hospitals that perform gender reassignment surgery on minors

Young Children Do Not Receive Medical Gender Transition Treatment

By Kate Yandell

Posted on May 22, 2023

SciCheck Digest

Families seeking information from a health care provider about a young child’s gender identity may have their questions answered or receive counseling. Some posts share a misleading claim that toddlers are being “transitioned.” To be clear, prepubescent children are not offered transition surgery or drugs.

Some children  identify  with a gender that does not match their sex assigned at birth. These children are referred to as transgender, gender-diverse or gender-expansive. Doctors will listen to children and their family members, offer information, and in some cases connect them with mental health care, if needed.

But for children who have not yet started puberty, there are  no recommended  drugs, surgeries or other gender-transition treatments.

Recent social media  posts   shared  the misleading  claim  that medical institutions in North Carolina are “transitioning toddlers,” which they called an “experimental treatment.” The posts referenced a  blog post  published by the Education First Alliance, a conservative nonprofit in North Carolina that says  many schools are engaging in “ideological indoctrination” of children and need to be reformed.

The group has advocated the passage of a North Carolina bill  to restrict medical gender-transition treatment before age 18. There are now  18 states  that have taken action to restrict  medical transition treatments  for  minors .

A widely shared  article  from the Epoch Times citing the blog post bore the false headline: “‘Transgender’ Toddlers as Young as 2 Undergoing Mutilation/Sterilization by NC Medical System, Journalist Alleges.” The Epoch Times has a history of publishing misleading or false claims. The article on transgender toddlers then disappeared from the website, and the Epoch Times published a new  article  clarifying that young children are not receiving hormone blockers, cross-sex hormones or surgery. 

Representatives from all three North Carolina institutions referenced in the social media posts told us via emailed statements that they do not offer surgeries or other transition treatments to toddlers.

East Carolina University, May 5: ECU Health does not offer gender affirming surgery to minors nor does the health system offer gender affirming transition care to toddlers.

ECU Health elaborated that it does not offer puberty blockers and only offers hormone therapy after puberty “in limited cases,” as recommended in national guidelines and with parental or guardian consent. It also said that it offers interdisciplinary gender-affirming primary care for LGBTQ+ patients, including access to services such as mental health care, nutrition and social work.

“These primary care services are available to any LGBTQ+ patient who needs care. ECU Health does not provide gender-related care to patients 2 to 4 years old or any toddler period,” ECU said.

University of North Carolina, May 12: To be clear: UNC Health does not offer any gender-transitioning care for toddlers. We do not perform any gender care surgical procedures or medical interventions on toddlers. Also, we are not conducting any gender care research or clinical trials involving children. If a toddler’s parent(s) has concerns or questions about their child’s gender, a primary care provider would certainly listen to them, but would never recommend gender treatment for a toddler. Gender surgery can be performed on anyone 18 years old or older .

Duke Health, May 12: Duke Health has provided high-quality, compassionate, and evidence-based gender care to both adolescents and adults for many years. Care decisions are made by patients, families and their providers and are both age-appropriate and adherent to national and international guidelines. Under these professional guidelines and in accordance with accepted medical standards, hormone therapies are explicitly not provided to children prior to puberty and gender-affirming surgeries are, except in exceedingly rare circumstances, only performed after age 18.

Duke and UNC both called the claims that they offer gender-transition care to toddlers false, and ECU referred to the “intentional spreading of dangerous misinformation online.”

Nor do other medical institutions offer gender-affirming drug treatment or surgery to toddlers, clinical psychologist  Christy Olezeski , director of the Yale Pediatric Gender Program, told us, although some may offer support to families of young children or connect them with mental health care. 

The Education First Alliance post also states that a doctor “can see a 2-year-old girl play with a toy truck, and then begin treatment for gender dysphoria.” But simply playing with a certain toy would not meet the criteria for a diagnosis of gender dysphoria, according to the medical diagnostic manual used by health professionals.

“With all kids, we want them to feel comfortable and confident in who they are. We want them to feel comfortable and confident in how they like to express themselves. We want them to be safe,” Olezeski said. “So all of these tenets are taken into consideration when providing care for children. There is no medical care that happens prior to puberty.”

Medical Transition Starts During Adolescence or Later 

The Education First Alliance blog post does not clearly state what it means when it says North Carolina institutions are “transitioning toddlers.” It refers to treatment and hormone therapy without clarifying the age at which it is offered. 

Only in the final section of the piece does it include a quote from a doctor correctly stating that children are not offered surgery or drugs before puberty.

To spell out the reality of the situation: The North Carolina institutions are not providing surgeries or hormone therapy to prepubescent children, nor is this standard practice in any part of the country.

Programs and physicians will have different policies, but widely referenced guidance from the  World Professional Association for Transgender Health  and the  Endocrine Society  lays out recommended care at different ages. 

Drugs that suppress puberty are the first medical treatment that may be offered to a transgender minor, the guidelines say. Children may be offered drugs to suppress puberty beginning when breast buds appear or testicles increase to a certain volume, typically happening between ages 8 to 13 or 9 to 14, respectively.

Generally, someone may start gender-affirming hormone therapy in early adolescence or later, the American Academy for Pediatrics  explains . The Endocrine Society says that adolescents typically have the mental capacity to participate in making an informed decision about gender-affirming hormone therapy by age 16.

Older adolescents who want flat chests may sometimes be able to get surgery to remove their breasts, also known as top surgery, Olezeski said. They sometimes desire to do this before college. Guidelines  do not offer  a  specific age  during adolescence when this type of surgery may be appropriate. Instead, they explain how a care team can assess adolescents on a case-by-case basis.

A previous  version  of the WPATH guidelines did not recommend genital surgery until adulthood, but the most recent version, published in September 2022, is  less specific  about an age limit. Rather, it explains various criteria to determine whether someone who desires surgery should be offered it, including a person’s emotional and cognitive maturity level and whether they have been on hormone therapy for at least a year.

