

Clinical Impact Statement: Clients who identify as transgender or gender diverse who seek psychotherapy need competent, affirmative treatment and practitioners. In this article, the authors provide resources and recommendations for therapists to improve their provision of affirmative psychotherapy.

Recently, the population of people who identify as transgender or gender diverse has become more visible in U.S. society. Likewise, there have been calls by psychologists and counselors for more research and scholarship related to gender identity and issues that people who identify as gender diverse might face or present with in therapy. Psychotherapists have a number of guidelines and resources to assist in providing affirmative work with gender diverse clients. For example, the American Psychological Association (APA) published the Guidelines for Psychological Practice with Transgender and Gender Nonconforming People (APA, 2015). The Association for Lesbian , Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) developed their Competencies for Counseling Transgender Clients in 2009. The World Professional Association for Transgender Health (WPATH) published its Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People in 2011 (SOC 7.0) and is currently working on making revisions for SOC 8.0. A number of helpful articles and books to assist therapists have been published in recent years, such as Hendricks and Testa’s (2012) framework for clinical work with transgender and gender nonconforming clients; Singh and dickey’s (2017) text on affirmative counseling and psychological practice, as well as their instructional video on the topic (2018); and Budge’s (2015) article on writing letters for transgender clients.

It is beyond the scope of this article to provide a thorough, extensive review of the literature that is available. Instead, we pull from our own clinical experiences working with gender diverse clients and discuss some of the common themes and issues we frequently see. A caveat is that this article is based on our own experiences, which are limited to clients we have seen in the last approximately 10 years in rural, suburban, and urban areas of the Midwest and Southwest regions of the U.S. Our experiences have included private practice, college counseling centers, medical/hospital settings, public schools, and local LGBTQ centers. Therapists in regions such as the east and west coasts or who practice in different settings may have different experiences, and clients may need different types of resources, or may have better access to resources than our clients have. This article is based on our own professional opinions, is not exhaustive, and we are sure we have missed some things— we welcome others to share their own unique experiences in future publications.

To us, one of the first and most important things for therapists to understand is the importance of language when working with transgender or gender diverse clients. As recently as 2015, when the APA Guidelines were developed, the term gender non-conforming was used. More recently, it seems that the term gender diverse may be preferred as an umbrella term for anyone who does not identify as cisgender. The term cisgender refers to an individual whose sex assigned at birth is congruent with their gender identity. The term non-binary also appears to be more frequently used now than it was five years ago. However, some individuals may find terms like non-binary and non-conforming to be problematic, given that they define populations in relationship to societal expectations or based on who these individuals are not, as opposed to who they are. Thus, it is important for therapists to invite their clients to self-identify, and for therapists to share their own identities as well. Simple steps such as beginning to refer to gender identities rather than to gender identity provides verbal confirmation that the therapist views gender as reaching beyond fixed, binary categories.

Sensitivity to gender diversity has many implications for clinical practice. For example, clinical paperwork may need to be reconsidered. Having an open space on an intake form such as “Gender: _____” rather than offering choices might allow a client to use the language that is most appropriate. We prefer this to offering choices such as Male/Female/Other because this can be “othering.” Therapists should also initiate discussions about gender to fully understand how their clients identify rather than simply what terms their clients use to express their gender identities. We suggest that therapists self-educate and interact with transgender communities to stay current and competent. For example, simply watching online videos by transgender bloggers may provide valuable insight and growth. A great resource for therapists to keep up with terminology is the National Center for Transgender Equality (transequality.org). We also really like FORGE, which is based in Wisconsin but provides wonderful resources and publications that are applicable across the U.S. (forge-forward.org). The book Trans Bodies, Trans Selves: A Resource for the Transgender Community is also a valuable resource for clinicians wishing to gain insight and understanding about many dimensions of transgender experience (Erickson-Schroth, 2014).

Another issue that therapists should be aware of is the use of pronouns. Throughout this article, we use the pronouns “they/them/their” to refer to a singular client in examples. Again, we recommend that rather than assuming that a client who identifies as female would use she/her/hers pronouns, the therapist ask the client what the preferred pronouns are. This may also be included on an intake form with an open-ended response option such as “Pronouns: ______.” We also encourage therapists to offer their own pronouns at the beginning of a therapeutic relationship with a client. Demonstrating awareness that the clinician’s own pronouns are salient (and may not be assumed) communicates to the client that the therapist is thoughtful about the salience of gender identities in the therapeutic process.

Use of pronouns seems to vary by geographic area, current trends, and age of the client. We have found that our older clients tend to prefer more traditional he/him/her, she/her/hers, and they/them/their pronouns. Younger clients, and clients in larger cities or on the east or west coasts, may use pronouns such as ze/zim/zirs or ey/em/eirs. The websites we mentioned previously also have great charts and fact sheets about pronouns. Therapists may worry about getting pronouns “right,” or may accidentally use incorrect pronouns. Like any error made in therapy, we believe it is best to have a transparent conversation about this, apologize, and make a conscientious effort to do better next time. We strongly advise against the use of terms like “preferred” or “chosen” gender or pronouns; this implies that gender identity is chosen in some way. As we know from transgender scholarship, gender identity is not a choice and implying that it is may create considerable fractures in the therapeutic relationship.

Another term that therapists may hear in relation to this population is transition or more accurately transitions because the singular form of this word assumes that one type or process of transition applies to all transgender populations. It is important to know that while people who identify as transgender may choose to transition, many do not. Also, transition is a completely individual experience: No two transitions are alike. As part of transition, some clients may change their names. Whether a legal name change has happened or not, it is important that the therapist use the client’s identified name and offer a place on the intake form for this information. We understand that for some legal purposes, such as insurance billing, it may be necessary to track two names simultaneously; we do not feel this is an undue burden for the therapist. We have worked with clients who have wanted to experiment with how different names “felt” over time, and who have asked us to use multiple different names over time. We reflect this in our case notes and refer to clients using their current, identified name and pronouns.

For many clients who transition, it is helpful to put together a timeline or plan, including financial cost or resources. It is important to remember that transitions may occur on a variety of levels or within a variety of life domains. Social transitions may occur interpersonally between transgender people and their loved ones, family, and friends. Legal transitions involve name and gender marker changes on government documents. Some transition-related actions may include coming out to family members, friends, or coworkers; legal name change; gender marker change on identification and government documents; wardrobe change; and therapy, if required for hormone replacement therapy or for gender affirmation surgery. For clients who identify as male, other aspects of transition could include binding or packing. For clients who identify as female, transition might include removal of body hair through electrolysis, practicing voice (sometimes through coaching), or wearing breast prosthetics. Within the context of clinical work, therapists may benefit from knowing the extent to which a client has transitioned or plans to transition. Therapists may feel the need to ask deeply personal questions about aspects of physical transition. We encourage therapists to recognize how invasive these questions may be and how trusted and privileged therapists are as they engage in these conversations. Such questions should never be made out of personal interest or outside of the therapeutic interaction, and these conversations should be led by the client.

For any client who is transitioning, being misgendered is a frequent source of frustration, hurt, sadness, and anger. In our experience, clients are more forgiving of strangers who might misgender them (although this, too, is frustrating), while being misgendered by their close family and friends is particularly hurtful and rejecting. Family members and friends often misgender, either deliberately or by accident, even after multiple reminders. When a client tells a therapist about an experience of being misgendered and the hurt related to this, it is important for therapists to validate this experience. These clients may get messages such as “you’re making a big deal of this,” or “you will always be my little boy/girl,” or “don’t be so sensitive,” so it is crucial for therapists to listen and empathize. On the other hand, we have also had clients who have attempted to diminish these experiences in therapy, and for whom it took a while to recognize the pain these experiences were causing.

Therapists may wonder what therapy should actually look like. The approach that therapists take does not need to differ from the approach they may take with other clients, but should be affirmative in nature. We recommend that any therapist who works with gender diverse clients fully familiarize themselves with the APA guidelines, the ALGBTIC competencies, and the WPATH standards of care, at a minimum. It is important to note that clients who identify as transgender or gender diverse may present with other concerns, and gender identity may not be their foremost concern. The therapist should work collaboratively with the client in a client-centered manner. For example, if a client transitioned years ago, and presents with concerns related to her current romantic relationship, then the therapist should focus on the romantic relationship as the presenting concern, rather than the transgender identity. On the other hand, if a client states that they want to work toward transition and are hoping for a letter of recommendation from the therapist, it is important for the therapist to assist with that. Therapists who are unable to write letters of support or to aid the client in transition-related actions must be upfront about this at intake. We have heard stories from clients and community members who saw therapists for months before discovering that their therapists would not provide supporting letters. This can be devastating for a client because it has the possibility of setting their transition back and may separate them from necessary and/or life-saving services.

Consider this example of affirmative therapy: Imagine that Sam is your client. Sam is a 22-year old male-identified client who was assigned female at birth. Sam uses they/them/their pronouns. Sam tells you that they reached out to make an appointment with you because they are feeling frustrated with their previous therapist. Sam tells you that they are limiting and controlling food intake. Sam has periods of depression and suicidality and uses substances to cope. Sam also states that they are experiencing high levels of gender dysphoria. In this case, how would you proceed with the client? Would you focus on the disordered eating? Would you focus on the depression and suicidal thoughts? The client states that they think about dying or suicide more days than not. Does the client need treatment for substance abuse before going forward with psychotherapy? Would you recommend the client receive hormone therapy?

Clearly, it is important to consider the client’s safety. If a client is imminently in danger, then appropriate steps/precautions have to be taken. However, in our clinical judgment and experience, approaching the client as someone who is autonomous and who knows themselves as a gender diverse person should be foremost in the therapist’s mind. Budge (2015) provides an excellent discussion about the gatekeeping role that therapists are currently asked to play and whether this fits with our ethical code and moral principles.

With this client, as you explore issues related to gender, you learn that they are limiting food intake because experiencing menstrual periods heightens gender dysphoria and, subsequently, depressive symptoms. You learn that Sam’s family has rejected them completely so they are working 30 hours per week while maintaining a full course load at college. We recommend working with the client to explore gender, the current living situation, and to put gender first as a priority, while also doing frequent check-ins regarding suicidality and eating. WPATH (2011) guidelines strongly establish that being allowed to transition, and starting hormone replacement therapy, reduces depressive symptoms and improves mental health. Furthermore, starting hormone replacement therapy could reduce or halt menstrual cycles, which could also diminish gender dysphoria experienced by this client.

Though we have only been able to brush over the many themes and presenting concerns that may arise in work with gender diverse communities, we hope that this brief overview will provide a first step for therapists who wish to increase their competence with gender diverse clients. The body of literature regarding transgender and gender diverse affirmative practice is growing exponentially and therapists have the opportunity to reach this community in informed and thoughtful ways like never before. We hope you will choose to incorporate transgender affirmative awareness into your own practice.

Julie M. Koch, Ph.D.

Julie M. Koch, Ph.D. (she/her) is an Associate Professor and Head of the School of Community Health Sciences, Counseling and Counseling Psychology at Oklahoma State University. She has a small private practice that serves mostly transgender clients. Her research interests include training and development of therapists, microaffirmation, and multicultural counseling.

Cite This Article

Koch, J. M. & Knutson, D. (2018). Practice recommendations for psychotherapy with gender diverse clients. Psychotherapy Bulletin, 53 (2), 44-48.

American Psychological Association. (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832-864. doi: 10.1037/a0039906

Association of Lesbian, Gay, Bisexual, and Transgender Issues in Counseling. (2009). Competencies for counseling with transgender clients. Alexandria, VA: Author.

Budge, S. (2015). Psychotherapists as gatekeepers: An evidence-based case study highlighting the role and process of letter writing for transgender clients. Psychotherapy, 52(3), 287-297. doi: 10.1037/pst0000034

dickey, l. m., & Singh, A. A. (2018). Affirmative counseling with transgender and gender diverse clients [DVD]. United States: American Psychological Association.

Erickson-Schroth, L. (2014). Trans bodies, trans selves: A resource for the transgender community. New York, NY: Oxford University Press.

Hendricks, M. L., & Testa, R. J. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress

Model. Professional Psychology: Research and Practice, 43, 460-467. doi: 10.1037/a0029597

Singh, A., & dickey, l. m. (Eds.). (2017). Perspectives on sexual orientation and diversity. Affirmative counseling and psychological practice with transgender and gender nonconforming clients. Washington, DC: American Psychological Association.

World Professional Association for Transgender Health (2011). Standards of care for the health of transsexual, transgender, and gender nonconforming people: 7th Version. Retrieved from http://www.wpath.org

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Gender reassignment therapy is an umbrella term for all medical procedures regarding gender reassignment of both transgender and intersexual people. (Sometimes also called sex reassignment, as it alters physical sexual characteristics to be more in line with the individual’s psychological/social gender identity, rather than vice versa.)

Gender reassignment therapy consists of hormone replacement therapy (HRT), various surgical procedures (see below), and epilation for transwomen, that is permanent hair removal on the face and body is accomplished with electrolysis or laser hair removal.

Transsexual people who go through gender reassignment therapy usually change their social gender roles, legal names, and legal sex designation, in addition to undergoing the medical procedures discussed in this article. The entire process of change from one gender presentation to another is known as transition.

Sex reassignment surgery is the most common term for what would be more accurately described as genital reassignment surgery or genital reconstruction surgery . This refers to the procedures used to make male genitals in to female genitals and vice versa. Sex reassignment surgery, or SRS, can also refer to any surgical procedures which will reshape a male body into a body with a female appearance or vice versa.

Surgical procedures related to gender reassignment

For trans men , who transition from female to male:

• Sexual reassignment surgery female-to-male
• Mastectomy is the removal of female breasts and, in case of gender reassignment, the shaping of a male contoured chest.
• Hysterectomy is the removal of female internal sex organs.
• Metoidioplasty is the construction of a small penis out of the clitoris which has been enlarged by HRT
• Phalloplasty is specifically the construction of a neo-penis in transmen

For trans women , who transition from male to female:

• Sexual reassignment surgery male-to-female
• Vaginoplasty The shaping of a neo-vagina
• Penile inversion – the most common form of genital reassignment surgery.
• Colovaginoplasty – a particular form of genital reassignment surgery.
• Breast augmentation is the enlargement of breasts, which can be necessary if HRT did not yield satisfactory results.
• Facial feminization surgery

Requirements

The requirements for hormone replacement therapy vary greatly, often at least a certain time of psychological counseling is required, and so is a time of living in the desired gender role, if possible, to ensure that they can psychologically function in that life-role.

Generally speaking, physicians who perform sex-reassignment surgery require the patient to live as the opposite gender in all possible ways for at least a year (“cross-live”) prior to the start of surgery in order to assure that they can psychologically function in that life-role. This period is sometimes called the Real Life Test (RLT); it is part of a battery of requirements. Other frequent requirements are regular psychological counseling and letters of recommendation for this surgery.

Most professionals in the USA who provide services to transsexual women and men follow the controversial Standards of Care for Gender Identity Disorders put forth by the Harry Benjamin International Gender Dysphoria Association. Outside the USA, many other SOCs, protocols and guidelines exist, although the Harry Benjamin SOCs are certainly the best known. There exists a significant and growing political movement to redefine the SOC, asserting that they do not acknowledge the rights of self-determination and control over one’s body, and that they expect (and even in many ways requires) a monolithic transsexual experience when in reality there are as many different ways of being transsexual as there are transsexual people. In opposition to this movement is a group of transsexual persons and caregivers who assert that the SOC are in place to protect others from “making a mistake” and causing irreversible changes to their bodies that will later be regretted — though few post-operative transsexuals believe that sexual reassignment surgery was a mistake for them.

Controversy

Although the overwhelming majority of individuals who undergo gender reassignment are forever happy and content living as members of their target sex, some people still believe that gender reassignment is ineffective as a treatment for transsexuality, or that it is “wrong” and/or “immoral.”

Many religious conservatives believe that physical gender reassignment is sinful, and therefore cite evidence that transsexuality can be cured spiritually or psychologically. However, substantial evidence suggests that psychological treatments for transsexuality are highly ineffective.

Although it is undeniably offensive to transsexual women and men, some people consider transsexuals to be members of the physical sex assigned to them at birth, even after they have completed all aspects of gender reassignment. Their reasoning is often based in the facts that sex chromosomes cannot be changed with the procedures currently available, and that transsexuals do not have reproductive organs. Many other people believe that an individual’s sex is determined by factors such as gender presentation, gender identity, external genitalia, and sex hormones; and therefore, they consider transsexuals to be true members of their target sex. They often point to otherwise “normal” women and men who were either born without certain reproductive organs, or had them removed, as well as the existence of people whose sex chromosomes do not match their physical sex and gender identity, such as women with Complete Androgen Insensitivity Syndrome.

In 1967, John Money, a prominent sexologist at Johns Hopkins Hospital, recommended that David Reimer , a boy who had lost his penis during a botched circumcision, be sexually reassigned and raised as a girl. Despite being raised as a girl from the age of 18 months, Reimer was never happy as a girl, and when he learned of his sex reassignment, he immediately reverted to living as a male. Money never reported on the negative outcome of Reimer’s case, but in 1997, Reimer went public with the story himself. His case, as well as several cases of intersexed infants with conditions such as cloacal exstrophy who have been reassigned and raised as females, suggest that gender identity is innate and immutable.

In 1979, when Paul McHugh became chairman of the psychiatric department at Johns Hopkins, he ordered the department to conduct follow-up evaluations on as many of their former transsexual patients as possible. When the follow-ups were performed, they found that most of the patients claimed to be happy as members of their target sex, but that their overall level of psychological functioning had not improved. McHugh reasoned that to perform physical gender reassignment was to “cooperate with a mental illness rather than try to cure it.” At that time, Johns Hopkins closed its gender clinic and has not performed any sex reassignment surgeries since then. Many people have criticized McHugh’s conclusion, often stating their belief that the purpose of gender reassignment is to make transsexual people happy and content with their bodies, not to improve their psychological functioning.

Many medical textbooks state that “significant psychological problems often persist after surgical and hormonal sex reassignment.” However, these texts do not cite reputable sources on which they base their conclusions. Much less research has been done on transsexuality than on many other conditions such as Down syndrome, Cerebral palsy, and autism. However, many people, especially transsexual people, feel that physical gender reassignment is a highly effective treatment for transsexuality, and that medical researchers should have higher priorities than transsexuality. This is especially true of those who feel that “mainstream” medical professionals who research transsexuality are attempting to find ways to cure the condition psychologically; many transsexual people feel that physical gender reassignment is a far better treatment for their gender dysphoria than any psychological treatment or other treatment to “change the mind to match the body” rather than vice versa, ever would be.

Most of the published studies regarding gender reassignment are widely believed to be biased.

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The Columbia Gender and Sexuality Program (GSP) provides compassionate, personalized, and expert care to children, adolescents, adults, and families across the gender and sexuality spectrum.   

Walter Bockting, PhD, Program Director

Gender and sexual identity are vital to how we view ourselves and present ourselves to the world. Finding an identity that is representative of who we are is not always easy, and it can be especially challenging for those who identify in a way that does not conform to traditional views of gender or sexuality. We are here to help. 

Led by Drs. Walter Bockting and Kareen Matouk , the experts at GSP are known across the country for competent and sensitive counseling and care geared to the needs of transgender, nonbinary, and gender diverse individuals and their families. Everyone’s journey in defining their gender identity and sexual orientation is unique and we are here to provide affirming support at every step of the way.

The majority of transgender, nonbinary, and gender diverse children, adolescents, and adults are resilient in the face of prejudice and lead healthy, happy lives. However, for some, stigma attached to nonconformity in gender identity, gender expression, and sexual orientation can lead to significant mental health concerns, such as anxiety , depression , and suicidality.

Kareen Marie Matouk, PhD, Assistant Program Director

Our specialized interdisciplinary team across Columbia University Irving Medical Center offers services ranging from psychotherapy and medication management to hormone therapy and surgery. We utilize an evidence-based approach to mental health care that is focused on instilling pride and celebration of gender diversity. Our services are designed to help transgender, nonbinary, and gender diverse children, adolescents, adults, and their families by facilitating identity development, social support, and self-acceptance across the lifespan. Our clinic also serves cisgender, lesbian, gay, bisexual, and queer youth to promote their mental health and wellbeing.

GSP is ready to help parents and family members impacted by a loved one’s gender or sexual identity, fostering communication, mutual respect, and support. We work with families from various cultural and religious backgrounds, many of whom are struggling with understanding or accepting their child’s nonconformity in gender identity, gender expression, or sexual orientation, and who may be unsure how to proceed. We provide education related to gender dysphoria and thoughtful guidance related to questions that can arise regarding gender identity and role, including social transition and gender-affirming medical interventions. Our family approach also involves direct advocacy to assist in creating safe and affirming spaces in all aspects of an individual’s life. Thus, we work collaboratively with schools and other groups and organizations to ensure positive outcomes for individuals who are transgender, nonbinary, or otherwise diverse in gender and sexuality.

Dr. Bockting & Dr. Sevlever Talk About the Importance of the New Columbia Gender Identity Program

The Gender and Sexuality Program team provides a range of services tailored to each patient’s needs, including:

• Comprehensive psychiatric evaluations to assess gender dysphoria in the context of overall psychosocial development and health
• Specialized psychotherapy to engage children, adolescents, and adults in a process of exploring their identity, and find a gender expression that is comfortable
• Evaluation and referral for gender-affirming medical interventions, such as puberty suppression, gender-affirming hormone therapy and/or surgery
• Tailored treatment planning that involves collaborative input from patient, families, and other health professionals involved in the care of the patient
• Individual psychotherapy
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• Supportive group therapy for individuals and family members  
• Medication management for psychiatric conditions
• Expedited referral and coordination with other specialty services across Columbia University Irving Medical Center, community partners, and affiliated organizations

Group Therapy at GSP

Gender identity group therapy.

Leaders: Kareen Matouk, PhD Location:  Virtual Age Range: 18+ Meeting Time: Wednesdays, 4-5 pm Insurance/Cost: Aetna, Columbia University Employee Insurance Plan Accepted, otherwise $160/session Description: This adult gender affirming psychotherapy group for transgender and gender nonbinary individuals offers support over the course of participants’ identity development. This may include such goals as exploring gender identity and expression, making informed decisions about gender-affirming medical interventions, maintaining strong relationships with family and friends, and pursuing other life goals. Topics addressed may include coping with minority stress, finding a comfortable gender expression, support from transgender and gender non-binary peers, self-acceptance, sexuality and relationships, and family and community.

Parent Group for Parents of TGNB children

Leader: Felix García del Castillo, PhD Location: Virtual Age Range: 18+ (Parents) Meeting Time: Wednesdays, 5-6 pm Insurance/Cost: UHC-CU, Aetna, $160 for self-pay Other Notes: Open group, outside therapist or psychiatrist recommended Description: The group offers support to parents of TGNB and gender expansive children. Most parents have children who are adolescents/young adults. The group provides psychoeducation related to topics that impact the lives of TGNB individuals as well as support to parents as they navigate their child's transition and life as a TGNB person.

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• Kareen Matouk, PhD Assistant Professor in Medical Psychology (in Psychiatry) at CUIMC Assistant Program Director, Columbia Gender and Sexuality Program
• Felix L. Garcia del Castillo, PhD Assistant Professor in Medical Psychology (in Psychiatry) 
• Nathan Ha, MD, PhD Instructor in Psychiatry

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Preparation and Procedures Involved in Gender Affirmation Surgeries

If you or a loved one are considering gender affirmation surgery , you are probably wondering what steps you must go through before the surgery can be done. Let's look at what is required to be a candidate for these surgeries, the potential positive effects and side effects of hormonal therapy, and the types of surgeries that are available.

Gender affirmation surgery, also known as gender confirmation surgery, is performed to align or transition individuals with gender dysphoria to their true gender.

A transgender woman, man, or non-binary person may choose to undergo gender affirmation surgery.

The term "transexual" was previously used by the medical community to describe people who undergo gender affirmation surgery. The term is no longer accepted by many members of the trans community as it is often weaponized as a slur. While some trans people do identify as "transexual", it is best to use the term "transgender" to describe members of this community.

Transitioning

Transitioning may involve:

• Social transitioning : going by different pronouns, changing one’s style, adopting a new name, etc., to affirm one’s gender
• Medical transitioning : taking hormones and/or surgically removing or modifying genitals and reproductive organs

Transgender individuals do not need to undergo medical intervention to have valid identities.  

Reasons for Undergoing Surgery

Many transgender people experience a marked incongruence between their gender and their assigned sex at birth.   The American Psychiatric Association (APA) has identified this as gender dysphoria.

Gender dysphoria is the distress some trans people feel when their appearance does not reflect their gender. Dysphoria can be the cause of poor mental health or trigger mental illness in transgender people.

For these individuals, social transitioning, hormone therapy, and gender confirmation surgery permit their outside appearance to match their true gender.  

Steps Required Before Surgery

In addition to a comprehensive understanding of the procedures, hormones, and other risks involved in gender-affirming surgery, there are other steps that must be accomplished before surgery is performed. These steps are one way the medical community and insurance companies limit access to gender affirmative procedures.

Steps may include:

• Mental health evaluation : A mental health evaluation is required to look for any mental health concerns that could influence an individual’s mental state, and to assess a person’s readiness to undergo the physical and emotional stresses of the transition.  
• Clear and consistent documentation of gender dysphoria
• A "real life" test :   The individual must take on the role of their gender in everyday activities, both socially and professionally (known as “real-life experience” or “real-life test”).

Firstly, not all transgender experience physical body dysphoria. The “real life” test is also very dangerous to execute, as trans people have to make themselves vulnerable in public to be considered for affirmative procedures. When a trans person does not pass (easily identified as their gender), they can be clocked (found out to be transgender), putting them at risk for violence and discrimination.

Requiring trans people to conduct a “real-life” test despite the ongoing violence out transgender people face is extremely dangerous, especially because some transgender people only want surgery to lower their risk of experiencing transphobic violence.

Hormone Therapy & Transitioning

Hormone therapy involves taking progesterone, estrogen, or testosterone. An individual has to have undergone hormone therapy for a year before having gender affirmation surgery.  

The purpose of hormone therapy is to change the physical appearance to reflect gender identity.

Effects of Testosterone

When a trans person begins taking testosterone , changes include both a reduction in assigned female sexual characteristics and an increase in assigned male sexual characteristics.

Bodily changes can include:

• Beard and mustache growth  
• Deepening of the voice
• Enlargement of the clitoris  
• Increased growth of body hair
• Increased muscle mass and strength  
• Increase in the number of red blood cells
• Redistribution of fat from the breasts, hips, and thighs to the abdominal area  
• Development of acne, similar to male puberty
• Baldness or localized hair loss, especially at the temples and crown of the head  
• Atrophy of the uterus and ovaries, resulting in an inability to have children

Behavioral changes include:

• Aggression  
• Increased sex drive

Effects of Estrogen

When a trans person begins taking estrogen , changes include both a reduction in assigned male sexual characteristics and an increase in assigned female characteristics.

Changes to the body can include:

• Breast development  
• Loss of erection
• Shrinkage of testicles  
• Decreased acne
• Decreased facial and body hair
• Decreased muscle mass and strength  
• Softer and smoother skin
• Slowing of balding
• Redistribution of fat from abdomen to the hips, thighs, and buttocks  
• Decreased sex drive
• Mood swings  

When Are the Hormonal Therapy Effects Noticed?

The feminizing effects of estrogen and the masculinizing effects of testosterone may appear after the first couple of doses, although it may be several years before a person is satisfied with their transition.   This is especially true for breast development.

Timeline of Surgical Process

Surgery is delayed until at least one year after the start of hormone therapy and at least two years after a mental health evaluation. Once the surgical procedures begin, the amount of time until completion is variable depending on the number of procedures desired, recovery time, and more.

Transfeminine Surgeries

Transfeminine is an umbrella term inclusive of trans women and non-binary trans people who were assigned male at birth.

Most often, surgeries involved in gender affirmation surgery are broken down into those that occur above the belt (top surgery) and those below the belt (bottom surgery). Not everyone undergoes all of these surgeries, but procedures that may be considered for transfeminine individuals are listed below.

Top surgery includes:

• Breast augmentation  
• Facial feminization
• Nose surgery: Rhinoplasty may be done to narrow the nose and refine the tip.
• Eyebrows: A brow lift may be done to feminize the curvature and position of the eyebrows.  
• Jaw surgery: The jaw bone may be shaved down.
• Chin reduction: Chin reduction may be performed to soften the chin's angles.
• Cheekbones: Cheekbones may be enhanced, often via collagen injections as well as other plastic surgery techniques.  
• Lips: A lip lift may be done.
• Alteration to hairline  
• Male pattern hair removal
• Reduction of Adam’s apple  
• Voice change surgery

Bottom surgery includes:

• Removal of the penis (penectomy) and scrotum (orchiectomy)  
• Creation of a vagina and labia

Transmasculine Surgeries

Transmasculine is an umbrella term inclusive of trans men and non-binary trans people who were assigned female at birth.

Surgery for this group involves top surgery and bottom surgery as well.

Top surgery includes :

• Subcutaneous mastectomy/breast reduction surgery.
• Removal of the uterus and ovaries
• Creation of a penis and scrotum either through metoidioplasty and/or phalloplasty

Complications and Side Effects

Surgery is not without potential risks and complications. Estrogen therapy has been associated with an elevated risk of blood clots ( deep vein thrombosis and pulmonary emboli ) for transfeminine people.   There is also the potential of increased risk of breast cancer (even without hormones, breast cancer may develop).

Testosterone use in transmasculine people has been associated with an increase in blood pressure, insulin resistance, and lipid abnormalities, though it's not certain exactly what role these changes play in the development of heart disease.  

With surgery, there are surgical risks such as bleeding and infection, as well as side effects of anesthesia . Those who are considering these treatments should have a careful discussion with their doctor about potential risks related to hormone therapy as well as the surgeries.  

Cost of Gender Confirmation Surgery

Surgery can be prohibitively expensive for many transgender individuals. Costs including counseling, hormones, electrolysis, and operations can amount to well over $100,000. Transfeminine procedures tend to be more expensive than transmasculine ones. Health insurance sometimes covers a portion of the expenses.

Quality of Life After Surgery

Quality of life appears to improve after gender-affirming surgery for all trans people who medically transition. One 2017 study found that surgical satisfaction ranged from 94% to 100%.  

Since there are many steps and sometimes uncomfortable surgeries involved, this number supports the benefits of surgery for those who feel it is their best choice.

A Word From Verywell

Gender affirmation surgery is a lengthy process that begins with counseling and a mental health evaluation to determine if a person can be diagnosed with gender dysphoria.

After this is complete, hormonal treatment is begun with testosterone for transmasculine individuals and estrogen for transfeminine people. Some of the physical and behavioral changes associated with hormonal treatment are listed above.

After hormone therapy has been continued for at least one year, a number of surgical procedures may be considered. These are broken down into "top" procedures and "bottom" procedures.

Surgery is costly, but precise estimates are difficult due to many variables. Finding a surgeon who focuses solely on gender confirmation surgery and has performed many of these procedures is a plus.   Speaking to a surgeon's past patients can be a helpful way to gain insight on the physician's practices as well.

For those who follow through with these preparation steps, hormone treatment, and surgeries, studies show quality of life appears to improve. Many people who undergo these procedures express satisfaction with their results.

Bizic MR, Jeftovic M, Pusica S, et al. Gender dysphoria: Bioethical aspects of medical treatment . Biomed Res Int . 2018;2018:9652305. doi:10.1155/2018/9652305

American Psychiatric Association. What is gender dysphoria? . 2016.

The World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender-nonconforming people . 2012.

Tomlins L. Prescribing for transgender patients . Aust Prescr . 2019;42(1): 10–13.  doi:10.18773/austprescr.2019.003

T'sjoen G, Arcelus J, Gooren L, Klink DT, Tangpricha V. Endocrinology of transgender medicine . Endocr Rev . 2019;40(1):97-117. doi:10.1210/er.2018-00011

Unger CA. Hormone therapy for transgender patients . Transl Androl Urol . 2016;5(6):877-884.  doi:10.21037/tau.2016.09.04

Seal LJ. A review of the physical and metabolic effects of cross-sex hormonal therapy in the treatment of gender dysphoria . Ann Clin Biochem . 2016;53(Pt 1):10-20.  doi:10.1177/0004563215587763

Schechter LS. Gender confirmation surgery: An update for the primary care provider . Transgend Health . 2016;1(1):32-40. doi:10.1089/trgh.2015.0006

Altman K. Facial feminization surgery: current state of the art . Int J Oral Maxillofac Surg . 2012;41(8):885-94.  doi:10.1016/j.ijom.2012.04.024

Therattil PJ, Hazim NY, Cohen WA, Keith JD. Esthetic reduction of the thyroid cartilage: A systematic review of chondrolaryngoplasty . JPRAS Open. 2019;22:27-32. doi:10.1016/j.jpra.2019.07.002

Top H, Balta S. Transsexual mastectomy: Selection of appropriate technique according to breast characteristics . Balkan Med J . 2017;34(2):147-155. doi:10.4274/balkanmedj.2016.0093

Chan W, Drummond A, Kelly M. Deep vein thrombosis in a transgender woman . CMAJ . 2017;189(13):E502-E504.  doi:10.1503/cmaj.160408

Streed CG, Harfouch O, Marvel F, Blumenthal RS, Martin SS, Mukherjee M. Cardiovascular disease among transgender adults receiving hormone therapy: A narrative review . Ann Intern Med . 2017;167(4):256-267. doi:10.7326/M17-0577

Hashemi L, Weinreb J, Weimer AK, Weiss RL. Transgender care in the primary care setting: A review of guidelines and literature . Fed Pract . 2018;35(7):30-37.

Van de grift TC, Elaut E, Cerwenka SC, Cohen-kettenis PT, Kreukels BPC. Surgical satisfaction, quality of life, and their association after gender-affirming aurgery: A follow-up atudy . J Sex Marital Ther . 2018;44(2):138-148. doi:10.1080/0092623X.2017.1326190

American Society of Plastic Surgeons. Gender confirmation surgeries .

American Psychological Association. Transgender people, gender identity, and gender expression .

Colebunders B, Brondeel S, D'Arpa S, Hoebeke P, Monstrey S. An update on the surgical treatment for transgender patients . Sex Med Rev . 2017 Jan;5(1):103-109. doi:10.1016/j.sxmr.2016.08.001

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Center for Transgender and Gender Expansive Health

Gender-Affirming Care

Services and Appointments

The Johns Hopkins Center for Transgender and Gender Expansive Health offers comprehensive, evidence-based and affirming care for transgender youth and adults that is in line with the standards of care set by the World Professional Association for Transgender Health (WPATH). We offer services for children and adolescents, dermatology, facial gender surgery, fertility, gynecology and obstetrics, hormone treatment, hysterectomy, mental health, penile construction (phalloplasty/metoidioplasty), primary care, top surgery (mastectomy or augmentation), urology, vaginal construction (vaginoplasty), and voice therapy.

We are committed to serving gender diverse patients, whether transgender, nonbinary, gender fluid, or questioning. Our team provides safe and affirming care that is evidence based, trauma informed, and sensitive to each patient’s health needs throughout their lifetime. We provide primary care, hormone therapy, gynecologic services, urological care, mental health services, and gender affirming surgical services. We are here to support patients wherever they are in their gender affirmation journey.

Welcome Dr. Wendy Chen!

Wendy chen, m.d..

Wendy Chen is an assistant professor in the Johns Hopkins University School of Medicine Department of Plastic and Reconstructive Surgery. She is board certified by the American Board of Plastic Surgery, with a subspecialty certificate in surgery of the hand, as well as a fellow of the American College of Surgeons and an active member of the American Society of Plastic Surgeons. Her clinical expertise includes hand and wrist surgery and breast reconstruction, including post-mastectomy, as well as gender affirming top surgeries.

To schedule an appointment, call 844-546-5645

Our team is committed to providing high-quality, compassionate care that’s in line with the standards of care set by the World Professional Association for Transgender Health.

Transgender Medicine Elective

This course is a 2- or 4-week immersive clinical experience for urban health residents who want to learn more about the care of transgender and gender diverse patients.

Clinical Trials and Research Studies

See clinical trials and research options for the Center for Transgender and Gender Expansive Health community.

Complex Gender Microsurgery Fellowship

This fellowship will seek to train the future leaders in complex reconstructive surgery, gender affirming surgery, and microsurgery, with an additional focus on a multi-disciplinary approach to surgical planning and management.

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Center for Transgender and Gender Expansive Health’s New Name

The center’s medical director, Dr. Fan Liang, shares the reasons behind the Center for Transgender Health changing its name to the Johns Hopkins Center for Transgender and Gender Expansive Health, as well as introduces the center’s new mission statement.

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Treatment - Gender dysphoria

Treatment for gender dysphoria aims to help people live the way they want to, in their preferred gender identity or as non-binary.

What this means will vary from person to person, and is different for children, young people and adults. Waiting times for referral and treatment are currently long.

Treatment for children and young people

If your child may have gender dysphoria, they'll usually be referred to one of the NHS Children and Young People's Gender Services .

Your child or teenager will be seen by a multidisciplinary team including a:

• clinical psychologist
• child psychotherapist
• child and adolescent psychiatrist
• family therapist
• social worker

The team will carry out a detailed assessment, usually over 3 to 6 appointments over a period of several months.

Depending on the results of the assessment, options for children and teenagers include:

• family therapy
• individual child psychotherapy
• parental support or counselling
• group work for young people and their parents
• regular reviews to monitor gender identity development
• referral to a local Children and Young People's Mental Health Service (CYPMHS) for more serious emotional issues

Most treatments offered at this stage are psychological rather than medical. This is because in many cases gender variant behaviour or feelings disappear as children reach puberty.

Hormone therapy in children and young people

Some young people with lasting signs of gender dysphoria who meet strict criteria may be referred to a hormone specialist (consultant endocrinologist). This is in addition to psychological support.

Puberty blockers and gender-affirming hormones

Puberty blockers (gonadotrophin-releasing hormone analogues) are not available to children and young people for gender incongruence or gender dysphoria because there is not enough evidence of safety and clinical effectiveness.

From around the age of 16, young people with a diagnosis of gender incongruence or gender dysphoria who meet various clinical criteria may be given gender-affirming hormones alongside psychosocial and psychological support.

These hormones cause some irreversible changes, such as:

• breast development (caused by taking oestrogen)
• breaking or deepening of the voice (caused by taking testosterone)

Long-term gender-affirming hormone treatment may cause temporary or even permanent infertility.

However, as gender-affirming hormones affect people differently, they should not be considered a reliable form of contraception.

There is some uncertainty about the risks of long-term gender-affirming hormone treatment.

Children, young people and their families are strongly discouraged from getting puberty blockers or gender-affirming hormones from unregulated sources or online providers that are not regulated by UK regulatory bodies.

Transition to adult gender identity services

Young people aged 17 or older may be seen in an adult gender identity clinic or be referred to one from a children and young people's gender service.

By this age, a teenager and the clinic team may be more confident about confirming a diagnosis of gender dysphoria. If desired, steps can be taken to more permanent treatments that fit with the chosen gender identity or as non-binary.

Treatment for adults

Adults who think they may have gender dysphoria should be referred to a gender dysphoria clinic (GDC).

Find an NHS gender dysphoria clinic in England .

GDCs have a multidisciplinary team of healthcare professionals, who offer ongoing assessments, treatments, support and advice, including:

• psychological support, such as counselling
• cross-sex hormone therapy
• speech and language therapy (voice therapy) to help you sound more typical of your gender identity

For some people, support and advice from the clinic are all they need to feel comfortable with their gender identity. Others will need more extensive treatment.

Hormone therapy for adults

The aim of hormone therapy is to make you more comfortable with yourself, both in terms of physical appearance and how you feel. The hormones usually need to be taken for the rest of your life, even if you have gender surgery.

It's important to remember that hormone therapy is only one of the treatments for gender dysphoria. Others include voice therapy and psychological support. The decision to have hormone therapy will be taken after a discussion between you and your clinic team.

In general, people wanting masculinisation usually take testosterone and people after feminisation usually take oestrogen.