The Endocrine Society similarly offers criteria for when someone might be ready for genital surgery, but specifies that surgeries involving removing the testicles, ovaries or uterus should not happen before age 18.

“Typically any sort of genital-affirming surgeries still are happening at 18 or later,” Olezeski said.

There are no comprehensive statistics on the number of gender-affirming surgeries performed in the U.S., but according to an insurance claims  analysis  from Reuters and Komodo Health Inc., 776 minors with a diagnosis of gender dysphoria had breast removal surgeries and 56 had genital surgeries from 2019 to 2021.

Research Shows Benefits of Affirming Gender Identity

Young children do not get medical transition treatment, but they do have feelings about their gender and can benefit from support from those around them. “Children start to have a sense of their own gender identity between the ages of 2 1/2 to 3 years old,” Olezeski said.

Programs vary in what age groups they serve, she said, but some do support families of preschool-aged children by answering questions or providing mental health care.

Transgender children are at increased risk of some mental health problems, including anxiety and depression. According to the WPATH guidelines, affirming a child’s gender through day-to-day changes — also known as social transition — may have a positive impact on a child’s mental health. Social transition “may look different for every individual,” Olezeski said. Changes could include going by a different name or pronouns or altering one’s attire or hair style.

Two studies of socially transitioned children — including one with kids as young as 3 — have found minimal or no difference in anxiety and depression compared with non-transgender siblings or other children of similar ages.

“Research substantiates that children who are prepubertal and assert an identity of [transgender and gender diverse] know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender and benefit from the same level of social acceptance,” the AAP  guidelines  say, adding that differences in how children identify and express their gender are normal.

Social transitions largely take place outside of medical institutions, led by the child and supported by their family members and others around them. However, a family with questions about their child’s gender or social transition may be able to get information from their pediatrician or another medical provider, Olezeski said.

Although not available everywhere, specialized programs may be particularly prepared to offer care to a gender-diverse child and their family, she said. A child may get a referral to one of these programs from a pediatrician, another specialty physician, a mental health care professional or their school, or a parent may seek out one of these programs.

“We have created a space where parents can come with their youth when they’re young to ask questions about how to best support their child: what to do if they have questions, how to get support, what do we know about the best research in terms of how to allow kids space to explore their identity, to explore how they like to express themselves, and then if they do identify as trans or nonbinary, how to support the parents and the youth in that,” Olezeski said of specialized programs. Parents benefit from the support, and then the children also benefit from support from their parents. 

WPATH  says  that the child should be the one to initiate a social transition by expressing a “strong desire or need” for it after consistently articulating an identity that does not match their sex assigned at birth. A health care provider can then help the family explore benefits and risks. A child simply playing with certain toys, dressing a certain way or enjoying certain activities is not a sign they would benefit from a social transition, the guidelines state.

Previously, assertions children made about their gender were seen as “possibly true” and support was often withheld until an age when identity was believed to become fixed, the AAP guidelines explain. But “more robust and current research suggests that, rather than focusing on who a child will become, valuing them for who they are, even at a young age, fosters secure attachment and resilience, not only for the child but also for the whole family,” the guidelines say.

Mental Health Care Benefits

A gender-diverse child or their family members may benefit from a referral to a psychologist or other mental health professional. However, being transgender or gender-diverse is not in itself a mental health disorder, according to the  American Psychological Association ,  WPATH and other expert groups . These organizations also note that people who are transgender or gender-diverse do not all experience mental health problems or distress about their gender. 

Psychological therapy is not meant to change a child’s gender identity, the WPATH guidelines  say . 

The form of therapy a child or a family might receive will depend on their particular needs, Olezeski said. For instance, a young child might receive play-based therapy, since play is how children “work out different things in their life,” she said. A parent might work on strategies to better support their child.

One mental health diagnosis that some gender-diverse people may receive is  gender dysphoria . There is  disagreement  about how useful such a diagnosis is, and receiving such a diagnosis does not necessarily mean someone will decide to undergo a transition, whether social or medical.

UNC Health told us in an email that a gender dysphoria diagnosis “is rarely used” for children.

Very few gender-expansive kids have dysphoria, the spokesperson said. “ Gender expansion in childhood is not Gender Dysphoria ,” UNC added, attributing the explanation to psychiatric staff (emphasis is UNC’s). “The psychiatric team’s goal is to provide good mental health care and manage safety—this means trying to protect against abuse and bullying and to support families.”

Social media posts incorrectly claim that toddlers are being diagnosed with gender dysphoria based on what toys they play with. One post  said : “Three medical schools in North Carolina are diagnosing TODDLERS who play with stereotypically opposite gender toys as having GENDER DYSPHORIA and are beginning to transition them!!”

There are separate criteria for diagnosing gender dysphoria in adults and adolescents versus children, according to the Diagnostic and Statistical Manual of Mental Disorders. For children to receive this diagnosis, they must meet six of eight criteria for a six-month period and experience “clinically significant distress” or impairment in functioning, according to the diagnostic manual. 

A “strong preference for the toys, games or activities stereotypically used or engaged in by the other gender” is one criterion, but children must also meet other criteria, and expressing a strong desire to be another gender or insisting that they are another gender is required.

“People liking to play with different things or liking to wear a diverse set of clothes does not mean that somebody has gender dysphoria,” Olezeski said. “That just means that kids have a breadth of things that they can play with and ways that they can act and things that they can wear . ”

Editor’s note: SciCheck’s articles providing accurate health information and correcting health misinformation are made possible by a grant from the Robert Wood Johnson Foundation. The foundation has no control over FactCheck.org’s editorial decisions, and the views expressed in our articles do not necessarily reflect the views of the foundation.