Both usually have the additional effect of suppressing the release of "unwanted" hormones from the testes or ovaries.

Whatever hormone therapy is used, it can take several months for hormone therapy to be effective, which can be frustrating.

It's also important to remember what it cannot change, such as your height or how wide or narrow your shoulders are.

The effectiveness of hormone therapy is also limited by factors unique to the individual (such as genetic factors) that cannot be overcome simply by adjusting the dose.

Find out how to save money on prescriptions for hormone therapy medicines with a prescription prepayment certificate .

Risks of hormone therapy

There is some uncertainty about the risks of long-term cross-sex hormone treatment. The clinic will discuss these with you and the importance of regular monitoring blood tests with your GP.

The most common risks or side effects include:

• blood clots
• weight gain
• dyslipidaemia (abnormal levels of fat in the blood)
• elevated liver enzymes
• polycythaemia (high concentration of red blood cells)
• hair loss or balding (androgenic alopecia)

There are other risks if you're taking hormones bought over the internet or from unregulated sources. It's strongly recommended you avoid these.

Long-term cross-sex hormone treatment may also lead, eventually, to infertility, even if treatment is stopped.

The GP can help you with advice about gamete storage. This is the harvesting and storing of eggs or sperm for your future use.

Gamete storage is sometimes available on the NHS. It cannot be provided by the gender dysphoria clinic.

Read more about fertility preservation on the HFEA website.

Surgery for adults

Some people may decide to have surgery to permanently alter body parts associated with their biological sex.

Based on the recommendations of doctors at the gender dysphoria clinic, you will be referred to a surgeon outside the clinic who is an expert in this type of surgery.

In addition to you having socially transitioned to your preferred gender identity for at least a year before a referral is made for gender surgery, it is also advisable to:

• lose weight if you are overweight (BMI of 25 or over)
• have taken cross-sex hormones for some surgical procedures

It's also important that any long-term conditions, such as diabetes or high blood pressure, are well controlled.

Surgery for trans men

Common chest procedures for trans men (trans-masculine people) include:

• removal of both breasts (bilateral mastectomy) and associated chest reconstruction
• nipple repositioning
• dermal implant and tattoo

Gender surgery for trans men includes:

• construction of a penis (phalloplasty or metoidioplasty)
• construction of a scrotum (scrotoplasty) and testicular implants
• a penile implant

Removal of the womb (hysterectomy) and the ovaries and fallopian tubes (salpingo-oophorectomy) may also be considered.

Surgery for trans women

Gender surgery for trans women includes:

• removal of the testes (orchidectomy)
• removal of the penis (penectomy)
• construction of a vagina (vaginoplasty)
• construction of a vulva (vulvoplasty)
• construction of a clitoris (clitoroplasty)

Breast implants for trans women (trans-feminine people) are not routinely available on the NHS.

Facial feminisation surgery and hair transplants are not routinely available on the NHS.

As with all surgical procedures there can be complications. Your surgeon should discuss the risks and limitations of surgery with you before you consent to the procedure.

Life after transition

Whether you've had hormone therapy alone or combined with surgery, the aim is that you no longer have gender dysphoria and feel at ease with your identity.

Your health needs are the same as anyone else's with a few exceptions:

• you'll need lifelong monitoring of your hormone levels by your GP
• you'll still need contraception if you are sexually active and have not yet had any gender surgery
• you'll need to let your optician and dentist know if you're on hormone therapy as this may affect your treatment
• you may not be called for screening tests as you've changed your name on medical records – ask your GP to notify you for cervical and breast screening if you're a trans man with a cervix or breast tissue
• trans-feminine people with breast tissue (and registered with a GP as female) are routinely invited for breast screening from the ages of 50 up to 71

Find out more about screening for trans and non-binary people on GOV.UK.

NHS guidelines for gender dysphoria

NHS England has published what are known as service specifications that describe how clinical and medical care is offered to people with gender dysphoria:

• Non-surgical interventions for adults
• Surgical interventions for adults
• Interim service specification for specialist gender incongruence services for children and young people

Review of gender identity services

NHS England has commissioned an independent review of gender identity services for children and young people. The review will advise on any changes needed to the service specifications for children and young people.

Page last reviewed: 28 May 2020 Next review due: 28 May 2023

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The Battle Over Gender Therapy

More teenagers than ever are seeking transitions, but the medical community that treats them is deeply divided about why — and what to do to help them.

For this article, Emily Bazelon spoke with more than two dozen young people about their experiences. Credit... Anne Vetter for The New York Times

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By Emily Bazelon

• Published June 15, 2022 Updated March 17, 2023

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To hear more audio stories from publications like The New York Times, download Audm for iPhone or Android .

Scott Leibowitz is a pioneer in the field of transgender health care. He has directed or worked at three gender clinics on the East Coast and the Midwest, where he provides gender-affirming care, the approach the medical community has largely adopted for embracing children and teenagers who come out as transgender. He also helps shape policy on L.G.B.T. issues for the American Academy of Child and Adolescent Psychiatry. As a child and adolescent psychiatrist who is gay, he found it felt natural to work under the L.G.B.T. “umbrella,” as he put it, aware of the overlap as well as the differences between gay and trans identity.

It was for all these reasons that Leibowitz was selected, in 2017, to be a leader of a working group of seven clinicians and researchers drafting a chapter on adolescents for a new version of guidelines called the Standards of Care to be issued by the World Professional Association for Transgender Health (WPATH). The guidelines are meant to set a gold standard for the field of transgender health care, and this would be the first update since 2012. What Leibowitz and his co-authors didn’t foresee, when they began, was that their work would be engulfed by two intersecting forces: a significant rise in the number of teenagers openly identifying as transgender and seeking gender care, and a right-wing backlash in the United States against allowing them to medically transition, including state-by-state efforts to ban it.

During the last decade, the field of transgender care for youth has greatly shifted. A decade ago, there were a handful of pediatric gender clinics in the United States and a dozen or so more in other countries. The few doctors and therapists who worked in them knew one another, and the big debate was whether kids in preschool or elementary school should be allowed to live fully as the gender they identified as when they strongly and consistently asserted their wishes.

Now there are more than 60 comprehensive gender clinics in the United States, along with countless therapists and doctors in private practice who are also seeing young patients with gender-identity issues. The number of young people who identify as transgender nationally is about 300,000, according to a new report by the Williams Institute, a research center at U.C.L.A.’s law school, which is much higher than previous estimates. In countries that collect national data, like the Netherlands and Britain, the number of 13-to-17-year-olds seeking treatment for gender-identity issues has also increased, from dozens to hundreds or thousands a year.

Just as striking, the types of cases have changed. Many of the current group of teenagers haven’t told their families, from a young age, that they feel they are a different gender, though they often say they internalized such feelings for years. The average age when a young person first comes to a clinic tends to be around 14 or 15, according to some clinicians I talked to. Cases of teenagers coming out as trans aren’t new. But their prevalence is. In addition, the current caseload is around two-thirds youths who were “assigned female at birth,” in the current parlance of the field, and identify as trans boys — or as nonbinary, in a smaller but growing number of cases. In the past, by contrast, most patients at gender clinics were trans girls who were “assigned male at birth.”

As they worked on a draft of the adolescent chapter of the Standards of Care, the big debate among clinicians was how they should respond to the thousands of teenagers who are arriving at their doors. Some are asking about medication that suppresses puberty or about hormone-replacement treatments. Leibowitz and his co-authors thought that the timing of the rise in trans-identified teenagers, as well as research from Britain and Australia, suggested that the increased visibility of trans people in entertainment and the media had played a major — and positive — role in reducing stigma and helping many kids express themselves in ways they would have previously kept buried. At the same time, the authors acknowledged that they weren’t sure that visibility was the only factor at play.

As they wrote in their December draft chapter, part of the rise in trans identification among teenagers could be a result of what they called “social influence,” absorbed online or peer to peer. The draft mentioned the very small group of people who detransition (stop identifying as transgender), saying that some of them “have described how social influence was relevant in their experience of their gender during adolescence.” In adolescence, peers and culture often affect how kids see themselves and who they want to be. Their sense of self can consolidate, or they can try on a way of being that doesn’t prove right in the long run as the brain further develops the capacity for thinking long-term. To make matters more complicated, as a group, the young people coming to gender clinics have high rates of autism, depression, anxiety and eating or attention-deficit disorders. Many of them are also transgender, but these other issues can complicate determining a clear course of treatment.

Without stating them outright, the draft raises tricky questions: Could some of the teenagers coming out as trans today be different from the adults who transitioned in previous generations? For them the benefits are well established and the rate of regret is very low. How many young people, especially those struggling with serious mental-health issues, might be trying to shed aspects of themselves they dislike?

Leibowitz and his colleagues knew these were delicate issues. They were deeply troubled when right-wing politicians grasped the unsettled nature of these matters — which barely registered for most Americans 10 years ago — and turned them into political dynamite. In 2019, right-wing groups, the Heritage Foundation and Family Policy Alliance, which fought for many years against same-sex marriage, held a meeting on “Protecting Children From Sexualization” that covered “controversial medical treatments to treat gender dysphoria,” which is defined as a form of distress and is also a psychiatric diagnosis. Model legislation followed. Organizations like Family Policy Alliance helped state legislators draft a ban on gender-related medical treatment for anyone under age 18. Arkansas passed the first such ban in April 2021, and over the next months, similar bills were introduced in 18 other Republican-led state legislatures.

WPATH is a 3,300-member international organization, mostly made up of health care professionals. It came into existence in 1979, the year it issued its first Standards of Care. These standards influence the positions taken by major medical groups, including the American Academy of Pediatrics and the American Psychological Association, and the coverage offered by health insurers and national health services around the world. Trans and nonbinary practitioners are helping to write and oversee the new guidelines, called the SOC8 because it’s the eighth edition.

Over the eight months I reported on this story, I talked to more than 60 clinicians, researchers, activists and historians, as well as more than two dozen young people and about the same number of parents. WPATH gave me exclusive access to the final SOC8 (which is divided into 18 chapters, most of which address treatment for transgender adults) and lifted some of the confidentiality agreements the authors signed. Now the final version of the new Standards of Care is scheduled to come out this summer — in the midst of a raging political battle.

When I started talking to Leibowitz last December, he was watching the political attacks unfold with growing alarm. In his own state, Ohio, there was a bill afoot to ban the care he himself provides to trans young people and sees as essential to their well-being. His group’s job for the SOC8 was to be “as rigorous and scientific as possible,” he said, about how to translate the evidence about gender care into clinical practice. But they were acutely aware that any unknowns that the working group acknowledged — any uncertainties in the research — could be read as undermining the field’s credibility and feed the right-wing effort to outlaw gender-related care.

The group was stocked with experts, including Leibowitz’s co-leader for the adolescent chapter, the Dutch child psychiatrist Annelou de Vries, who for 19 years has worked at what was the first transgender pediatric clinic in the world, and the clinical psychologist Ren Massey, who is a former president of the Georgia Psychological Association and is transgender. When WPATH released the draft of the SOC8 for public comment, Leibowitz and his co-authors braced for the inevitable conservative attack. For teenagers who have parental consent, the draft adolescent chapter lowered to 14 (from 16 in the previous guidelines) the recommended minimum age for hormone treatments, which can permanently alter, in a matter of months, voice depth and facial and body hair growth and, later, other features like breast development. It set a minimum recommended age of 15, for breast removal or augmentation, also called top surgery. (The previous standards didn’t set a minimum age.)

Opponents of gender-related care did, indeed, denounce all of this. But Leibowitz and his co-authors also faced fury from providers and activists within the transgender world. This response hit them harder, as criticism from your colleagues and allies often does. It arose from two of the conditions the draft chapter established in order for young people to start taking puberty suppressants and hormones. First, the draft said, preteens and teenagers should provide evidence of “several years” of persistently identifying as, or behaving typically like, another gender, to distinguish kids with a long history from those whose stated identification is recent. And second, they should undergo a comprehensive diagnostic assessment, for the purpose of understanding the psychological and social context of their gender identity and how it might intersect with other mental-health conditions.

Assessments for children and adolescents have long been integral to the Standards of Care. But this time, the guard rails were anathema to some members of a community that has often been failed by health care providers. “The adolescent chapter is the worst,” Colt St. Amand, a family-medicine physician at the Mayo Clinic and a clinical psychologist, posted on the Facebook page of International Transgender Health, which has thousands of members and functions as a bulletin board for the field. (St. Amand is on the working group for another chapter in the SOC8 on hormone treatments.) In a publicly streamed discussion on YouTube on Dec. 5, activists and experts criticized the adolescent chapter, with the emotion born of decades of discrimination and barriers to care. “This statement sucks,” Kelley Winters, a moderator of International Transgender Health who is an interdisciplinary scholar and community advocate in the field, said of the assessment. “This is talking about singling out trans kids, and specifically with a mental-health provider, not medical staff, to interrogate, to go down this comprehensive inquisition of their gender.” The requirement for evidence of several years of gender incongruity before medical treatment is “harmful and destructive and abusive and unethical and immoral,” said Antonia D’orsay, another moderator of the group who is a sociologist and psychologist. In January, in a public comment to WPATH, International Transgender Health blasted the adolescent chapter for “harmful assertion of psychogatekeeping” that “undermines patient autonomy.”

And just like that, after four years of painstaking work, Leibowitz, de Vries and the rest of their group were being called out as traitors by peers and the community they sought to care for. “We understood the enormity of the need for these standards from the beginning,” Leibowitz told me. “I’m not sure we recognized the enormity of the controversy. It’s a result of the fact that our world, the world of gender care, has exploded.”

In the 1950s and ’60s, a small cadre of doctors in Europe and the United States started to talk about how to evaluate adults who wanted to medically transition. Harry Benjamin, the endocrinologist for whom WPATH was originally named, embraced the idea that the people he agreed to treat (mostly trans women) were “born in the wrong body.” Fearing lawsuits from dissatisfied patients, the doctors were quick to exclude patients for reasons of mental stability. And, arbitrarily, they only included those who they believed would go on to pass as the gender they identified with, as Beans Velocci, a historian at the University of Pennsylvania, wrote in an article last year in TSQ: Transgender Studies Quarterly. Some doctors made trans adults promise to live as heterosexuals after they transitioned.

The small group of clinicians who wrote the first Standards of Care were all cisgender. After WPATH was created in 1979, transgender advocates increasingly gained influence in the organization, but many transgender people viewed subsequent versions of the standards as imposing paternalistic and demeaning barriers to treatment. For some genital surgery, the standards required adults to live for a year as the gender they identified with and to provide referrals from two mental-health professionals. The SOC8 is the first version to dispense with these requirements, adopting a model of “shared decision-making” between adult patient and surgeon.

The leap toward medical transition for young people occurred in the Netherlands in the 1980s. Peggy Cohen-Kettenis, a Dutch clinical psychologist specializing in children, began receiving referrals of teenagers who were experiencing gender dysphoria (then called gender identity disorder). But therapy wasn’t the primary answer, Cohen-Kettenis, who is retired, told me over the phone this spring. “We can sit and talk forever, but they really needed medical treatment.” As their bodies developed in ways they didn’t want, “they only did worse because of that.” She decided to help a few of her patients start hormone treatments at 16 rather than waiting until 18, the practice in the Netherlands and elsewhere at the time. She monitored them weekly, then monthly. “To my surprise, the first couple were doing much better than when they first came,” she said. “That encouraged me to continue.”

Cohen-Kettenis helped establish a treatment protocol that proved revolutionary. The first patient, known as F.G., was referred around 1987 to Henriette A. Delemarre-van de Waal, a pediatric endocrinologist who went on to found the gender clinic in Amsterdam with Cohen-Kettenis. At 13, F.G. was in despair about going through female puberty, and Delemarre-van de Waal put him on puberty suppressants, with Cohen-Kettenis later monitoring him. The medication would pause development of secondary sex characteristics, sparing F.G. the experience of feeling that his body was betraying him, buying time and making it easier for him to go through male puberty later, if he then decided to take testosterone. Transgender adults, whom Cohen-Kettenis also treated, sometimes said they wished they could have transitioned earlier in life, when they might have attained the masculine or feminine ideal they envisioned. “Of course, I wanted that,” F.G. said of puberty suppressants, in an interview in “The Dutch Approach,” a 2020 book about the Amsterdam clinic by the historian Alex Bakker. “Later I realized that I had been the first, the guinea pig. But I didn’t care.”

Over the next decade, Cohen-Kettenis and Delemarre-van de Waal designed an assessment for young people who seemed like candidates for medical treatment. In questionnaires and sessions with families, Cohen-Kettenis explored the reasons for a young person’s gender dysphoria, considering whether it might be better addressed by therapy or medication or both. The policy was to delay treatment for those with issues like attention-deficit and eating disorders or who lacked stable, supportive families, in order to eliminate factors that might interfere with the treatment. “We did a lot of other work before letting them start, which created a lot of frustration for them,” Cohen-Kettenis said. “Maybe we were too selective in the early stages.” In retrospect, she says, she thinks young people who might have benefited were excluded.

The stringent screenings seemed critical, however, given the opposition they faced. Other doctors, in the Netherlands and outside it, publicly accused them of recklessness. At a low moment, at a medical conference in the late 1990s, she said, they were likened to Nazis experimenting on children.

Cohen-Kettenis stressed that she and her growing team at the Amsterdam clinic were not channeling children toward a particular outcome. The Dutch advised what they called “watchful waiting.” Throughout his childhood, with his parents’ support, F.G. lived as a boy, with short hair and a gender-neutral nickname. But Cohen-Kettenis counseled parents to “keep the door open, as much as possible, for children to be able to change back.” Among the adolescents who came to the clinic beginning at the age of puberty, 41 percent went on puberty suppressants, and more than 70 percent received hormone treatments and went on to surgery.

The Amsterdam clinic attracted international interest. Norman Spack, an endocrinologist at Boston Children’s Hospital who began treating transgender adults in the 1980s, and Laura Edwards-Leeper, then a child psychologist there, visited Amsterdam in 2007 for a gathering of clinicians from countries including Canada, Britain, Norway and Belgium. Spack and Edwards-Leeper went back to Boston, where they and another doctor were opening the first dedicated gender clinic for kids in the United States that provided medical treatment based on the fundamentals of the Dutch approach — a comprehensive assessment before patients could begin puberty suppressants or hormone treatments and close consultation between a clinic’s mental-health professionals and medical doctors.

Scott Leibowitz joined the Boston clinic as a psychiatrist in training a year later. In the early days, families traveled long distances for appointments. The waiting list grew. Edwards-Leeper and Spack eventually shortened the period a child had to be in therapy before the clinic did its own assessment, from a year to between three and six months. “If a child was on the cusp of puberty, and anxious about how their body was about to change, we tried to squeeze them in faster, which I still think is really important,” Edwards-Leeper says.

In 2011, de Vries and her colleagues published the first of two landmark studies about medical interventions in adolescence. Among the first 70 patients who received puberty suppressants at the Amsterdam clinic after their initial assessment at the mean age of about 13½, the researchers found “a significant decrease in behavioral and emotional problems over time.” A second study published in the journal Pediatrics in 2014, of about 55 of those who went from puberty suppressants to hormone treatments at the mean age of about 16½, showed that five years after starting hormone treatments and at least one year after surgery, they had the same or better levels of well-being as a control group of cisgender adults their age. None of the 55 regretted their treatment. (The 15 of the original 70 who were not included in the follow-up study did not take part mainly because of the timing of their surgery.)

For the first time, a long-term, peer-reviewed study showed positive outcomes after medical treatment in adolescent patients who’d gone through Cohen-Kettenis and Delemarre-van de Waal’s protocol. They had all been through a version of the type of assessment the December draft of the SOC8 adolescent chapter would recommend years later. They had experienced gender dysphoria since childhood (according to their families), lived in supportive environments and had no interfering mental-health conditions. As is often the case in medicine, the question for those drafting the SOC8 would be how to apply the findings of a particular cohort to the growing numbers of teenagers lining up at clinics in a host of countries.