Rafferty, Jason. “ Gender-Diverse & Transgender Children .” HealthyChildren.org. Updated 8 Jun 2022.

Coleman, E. et al. “ Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 .” International Journal of Transgender Health. 15 Sep 2022.

Rachmuth, Sloan. “ Transgender Toddlers Treated at Duke, UNC, and ECU .” Education First Alliance. 1 May 2023.

North Carolina General Assembly. “ Senate Bill 639, Youth Health Protection Act .” (as introduced 5 Apr 2023).

Putka, Sophie et al. “ These States Have Banned Youth Gender-Affirming Care .” Medpage Today. Updated 17 May 2023.

Davis, Elliott Jr. “ States That Have Restricted Gender-Affirming Care for Trans Youth in 2023 .” U.S. News & World Report. Updated 17 May 2023.

Montgomery, David and Goodman, J. David. “ Texas Legislature Bans Transgender Medical Care for Children .” New York Times. 17 May 2023.

Ji, Sayer. ‘ Transgender’ Toddlers as Young as 2 Undergoing Mutilation/Sterilization by NC Medical System, Journalist Alleges .” Epoch Times. Internet Archive, Wayback Machine. Archived 6 May 2023.

McDonald, Jessica. “ COVID-19 Vaccines Reduce, Not Increase, Risk of Stillbirth .” FactCheck.org. 9 Nov 2022.

Jaramillo, Catalina. “ Posts Distort Questionable Study on COVID-19 Vaccination and EMS Calls .” FactCheck.org. 15 June 2022.

Spencer, Saranac Hale. “ Social Media Posts Misrepresent FDA’s COVID-19 Vaccine Safety Research .” FactCheck.org. 23 Dec 2022.

Jaramillo, Catalina. “ WHO ‘Pandemic Treaty’ Draft Reaffirms Nations’ Sovereignty to Dictate Health Policy .” FactCheck.org. 2 Mar 2023.

McCormick Sanchez, Darlene. “ IN-DEPTH: North Carolina Medical Schools See Children as Young as Toddlers for Gender Dysphoria .” The Epoch Times. 8 May 2023.

ECU health spokesperson. Emails with FactCheck.org. 12 May 2023 and 19 May 2023.

UNC Health spokesperson. Emails with FactCheck.org. 12 May 2023 and 19 May 2023.

Duke Health spokesperson. Email with FactCheck.org. 12 May 2023.

Olezeski, Christy. Interview with FactCheck.org. 16 May 2023.

Hembree, Wylie C. et al. “ Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline .” The Journal of Clinical Endocrinology and Metabolism. 1 Nov 2017.

Emmanuel, Mickey and Bokor, Brooke R. “ Tanner Stages .” StatPearls. Updated 11 Dec 2022.

Rafferty, Jason et al. “ Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents .” Pediatrics. 17 Sep 2018.

Coleman, E. et al. “ Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7 .” International Journal of Transgenderism. 27 Aug 2012.

Durwood, Lily et al. “ Mental Health and Self-Worth in Socially Transitioned Transgender Youth .” Journal of the American Academy of Child and Adolescent Psychiatry. 27 Nov 2016.

Olson, Kristina R. et al. “ Mental Health of Transgender Children Who Are Supported in Their Identities .” Pediatrics. 26 Feb 2016.

“ Answers to Your Questions about Transgender People, Gender Identity, and Gender Expression .” American Psychological Association website. 9 Mar 2023.

“ What is Gender Dysphoria ?” American Psychiatric Association website. Updated Aug 2022.

Vanessa Marie | Truth Seeker (indivisible.mama). “ Three medical schools in North Carolina are diagnosing TODDLERS who play with stereotypically opposite gender toys as having GENDER DYSPHORIA and are beginning to transition them!! … ” Instagram. 7 May 2023.

More people are getting gender-affirming care, under attack in many states. Few are kids

The number of people seeking gender-affirming surgeries such as breast and chest operations or genital reconstruction nearly tripled during the three years before the coronavirus pandemic, a new study shows.

The study tracked more than 48,000 patients who had operations in hospitals and same-day surgery centers from 2016 through 2020, the most recent data available. The number of patients getting these operations nearly tripled from 4,552 in 2016 to 13,011 in 2019, before decreasing slightly in 2020 amid the coronavirus restrictions that postponed or halted many types of non-emergency operations, according to the study published Wednesday in JAMA Network Open .

Gender-affirming surgeries were most popular with young adults; more than 25,000 people ages 19 to 30 received these procedures. Fewer than 8% of patients − a total of 3,678 − were 12- to 18-year-olds, a group scrutinized by lawmakers pursuing restrictions mainly in conservative states .

Banned: Gender-affirming care for minors no longer allowed in North Carolina

Insurance coverage, awareness, satisfaction drive gender operations

Dr. Jason D. Wright, the study's lead author and an associate professor of gynecologic oncology at Columbia University, said the purpose of the study was to get an accurate count on such operations at hospitals and outpatient surgery centers.

The researchers sifted through databases to find people diagnosed with gender identity disorder , transsexualism or a personal history of sex reassignment. From there, researchers tracked whether those patients sought a range of gender-affirming surgeries.

More than half of the people in the study had breast and chest procedures, making it the most common type of gender-affirming operation. More than 1 in 3 people received genital reconstruction − a category that included any surgical intervention of the male or female genital tract. Others sought facial and cosmetic procedures such as hair removal, hair transplants, liposuction and collagen injections.

Gender-affirming surgeries are becoming more common as insurers offer more robust coverage. About 3 in 5 patients were covered by a private insurance plan, and 1 in 4 had Medicaid, the government health insurance plan for low-income and disabled residents.

People are also more aware these surgeries are available, Wright said.

"More patients have had access to these procedures," Wright said. "Not only are most of these procedures very safe from a complication standpoint, but they're also associated with favorable outcomes with relatively high rates of patient satisfaction."

Proud purple to angry red: These Florida residents feel unwelcome in 'new' Florida

22 states restrict gender-affirming care for minors

Last week, North Carolina Republican state lawmakers overrode Democratic Gov. Roy Cooper’s veto and passed legislation barring surgical gender-transition procedures to anyone under 18, with some exceptions. The legislation, which takes effect immediately, also prohibits medical professionals from providing hormone therapy puberty-blocking drugs.

Minors who had begun treatment before Aug. 1 may continue receiving that care if their doctors deem it medically necessary and their parents consent.

Louisiana, Texas, Missouri, Florida and Nebraska are among states that passed legislation restricting gender-reassignment operations among minors or limiting other gender-affirming care. In all, 22 states have restrictions on gender-affirming operations or related care for transgender minors.

"These are happening in conservative, Republican-led states. The language being used to promote the policies is around protection," said Lindsey Dawson, associate director of HIV policy and director of LGBTQ+ health policy for KFF, a nonpartisan health foundation. "But really, the policies target gender-diverse young people and aim to restrict providers from delivering what is widely considered best-practice medical care."

Wright said the study provides data on how frequently gender-affirming surgeries are performed and requested − important information for doctors to consider when discussing care with patients.

"More patients are asking for information about these services," Wright said. "As these procedures become more common, we need to have the expertise to care for transgender populations who are interested in surgery."

Contributing: The Associated Press

• Privacy Policy

Top Florida Hospital System to Perform Genital Surgery on Minor Transgender Children

The University of Miami Health System is on record admitting that they will perform surgical procedures, including gender genital affirming surgery and double mastectomies on transgender children as long as one parent consents.

UM Health provides an array of LGBTQ+ Services to transgendered persons, such as gender-affirming hormone therapy, gynecology, mental health, plastic surgery, primary care, and voice treatments.

According to its website , physicians will perform procedures on children, including cosmetic and plastic surgery, with the following stipulations:

“Patients under the age of 18 will need parental consent for genital procedures. For patients with Gender Identity diagnosis, our physician staff will follow the guidelines of the World Professional Association of Transgender Health (WPATH). These guidelines are established to ensure that you are fully prepared for surgery. They recommend one/two referral letters prior to undergoing surgery. These letters must be from an experienced mental health professional, who you have worked with for over a year. Letters must state that gender-affirming surgery is the correct course of treatment for the patient.”

A source, who wishes to remain anonymous, spoke to a representative on the phone regarding gender-affirming surgery for her 16-year-old daughter seeking to transition to a male. The representative advised that initial consultations are done with the plastic surgeon, Dr. Sarah Denker.

The representative also confirmed that UM would perform a double mastectomy or "top surgery" on a girl as young as 16 years old.

As for genital surgery, the representative indicated that the surgeon could discuss those options during an in-person consultation.

Parental Objection

When asked whether consent is required from both parents, Lauren Foster, Director of Concierge and LGBTQ+ Services in the Office of Patient Experience, advised that consent from one parent is enough. She reiterated that even if the other parent is opposed to these permanent medical procedures being performed on their child, their facility only requires one parent’s consent.

In other words, a parent who does not believe that this life-changing surgical procedure is appropriate for their child may be excluded from the decision-making process, and may have little recourse to prevent the procedure from taking place. It also means that the surgery may be performed without one parent's knowledge.

Genital Surgery on Minors

UM Health’s website clearly states that its doctors perform genital surgery, also called “bottom surgery,” on minor children with at least one parent's consent.

However, this practice appears to contradict recommendations from major medical organizations. The Endocrine Society, for example, does not recommend genital surgery for minors.

In fact, Boston Children’s Hospital makes it abundantly clear that “all genital surgeries are only performed on patients age 18 and older.”

As reported by the Tampa Bay Times, the Chief of Pediatric Endocrinology at the University of Florida, Dr. Michael Haller, confirmed the American Academy of Pediatrics has established a standard of care for transgendered youth, which dictates that genital surgeries should only be offered to people 18 and above.

The University of Miami may be violating this standard of care.

State Policy

Governor Ron DeSantis has been adamantly opposed to the practice of performing permanent surgery on transgender youth. During a press conference in August, Gov. DeSantis said, “They talk about these very young kids getting gender-affirming care. What they don’t tell you what that is that they are giving very young girls double mastectomies, they want to castrate these young boys — that’s wrong.”

In response to a petition by the Florida Department of Health, the Florida Board of Medicine is now in the process of developing rules for treating transgender children.

The topic has been a major policy debate in Florida, particularly regarding State-providers like Medicaid and whether gender reassignment treatments should be covered. In August, DeSantis signed a law banning Medicaid from covering gender reassignment procedures.

Are Florida Tax Dollars Funding These Procedures?

While the University of Miami Health System is a private institution, it receives many subsidies and funding from the State of Florida. In fact, Florida’s 2022 “Freedom First Budget” included millions of dollars allocated to UM’s Health System.

The question remains whether Floridians are indirectly footing the bill for radical genital surgeries on minors. While monies are directly allocated to specific needs, could the health system's administrators ultimately decide to reallocate those taxpayer dollars to fund other departments?

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Gender Clinic

Gender-affirming care at seattle children’s.

Seattle Children’s Gender Clinic provides gender-affirming medical care for adolescents:

• Whose gender identity is different from their sex at birth
• Who do not identify with the traditional definitions of male or female         

We accept new patients ages 9 to 17.75 at the time of referral who have already started puberty. Patients ages 17.75 and older and patients who have not yet started puberty will be directed to community resources. Our clinic primarily provides gender-affirming medical care (such as puberty blockers and gender-affirming hormones). Gender-affirming medical care for patients under age 18 requires consent from any parent or guardian that has medical decision-making rights for that patient, unless the patient is an emancipated minor .