In the United States and Canada, meanwhile, two dueling approaches to therapy for young children, before they reached puberty, were vying for supremacy. At what is now called the Child and Adolescent Gender Center at the University of California, San Francisco, Diane Ehrensaft, a developmental and clinical psychologist, was counseling families to take what she and others called a “gender affirming” approach, which included a social transition: adopting a new name and pronouns for a child who expressed such a preference, along with letting kids dress and play as they pleased.

For years, Ehrensaft’s intellectual foil was Ken Zucker , a psychologist and prominent researcher who directed a gender clinic in Toronto. Between 1975 and 2009, Zucker’s research showed that most young children who came to his clinic stopped identifying as another gender as they got older. Many of them would go on to come out as gay or lesbian or bisexual, suggesting previous discomfort with their sexuality, or lack of acceptance, for them or their families. Based on this research, in some cases Zucker advised parents to box up the dolls or princess dresses, so a child who was being raised as a boy (a majority then) wouldn’t have those things to play with.

In 2012, the last version of WPATH’s Standards of Care , with Cohen-Kettenis and Zucker among the authors, cited his work 15 times and called social transition in early childhood “controversial.” The American Psychological Association said in 2015 guidelines that there was no consensus about a best practice for children before puberty, describing both accepting children’s “expressed gender identity” (citing de Vries and Cohen-Kettenis, Ehrensaft, Edwards-Leeper and Spack, among others) and, alternatively, encouraging them to “align with their assigned gender roles” (citing Zucker, among others).

At the end of 2015, the Canadian medical center that ran Zucker’s clinic in Toronto shut it down because of complaints from activists about his method. (Zucker sued the center for defamation and later received an apology and a settlement of $450,000.) In February 2017, protesters interrupted and picketed a panel featuring Zucker at the inaugural conference of USPATH (the U.S. affiliate of WPATH) in Los Angeles. That evening, at a meeting with the conference leaders, a group of advocates led by transgender women of color read aloud a statement in which they said the “entire institution of WPATH” was “violently exclusionary” because it “remains grounded in ‘cis-normativity and trans exclusion.’” The group asked for cancellation of Zucker’s appearance on a second upcoming panel. Jamison Green, a trans rights activist and former president of WPATH, said the board agreed to the demand. “We are very, very sorry,” he said.

After that controversy, other providers were on notice that Zucker’s methods were no longer acceptable. His approach was likened to conversion therapy, which treats being gay or trans as a mental illness to be cured, and which many states and localities have made illegal .

The Amsterdam clinic shifted, too. Some Dutch families socially transitioned kids on their own, which de Vries and her colleagues accepted; they began counseling other families about social transition too. Though the Amsterdam researchers’ previous results, like Zucker’s, showed that most kids who came to the clinic in elementary school later realigned with the genders of their birth, and often came out as gay, lesbian or bisexual, de Vries and her colleagues now see those findings as a product of their time , when the children whom parents brought to the clinic included many boys with an interest in wearing feminine clothing and playing with dolls that didn’t turn out to be gender dysphoria. Today many Dutch parents are more accepting of this behavior, and the Amsterdam clinicians think that as a result, most of the children who come to the clinic are asserting a strong and persistent gender preference. It’s more likely that such children will stay the course of being transgender, research shows. One long-term study , published in 2021, of 148 kids in the United States who socially transitioned with their families’ support between the ages of 8 and 14, found that five years later their psychological well-being was on par with their siblings and a control group of cisgender peers.

There is a separate chapter in the SOC8 that focuses on young children and that recommends that health care professionals and parents support social transition when it originates with the child while also recognizing that for some kids, gender is fluid. An outstanding question, asked by gay commentators like the author Andrew Sullivan, is whether some kids who socially transition today, and remain trans, would have grown up to be gay or lesbian in previous generations. “I know there are worries that effeminate males can be assumed to be female or masculine girls can be assumed to be male,” says Amy Tishelman, the lead author of the SOC8 chapter on children and a child psychologist who is the former director of clinical research at the gender clinic at Boston Children’s Hospital. “That’s not what we’re advocating. Support for trans people should not be a way of limiting what a girl or a boy or a woman or a man or a person can be.”

A few months before the release of the December draft of the SOC8, WPATH had a preview of the firestorm to come. In October 2021, the journalist Abigail Shrier published a post called “Top Trans Doctors Blow the Whistle on ‘Sloppy’ Care” on the Substack of Bari Weiss, a former opinion editor and writer for The New York Times.” The word “sloppy” was a quote from Erica Anderson, a clinical psychologist who was a past president of USPATH and who worked at the U.C.S.F. gender center for years before leaving in October (for unrelated reasons). She told Shrier she expected more regret among young people because some providers were rushing them toward medication without sufficient mental-health evaluations.

Shrier also quoted Marci Bowers, a gynecologic and reconstructive surgeon who is slated to be the next president of WPATH, who voiced a separate concern about blocking puberty too early. Though there is no published data on this question, over hundreds of surgeries, Bowers has found that trans girls who don’t go through male puberty may find it difficult to have an orgasm after they have genital surgery as adults. They also could have less penile tissue with which to create a vagina, which can lead to more complications from surgery, according to Bowers. These concerns apply in a small percentage of cases in the United States, as most teenagers come to gender clinics at 14 or older, after puberty. But for the younger kids, Bowers advocated delaying puberty suppressants to a later stage of development.

Anderson and Bowers are transgender women, which brought more attention to their critique and to their decision to talk to Shrier, who is the author of a 2020 book, “Irreversible Damage: The Transgender Craze Seducing Our Daughters,” which many trans people and their allies abhor. Many trans health providers were furious. “I was like, Whoa, what is this? And then I texted Erica,” says Maddie Deutsch, the president of USPATH and a professor at U.C.S.F. as well as the medical director of the Gender Affirming Health Program there, who is also transgender. “We were all broadsided.” She worries about the political fallout. “States like Texas and Florida are looking to these articles to fan the flames.”

About a week after Shrier’s post appeared, USPATH and WPATH issued a statement opposing “the use of the lay press” for scientific debate about gender-related medical treatment. Anderson disagreed with the directive. “Some of our colleagues would have us shut up,” she told me in the fall. “No. It’s not OK to ignore the problems.” In late November, she and the child psychologist Laura Edwards-Leeper published an opinion essay in The Washington Post . They said they were “disgusted” by the proposed state bans on gender-related medical treatment for minors, but they warned that some providers in the United States were “hastily dispensing medicine” and skipping comprehensive assessments.

‘Young people are quite capable of understanding themselves, but not all of them will.’

The following week, news broke in Texas that the only gender clinic for adolescents that provides hormone therapy in the Dallas region, Genecis, was being disbanded, a result of political pressure from Gov. Greg Abbott . “We have wolves at the door,” says Ehrensaft, who worked with Anderson at U.C.S.F. and is an author on the SOC8 chapter on children with Edwards-Leeper. “Conversations among us get aired as controversy and confusion. You end up eating your own instead of making the wolves go away.” Others were scathing about placing blame. “Every time a law passes blocking trans youth from getting care, I hope it’s called an Edwards-Leeper law,” Andrew Cronyn, a pediatrician and a former adviser on policy about L.G.B.T. health for the American Academy of Pediatrics, wrote on a professional email list with more than 500 recipients. “And I hope that every time one of the youth who is blocked from affirmative care dies, she gets sent a copy of the obituary.” He subsequently apologized and the post was removed at his request.

When I spoke to Bowers in December, she distanced herself from Anderson and Edwards-Leeper. “The most important thing is access to care,” she said. “And that is a much bigger problem than the issue of how the medical community and transition is failing people.” But she remained intent on drawing attention to her concerns about the early suppression of puberty. “Sexual satisfaction is a huge thing,” she said. “You’ve got to talk about it.”

Partly in response to Bowers’s concerns, the December draft of the SOC8 adolescent chapter suggested that health care providers discuss “future unknowns related to sexual health” when families consider puberty suppressants. The Amsterdam clinic often waits to prescribe suppressants until later in puberty.

In the United States, waiting would be a major shift for the relatively small group of younger kids at gender clinics. For them, families weigh the relief the medications can provide against the health implications. Taking puberty suppressants (or hormones) for gender affirmation is “off-label,” meaning this specific use of the medications is not approved by the Food and Drug Administration. Off-label prescriptions are common and don’t imply anything improper, but there may be less research about the drug’s effects. If young people continue on to hormone treatments, puberty suppressants “probably” compromise fertility, especially for trans girls, Stephen M. Rosenthal, a pediatric endocrinologist at the gender center at U.C.S.F. who is on the group for the SOC8 chapter on hormone treatments, explained in a review last year for Nature Reviews Endocrinology. The medication can also prevent bone density from increasing as it typically would, and while levels returned to normal in trans boys who went on to hormone therapy, they remained low in trans girls who did the same, according to a 2020 study from the Amsterdam clinic. Little is known about the impact on brain development. “The relative paucity of outcomes data raises notable concerns,” Rosenthal wrote in his review. But he has no hesitation about prescribing puberty suppressants to kids who are deemed ready for them at his clinic. “The observed benefits greatly outweigh the potential adverse effects,” he said.

As winter approached, criticism of Anderson and Edwards-Leeper by their peers mounted as right-wing attacks on medical care for minors grew louder. In early November, the board of USPATH privately censured Anderson, who served as a board member. In December, the board imposed a 30-day moratorium on speaking to the press for all board members. That month, Anderson resigned.

In February, Governor Abbott ordered child-abuse investigations of parents and providers in Texas who give gender-related medical treatments to kids, generating national headlines and causing fear and anguish for families. In March, Arizona became the second state to ban gender medical care for minors. (The law, which applies to surgery, not medications, is scheduled to go into effect in 2023.)

The next month, four doctoral students in psychology asked to drop Edwards-Leeper from their dissertation committees at Pacific University, where she is an emeritus professor. And yet in the same week, she presented on the SOC8 adolescent chapter at the annual pediatric conference of the American Psychology Association, where the moderator of one of her panels praised her for her bravery in voicing her concerns about her field. The roller coaster of reaction, at the same time kids were losing access to care altogether in red states, shook Edwards-Leeper and her co-authors of the SOC8 chapters on adolescents and children. They didn’t want to be blamed for the right-wing backlash — neither by activists nor their own peers.

Watching the waves of conflict break, Leibowitz worried. He respected Bowers, Anderson and Edwards-Leeper for raising difficult issues but could see their views being mischaracterized to justify banning gender-related care. For people who don’t know much about the issues, “banning the care probably sounds more enticing than the idea that kids are dictating what treatment they should get,” he says. “Our guidelines are the voice from the middle.”

One morning over the phone, Leibowitz explained to me the elements of the mental-health assessments he saw as essential. His starting point, when a child presents as transgender, is obtaining a complete diagnostic profile. This means understanding the relationship between gender dysphoria and any other conditions (like depression or an eating disorder) or another factor that might be causing discomfort (like trauma or feeling confined by gender stereotypes) before coming up with a treatment plan. “It’s about understanding how the issues that might make someone experience gender dysphoria are connected,” he said.

As Leibowitz and his co-authors discussed revisions over video calls and email, colleagues who were critical of the draft chapter were also working together. Colt St. Amand, the psychologist and physician who disparaged the adolescent chapter on the Facebook page of International Transgender Health, brought together a collective of 16 mental-health professionals who are either transgender (as he is) or nonbinary, or have a close family member who is, to talk about how the assessment guidelines in the adolescent chapter fit with their lived experience and professional knowledge.

St. Amand thinks the purpose of an assessment is not to determine the basis of a kid’s gender identity. “That just reeks of some old kind of conversion-therapy-type things,” he told me over the phone in April. “I think what we’ve seen historically in trans care is an overfocus on assessing identity.” He continued: “People are who they say they are, and they may develop and change, and all are normal and OK. So I am less concerned with certainty around identity, and more concerned with hearing the person’s embodiment goals. Do you want to have a deep voice? Do you want to have breasts? You know, what do you want for your body?”

The draft of the adolescent chapter suggests that “extended assessments” may be useful for young people who are autistic or have some characteristics of autism without a full diagnosis. “One of the key accommodations for autistic youth is providing more time and structure to support the young person’s self-advocacy and communication capacity,” said John Strang, the specialist on the intersection of autism and gender identity on the SOC8 adolescent and child chapters and a neuropsychologist at Children’s National Hospital in Washington, D.C. But St. Amand calls a standard of extended assessments a “gross generalization” and “discriminatory.”

The priority for the collective St. Amand organized, which is working on a series of articles and training materials, is to ensure that transgender and nonbinary youth get the care they need rather than to shield teenagers from taking medication with effects they might later decide they didn’t want. St. Amand’s focus is on a young person’s response after beginning puberty suppression or hormone therapy. “If that is the right thing for them, then the response over time will tell me,” he says. “Once we start those interventions, we are checking in with the patient to see how they’re doing.” If the drugs don’t suit them, in his view, they can simply stop.

Other providers, however, see an ethical dilemma stemming from the principle of justice — which promotes access to care for trans youth — and the principle of doing no harm. “I wouldn’t recommend just initiating testosterone straight away,” says Nathaniel Sharon, a child psychiatrist in New Mexico who has helped shape mental-health policy that affects transgender young people for the American Academy of Child & Adolescent Psychiatry. “Their voice gets permanently low. They’re hairy. Their clitoris is enlarged. And what do you do now? I just find that inappropriate and unsafe.”

The differences among gender-affirming providers over assessments and medical intervention don’t break down along cisgender-transgender lines. Some transgender practitioners, like Sharon and Ren Massey, a psychologist on the SOC8 adolescent chapter, support the chapter’s approach to assessments. “We need to understand that the reality is that adolescents go through a lot of developmental changes and have a lot of internal and external influences on their development,” Massey says. And some transgender activists also support a cautious approach. “It is life changing,” Jamison Green, the former president of WPATH, says of transitioning. “It is all encompassing. If it’s right for you, then it’s really important. It’s very easy to get interested in a new idea, get excited and not think it through all the way. Young people are quite capable of understanding themselves, but not all of them will. That’s why I think prudence is useful.”

Leibowitz had a related concern. For young people who have yearned for puberty suppressants or hormone treatments, reversing course can be difficult, he says. “Some people, once they make the decision, they’re not going to go against it, because they feel internal pressure to continue. They might be susceptible to feeling ashamed.”

Research is just beginning about why young people halt medical treatment and what it means for them. Some continue to identify as trans or nonbinary, like Nova West, a 27-year-old filmmaker I spoke to, who was happy with top surgery and the way testosterone lowered their voice and helped them build muscle — and then stopped the treatment because they didn’t want to go bald (which sometimes happens) and felt they’d reached their “optimal gender expression.”

Others decide they want to fully detransition and return to their cis identities. Grace Lidinsky-Smith, who is 28, has written about her regret over taking testosterone and having her breasts removed in her early 20s. She told me that she wished she’d had the kind of comprehensive assessment the last Standards of Care endorsed for adults. “That would have been really good for me,” she said.

St. Amand and the collective argue that as no study has directly compared different types of assessment, there’s no evidence that the Amsterdam clinic’s approach is better. They point to research from clinics in the United States, which shows small-to-moderate improvements in depression and anxiety and large improvements in body-related dysphoria for young patients six months or a year after beginning medication. One of those studies is by the clinical child psychologist Laura Kuper, based on a sample of young patients, some of who went through a streamlined assessment process that Kuper helped design at the Genecis program in Dallas. “In medicine in general, if you find a new treatment and it seems overwhelmingly helpful, you start to roll it out before you have a 10-year follow up,” says Kuper, who helped start the collective with St. Amand and is one of the authors of a SOC8 chapter on nonbinary individuals. “You continually reflect on new research and clinical findings as you go.”

It’s not yet known how well improvement in the short term predicts how teenagers today will feel as older adults about the changes they made to their bodies. In their draft chapter, Leibowitz, de Vries, Massey and their co-authors note that to date, only the Amsterdam clinic, with its comprehensive assessments, has results showing strong psychological benefits later in life for people who medically transitioned in their teens. Today, the Amsterdam clinic usually requires at least six monthly sessions (following a longer period on a waiting list) to begin medical treatment. “We’ve always said, Do it in a careful way,” de Vries says.

Most of the young people today who come to clinics for treatment are affluent and white, live in progressive metropolitan areas and have health insurance. For them, gender-related care has become more accessible since 2016, when the Obama administration included gender identity in a rule against denying health care benefits on the basis of sex. If a provider deems the care medically necessary, it’s possible to get insurance coverage for puberty suppressants, which can be injected or implanted under the skin, and hormone treatments, which can be taken orally, injected or applied as a gel or a patch. Each can cost thousands of dollars a year.

But in other parts of the country, there is often no gender clinic and sometimes no therapist or doctor to help transgender kids — who often still face bullying and harassment — navigate the process of coming out. “I have a patient in rural Mississippi who tried to find mental-health support, but it was traumatic,” says Izzy Lowell, a family-practice doctor and the founder of QueerMed, which treats patients mostly via telemedicine (without in-person visits) in about a dozen states covering the Southeast. In effect, states like Arkansas are banning care where it is already rare.

‘I say to parents, “I have no idea if your child is trans or not — they need an open field to explore.” ’

Finding care can also be harder for low-income or religious families and families of color. Lizette Trujillo, a mother in Arizona, told me that when she realized her son was trans several years ago, she found a parent support group on Facebook where her family was one of only two that were Hispanic. When she became the group’s facilitator, she worked to get the word out in her community. But some parents are reluctant to join because of their religious backgrounds, and the wave of bills to ban gender-related medical treatment is generally increasing families’ fears. “It’s terrifying,” Trujillo said. “It was the first time my son was actually afraid. ‘Could this happen here? Will you make sure I’m safe?’ He’s 14.”

Among those who had access to care, many parents and kids told me they were deeply grateful for a relatively smooth path to medical transition. Tori (a nickname) told her parents she didn’t want a boy’s body at the beginning of seventh grade. Her pediatrician in Atlanta referred her to QueerMed, Lowell’s practice. “We asked all our questions,” says Tori’s father, who belongs to the local chapter of TransParent USA, a national support group. “What if she changes her mind? What can you and can’t you come back from? There was no question on the table they didn’t have a research-based answer for. You see your kid light up at the answers, and you say, ‘OK, this is the right thing to do.’” Tori says she just wishes her transition could go faster.

Other parents, however, were bewildered by a landscape in which there are no labels for distinguishing one type of therapeutic care from another. In recent years, the Endocrine Society, the American Psychological Association, the American Psychiatric Association and the American Academy of Pediatrics have endorsed gender-affirming care as the only acceptable approach. But the major medical groups tended to speak in broadly supportive terms without specifying how providers should actually do it.

It’s not clear how common comprehensive assessments are among gender-affirming providers in the United States. “The American Psychiatric Association doesn’t really have an official position on the best way to treat the kids,” says Jack Drescher, a clinical professor of psychiatry at Columbia University who helped write the group’s position statements.

One mother in New England told me about talking to a therapist when her 6-year-old, Charlie (a nickname), became tearful about using the girls’ bathroom and urgently asked for a buzz cut. Without meeting Charlie, the therapist told the mother during a single session that her child was a trans boy. Feeling overwhelmed, the mother took Charlie to another therapist, Julie Mencher. “I say to parents, ‘I have no idea if your child is trans or not,’” Mencher told me. “They need an open field to explore.” Charlie, who is now 12, told me that he figured out over the next year or so that he was sure of his male identity. His parents could see it solidifying and supported his wish to go on puberty suppressants. “The first therapist was right,” his mother says. “But we needed a process we could trust.”

I also talked to parents who were surprised when their teenagers came out as trans. Some wanted to be both supportive and cautious. Four years ago, when she was 12, Catherine (her middle name) left a note under her mother’s pillow saying she was a trans boy. She followed a script from YouTube videos she’d watched of other teenagers coming out. Catherine’s mother says she looked for a therapist who “would be open to whatever came,” and found Jennifer Butzen, a licensed counselor in the Atlanta area. Butzen estimates that about two-thirds of her young clients with gender-identity issues eventually choose to go on hormones, while the other one-third either are nonbinary, nonconforming or trans but decide not to have medical interventions or are cisgender.

Butzen told me about the influence of the types of YouTube videos Catherine watched. She calls them “butterfly videos” because of their curated, beautiful portrayal of self-transformation. For some kids, the videos are a valuable resource — a bridge to the self they desire that they can’t easily find in real life. But others, Butzen finds, are on a less coherent search for belonging. “Being trans comes with goals — this is what to do,” Butzen says. “It comes with a support network and a cause to fight for.” Online, where the stakes start relatively low, teenagers in progressive communities can trade in a cisgender, heterosexual, white identity — the epitome of privilege and oppression — to join a community with a clear claim to being marginalized and deserving of protection.

When Catherine started seeing Butzen, the pair talked about sexuality as well as gender identity and did exercises, using a whiteboard, about male and female stereotypes, which Butzen wants her clients to know they can challenge whatever their gender. Butzen also explained the physical and social changes that come with medical transition. “Everything became more real, and it got a little scary,” Catherine says. “But I was in this forward movement, like, ‘I have to do this.’”

But one day on the way to her appointment with Butzen, Catherine started crying and told her mother she’d been lying to herself. In retrospect, she thinks the YouTube videos gave her a way to relieve discomfort she felt about being attracted to girls, which wasn’t accepted at her Catholic school. Later, Catherine came out as bisexual. If her parents had said no to the idea that she was trans, she says, “I would have revolted against them.” But when they gave her room to explore, “I internalized what I wanted to do.”

Other teenagers talked about the way misogyny affected their thinking. One 18-year-old, Kat (a nickname), started using a boy’s name and pronouns four years ago and asked to take puberty suppressants, as a friend was doing in her Midwestern college town. Her mother said no to medication. She worried about the health effects and the role of peer influence; she also told me she wanted to make sure her child understood there was no right or wrong way to be a girl. “I didn’t get it as well as other people did, what being a girl even meant,” Kat told me, looking back. “And my mental health wasn’t great. I was cutting around that time.” At about 17, she went back to her girl’s name and pronouns. “I still have weird, internalized misogyny in my brain I’m trying to get over,” she says. “I don’t even get where it’s coming from.”

In other families, a teenager’s decision to come out was a source of prolonged conflict. F., now 18 and living in Maryland, started identifying as a trans boy and binding his breasts in seventh grade. His mother told me that when she found out, she told F. she didn’t believe anyone was born in the wrong body. Later, she went to a protest at a gender clinic in Washington, D.C., which upset F. His group of friends, which included other trans and queer kids, became “a really big part in me being able to be myself,” he says. These days, F., who has not medically transitioned, identifies as nonbinary. “I’m kind of coming to terms with my body,” he says. “Who’s to say my body is female? I’m not a girl and it’s my body. Don’t put your labels on me.”

To parents who doubt the authenticity of a child’s assertion or oppose medical treatments their kids strongly want, the smooth road to gender care looks like a dangerously slippery slope. Such parents have increasingly found each other online, in Facebook groups and on websites. Last fall, an international group called Genspect started holding web-based seminars that are critical of social and medical transition and, a spokeswoman said, gained thousands of members.

Some Genspect parents told me the rise in trans-identified teenagers was the result of a “gender cult” — a mass craze. (In February, an anonymous parent on a Substack newsletter affiliated with Genspect wrote a post called “It’s Strategy People!” about how the group gets its perspective into the media by making sure not to talk about their kids as “mentally ill” or “deluded.”) Other parents said they were not conservative and generally supported L.G.B.T. rights but not medical transition for their own children or usually for anyone under the age of 18. Several parents argued that though 18 is the legal age to vote, buy a gun and consent to medical treatment, in this single area of medicine — gender-related treatment — the age of consent should be 25, when brain development is largely complete. (At 18, these parents are aware, teenagers can go to Planned Parenthood, one of the largest providers of gender-affirming hormones in the country, and receive hormones after a roughly half-hour consultation and giving consent.)

Several Genspect parents told me their teenagers came out as trans after struggling for years with serious mental-health issues. One mother in Northern California said her child had previously been hospitalized for a suicide attempt and started identifying as trans while spending many hours online. The mother said yes to puberty suppressants at the recommendation of a local gender clinic, but her child became more volatile, she said. Around 15, her child wanted to progress to hormone treatment, which the gender clinic supported, according to emails I reviewed. When the mother refused, she became the object of her child’s fury. “What if I’m wrong?” she asked. “Knowing my kid sees me as the barrier to happiness — that’s the worst part. I feel like a monster.”

As the United States battled over whether gender-related care should be banned or made more accessible, a few European countries that had some liberal practices concerning young people seeking medication imposed new limits recently. In February, the national health board in Sweden limited access to puberty suppressants and hormones before the age of 18 to “exceptional cases” and in research settings. The shift followed a Swedish public-television documentary that claimed doctors tried to hide spinal damage in a young patient whose bone density wasn’t adequately monitored. Finland has similarly restricted access. One month after Sweden’s decision, the National Academy of Medicine in France called for “great medical caution” regarding treatment for young people, citing health risks (including for bone density and fertility) and noting the unexplained rise in trans-identified teenagers.

In March, I visited the Amsterdam clinic to talk to de Vries about its trailblazing program and what she made of the responses of other European countries. We talked in her office, near a waiting room with a foosball table and artsy photos of an androgynous masked dancer. As a child, de Vries told me she resisted stereotypical gender roles. “Why were the boys asked to help the teacher carry heavy loads and the girls had to bring coffee and tea?” she said. “You could make me quite angry by asking me as a kid to do those things, as a girl.”

Working in her clinic now, de Vries is concerned about the waiting list, which she called “devastating.” Young people often wait two years or more for an appointment in the Netherlands. One of them, a theater student named Yaël who is now 22, told me that the delay felt endless. “My friends started growing beards, and people were looking at me like they were the guys and I was a girl or their little brother,” he said. “It was just very frustrating and depressing.” He remembered the day he started hormones at 16. “Someone came to the door to deliver a package, and when I signed for it, he said, ‘Have a good day, ma’am.’ For the first time, it didn’t bother me. I thought, I know in a couple of months you won’t say that.” He added, “I can’t imagine a life without being able to transition.”

De Vries said she was disappointed by the developments in Scandinavia and France. But she thought the retreat in those countries signaled a different kind of conservatism, about how to practice medicine in light of scientific uncertainty, from the bans in the red American states, fueled by anti-trans vitriol. The shift from European health authorities also suggested that scientists and physicians who don’t have the clinical experience of seeing young people receive gender treatments felt more constrained by the limitations of the research.

England’s National Health Service, too, asked for an independent review of the country’s gender-identity services (following a whistle-blower’s report in 2018 that the nation’s only pediatric clinic was fast-tracking young people into medical treatment and a lawsuit by a former patient — who later detransitioned — over the care she received there). Hilary Cass, a prominent pediatrician, is leading that effort. In a preliminary report in February that doesn’t make a final recommendation, she said the “lack of available high-level evidence” about puberty suppressants and hormone therapy for young people was “too inconclusive to form the basis of a policy position” on whether to continue the treatments. She also described a “mismatch” between the ethical responsibilities of clinicians to meet certain standards before a treatment and the distress some young people feel about a detailed assessment because they want “rapid access to physical interventions.” Like the SOC8 adolescent chapter, Cass suggested that the Dutch approach to assessment is the one best supported by the research.

New findings continue to support that approach. In April, de Vries presented data at a pediatric conference, still unpublished, about more than 80 patients from the clinic’s early cohort who were now between the ages of 25 and 50. (The response rate was about 50 percent.) According to the answers they provided, the trans men were doing just as well, in terms of mental health, as the general population. The trans women were slightly below the norm. No one in the group had reversed their hormonal treatments or surgeries. There is no published research on the physical effects in middle or old age of having transitioned in adolescence; the Amsterdam clinic is now collecting data on this question.

‘In our society right now, something is either all good or all bad. Either there should be a vending machine for gender hormones or people who prescribe them to kids should be put in jail.’

In a video chat this spring, I talked to F.G., the first patient to take puberty suppressants for gender affirmation 35 years ago, when he was 13. He’s a veterinarian, and when we spoke, he wore a yellow track jacket and had a short brush cut and a patch of beard under his lip. He told me that when he was a child, he wanted simply to be a boy. But of course that was impossible. Taking medication to stop puberty, he said, saved his life. He waited until he was 18 for hormone treatment. It would be unusual now to have such a prolonged stint on puberty suppressants. F.G. says he never wanted to have children, though he’s not sure if that’s because he didn’t know if he could. For years, he stayed away from romantic and sexual relationships, but that changed in his 30s, and these days he has a serious girlfriend.

F.G. has watched the rise in numbers of transgender young people with a mix of joy and trepidation. He thinks kids who want the medical treatment he received should go through a significant assessment process. “It makes me sound a bit of a hypocrite, because I needed that to be who I am,” he said. And yet the time on the suppressants, to test the strength of his own desires, was essential to his peace of mind. “I really, really thought about it,” he said, “and I’ve never been so sure of anything in my whole entire life.”

In March, the Biden administration’s Department of Health and Human Services put out a statement unequivocally supporting gender care for minors , “when medically appropriate and necessary,” as a matter of federal civil rights law. But the backlash was gaining momentum. The bill to ban trans medical treatment that Leibowitz had been worrying about was moving through the Ohio House; in April, Alabama passed a similar bill. On Fox News, Tucker Carlson called treatment for young people “chemical castration.” And the Florida Department of Health issued guidelines that opposed social or medical transition for kids of any age. Conservatives usually champion parental authority, but in families with trans kids, they were lining up to take it away.

Judges blocked the statewide bans, but in some cases, preteens and teenagers were losing access to a course of medication they’d already begun because pharmacies refused to fill prescriptions and doctors or hospitals preemptively stopped treatment, fearing liability or political opposition. In Texas, Ximena Lopez, a pediatric endocrinologist who worked at Genecis, the Dallas program that was forced to disband in November, sued to continue to see patients, and Leibowitz prepared to testify in support of her case. (Lopez has continued to see her previous patients and is temporarily accepting new ones under a one-year injunction.)

Leibowitz was frustrated by a political dilemma. To defend against the bans, some gender-affirming providers were oversimplifying aspects of the treatments. They said minors never or almost never had surgery at all, even though top surgery is important to some trans teenagers to relieve their dysphoria and is rising. (In the Kaiser Permanente health care system in Northern California, the incidence rose from a handful of operations in 2013 to nearly 50 in 2019, according to a study published in Annals of Plastic Surgery in May. Only two of the 200-plus teenagers in the study said they regretted the surgery at least one year later.)

To make the urgent case that medical interventions are necessary, some providers started emphasizing the risk of suicide among trans kids. The rate of suicide attempts among them in the previous year is terribly high — nearly 35 percent in a 2017 survey of high school students by the Centers for Disease Control and Prevention compared with single digits for the cisgender population. A 2020 study of trans patients of all ages, over more than four decades, at the Amsterdam clinic, found that deaths by suicide, which are fortunately rare, though still higher than for the general Dutch population, seem to “occur during every stage of transitioning.”

In the overheated political moment, however, parents were getting the terrifying message that if they didn’t quickly agree to puberty suppressants or hormone treatments, their children would be at severe risk. Many parents told me they’d heard the mantra: “It’s better to have a live son than a dead daughter.”

In individual cases, teenagers often say that being able to medically transition is lifesaving. Jack Turban, a fellow in psychiatry at Stanford Medical School, has become a major voice in the media and on Twitter among gender-affirming providers including on the question of medications and suicide risk. He leads a research team that worked with data from a 2015 survey of transgender adults in the United States. The survey asked respondents if they remembered taking puberty suppressants or hormone treatments before age 18. Using those adult recollections, Turban’s team published articles in 2020 and 2022 finding an association between taking puberty suppressants and hormone treatments and having lower odds of suicidal thoughts in adulthood. But the studies didn’t find the same link between taking the medications in adolescence and actually planning or attempting suicide. (Through a Stanford spokeswoman, Turban said he didn’t have time to talk to me.)

Another 2022 study based on a different survey, by researchers from the Trevor Project (which provides crisis support to L.G.B.T.Q. young people), did show a 40 percent lower incidence in recent depression and in past-year suicide attempts for transgender and nonbinary 13-to-17-year-olds who said they had hormone treatments. There was no such finding for 18-to-24-year-olds.

The survey-based studies received prominent media coverage. But this research doesn’t prove that young people who get puberty suppressants or hormones are at lower risk because of the medications, points out Christine Yu Moutier, a psychiatrist and the chief medical officer for the American Foundation for Suicide Prevention. The adults who remembered getting the treatments as teenagers could have had other advantages — “socioeconomic factors, having health insurance, having supportive families” — that better accounted for why their rates of suicidal thoughts or attempts were lower, Moutier says. And they could have received the medications they wanted in part because their mental health was evaluated as stable beforehand.

One of the clearest and most consistent findings about L.G.B.T. young people is that support from their families is essential for protecting them from a host of poor outcomes, from depression and suicide attempts to homelessness. The Family Acceptance Project, a research and intervention program for families of L.G.B.T. children, tells parents that refusing to use a child’s chosen names and pronouns is a form of rejection. But the project stops short of saying that parents who delay or refuse to consent to medication, despite their children’s wishes, are rejecting them or putting them at risk.

In the heat of a battle like the one raging over gender-related medical care for minors, insisting on precision about scientific evidence can seem nitpicky. But Leibowitz thinks gaining the trust of families necessitates acknowledging complexity. “It’s irresponsible to reinforce very scary statistics to families in an attempt to gain consent for treatment,” Leibowitz says. “This strategy doesn’t build the type of love and acceptance that a child needs, which is truly at the heart of preventing suicidal behavior.”

Maddie Deutsch, the president of USPATH, worries that the loud voices on all sides are the extreme ones. “In our society right now, something is either all good or all bad,” she says. “Either there should be a vending machine for gender hormones or people who prescribe them to kids should be put in jail.”

At a hearing called by the Ohio Assembly in May, supporters testified in favor of a ban on gender-related medical treatment, called the “Save Adolescents From Experimentation Act,” while opponents rallied outside the hearing-room window. One conservative activist singled out Leibowitz for attack, based on statements he has made about gender-affirming care and supporting transgender young people and their families. It felt surreal to him to hear his remarks turned into fodder for testimony about how parents were being “coerced” into agreeing to medical intervention. It was a reminder, if he needed one, that for all the care and moderation he tried to take, he would always be perceived as dangerous by the right.

The 62-page final version of the adolescent chapter, which WPATH sent me the first week of June, is scheduled to be released this summer. It will include a key change in the top-line recommendations of the SOC8, in response to advocates like International Transgender Health. In place of the December draft’s recommendation of evidence of several years of gender incongruence before a preteen or teenager begins any medical intervention, the final chapter set a vaguer timeline: gender incongruence that is “marked and sustained over time.” Below their recommendations, Leibowitz, de Vries and their committee did note that several years of experience is important for teenagers who want hormones and surgery but said that for puberty suppressants, several years was “not always practical or necessary.” In the end, the chapter sided with the trans advocates who didn’t want kids to have to wait through potentially painful years of physical development.

Leibowitz, de Vries and their co-authors held their ground on assessments. The final version of their chapter said that because of the limited long-term research, treatment without a comprehensive diagnostic assessment “has no empirical support and therefore carries the risk that the decision to start gender-affirming medical interventions may not be in the long-term best interest of the young person at that time.”

“Sometimes I feel that the field is so polarized that I worry whether the guidelines will be followed — how much authority will they have?” de Vries said of the upcoming publication of the chapter. “But I think a sensible reader will read a very nuanced, thoughtful approach that will help those who really need it.”

In the run-up to the release of the final SOC8, Leibowitz couldn’t imagine a more nerve-racking moment to make the guidelines public. In early June, the administration of Gov. Ron DeSantis of Florida asked the state’s health department essentially to ban gender-related medical care for minors — and in addition, to lay the groundwork to take that care away from trans adults with a report that justified ending Medicaid coverage for them.

Leibowitz said he hoped the SOC8 would improve the quality of care. He knew it wouldn’t settle the larger debates about how well teenagers know themselves and how parents and professionals should respond to them. “It’s convenient to say there’s not enough evidence if you don’t believe in the treatment — and that there’s enough evidence, if you do believe,” Leibowitz said. The clinical experience he had, seeing kids every day, was uppermost. “Evidence matters, yes, but common sense matters, too.”

Emily Bazelon is a staff writer for the magazine and the Truman Capote fellow for creative writing and law at Yale Law School. Her 2019 book, “Charged,” won the Los Angeles Times Book Prize in the current-interest category. Anne Vetter is a photographer and writer in California and Massachusetts. Their work is focused on the fluidity of identity, as well as Jewishness, whiteness and wealth.

Editors’ note: An earlier version of this article referred to the first patient to receive puberty suppressants from doctors at the Amsterdam clinic as “Patient Zero.” (In an interview, the patient used the term to describe himself as the first to receive treatment.) After publication, some readers took issue with the term, which in other contexts can suggest the initial case in an outbreak of contagious disease. That was not the intended meaning here. The phrase has now been replaced by “the first patient.”

An earlier version of this article referred incorrectly to the comprehensive assessment that Grace Lidinsky-Smith said she wished she had received. It was the last Standards of Care endorsed for adults by the World Professional Association for Transgender Health, not for adolescents. And the article referred incorrectly to Colt St. Amand’s role at the Mayo Clinic. He is a family medicine physician at Mayo and works as a clinical psychologist in private practice.

An earlier version of this article misstated who leveled the complaints about Ken Zucker’s method in his gender clinic in Toronto that led to the clinic’s closure. It was shut down because of complaints from activists; no parent group complained about his method.

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Hormone therapy for transgender patients

Many transgender men and women seek hormone therapy as part of the transition process. Exogenous testosterone is used in transgender men to induce virilization and suppress feminizing characteristics. In transgender women, exogenous estrogen is used to help feminize patients, and anti-androgens are used as adjuncts to help suppress masculinizing features. Guidelines exist to help providers choose appropriate candidates for hormone therapy, and act as a framework for choosing treatment regimens and managing surveillance in these patients. Cross-sex hormone therapy has been shown to have positive physical and psychological effects on the transitioning individual and is considered a mainstay treatment for many patients. Bone and cardiovascular health are important considerations in transgender patients on long-term hormones, and care should be taken to monitor certain metabolic indices while patients are on cross-sex hormone therapy.

Introduction

Transgender individuals experience discord between their self-identified gender and biological sex. Transgender men are individuals who were assigned female at birth but identify as men, and transgender women are individuals who were assigned male at birth but identify as women. While research in this area is sparse, the current evidence points toward a biologic etiology for transgenderism. These data come from studies examining children with congenital genitourinary anomalies who were assigned gender at birth ( 1 , 2 ), as well as postmortem cadaveric studies ( 3 ). Estimation of prevalence of transgenderism has historically been challenging. The most recent estimates in the United States have been reported from survey studies, and range from 0.3–0.5% ( 4 , 5 ).

The number of transgender individuals seeking cross-sex hormone therapy has risen over the years ( 6 ). The administration of exogenous virilizing hormones is considered medically necessary for many transgender individuals ( 7 ). Many transgender men seek therapy for virilization and the mainstay treatment is exogenous testosterone. Transgender women desire suppression of androgenic effects and often use anti-androgen therapy with feminizing exogenous estrogens.

The purpose of this review is to present updates on the current hormonal regimens used by transgender patients, to discuss the safety and efficacy of these treatments, and to provide a summary of the current data that exist on both their short- and long-term effects.

Both the World Professional Association for Transgender Health (WPATH) and the Endocrine Society have created transgender-specific guidelines to help serve as a framework for providers caring for gender minority patients. These guidelines are mostly based on clinical experience from experts in the field. Guidelines for hormone therapy in transgender men are mostly extrapolations from recommendations that currently exist for the treatment of hypogonadal natal men and estrogen therapy for transgender women is loosely based on treatments used for postmenopausal women.

In the past, the guidelines for hormone therapy initiation recommended that all patients undergo a “real life test” prior to starting medical therapy. This test required patients to live full-time as their self-affirmed gender for a predetermined period of time (usually 12 months) before starting cross-sex hormones. The recommendation was intended to help patients transition socially. However, both above-mentioned societies have recognized that this step is unreasonable for many patients as social transition can be very challenging if there is incongruence between an individual’s self-affirmed gender and their physical appearance. As a result, the updated guidelines do not require this step, and instead, the societies recommend that patients transition socially and with medical therapy at the same time ( 7 , 8 ).