Brief mental health support focused on family decision making and mental health documentation prior to initiating gender-affirming care is also available. If you are looking for gender-affirming mental health services only, or for ongoing mental health support, here are some community resources .  

• Fully accepts and treats each individual with respect
• Gives each patient personalized care
• Follows current best practices for transition-related treatments
• Provides referrals for gender-affirming surgery (which Seattle Children’s offers for patients through age 26 in some cases)

Services We Provide

Some people want to delay puberty from progressing. This option is available to youth who have started puberty but who have not yet completed puberty. The medicine to block puberty is called a gonadotropin-releasing hormone (GnRH) agonist. It stops the body from making the hormones that lead to puberty changes. Puberty delay is temporary. If you stop taking the medicine, you will go through puberty of the sex you were born into. We work with you and your family to decide if this is a good choice for you. We also talk about the cost and the best time to start.  Read more (PDF) ( Spanish ).

Gender-affirming hormones help make a person’s physical body match their inner gender identity. These hormones let a person develop in a way that is different from the sex they were born into.

For people interested in feminizing hormones, estrogen is the main hormone used. For people interested in masculinizing hormones, testosterone is primarily used. Starting hormones changes the body in various ways. Some of the changes may be permanent. Other changes may be reversible. We do a careful evaluation as we help you and your family navigate the medical transition process. Read more about  feminizing hormone therapy  (PDF) and  masculinizing hormone therapy (PDF).

Youth who are gender diverse are more likely to be diagnosed with autism spectrum disorder or show similar social challenges than other children and teens. We work closely with the Seattle Children’s Autism Center team to coordinate care for children and teens with autism and related social challenges. Some providers at the Autism Center are experienced in caring for youth with autism who also have gender dysphoria.

Your first visit in the Gender Clinic may be with a mental health therapist (for patients 13 years and older) before you see a medical provider. Our team will continue to support you and your family with any questions or concerns that arise as you pursue gender-affirming medical care, but we do not offer ongoing mental health therapy appointments. If you are interested in finding an ongoing mental health therapist, here are some community resources . If you have an existing mental health provider and feel comfortable with our team collaborating with them, we can coordinate your care to ensure you are receiving all of the support you need.

Other Gender-Affirming Services Seattle Children’s Provides

Gender-affirming surgery for teens and young adults.

Seattle Children’s plastic surgeons perform gender-affirming surgery through our Surgical Gender Affirmation Program. We work closely with patients and families to make decisions about surgery age and timing. Patients must be 18 or older by the time of surgery for gender-affirming genital procedures. For other surgeries, timing depends on many factors, like the patient’s stage of puberty and how surgery fits with the rest of their gender-related healthcare. A typical age is mid-teens or older.

The Surgical Gender Affirmation Program take referrals for established patients in Seattle Children’s Gender Clinic, as well as patients getting gender-affirming care from providers outside of Seattle Children’s.  Read more .

Why choose Seattle Children’s Gender Clinic?

Seattle Children's Gender Clinic is a multidisciplinary clinic for youth who are transgender or gender diverse.

We employ best practices based on best medical evidence for our patients who are transgender and gender diverse. Dr. Cora Breuner co-authored the first policy statement by the American Academy of Pediatrics on the subject. We base our treatments on the most current research and continue to update our best practices accordingly.

Our medical providers have special training in  adolescent medicine , how hormones regulate the body (endocrinology) and  emotional health . This team approach is called multidisciplinary care. Social workers, nurses and medical assistants are also part of the team.

Seattle Children’s plastic surgeons have special training in gender-affirming surgery for teens and young adults.

We tailor treatment to you and your family. We take into account your age, stage of puberty, desired future treatments, support systems and any current or past health problems.

Our specialists work together to coordinate care – all in 1 place when possible. Our team works with you and your whole family to make sure everyone is comfortable with treatment options moving forward.

Our team is involved in research focused on improving the care provided to transgender and gender-diverse youth and their families. Some of our team’s recent research projects and publications are focused on:

• Autism and gender diversity
• Barriers to gender-affirming care
• Bone mineral density in gender-diverse people
• Family experiences in a gender clinic
• Peer support
• Transition to adult healthcare providers
• Use of names and pronouns in the electronic medical record

Scheduling an Appointment With the Gender Clinic

• If you are looking for mental health services only, please use these community resources as we do not provide ongoing mental health therapy.
• We require a referral from your primary care provider to make an appointment. Please call 206-987-2028 to make an appointment after a referral has been submitted.
• If your primary care provider or mental health provider would like to consult with one of the members of the Gender Clinic team regarding your care, please have them submit an electronic consultation .
• If you already have an appointment, learn more about how to prepare  and  what to expect .
• Learn about gender care resources  such as useful links, videos and recommended reading for you and your family.

Confidentiality in Washington State

Parents and caregivers are very important for ensuring the growth and development of adolescents into healthy adults. We encourage adolescents to speak with their parents or caregivers about their health.

As providers, we are also dedicated to helping adolescents and young adults develop independence and practice being involved in medical decisions. As recommended by the American Academy of Pediatrics, the Society for Adolescent Health and Medicine and the American College of Obstetrics and Gynecology, we offer time in the Adolescent Medicine Clinic to talk with your provider alone.

Gender-affirming medical care (such as puberty blockers, estradiol, and testosterone) for patients under age 18 requires consent from any parent or guardian that has medical decision-making rights for that patient, unless the patient is an emancipated minor . Our team can help answer questions about consent if needed.

Under Washington state law, adolescents have the right to seek medical care for the following conditions, even without parent or caregiver consent:

• Birth control and pregnancy-related treatment
• Mental health conditions if 13 or older
• Alcohol and drug problems if 13 or older
• Sexually transmitted infections, including HIV/AIDS testing, if 14 or older

Washington state privacy laws limit parent and caregiver access to adolescents’ health information. Adolescents’ medical records are private and confidential. The patient chooses whether to consent to releasing medical information, including to parents or caregivers.