WPATH recommends that hormone therapy should be initiated once psychosocial assessment has been completed, the patient has been determined to be an appropriate candidate for therapy, and informed consent reviewing the risks and benefits of starting therapy has been obtained. Per WPATH, a referral is required by a qualified mental health professional, unless the prescribing provider is qualified in this type of assessment. The criteria for therapy include: (I) persistent well-documented gender dysphoria (a condition of feeling one’s emotional and psychological identity as male or female to be opposite to one’s biological sex) diagnosed by a mental health professional well versed in the field; (II) capacity to make a fully informed decision and to consent for treatment; (III) age of majority; and (IV) good control of significant medical and/or mental comorbid conditions.

This fourth criterion can sometimes be the most challenging to interpret. Many patients may have concurrent mood disorders related to their gender dysphoria, and experienced providers may have success alleviating the severity of these symptoms by allowing the patient to begin the medical transition process. Later in this review I discuss the effects hormones have on quality of life and perception of personal well-being. This is a key concept and should be considered when patients are being evaluated for hormone therapy initiation. Patients with comorbid psychiatric conditions should be closely monitored and mental health support remains paramount for these patients.

Testosterone

Testosterone therapy is used to suppress female secondary sex characteristics and masculinize transgender men. The therapy used resembles hormone replacement regimens used to treat natal men with hypogonadism and most of the preparations are testosterone esters.

Current formulations for testosterone are presented in Table 1 . Oral formulations such as testosterone undecanoate (Andriol ® ) are used in Europe but continue to not be available in the United States due to concerns about first-pass metabolic effects from the drug. The most commonly used formulations in the United States are those that are administered via the intramuscular or subcutaneous route, and include testosterone enanthate (Delatestryl ® ) and cypionate (Depo ® -Testosterone). These are usually administered weekly, but if higher doses are needed to reach adequate physiologic levels, the dosing interval can be extended to every 10 to 14 days. Testosterone undecanoate (Aveed ® ) is a long-acting testosterone that can be administered every 12 weeks and was approved by the FDA in 2014 for treatment of male hypogonadism, and it can be used off-label to treat gender dysphoria in transgender men. Transdermal options (Androgel ® , Androderm ® ) are also good alternatives for some patients.

Before a patient is started on testosterone, a baseline hematocrit and lipid profile should be obtained, as these indices will change over time. In addition, if a patient is at significant risk for osteoporosis, a baseline bone mineral density should be obtained ( 9 ). Most providers start testosterone therapy with half the anticipated dose needed to reach maximum virilization in a patient. Goal testosterone levels (male physiologic range) are 300–1,000 ng/dL, and testosterone dosages can be quickly titrated to reach adequate levels. Studies exist looking at dose-response with regard to virilization once testosterone is initiated. Nakamura et al. ( 10 ) showed that early onset of treatment effects of testosterone therapy is dose-dependent, but within six months of initiating therapy, higher doses are no more effective than lower doses. Therefore, while higher doses may achieve desirable effects sooner, the risks associated with fast titration need to be assessed, and patients should be aware that testosterone effects eventually become the same over the intermediate-term.

Testopel ® are FDA-approved testosterone pellets that are implanted subcutaneously. Once implanted, the pellets slowly release testosterone for a long-acting androgenic effect. They are approved for the treatment of primary hypogonadism and hypogonadotropic hypogonadism. Our group recommends that patients first be started on an alternative form of testosterone until maximum virilization is achieved and maintenance dosing is then necessary. Patients may then be transitioned to the implanted pellets. The number of pellets to be implanted depends upon the minimal daily requirements of testosterone needed to reach physiologic levels. Each pellet is cylindrical in shape and contains 75 mg of testosterone and six pellets may be implanted with each pass of the insertion device that is provided with the kits. Two pellets should be inserted for every 25 mg of parenteral testosterone needed weekly. The pellets are placed in a fatty area under the skin. Most commonly, the upper gluteal region or hip is used as a site for implantation. Approximately 1/3 of the pellets become absorbed in the first month, 1/4 in the second month and 1/6 in the third month. The effects of the pellets may last up to 6 months, but most patients require re-implantation every 3 to 4 months.

Hormone therapy for transgender women is intended to feminize patients by changing fat distribution, inducing breast formation, and reducing male pattern hair growth ( 11 ). Estrogens are the mainstay therapy for trans female patients. Through a negative feedback loop, exogenous therapy suppresses gonadotropin secretion from the pituitary gland, leading to a reduction in androgen production ( 12 ). Estrogen alone is often not enough to achieve desirable androgen suppression, and adjunctive anti-androgenic therapy is also usually necessary.

Ethinyl estradiol used to be the mainstay of most estrogen-directed therapies. This is no longer the case, as clinical evidence has showed a strong relationship between ethinyl estradiol and the incidence of deep venous thrombosis ( 13 ). As a result, there are strong recommendations against the use of ethinyl estradiol in transgender patients ( 8 ). Oral (Estrace ® , Gynodiol ® ) and transdermal (Alora ® , Climera ® , Esclim ® , Estraderm ® , Vivelle ® ) estradiol and parenteral estradiol valerate (Delestrogen ® ) are currently the preferred formulations of estrogen. See Table 2 for dosing recommendations. No studies have examined the efficacy of the different formulations specific to transgender hormone management. After the age of 40, transdermal formulations are recommended as they bypass first pass metabolism and seem to be associated with better metabolic profiles ( 14 ).

There are no unanimous recommendations for the use of anti-androgens. Options are also listed in Table 2 . Spironolactone is one of the most common medications used to suppress endogenous testosterone in trans female patients. The biggest risk associated with spironolactone is hyperkalemia, and this should be closely monitored. Other options include 5α-reductase inhibitors such as finasteride, but these can be associated with liver toxicity and may not be as effective as spironolactone ( 8 ). GnRH agonists can be very expensive, and are not always a good option for patients. Progestins are used by some providers, but should be used with caution as there is a theoretical risk of breast cancer associated with long-term exogenous progesterone use ( 15 ).

Effects of testosterone and estrogen

Many trans men seek maximum virilization, while others desire suppression of their natal secondary sex characteristics only. As a result, hormone therapy can be tailored to a patient’s transition goals, but must also take into account their medical comorbidities and the risks associated with hormone use.

Within three months of initiating testosterone therapy, the following can be expected: cessation of menses (amenorrhea), increased facial and body hair, skin changes and increased acne, changes in fat distribution and increases in muscle mass, and increased libido ( 11 , 16 ). Later effects include deepening of the voice, atrophy of the vaginal epithelium, and increased clitoral size. Male pattern hair loss also can occur over time as a result of androgenic interaction with pilosebaceous units in the skin ( 17 ). Some patients find this favorable as it may be considered masculinizing. For those who do not find it favorable, 5α-reductase inhibitors can be used as adjuncts to combat alopecia. However, patients should be made aware of the potential side effects on sexual functioning that can be associated with these medications, and they should be counseled that no data exist on the use of these medications in transgender men ( 18 ). In most female-to-male patients (unless testosterone is administered during the peri-pubertal period), there is some degree of feminization that has taken place that cannot be reversed with exogenous testosterone. As a result, many transgender men are shorter, have some degree of feminine subcutaneous fat distribution, and often have broader hips than biologic males ( 19 ).

The following changes are expected after estrogen is initiated: breast growth, increased body fat, slowed growth of body and facial hair, decreased testicular size and erectile function. The extent of these changes and the time interval for maximum change varies across patients and may take up to 18 to 24 months to occur. Use of anti-androgenic therapy as an adjunct helps to achieve maximum change.

Hormone therapy improves transgender patients’ quality of life ( 20 ). Longitudinal studies also show positive effects on sexual function and mood ( 16 , 18 ). There is biologic evidence that may explain this. Kranz et al. ( 21 ) have looked at the acute and chronic effects of estrogen and testosterone on serotonin reuptake transporter (SERT) binding in trans men and women. SERT expression has been shown to be reduced in individuals with major depression ( 22 ). Kranz et al. found that androgen treatment in transmen increased SERT binding in several places in the brain and anti-androgen and estrogen therapy led to decreases in regional SERT binding in trans women. These types of data are preliminary, but do point to the important role of hormone therapy in patients who suffer from gender dysphoria.

Hormone therapy may even have a positive effect on physiologic stress as well. Colizzi et al. ( 23 ) looked at 70 transgender patients on hormone therapy and measured their cortisol levels as well as their perceived stress before and 12 months after starting hormone therapy. They found that after starting cross-sex hormones, both perceived stress and cortisol were significantly reduced. This finding also has important implications for treatment.

Surveillance

Surveillance recommendations for cross-sex hormone therapy are listed in Tables 3 and ​ and 4 . 4 . Patients on testosterone should be monitored every 3 months for one year and then every 6 to 12 months thereafter. Tables 3 and ​ and 4 4 display surveillance recommendations for trans men and women. Hormones should be carefully monitored to avoid a prolonged hypogonadal state if dosing is too low, which can lead to significant losses in bone mineral density; and to avoid exposures to supraphysiologic levels, which could have significant physiologic and metabolic effects ( 24 ).

Sex steroids—testosterone and estradiol—are necessary to maintain bone health in men and women, respectively. They are responsible for bone growth and turnover, and hypogonadal states in both males and females can result in clinically significant bone loss. Testosterone has a direct role in bone health maintenance, but the steroid is also aromatized peripherally to estradiol, which has a very important role as well ( 25 ). Testosterone also has an important role in increasing muscle mass, which further helps with bone health preservation. Studies have looked at bone health in transgender men on long-term testosterone therapy. Exogenous testosterone appears to have an anabolic effect on cortical bone and when dosed at physiologic levels, is adequate enough to avoid issues with bone demineralization in transgender patients ( 26 ). Transgender women may be at higher risk for bone loss despite estrogen use ( 27 ). This is likely a result of anti-androgen use, and therefore, providers should consider stopping anti-androgen therapy if and when patients undergo orchiectomy with or without genital confirmation surgery. Screening for bone loss should be performed per the guidelines for the general population, unless a patient has baseline low bone mineral density, or is at risk for osteoporosis (tobacco use, alcohol abuse, previous fractures, eating disorder, family history of osteoporosis). Patients at risk should be screened sooner and more regularly.

It is not clear whether use of exogenous testosterone increases the risk of cardiovascular disease in transgender men. Some studies have shown that testosterone has a negative effect on indices that may increase the risk of cardiovascular events. For instance, Gooren and Giltay ( 28 ) showed that long-term testosterone use reduced high-density lipoprotein cholesterol and increased triglycerides as well as inflammatory markers. Other studies have found similar changes. Wierckx et al. ( 16 ) looked at 50 patients on testosterone for a mean time of 10 years and found that many patients had elevated cholesterol and serum triglycerides while several had elevated blood pressure. Despite these metabolic changes, and negative impact on potential risk factors for cardiovascular disease, no studies have found an increase in the occurrence of cardiovascular events such as myocardial infarction, deep vein thrombosis, and cerebrovascular events ( 16 , 29 , 30 ).

Studies looking at the effects of estrogen on cardiovascular disease in transgender women are not very conclusive, but do show that there may be a trend toward an increased risk of heart disease, which should be further studied. Use of oral ethinyl estradiol appears to be strongly associated with cardiovascular events ( 30 ) and should therefore be avoided as a mainstay therapy for patients ( 31 ). In addition, diabetes is a significant risk factor for cardiovascular disease and may have an important role in raising the risk of cardiovascular morbidity in trans women on estrogen, as this comorbidity has been found to be prevalent among the transgender population ( 32 ).

Large-scale prospective studies are lacking. Many of the studies that currently exist have small patient numbers as well as short or medium-term follow-up, and very few of the patients studied are over the age of 65. Furthermore, no head-to-head comparisons of hormone regimens have been published. It is therefore, not possible to draw definitive conclusions about the adverse effects of long-term cross-sex hormone use.

Special considerations

Routine laboratory monitoring of patients on cross-sex hormone therapy can be challenging because results are often reported using gender-specific reference intervals, which are not all appropriate for transgender patients. With the exception of cholesterol, triglycerides, hemoglobin and hematocrit, there are few published data on reference ranges for cardiovascular and metabolic measurements that may be important in the diagnosis and management of other diseases in transgender patients. Roberts et al. ( 33 ) looked at metabolic indices in male-to-female patients on hormone therapy in order to determine appropriate reference ranges. They found that hemoglobin, hematocrit and low-density lipoprotein resembled biologic female ranges. However, alkaline phosphatase, potassium, and creatinine levels were similar to male reference levels. And, importantly, triglyceride levels were higher than both biologic male and female reference ranges. From their study, the authors concluded that it is not possible to predict reference ranges for transgender women based only on what is already known about postmenopausal women on estrogen therapy, and that new reference ranges must be studied and validated to avoid diagnostic errors in this patient population.

Adolescents also seek hormone therapy for treatment of gender dysphoria. The purpose of this review was to cover guidelines and management for adult patients, but it is important to mention special considerations that must be taken when treating adolescent patients. Cross-sex hormones are usually recommended at the age of sixteen ( 7 ). However, in some situations when delay of therapy may lead to psychologic and cognitive trauma in a child, it may be appropriate to commence therapy earlier ( 34 ). In these cases, and most adolescent cases, it is important to have a multi-disciplinary approach to treatment and management, and parental support is imperative. In youth who have reached Tanner Stage 2 development, GnRH agonists are used to suppress endogenous hormones to avoid full pubertal development and cross-sex hormone therapy is initiated by or at age sixteen. There are many ethical issues to address in the care of the adolescent transgender patient, and the care of this patient population should be left to specialists who are well versed in this type of care.

It is not uncommon for patients to seek hormone therapy from alternative sources ( 35 ). In a recently published cross-sectional analysis, Mepham et al. ( 36 ) found that one in four trans women self-prescribe cross-sex hormones, most commonly through the Internet. In another study looking at 314 trans women in San Francisco, 49% were found to be taking hormones not prescribed by a clinician ( 37 ). Over the years, as more medical providers are gaining better experience prescribing hormones, patients are less likely to acquire hormones from these outside sources. It is important to screen patients for outside use, and to educate them about the risks associated with this. Patients sometimes feel that road blocks are placed in front of them when hormones are not prescribed right away, especially if they are being asked to seek further psychiatric care before initiating hormones. Some patients do require additional mental health care, but the time should be taken to explain to patients that the provider who intends to prescribe hormones to patients is not trying to “gate keep” the patient away from this type of therapy, but rather, he or she is ensuring that the patient has a positive outcome on the therapy. This again speaks to the importance of a multi-disciplinary approach to the care of these patients.

Conclusions

Many transgender individuals seek cross-sex hormone therapy for treatment of gender dysphoria. Hormone therapy plays an integral role in the transition process for patients. Guidelines exist to help providers prescribe and monitor therapy. Hormone therapy has been shown to be associated with positive outcomes for patients, but there are important metabolic implications of therapy that must be carefully considered when treating patients.

Acknowledgements

Conflicts of Interest : The author has no conflicts of interest to declare.

Gender Identity, Hormone Therapy, and Cardiovascular Disease Risk

• PMID: 30340769
• DOI: 10.1016/j.cpcardiol.2018.09.003

Transgender individuals represent a medically underserved and under researched population. There is a growing number of studies illustrating the importance of hormone therapy treatments in transgender men and women to assist ameliorating gender dysphoria and promoting well-being. However, the cardiovascular effects of these hormones are controversial. Large longitudinal epidemiological studies of cardiovascular event outcomes in these populations do not exist. In addition, studies of cardiovascular complications of transgender hormone therapy are limited in number and complicated by poor control of medication regimen, presence of gender confirming surgery, use of prescribed medications for prevailing conditions, and alcohol, smoking or illicit substance use, and comorbidities, such as HIV infection. The following provides an overview of current guidelines for hormone therapy regimens used by transgender individuals, as well as what is known about the use of exogenous hormones on the cardiovascular system and cardiovascular disease risk. Several gaps in our understanding of the cardiovascular effects of endogenous and exogenous hormones in treated transgender individuals are identified, which provide direction for future study.

Copyright © 2018. Published by Elsevier Inc.

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• Cardiovascular Diseases / psychology
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• Sex Reassignment Procedures* / adverse effects
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An alternative to gender transition

Those who disagree with medical and social transition efforts deserve treatment that respects their values..

By Chelsea Johnson , Jeff Bennion , David Haralson

The recently published Cass Review in the United Kingdom highlights the tumultuous debate surrounding gender-related distress and how to best provide professional support, particularly with young people. A little more than a year ago, Utah prohibited pharmaceutical and surgical transition for minors, following the lead of several other states and countries that have banned or severely curtailed these treatments for minors. At the same time, other states and countries have moved in the opposite direction, expanding access to these treatments and disciplining those who publicly oppose them. What is to be done? And what about the vulnerable young people and their families caught in the middle?

We agree with Dr. Hilary Cass when she urges clinicians and others on all sides to stop vilifying each other and instead engage in open, respectful debate about how to best conceptualize and treat gender distress. She describes the difficulty clients and families face in finding timely therapeutic support, and the need for clinicians to provide sensitive and cautious care to developing youth.

Yet research in this area is controversial and often generates seemingly contradictory conclusions. Sincere and caring providers come down on different sides of this issue and disagree, sometimes bitterly. While we respect the skills and devotion of medical providers, we believe, based on our own values and our understanding of the scientific research, that psychological and family therapy — without the inclusion of medical and social transition options — is the best treatment approach, especially among young people.

It seems research supporting our position is growing, as is skepticism about the benefits of transition. Recently, England’s National Health Service gender clinic, known as the Gender Identity Development Service, published a study on the effects of puberty blockers they had been administering at the clinic for eight years. The study reported that there was no improvement in psychological function among the young people undergoing this treatment.

A deeper analysis by an independent researcher showed a more nuanced finding: roughly one-third of patients got worse, one-third stayed the same and one-third improved in their psychological function — accompanied by all the medical risks entailed in prolonged use of puberty blockers, including reduced bone density, height, infertility and stunted brain development. As a result, England has seriously curtailed these treatments for young people.

For years, the loudest voices have assured distraught parents that social transition, puberty blockers and cross-sex hormones are safe and easily reversible and provide such dramatic mental health benefits as to be “life-saving.” While some research suggests that these social and medical efforts sometimes improve client well-being, other research indicates that little to no benefit is derived from these interventions. Additionally, puberty blockers are often the first step in a more invasive and permanent transition process that includes cross-sex hormones and surgery.

Despite these side effects and questions over benefits, parents who do not believe medicalization is the best treatment route for their child sometimes feel pressured to travel down the medicalized pathway against their intuition. We believe psychological and family-centered treatments have much to offer gender-distressed clients and their families, and that we don’t need to reinvent the wheel — we just need to use it with this population. Regular, family-centered therapy can be used to promote strong relationships, body acceptance and authentic living.

As independent family therapists, we came together during the debate and passage of Utah’s HB40 law restricting medicalization and surgery for minors. We supported the law , but also understood that families would need more support than ever. The distress and anguish these young people and their families feel is real, and their need for support and effective treatment is great.

We recently founded the Gender Harmony Institute to implement best practices of regular, time-tested therapy in treating this population and pairing it with solid research that monitors the well-being of our clients even after they terminate treatment with us; follow-up is all too lacking in this area where there are still so many unknowns. We recognize that not all clients and families will want or will respond to treatment that is limited to psychological and family therapy. In these cases, we will flexibly adjust treatment interventions according to client responsiveness and well-being. If clients desire support for legal, social and/or medical transition, we will refer them to professionals to help them in these areas, while continuing to support their overall well-being.

Additionally, our nonprofit model allows us to receive grants and donations to provide subsidized care to a growing population that sometimes lacks economic means. For maximal impact, Gender Harmony Institute also plans to disseminate what we are learning through training and certification programs directed at other clinicians, parents and schools. We’re gathering caring providers in Utah and around the country to apply well-established and empirically validated psychological and family treatments for gender-related distress.

Our clinic’s treatments are based on time-tested theories and methods such as developmental psychology, attachment, cognitive behavioral therapy, family systems, social learning, minority stress, mindfulness and more. These methods help parents discover additional ways to provide warm and steady support while also setting boundaries and honoring their own and their child’s integrity. They assist families in being more open and becoming better at disagreeing. They also allow for gender nonconformity and authenticity in the ongoing process of reconciling sex and puberty with social expectations, individual temperament and life goals.

Three examples of clients we have treated demonstrate the power of this approach:

1. A teenage girl told her parents that she “really is a boy.” At first, she thought the only way to deal with her gender-related distress was to socially transition. She was highly anxious and vacillated between shutting down and becoming angry when talking to her parents about her experience.. We supported the family in strengthening their connection, accepting her experience of same-sex attraction, and navigating the challenges of female puberty. Now, she has far less anxiety about her relationship with her parents, her body and her sexuality, and happily identifies as a gender-nonconforming girl.

2. A young adult woman came in because her parents suggested that therapy would be helpful as she makes steps toward medicalization. Through therapy, she realized where some of her anxieties were coming from — difficulties fitting in with others in the past, neglect as a child, a strained relationship with her parents and difficulty maintaining employment. While she still feels unable to fully accept her body, she is more confident, has better relationships with her friends and parents, and is able to tolerate work she does not fully enjoy. She also has a better understanding of the risks and the reasons why she is choosing a medical pathway.

3. A teenage boy came to therapy at the insistence of his parents after he announced that he “is a girl.” He is autistic and had been struggling with his mental health and peer relationships. Through therapy, he noticed that he started thinking he was transgender when he was experiencing a depressive episode. We supported him in learning to better communicate with friends, regulate his emotions and engage in self-care — getting enough sleep, having a healthy relationship with tech, spending enough time outside and staying active. Now, he says he doesn’t think about gender very much, and focuses most of his energy on building healthy relationships and taking good care of himself.

These examples demonstrate the value of taking a comprehensive, family-focused approach to gender-related distress. There are a variety of professional options to support families facing this complex experience, and there is always opportunity for families to strengthen their relationships — even when strong disagreement persists. We invite clinicians, gender-related distress patients, families and community leaders to partner with us to support families and clients by helping them strengthen their relationships, accept their bodies and live authentically.

Chelsea Johnson, M.S., is a licensed marriage and family therapist and president of Gender Harmony Institute. David Haralson, Ph.D., is a licensed marriage and family therapist and approved supervisor and clinical director of Gender Harmony Institute. Jeff Bennion, M.S., is a licensed marriage and family therapist and vice president of Gender Harmony Institute.

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• 28 May 2024

Heed lessons from past studies involving transgender people: first, do no harm

• Mathilde Kennis 0 ,
• Robin Staicu 1 ,
• Marieke Dewitte 2 ,
• Guy T’Sjoen 3 ,
• Alexander T. Sack 4 &
• Felix Duecker 5

Mathilde Kennis is a researcher in cognitive neuroscience and clinical psychological science at Maastricht University, the Netherlands.

You can also search for this author in PubMed   Google Scholar

Robin Staicu is a neuroscientist and specialist in diversity, equity and inclusion at Maastricht University, the Netherlands.

Marieke Dewitte is a sexologist and assistant professor in clinical psychological science at Maastricht University, the Netherlands.

Guy T’Sjoen is a clinical endocrinologist and professor in endocrinology at Ghent University Hospital, Belgium, the medical coordinator of the Centre for Sexology and Gender at Ghent University Hospital, and one of the founders of the European Professional Association for Transgender Health.

Alexander T. Sack is a professor in cognitive neuroscience at Maastricht University, the Netherlands.

Felix Duecker is an assistant professor in cognitive neuroscience at Maastricht University, the Netherlands.

You have full access to this article via your institution.

Over the past few decades, neuroscientists, endocrinologists, geneticists and social scientists have conducted numerous studies involving transgender people, meaning those whose gender identity does not conform to that typically associated with the sex to which they were assigned at birth. Justifications for doing such research have shifted over the years and, today, investigators are increasingly focused on assessments of transgender people’s mental health or the impact of hormone therapies.

But such work raises challenges. Despite researchers’ best intentions, these studies can perpetuate stigmas and make it even harder for transgender people to access appropriate medical care.

Here we focus on neuroscientific approaches to the study of transgender identity to explore how investigators might navigate these concerns.

Brain scanning

In 1995, neuroscientists at the Netherlands Institute for Brain Research in Amsterdam published findings from a post-mortem study, which included six transgender individuals 1 . They found that the volume of part of the brain’s hypothalamus — called the bed nucleus of the stria terminalis, which tends to be larger in men than in women — corresponded to the gender identity of the transgender individuals, not to their sex assigned at birth. Although the data were only correlative, the researchers suggested that people identify as transgender because of changes in the brain that happen before birth — in other words, that someone can be born with a male-typical body and brain characteristics more typical of a female brain, and vice versa.

Sex and gender in science

Since it was published, the paper has been cited more than 1,000 times, and at least a dozen researchers have probed this theory and related ones using tools such as structural and functional magnetic resonance imaging (MRI).

Although the results of these analyses have been inconsistent, several ideas have nonetheless arisen about a neurobiological basis for gender dysphoria — the distress associated with a person’s gender identity not aligning with the sex they were assigned at birth. These include the ‘own-body perception’ theory 2 , which proposes that a reduced structural and functional connectivity between certain brain networks is responsible. (Previous work has associated these networks with brain regions thought to be involved in people’s ability to link their own body to their sense of self 3 .)

As analytical tools and methods advance, brain research is becoming more sophisticated. The number of neuroscientific studies that include transgender participants has increased considerably since 1991 (see ‘On the rise’).

Some neuroscientists are using functional MRI to study the effects of hormone therapy on brain structure 4 and to examine cognitive processes such as face perception 5 . Others are applying machine-learning techniques to establish whether features in brain scans of cis- and transgender people correlate with their gender identity 6 . Researchers are also trying to assess whether particular features identified in brain scans make it more likely that transgender individuals will benefit from gender-affirming hormone therapy 7 . And some are conducting ‘mega-analyses’ — pooling the brain scans of hundreds of participants — to identify brain characteristics that are specific to transgender people 8 .

Help or harm?

One concern arising from such studies is that neuroscientific findings related to transgender identity could make it even harder for some people to access medical treatment that could help them.

In countries or regions where gender-affirming medical treatment is available, individuals often need a diagnosis of ‘gender dysphoria’ or ‘gender incongruence’ to be eligible for hormone therapy or gender-affirming surgery, and to be reimbursed for such treatments. Results from brain scans could be included in the suite of measurements used to assess whether someone is experiencing gender dysphoria or incongruence.

Those in favour of such requirements argue that it is necessary to prevent people taking irreversible steps that they might regret. Hormonal therapy can have adverse effects on fertility, for instance 9 . However, many transgender people argue that whether someone can receive gender-affirming hormone therapy or other treatment shouldn’t depend on a health-care practitioner deciding that they experience ‘enough’ gender dysphoria to be eligible 10 . The current approach, combined with a shortage of specialists qualified to make such diagnoses, has been linked to long waiting lists. In the Netherlands, waiting times can be more than two years .

A second possibility is that neuroscientific findings related to transgender identity will fuel transphobic narratives 11 .

Take the debate on social media and other platforms about gendered public spaces in countries such as the United States , the United Kingdom and Brazil 12 . Some people argue that allowing transgender women to access infrastructure, such as public toilets or women’s prisons, threatens the safety of “real women” . Neuroscientific research is sometimes misused to bolster flawed claims about what ‘real’ means.

Moreover, such studies could exacerbate tensions between scientific and transgender communities.

Scientists are aiming to identify brain characteristics that are specific to transgender people. Credit: Alain Jocard/AFP/Getty

Although cis- and transgender researchers have taken steps to improve people’s understanding, there is a history of tension between the scientific and transgender communities 13 . In the late 1980s, for instance, a sexologist argued that trans women who are mainly attracted to women experience sexual arousal from their own expression of femininity. He described their feelings of gender dysphoria as resulting from paraphilia — a sexual interest in objects, situations or individuals that are atypical 14 . This theory has not held up under broader scientific scrutiny 15 , but it has become notorious in the transgender community and, from our discussions with transgender people and discussions by other groups 16 , it is clear that such studies have reduced transgender people’s trust in science.

How four transgender researchers are improving the health of their communities

In 2021, for example, a neuroimaging study with transgender participants was suspended in the United States after backlash from the transgender community. The study would have involved showing participants images of themselves wearing tight clothes, with the intention of triggering gender dysphoria — an experience that is associated with depression, anxiety, social isolation and an increased risk of suicide. The study’s researchers had acquired ethical approval from their research institute and obtained informed consent from the participants. Yet they had failed to anticipate how the transgender community would perceive their experimental procedure.

In 2022, to learn more about how transgender people view current neuroscientific approaches to the study of transgender identity, we conducted focus-group interviews that lasted for three hours with eight transgender participants — all of whom had differing levels of knowledge about the topic.

The group expressed concern that studies that look for a neurological basis to transgender identities could have a pathologizing effect. “I think questions of aetiology are just inherently wrong,” one participant said. “We don’t ask ‘Why is someone’s favourite colour blue?’. These are questions that come from wanting to pathologize.” Participants also agreed that a biological-determinist approach does not do justice to the complex and layered experience of identifying as transgender.

Decades of work aimed at establishing how science can benefit minority groups 17 suggest that neuroscientists and other scholars could take several steps to ensure they help rather than harm transgender, non-binary and intersex individuals and other people who don’t conform to narrow definitions around sex and gender. Indeed, the four actions that we lay out here are broadly applicable to any studies involving marginalized groups.

Establish an advisory board. Researchers who work with transgender participants should collaborate with an advisory board that ideally consists of transgender people and members of other groups with relevant perspectives, including those who have some understanding of the science in question. Funding agencies should support such initiatives, to help prevent further distrust being sown because of how studies are designed.

Set up multidisciplinary teams. Researchers trained in neuroscience will view phenomena such as transgender identity through a different lens from, say, those trained in psychology. To prevent the outcomes of neuroscientific and other studies being described and published in an overly deterministic and simplistic way 18 , research teams should include social scientists. Ideally, such collaborations would also include transgender researchers or others with diverse gender identities, because their input would help to prevent a cis-normative bias in study design and in the interpretation of results. Indeed, our own group has benefited from this diversity (one of us is transgender).

Prioritize research that is likely to improve people’s lives. Neuroscientists and others engaged in research involving transgender participants, non-binary people or individuals with diverse gender identities should prioritize research questions that are likely to enhance the health of these groups. Although the applications of basic research can be hard to predict, investigations into the neurobiological impacts of hormone treatment on the brain, for instance, could be more directly informative to health-care practitioners and transgender individuals than might investigations into the underlying bases of transgender identity.

Rethink how ethical approval is obtained. Ethical boards at universities typically consist of scientists with diverse backgrounds. But it is unrealistic to expect them to be educated on the sensitivities of every minority group, whether in relation to gender, religion, ethnicity or anything else. One way to address this problem is for ethical boards to require researchers to state what feedback and other information they have gathered through community engagement. A university’s ethical review committee could then evaluate whether the researchers have done enough to understand and address people’s concerns and sensitivities.

Our aim is not to halt scientific enquiry. But when it comes to transgender identity, knowledge cannot be pursued in isolation from the many societal factors that shape how that knowledge is received and acted on.

Nature 629 , 998-1000 (2024)

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RELIST WATCH

Restrictions on gender-affirming medical care – and assault weapons.

The Relist Watch column examines cert petitions that the Supreme Court has “relisted” for its upcoming conference. A short explanation of relists is available here .

After going two conferences without any new relists, the Supreme Court ended the relist drought this week with a vengeance. We have 12 new relists, several of which are potential blockbusters if the court grants review.

Gender-affirming care

Three of the cases involve constitutional challenges brought against state prohibitions on providing gender-affirming care to minors: United States v. Skrmetti ,   L. W. v. Skrmetti , and  Jane Doe 1 v. Kentucky ex rel. Cameron . Last year, Tennessee and Kentucky were among a group of more than 20 states that enacted laws that prohibit giving transgender youths under the age of 18 medical treatment to align their appearance with their gender identity.

Tennessee’s law forbids medical treatments that are intended to allow a minor “to identify with, or live as, a purported identity inconsistent with the minor’s sex” or to treat “purported discomfort or distress from a discordance between the minor’s sex and asserted identity.” Kentucky’s law prohibits medical treatments “for the purpose of attempting to alter the appearance of, or to validate a minor’s perception of, [a] minor’s sex.” Both provisions outlaw a range of treatments, including gender-reassignment surgery. But the challenges before the court specifically concern two nonsurgical treatments: the administration of puberty blockers to stop physical changes brought on by puberty; and hormone therapy, which seeks to produce physiological changes to conform physical appearance with gender identity.

Transgender youths and their parents in both states quickly brought constitutional challenges in federal court, seeking to enjoin the laws before they went into effect. The challengers first argue that the restrictions discriminate on the basis of sex and therefore violate the 14th Amendment’s equal protection clause. They contend that the laws allow the use of puberty blockers and hormone therapy to conform a minor’s appearance to their birth sex, while barring transgender minors from using the same treatments. Second, the challengers argue that the prohibitions violate the 14th Amendment’s due process clause by infringing upon parents’ rights to make medical decisions for their children. The Biden administration intervened on the challengers’ side in the Tennessee case.

Federal district courts in both states granted the challengers’ requests to block the laws from going into effect. Kentucky and Tennessee then asked the U.S. Court of Appeals for the 6th Circuit to lift those orders while they appealed. The court of appeals refused, instead expediting argument. By a split vote, the 6th Circuit then reversed the lower courts’ rulings , concluding that the states were likely to win their appeals. The court thus allowed the laws go into effect.

The Biden administration, together with the Tennessee and Kentucky families, seek reversal of the 6th Circuit’s ruling. All three challengers maintain that the laws violate the equal protection clause, arguing that under Bostock v. Clayton County (in which the Supreme Court held that firing transgender employees on the basis of their gender identity violates federal employment discrimination laws) drawing distinctions on the basis of gender identity constitute prohibited action on the basis of sex. The private challengers also argue that the laws violate the due process clause because the Supreme Court has repeatedly struck down state restrictions on parents’ ability to raise their children as they see fit.

Just last month, the Supreme Court granted Idaho’s request for a partial stay of a lower-court injunction, thus permitting the state’s ban on gender-affirming care to go into effect until the court rules on any cert petition – although the injunction still remained in force as to the plaintiffs in that case, thus permitting the plaintiffs there to receive treatment.

There are some differences in the case – in the Idaho case, the district court’s decision to grant relief beyond the plaintiffs – a so-called “universal injunction” – was more prominent.  But the grant of a stay suggests that a majority of the court believes the issue is certworthy and that the state is likely to succeed. A grant in this case would make next term very interesting indeed.

Assault weapons

In early 2023, Illinois adopted the Protect Illinois Communities Act, which prohibits the possession of assault weapons and high-capacity magazines. The state law’s definition of “assault weapon” essentially followed the federal-law definition. The act prohibits possession of certain semiautomatic pistols and rifles. A semiautomatic rifle falls under the law’s proscriptions if it has a detachable magazine and one or more of the following features: a pistol grip or thumbhole stock; any feature capable of functioning as a protruding grip for the non-trigger hand; a folding, telescoping, thumbhole, or detachable stock or a stock that otherwise enhances the concealability of the weapon; a flash suppressor; a grenade launcher; or a barrel shroud. The definition also includes a semiautomatic rifle with a fixed magazine capacity of more than 10 rounds (except those that accept only .22 caliber rimfire ammunition). Finally, there is a lengthy list of particular models that fall within the scope of the statute, notably all “AK” weapons (modeled after the Russian AK-47) and all “AR” weapons (those modeled after the AR-15). People who owned such weapons before the effective date of the law are permitted to retain them, subject to some geographic restrictions on use; otherwise, possession is a crime. Several Illinois municipalities adopted similar legislation.

Gun owners, dealers, and interest groups brought a number of lawsuits arguing that the law violated their rights under the Second Amendment to keep and bear arms and sought to block the state from enforcing the law. Roughly speaking, plaintiffs in northern Illinois, which is more urban, lost; plaintiffs in southern Illinois, which is more rural, were successful, and a judge there held that the statute was unconstitutional in all its applications and barred the state from enforcing it.

In a consolidated appeal, a divided panel of the U.S. Court of Appeals for the 7th Circuit affirmed the denial of relief for the northern cases and reversed the grant of relief for the southern ones. The panel said that, “[u]sing the tools of history and tradition to which the Supreme Court directed us in [ District of Columbia v. ] Heller  and [ New York State Rifle & Pistol Ass’n v. ] Bruen ,” which instructed courts to look for analogous laws in history when considering the constitutionality of restrictions on the personal right to bear arms, “the state and the affected subdivisions have a strong likelihood of success in the pending litigation.” The 7th Circuit reasoned that “these assault weapons and high-capacity magazines are much more like machineguns and military-grade weaponry” that are not protected by the Second Amendment “than they are like the many different types of firearms that are used for individual self-defense,” and thus they can be regulated or banned.

Six petitions have been filed seeking review of that determination: Harrel v. Raoul , Herrera v. Raoul , Barnett v. Raoul , National Association for Gun Rights v. City of Naperville, Illinois , Langley v. Kelly , and Gun Owners of America, Inc. v. Raoul . Given the ubiquity of AR- and AK-type firearms, this case will likely be a blockbuster if granted.

Environmental law

The Clean Water Act of 1972 regulates the discharge of pollutants into regulated waters. The city and county of San Francisco received a permit from the EPA under the law’s National Pollutant Discharge Elimination System that allowed San Francisco to discharge from its wastewater treatment facility into the Pacific Ocean. San Francisco challenged the terms of its permit, arguing that the permit contained terms so vague that it failed to tell the city how much it needed to limit or treat its discharges to comply with the act, while simultaneously exposing it to liability for violating the permit provisions. After exhausting administrative remedies, San Francisco petitioned the U.S. Court of Appeals for the 9th Circuit for review.

A divided panel of the 9th Circuit denied San Francisco’s petition , concluding that the provisions are not unduly vague and are “consistent with the CWA and its implementing regulations.” In dissent, Judge Daniel Collins concluded that those provisions were “inconsistent with the text of the CWA.” He argued that the permit violated the CWA by making the permittee responsible for maintaining water quality standards without specifying what limitations on discharges would satisfy its responsibility.

San Francisco now seeks review , arguing that the 9th Circuit’s decision conflicts with decisions of the U.S. Court of Appeals for the 2nd Circuit and the Supreme Court itself. The government denies that there’s any such split.

Yes, that Michael Avenatti

Michael Avenatti enjoyed his 15 minutes of fame representing porn star Stormy Daniels in her suit against then-President Donald Trump. Afterwards, while representing youth basketball coach Gary Franklin in sponsorship negotiations with sports clothing company Nike, Avenatti threatened to disclose certain documents (that his client had not authorized him to disclose) unless Nike paid him and a colleague more than $10 million to do an “internal investigation” into sports corruption. Based on the conduct, Avenatti was convicted in federal court of extortion and fraud for depriving his client of his “honest services,” prohibited by 18 U.S.C. § 1346. The U.S. Court of Appeals for the 2nd Circuit affirmed his conviction.

In his petition in Avenatti v. United States , Avenatti raises two claims . First, he argues that 18 U.S.C. § 1346 is void “both on its face and” as applied to him because, as Justice Neil Gorsuch said in his concurring opinion in last year’s Percoco v. United States , “[t]o this day, no one knows what ‘honest-services fraud’ encompasses.” Avenatti claims that he did not defraud his client – he “at worst … abus[ed] his fiduciary duty as Franklin’s attorney by leveraging Franklin’s claims to pursue compensation for himself.” Second, he argues that most courts besides the 2nd Circuit have held that civil litigation conduct — and in particular, an attorney’s settlement demand — cannot support federal criminal extortion liability. Avenetti argues that under the 2nd Circuit’s rule, what would normally be handled by bar discipline is converted into a 20-year felony. The government responds that Avenatti raised neither claim before the court of appeals and that they are therefore procedurally defaulted; and even if they weren’t, those claims are meritless.

The Surpeme Court has long been skeptical of the honest-services fraud statute and the risks of overcriminalizing sharp business dealings, so one or more of the justices is surely taking a close look at this case.