However, if a situation arises where someone’s health or well-being is in immediate danger, we must inform parents or caregivers immediately and include them in the plan to keep everyone safe.

Contact the Gender Clinic  at  206-987-2028 to make an appointment or for questions about scheduling.

Youth or families who need additional support resources that are not available on our website can contact our care navigators at  206-987-5768 . The care navigators are not able to assist with scheduling questions.

Providers, see  how to refer a patient .

Telemedicine at Seattle Children’s

You may be offered a telehealth (virtual) appointment.  Learn more .

Paying for Care

Learn about  paying for care at Seattle Children’s, including insurance coverage, billing and financial assistance.

Access Additional Resources

Get resources for patients and families , including information on food, housing, transportation, financial assistance, mental health and more.

Also in This Section…

• What to Expect
• Patient and Family Education
• Education and Resources for Healthcare Professionals
• Refer a Patient
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Seattle Children’s complies with applicable federal and other civil rights laws and does not discriminate, exclude people or treat them differently based on race, color, religion (creed), sex, gender identity or expression, sexual orientation, national origin (ancestry), age, disability, or any other status protected by applicable federal, state or local law. Financial assistance for medically necessary services is based on family income and hospital resources and is provided to children under age 21 whose primary residence is in Washington, Alaska, Montana or Idaho.

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Gender and Sexuality Development Program

Children’s Hospital of Philadelphia is committed to providing the best and most compassionate care to the patients and families we serve. We look forward to working with our newly elected officials and continuing to advocate for policies that protect comprehensive healthcare for all children, inclusive of their gender identity. We fully support our colleagues in the Gender & Sexuality Development program and will continue to ensure that our patients and families have access to the highest quality care.

The Gender and Sexuality Development Program offers psychosocial and medical support for gender nonconforming, gender expansive and transgender children and youth up to age 21 and their families. Our multidisciplinary team includes specialists in gender identity development from Social Work and Family Services , Adolescent Medicine , Endocrinology , and Behavioral Health . We work with your family to best meet the needs of your child or youth who is transgender or gender nonconforming. We also provide consultation and training for providers and organizations interested in learning how to better serve the needs of gender nonconforming youth.

Learn more about the Gender and Sexuality Program

How We Can Help

The Gender Program offers a variety of services based on individual and family needs. Our services include:

• Comprehensive gender assessment
• Gender affirming medical care
• Monthly support groups
• Insurance advocacy
• Legal support
• Lending library for parents, children and adolescents
• Connections to local stylists and salon owners who are LGBTQ friendly
• School, church, community, and healthcare provider trainings
• Referrals for ongoing outpatient therapy and/or psychiatric treatment

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What Trans Health Care for Minors Really Means

As of April 2022, two states have passed bills banning gender-affirming care – health care related to a transgender person’s medical transition – for transgender youth, and 20 states are considering laws that would do so. If passed in all these states, more than a third of transgender teens aged 13 to 17 would live in a state that prohibits them from accessing trans health care. But the meaning of gender-affirming care for young people, and what it looks like on the ground, isn’t always clear. The cloud of politics surrounding these bills has obscured the medical reality of how and when trans youth can get the treatments they seek.

Gender-affirming care encompasses nonsurgical treatments like mental health care, puberty blockers, hormone therapy, and reproductive counseling, as well as surgical options like “top” or “bottom” surgery. These treatments can be years-long, incremental processes that may only begin with the approval of parents and health care providers.

The bills banning this kind of care have caused confusion about what gender-affirming care for trans youth actually involves. Some have characterized care like puberty blockers and hormone therapy as child abuse despite the fact that a range of medical associations, including the American Academy of Pediatrics and the American Medical Association, supports them. Some of the bills also present incorrect medical information, like falsely stating that puberty blockers cause infertility (they do not).

In fact, gender-affirming care looks quite different for youth of different ages. Young children – those who have not yet gone through puberty – can’t medically transition. Instead, their transition is entirely social; a gender-expansive child can choose a new name and pronouns, cut their hair, or dress in a different style.

The next step of a child’s transition, if they and their family choose, is to take puberty blockers: medications that essentially press pause on puberty. Puberty blockers have long been given to cisgender children for precocious puberty, a phenomenon which can cause puberty to begin at an unusually young age, such as 7 or 8. As gender-affirming care, puberty blockers are only prescribed to a child once they have begun puberty, which for those assigned female at birth can begin around age 8, or slightly earlier for those who are Black or Hispanic; children assigned male at birth usually hit puberty about 2 years later, according to the Cleveland Clinic .

Physical development in children is measured on what’s called the Tanner Scale, which tracks the progress of puberty from Tanner Stage 1 (prepubescence) to Tanner Stage 5 (sexual maturity). The start of puberty, or Tanner Stage 2, is signaled by breast budding for those assigned female at birth and testicular enlargement for those assigned male at birth, says David Inwards-Breland, MD, MPH, co-director of the Center for Gender Affirming Care at Rady Children's Hospital-San Diego. Some clinics will not offer puberty blockers until a child has reached Tanner Stage 3 or 4, meaning they are only one or two stages away from the end of puberty, according to the Standards of Care (SOC) published by the World Professional Organization for Transgender Health.

To be eligible for puberty blockers, a child should have a “long-lasting and intense pattern of gender nonconformity or gender dysphoria,” according to the SOC. (The latest version of the SOC was released in 2012, and an updated edition is expected this spring .) Gender dysphoria is often evaluated by a mental health professional, who may want to see the child and their family for a number of sessions before making a diagnosis.

After taking puberty blockers, which are fully reversible, a child can still undergo their natural puberty, or they may begin to medically transition and eventually undergo gender-affirming hormone treatment with parental consent. The Endocrine Society recommends waiting to prescribe hormones until an adolescent can give informed consent, which is generally recognized as age 16, though it is widely accepted that starting before age 16 is appropriate in many cases. For those assigned female at birth, this would mean taking testosterone, and for those assigned male at birth, estrogen with or without a progestin and an anti-androgen. Hormone treatment is considered “partially reversible” by the SOC because some changes it causes, such as body fat redistribution, are reversible, and others, such as deeping of the voice from testosterone, are permanent.

To receive hormone treatment, a trans child should have “persistent, well-documented gender dysphoria,” according to the SOC, often as determined by a mental health care provider, who will then write a letter of recommendation for the treatment. And although the Endocrine Society recommends waiting until age 16 to start hormones, it recognizes that there may be compelling reasons to begin treatment earlier. In practice, many do receive it before this age. And a draft of the new version of the SOC drops the minimum recommended age for starting hormones to 14.

“It's not totally around age because we tend to do peer-congruent transition,” Inwards-Breland says. In other words, he wants his trans patients to be able to fit in with their peers when they’re going through puberty – and ideally, not be going through puberty late in high school, long after their peers. “Probably the youngest would be around 13,” he says of when he would start a teenager on hormones.

Deciding when an adolescent should begin hormones is a process that should involve the child, their family, and a multidisciplinary team, says Stephanie Roberts, MD, a pediatric endocrinologist at the Gender Multispeciality Service at Boston Children’s Hospital. “We really try to keep it extremely flexible and individualized, and to work with the young person and their family over time to help them meet their [transition] goals.”

The third step sometimes taken as part of gender-affirming treatment is surgery. Some surgeries are options for trans adolescents while others are not. The Endocrine Society recommends that surgery involving the genitals be delayed until a person reaches the age of consent, which is 18 in the United States.

For adolescents who are assigned female at birth, top surgery can be performed to create a flat chest. The Endocrine Society states that there is not enough evidence to set a minimum age for this type of gender-affirming surgery, and the draft of the updated SOC recommends a minimum age of 15. “Usually, for a [person] assigned female at birth, the chest tissue continues to mature until around 14 or 15,” Inwards-Breland says. “What I've seen surgeons do is after 14, they feel more comfortable.” If, though, a person is started on puberty blockers followed by hormone therapy from a relatively early age – around 13 – they will never develop breast tissue and wouldn’t need surgery to remove it.

Although trans youth are technically allowed to receive certain forms of gender-affirming care, in practice, it’s often difficult.

One common barrier is family approval. For minors, parental consent is needed for any form of gender-affirming care, and not all parents are willing to give it. Some parents never give consent; for others, it can take a while to learn about transgender health and get comfortable with letting their child medically transition.

Even parents who want to be supportive can slow things down. When Rose, a transgender girl in California’s Bay Area, came out to her mom, Jessie, around age 15, she became a patient at the gender clinic at Stanford Children’s Health and soon began taking puberty blockers (Jessie asked that their first names only be used due to privacy concerns). Rose wanted to begin hormone therapy shortly thereafter, but Jessie was hesitant. She wanted to make sure she was doing the right thing for her daughter.

“I didn’t know too much about the impact of hormone therapy, and to be frank, I even questioned will she be regretting her choices later and decide this is not what she wanted,” Jessie says. “As a parent, we ask all sorts of questions and try to look at all angles, try to figure out what should we do as a parent to be responsible?”

After receiving education at the clinic and having some tough conversations, Jessie gave her consent and Rose started on hormones about a year later. “The weight of responsibility for the parent, making that decision for their kid, it’s very daunting.”

Another major issue is the availability of pediatric gender clinics. Comprehensive multidisciplinary clinics are rare outside urban areas, Inwards-Breland says. Primary care providers can offer trans health care, but many aren’t experienced in it, particularly for trans youth.

“We still have these deserts where we don't have high-quality transgender health care programs available,” Roberts says. “Now we have more than 50 pediatric transgender health care programs available across the country, but there's still areas where patients and their families may need to travel long distances to access care.”

If a family is able to find a program, they often face long wait times before they can get a foot in the door. Rose’s original wait time was 6 months, and she was lucky to get in after 3, Jessie says. “That’s how she feels: She’s lucky. She’s one of the few lucky ones,” Jessie says.

For those who don’t have access to in-person care, there are telemedicine options. Organizations like Queermed provide remote care to adolescents, including puberty blockers and hormone therapy, in 14 states in the Southeast, where regular care is limited.

Once they’re in, families must navigate insurance coverage, which is inconsistent across public and private plans. “Even if a patient is insured, they may still be underinsured with respect to accessing transgender-related health care,” Roberts says. And insurance appeals can add further delays.

Distrust of the medical system, including fear of discrimination and being misgendered, can also lead trans youth to delay seeking care.

These obstacles are in states where gender-affirming care for trans youth is legal. The barriers introduced by the recent wave of anti-trans legislation in some states make it illegal in some cases for a child to access gender-affirming care. And this onslaught of bills doesn’t seem to be stopping anytime soon.

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The Center for Transyouth Health and Development

The Center for Transyouth Health and Development at Children’s Hospital Los Angeles is dedicated to providing affirming care for transgender and gender diverse children, adolescents, young adults and their families. As one of the oldest and largest transyouth programs, the Center partners with youth and their families to advance the field through innovative practice, training and research.

The multidisciplinary team at the CTYHD is dedicated to partnering with young people and their families as they navigate their gender journey, uncover their gifts while helping to remove any institutional barriers blocking their path to achieving their authentic selves.

What Makes our Center Different?