Last up is a capital case, Medrano v. Texas . Rodolfo Medrano was a member of a south Texas gang charged with capital murder for the shooting deaths of six rival gang members during a robbery. When Medrano was arrested, he invoked his Miranda rights and told police he wanted to speak to an attorney. Police then spoke to Medrano’s wife and told her (falsely) that he was not believed to be involved and would be released if he spoke to police. She persuaded Medrano to talk, and he confessed to providing the guns. Medrano protested that he only provided guns for a robbery and was not present and did not expect the shootings to occur, but the jury found him criminally responsible. That testimony was then introduced against him at trial, and he was convicted of murder and sentenced to death. His conviction and sentence were affirmed on appeal, and his first petition for state post-conviction relief was denied.

Medrano then filed a second petition for state post-conviction relief, alleging that his Miranda rights were violated because police responded to his invocation of his right to silence by persuading his wife to talk to him. He also argued that expert testimony introduced against him violated his due process rights. The Texas Court of Criminal Appeals concluded that Medrano’s application failed to satisfy a state rule of criminal procedure governing successive petitions, and therefore dismissed his application as an “abuse of the writ” of habeas corpus.

In his petition , Medrano renews his argument that law enforcement officers violated his Miranda rights by using his wife to circumvent his invocation of his right to silence. He also argues that the rule invoked by the Texas Court of Criminal Appeals was not actually an “adequate and independent state ground” precluding review of his petition on the merits. He explains that the rule itself permitted a subsequent petition if the defendant could make a showing that but for a violation of the Constitution, no rational juror could have found him guilty. That condition is satisfied here, Medrano says, because the principal evidence introduced against him was the confession he says was improperly procured. In a supplemental brief , Medrano says that his second question is related to an issue the court will be considering next term in Glossip v. Oklahoma , so at minimum, the court should hold his petition for resolution of that case.

We’ll know more soon. Until next time!

New Relists

L.W. v. Skrmetti , 23-466 Issues : (1) Whether Tennessee’s  Senate Bill 1 , which categorically bans gender-affirming healthcare for transgender adolescents, triggers heightened scrutiny and likely violates the 14th Amendment’s equal protection clause; and (2) whether Senate Bill 1 likely violates the fundamental right of parents to make decisions concerning the medical care of their children guaranteed by the 14th Amendment’s due process clause. (rescheduled before the Mar. 15, Mar. 22, Mar. 28, Apr. 12, Apr. 19, Apr. 26 and May 9 conferences; relisted after the May 16 conference)

United States v. Skrmetti , 23-477 Issue : Whether Tennessee  Senate Bill 1 , which prohibits all medical treatments intended to allow “a minor to identify with, or live as, a purported identity inconsistent with the minor’s sex” or to treat “purported discomfort or distress from a discordance between the minor’s sex and asserted identity,” violates the equal protection clause of the 14th Amendment. (rescheduled before the Mar. 15, Mar. 22, Mar. 28, Apr. 12, Apr. 19, Apr. 26 and May 9 conferences; relisted after the May 16 conference)

Jane Doe 1 v. Kentucky ex rel. Coleman, Attorney General , 23-492 Issues : (1) Whether, under the 14th Amendment’s due process clause,  Kentucky Revised Statutes Section 311.372(2) , which bans medical treatments “for the purpose of attempting to alter the appearance of, or to validate a minor’s perception of, the minor’s sex, if that appearance or perception is inconsistent with the minor’s sex,” should be subjected to heightened scrutiny because it burdens parents’ right to direct the medical treatment of their children; (2) whether, under the 14th Amendment’s equal protection clause, § 311.372(2) should be subjected to heightened scrutiny because it classifies on the basis of sex and transgender status; and (3) whether petitioners are likely to show that § 311.372(2) does not satisfy heightened scrutiny. (rescheduled before the Mar. 15, Mar. 22, Mar. 28, Apr. 12, Apr. 19, Apr. 26 and May 9 conferences; relisted after the May 16 conference)

City and County of San Francisco v. Environmental Protection Agency , 23-753 Issue : Whether the  Clean Water Act  allows the Environmental Protection Agency (or an authorized state) to impose generic prohibitions in National Pollutant Discharge Elimination System permits that subject permit-holders to enforcement for violating water quality standards without identifying specific limits to which their discharges must conform. (relisted after the May 16 conference)

Harrel v. Raoul , 23-877 Issues : (1) Whether the Constitution allows the government to prohibit law-abiding, responsible citizens from protecting themselves, their families, and their homes with semiautomatic firearms that are in common use for lawful purposes; (2) whether the Constitution allows the government to prohibit law-abiding, responsible citizens from protecting themselves, their families, and their homes with ammunition magazines that are in common use for lawful purposes; and (3) whether enforcement of Illinois’s semiautomatic firearm and ammunition magazine bans should be enjoined. (relisted after the May 16 conference)

Herrera v. Raoul , 23-878 Issues : (1) Whether semiautomatic rifles and standard handgun and rifle magazines do not count as “Arms” within the ordinary meaning of the Second Amendment’s plain text; and (2) whether there is a broad historical tradition of states banning protected arms and standard magazines from law-abiding citizens’ homes. (relisted after the May 16 conference)

Barnett v. Raoul , 23-879 Issue : Whether Illinois’ sweeping ban on common and long-lawful arms violates the Second Amendment. (relisted after the May 16 conference)

National Association for Gun Rights v. City of Naperville, Illinois , 23-880 Issues : (1) Whether the state of Illinois’ ban of certain handguns is constitutional in light of the holding in  District of Columbia v. Heller  that handgun bans are categorically unconstitutional; (2) whether the “in common use” test announced in  Heller  is hopelessly circular and therefore unworkable; and (3) whether the government can ban the sale, purchase, and possession of certain semi-automatic firearms and firearm magazines that are possessed by millions of law-abiding Americans for lawful purposes when there is no analogous Founding-era regulation. (relisted after the May 16 conference)

Langley v. Kelly , 23-944 Issues : (1) Whether the state of Illinois’ absolute ban of certain commonly owned semi-automatic handguns is constitutional in light of the holding in  District of Columbia v. Heller  that handgun bans are categorially unconstitutional; (2) whether the state of Illinois’ absolute ban of all commonly owned semi-automatic handgun magazines over 15 rounds is constitutional in light of the holding in  Heller  that handgun bans are categorially unconstitutional; and (3) whether the government can ban the sale, purchase, possession, and carriage of certain commonly owned semi-automatic rifles, pistols, shotguns, and standard-capacity firearm magazines, tens of millions of which are possessed by law-abiding Americans for lawful purposes, when there is no analogous historical ban as required by  Heller  and  New York State Rifle & Pistol Ass’n, Inc. v. Bruen . (relisted after the May 16 conference)  

Gun Owners of America, Inc. v. Raoul , 23-1010 Issue : Whether Illinois’ categorical ban on millions of the most commonly owned firearms and ammunition magazines in the nation, including the AR-15 rifle, violates the Second Amendment. (relisted after the May 16 conference)

Medrano v. Texas , 23-5597 Issues : (1) Whether under all the circumstances, including an officer’s knowing and deliberate deployment of Petitioner’s wife to elicit statements from Petitioner while he was in custody, the falsity of the information the officer gave her to convey to the petitioner, the strength of the incentive he proffered to induce the Petitioner to speak, and the fact that similar tactics were deliberately employed to obtain confessions Petitioner’s codefendants, introduction of the resulting statement Petitioner’s Fifth and Fourteenth Amendment rights under Miranda v. Arizona, 384 U.S. 436 (1966); (2) Whether the Texas Court of Criminal Appeals’ determination that the Petitioner’s subsequent petition failed to satisfy the requirements of Article 11.071, § 5(a)(2) was an adequate and independent state ground precluding merits review of his claim where that provision authorizes a subsequent petition when “by a preponderance of the evidence, but for a violation of the United States Constitution no rational juror could have found the applicant guilty beyond a reasonable doubt” and the confession whose constitutionality Petitioner is challenging was the only significant evidence linking him to the capital murder with which he was charged. (relisted after the May 16 conference)

Avenatti v. United States , 23-6753 Issues : (1) whether 18 U.S.C. § 1346, making it a crime to engage in “honest services fraud,” is void for vagueness; (2); whether civil litigation conduct – in particular, an attorney’s settlement demand – can support federal criminal extortion liability. (relisted after the May 16 conference)

Returning Relists

Hamm v. Smith , 23-167 Issues : (1) Whether  Hall v. Florida  and  Moore v. Texas  mandate that courts deem the standard of “significantly subaverage intellectual functioning” for determining intellectual disability in  Atkins v. Virginia  satisfied when an offender’s lowest IQ score, decreased by one standard error of measurement, is 70 or below; and (2) whether the court should overrule  Hall  and  Moore , or at least clarify that they permit courts to consider multiple IQ scores and the probability that an offender’s IQ does not fall at the bottom of the lowest IQ score’s error range. (relisted after the Jan. 5, Jan. 12, Jan. 19, Feb. 16, Feb. 23, Mar. 1, Mar. 15, Mar. 22, Mar. 28, Apr. 12, Apr. 19, Apr. 26, May 9 and May 16 conferences)

Cunningham v. Florida , 23-5171 Issue: Whether the Sixth and Fourteenth Amendments guarantee the right to trial by a 12-person jury when the defendant is charged with a felony (rescheduled before the Nov. 17, Dec. 1, Dec. 8, Jan. 5, Jan. 12, Jan. 19, Feb. 16, Feb. 23, Mar. 1, Mar. 15, Mar. 22 and Mar 28 conferences; relisted after the Apr. 12, Apr. 19, Apr. 26, May 9 and May 16 conferences)

Guzman v. Florida , 23-5173 Issue: Whether the Sixth and Fourteenth Amendments guarantee the right to trial by a 12-person jury when the defendant is charged with a felony (rescheduled before the Dec. 1, Dec. 8, Jan. 5, Jan. 12, Jan. 19, Feb. 16, Feb. 23, Mar. 1, Mar. 15, Mar. 22 and Mar 28 conferences; relisted after the Apr. 12, Apr. 19, Apr. 26, May 9 and May 16 conferences)

Crane v. Florida , 23-5455 Issue: Whether the Sixth and Fourteenth Amendments guarantee the right to trial by a 12-person jury when the defendant is charged with a felony (rescheduled before the Dec. 1, Dec. 8, Jan. 5, Jan. 12, Jan. 19, Feb. 16, Feb. 23, Mar. 1, Mar. 15, Mar. 22 and Mar 28 conferences; relisted after the Apr. 12, Apr. 19, Apr. 26, May 9 and May 16 conferences)

Arellano-Ramirez v. Florida , 23-5567 Issue: Whether the Sixth and Fourteenth Amendments guarantee the right to trial by a 12-person jury when the defendant is charged with a felony (rescheduled before the Dec. 1, Dec. 8, Jan. 5, Jan. 12, Jan. 19, Feb. 16, Feb. 23, Mar. 1, Mar. 15, Mar. 22 and Mar 28 conferences; relisted after the Apr. 12, Apr. 19, Apr. 26, May 9 and May 16 conferences)

Jackson v. Florida , 23-5570 Issue: Whether the Sixth and Fourteenth Amendments guarantee the right to trial by a 12-person jury when the defendant is charged with a felony (rescheduled before the Dec. 1, Dec. 8, Jan. 5, Jan. 12, Jan. 19, Feb. 16, Feb. 23, Mar. 1, Mar. 15, Mar. 22 and Mar 28 conferences; relisted after the Apr. 12, Apr. 19, Apr. 26, May 9 and May 16 conferences)

Sposato v. Florida , 23-5575 Issue: Whether the Sixth and Fourteenth Amendments guarantee the right to trial by a 12-person jury when the defendant is charged with a felony (rescheduled before the Dec. 1, Dec. 8, Jan. 5, Jan. 12, Jan. 19, Feb. 16, Feb. 23, Mar. 1, Mar. 15, Mar. 22 and Mar 28 conferences; relisted after the Apr. 12, Apr. 19, Apr. 26, May 9 and May 16 conferences)

Morton v. Florida , 23-5579 Issue: Whether the Sixth and Fourteenth Amendments guarantee the right to trial by a 12-person jury when the defendant is charged with a felony (rescheduled before the Dec. 1, Dec. 8, Jan. 5, Jan. 12, Jan. 19, Feb. 16, Feb. 23, Mar. 1, Mar. 15, Mar. 22 and Mar 28 conferences; relisted after the Apr. 12, Apr. 19, Apr. 26, May 9 and May 16 conferences)

Aiken v. Florida , 23-5794 Issue: Whether the Sixth and Fourteenth Amendments guarantee the right to a trial by a 12-person jury when the defendant is charged with a felony. (rescheduled before the Mar. 22 and Mar 28 conferences; relisted after the Apr. 12, Apr. 19, Apr. 26, May 9 and May 16 conferences)

Enrriquez v. Florida , 23-5965 Issue: Whether the Sixth and Fourteenth Amendments guarantee the right to a trial by a 12-person jury when the defendant is charged with a felony. (rescheduled before the Mar. 15, Mar. 22 and Mar 28 conferences; relisted after the Apr. 12, Apr. 19, Apr. 26, May 9 and May 16 conferences)

Bartee v. Florida , 23-6143 Issue: Whether the Sixth and Fourteenth Amendments guarantee the right to a trial by a 12-person jury when the defendant is charged with a felony. (relisted after the Apr. 12, Apr. 19, Apr. 26, May 9 and May 16 conferences)

Manning v. Florida , 23-6049 Issue: Whether the Sixth and Fourteenth Amendments guarantee the right to a trial by a 12-person jury when the defendant is charged with a felony. (rescheduled before the Mar. 22 and Mar 28 conferences; relisted after the Apr. 12, Apr. 19, Apr. 26, May 9 and May 16 conferences)

Tillman v. Florida , 23-6304 Issue: Whether the Sixth and Fourteenth Amendments guarantee the right to a trial by a 12-person jury when the defendant is charged with a felony. (relisted after the Apr. 19, Apr. 26, May 9 and May 16 conferences)

Sanon v. Florida , 23-6289 Issue: Whether the Sixth and Fourteenth Amendments guarantee the right to a trial by a 12-person jury when the defendant is charged with a felony. (relisted after the Apr. 19, Apr. 26, May 9 and May 16 conferences)

Posted in Cases in the Pipeline

Cases: City and County of San Francisco v. Environmental Protection Agency , Harrel v. Raoul , Herrera v. Raoul , Barnett v. Raoul , National Association for Gun Rights v. City of Naperville, Illinois , Langley v. Kelly , Hamm v. Smith , Gun Owners of America, Inc. v. Raoul , L. W. v. Skrmetti , Medrano v. Texas , United States v. Skrmetti , Avenatti v. United States , Jane Doe 1 v. Kentucky ex rel. Coleman, Attorney General

Recommended Citation: John Elwood, Restrictions on gender-affirming medical care – and assault weapons , SCOTUSblog (May. 24, 2024, 10:49 AM), https://www.scotusblog.com/2024/05/restrictions-on-gender-affirming-medical-care-and-assault-weapons/

Privacy Overview

Texas district judge blocks Ken Paxton's demands for PFLAG gender-affirming care records

A Travis County state District Court on Monday blocked Texas Attorney General Ken Paxton from demanding information from a nationwide LGBTQ+ organization about its support for families seeking gender-affirming medical care for transgender youths, finding that there is "a substantial likelihood" that the nonprofit's case against the state "will prevail after a trial on the merits."

The LGBTQ+ organization, PFLAG National, sued the attorney general's office Feb. 29 after receiving what it called an "outrageous and unconstitutional demand" for records. The civil investigative demand that Paxton sent to PFLAG seeks information about alleged "misrepresentations regarding Gender Transitioning and Reassignment Treatments" as well as relating to the nonprofit's statements in Loe v. Texas and PFLAG v. Abbott, two cases in which the group is suing the state on behalf of families that have sought or provided gender-affirming care to their children.

In Loe v. Texas, the Texas Supreme Court in January heard oral arguments on whether parents in the state have the right to let their children receive gender-affirming medical care after the Legislature last year passed Senate Bill 14, a law that went into effect in September and prohibits doctors in Texas from providing certain gender-affirming medical treatments — including puberty blockers, hormone therapy and certain surgeries — to minors experiencing gender dysphoria, a condition in which a person’s gender identity doesn’t match their sex at birth.

After a Monday morning hearing, District Court Judge Amy Clark Meachum, a Democrat, issued the temporary injunction against Paxton's "unlawful" demands for information and documents, writing that the attorney general's office exceeded its authority.

The injunction replaces a temporary restraining order that Judge Maria Cantú Hexsel of the 53rd District Court issued March 1, which would have expired Friday, and will remain active until the case is resolved. A trial is set for 9 a.m. June 10.

In addition to allowing PFLAG to keep its information private, the judge's order bars Paxton from retaliating against the organization.

“PFLAG National has consistently protected Texas families with transgender youth in the face of the State’s persecution,” Chloe Kempf, an attorney for the ACLU of Texas, said in a statement. “This court ruling is a critical step in allowing PFLAG National and its members to join together and advocate for each other, free from the threat of the attorney general’s retaliation and intimidation."

In its original petition, lawyers for the group wrote that it appeared Paxton's office was "seeking to determine which Texas families are seeking to access gender-affirming care for their transgender adolescents" in multiple civil investigative demands, which could reveal the families' identities.

In Monday's injunction order as in the March 1 temporary restraining order , the court wrote that the requests for information and documents are "unlawful" and that PFLAG and its members — the parents and families of transgender youths — would suffer "immediate and irreparable injury" if the attorney general were allowed to obtain information ahead of a trial.

The order states that Paxton's office's requests would have inhibited families' exercise of free speech and harmed their ability to "avail themselves of the courts when their constitutional rights are threatened." The order also says the demands would have led to "gross invasions of both PFLAG's and its members' privacy in an attempt to bypass discovery stays entered in both Loe v. Texas and PFLAG v. Abbott."

Paxton's office did not respond to an American-Statesman request for comment Monday.

In a statement Feb. 29 about the lawsuit, Paxton said he is going after PFLAG for hiding what he called "incriminating documents" that he thinks will answer the question of whether "medical providers are committing insurance fraud in order to circumvent" SB 14.

“Texas passed SB 14 to protect children from damaging, unproven medical interventions with catastrophic lifelong consequences for their health,” Paxton said in the statement. “Any organization seeking to violate this law, commit fraud, or weaponize science and medicine against children will be held accountable.”

More: Is Texas' ban on gender-affirming care for minors constitutional? Supreme Court hears case

The state has argued that gender-affirming care treatments are ineffective and potentially dangerous in the long term for minors, largely tossing aside discrimination concerns and the effects on parents' rights to seek medical treatment for their children.

Major medical associations, including the American Academy of Pediatrics, the American Medical Association, and the American Psychiatric Association, support the provision of developmentally-appropriate and individualized gender-affirming medical care for transgender youth, saying it can be lifesaving and medically necessary. 

Paxton's requests to PFLAG also come after several efforts by the attorney general's office to obtain medical records of Texas residents who might have received gender-affirming care at out-of-state hospitals in  Seattle  and Georgia. Seattle Children's Hospital  sued the attorney general's office  over Paxton's requests in December.

In requesting records dating back to 2022, Paxton's office cites a state provision that forbids companies from making "misrepresentations regarding Gender Transitioning Treatments and Procedures and Texas law" in advertisements sent to Texas residents.

Several motions in PFLAG's case against the attorney general are still pending, including a motion from Paxton that the court "modify and clarify" the initial restraining order and another plea that the office filed Friday.

In a statement Monday afternoon, Brian K. Bond, CEO of PFLAG National, celebrated the court's decision.

“PFLAG families in Texas gained further protection today when the court reaffirmed that the Attorney General can’t two-step around the law,” Bond wrote. “PFLAG National will continue to fight to protect our families, because trans youth and their loved ones deserve better, and loving your LGBTQ+ kid is always the right thing to do.”

Statesman staff writer Hogan Gore contributed to this report.

This article originally appeared on Austin American-Statesman: Texas district judge blocks Ken Paxton's demands for PFLAG gender-affirming care records