The Center for Transyouth Health and Development rejects the gatekeeper model of care and focuses on how to help our patients and families in the least restrictive environment possible. The CTYHD focuses on gender-affirming care and strives to make all our patients and their families feel welcomed and understood.

Services Available at CTYHD

• Gender-affirming medical treatment and mental health services
• Family support services and linkage to outside resources
• Case management services, including assistance with legal name and gender marker changes
• Peer Support groups
• Sexual health education including groups, one-on-one navigation services and HIV/STD (Sexually Transmitted Disease) screening and treatment.
• Access to PEP (Post Exposure Prophylaxis) and PrEP (Pre Exposure Prophylaxis) for HIV prevention.
• Voluntary participation in ground breaking research

The CTYHD is a national leader in conducting ground-breaking research designed to advance our understanding and practice of gender-affirming health care and related services among transgender and gender-nonconforming youth.

Below are recent peer-reviewed journal articles reflecting some of our notable contributions (current and past CTYHD authors in bold).

• Julian, JM , Salvetti, B , Held, JI , Murray, PM , Lara-Rojas, L ,  Olson-Kennedy, J . The Impact of Chest Binding in Transgender and Gender Diverse Youth and Young Adults. Journal of Adolescent Health . 2020 October. doi: https://doi.org/10.1016/j.jadohealth.2020.09.029
• Hidalgo MA , Chen D. Experiences of Gender Minority Stress in Cisgender Parents of Transgender/Gender-expansive Prepubertal Children: A Qualitative Study. Journal of Family Issues. Forthcoming.
• Olson-Kennedy J, Warus J, Okonta V, Belzer M, Clark LF. , Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults: Comparisons of Nonsurgical and Postsurgical Cohorts. JAMA Pediatr. 2018 May 1;172(5):431-436. doi: 10.1001/jamapediatrics.2017.5440.
• Olson-Kennedy J, Okonta V, Clark LF, Belzer M , Physiologic Response to Gender-Affirming Hormones Among Transgender Youth, Journal of Adolescent Health, Volume 0, Issue 0 Published online October 2017; Physiologic Response to Gender-Affirming Hormones Among Transgender Youth. DOI: http://dx.doi.org/10.1016/j.jadohealth.2017.08.005
• Hidalgo MA , Chen D, Garofalo R, Forbes C. Perceived Parental Attitudes of Gender Expansiveness: Development and Preliminary Factor Structure of a Self-report Youth Questionnaire. Transgender Health, 2(1), 180-187; 2017.
• Olson J , Garofalo R., The peripubertal gender-dysphoric child: puberty suppression and treatment paradigms. Pediatr Ann. 2014 Jun;43(6):e132-7. doi: 10.3928/00904481-20140522-08. PMID: 24972421
• Hidalgo MA , Ehrensaft D, Tishelman AC, Clark LF , Garofalo R, Rosenthal SM, Spack, N, Olson J. The gender affirmative model: What we know and what we aim to learn. Human Development. 56(5):285-90, 2013.
• Olson J, Clark L, Schrager S, Simons L, Belzer M. Baseline characteristics of transgender youth naïve to cross sex hormone therapy, J Adol Health, February 2013 (Vol. 52, Issue 2, Supplement 1, S35-S36.

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What medical treatments do transgender youth get?

Transgender medical treatment for children and teens is increasingly under attack in many states, labeled child abuse and subject to criminalizing bans. But it has been available in the United States for more than a decade and is endorsed by major medical associations.

Many clinics use treatment plans pioneered in Amsterdam 30 years ago, according to a recent review in the British Psych Bulletin. Since 2005, the number of youth referred to gender clinics has increased as much as tenfold in the U.S., U.K, Canada and Finland, the review said.

The World Professional Association for Transgender Health, a professional and educational organization, and the Endocrine Society, which represents specialists who treat hormone conditions, both have guidelines for such treatment . Here’s a look at what’s typically involved.

Puberty blockers

Children who persistently question the sex they were designated at birth are often referred to specialty clinics providing gender-confirming care. Such care typically begins with a psychological evaluation to determine whether the children have “gender dysphoria,” or distress caused when gender identity doesn’t match a person’s assigned sex.

Children who meet clinical guidelines are first offered medication that temporarily blocks puberty . This treatment is designed for youngsters diagnosed with gender dysphoria who have been counseled with their families and are mature enough to understand what the regimen entails.

‘I know who I am’: Transgender youth on the value of support, respect for their identities

The medication isn’t started until youngsters show early signs of puberty — enlargement of breasts or testicles. This typically occurs around age 8 to 13 for girls and a year or two later for boys.

The drugs, known as GnRH agonists, block the brain from releasing key hormones involved in sexual maturation. They have been used for decades to treat precocious puberty, an uncommon medical condition that causes puberty to begin abnormally early.

The drugs can be given as injections every few months or as arm implants lasting up to year or two. Their effects are reversible — puberty and sexual development resume as soon as the drugs are stopped.

Some kids stay on them for several years. One possible side effect: They may cause a decrease in bone density that reverses when the drugs are stopped.

After puberty blockers, kids can either go through puberty while still identifying as the opposite sex or begin treatment to make their bodies more closely match their gender identity.

For those choosing the second option, guidelines say the next step is taking manufactured versions of estrogen or testosterone — hormones that prompt sexual development in puberty . Estrogen comes in skin patches and pills. Testosterone treatment usually involves weekly injections.

READ MORE: The history behind International Transgender Day of Visibility

Guidelines recommend starting these when kids are mature enough to make informed medical decisions. That is typically around age 16, and parents’ consent is typically required, said Dr. Gina Sequiera, co-director of Seattle Children’s Hospital’s Gender Clinic.

Many transgender patients take the hormones for life, though some changes persist if medication is stopped.

In girls transitioning to boys, testosterone generally leads to permanent voice-lowering, facial hair and protrusion of the Adam’s apple, said Dr. Stephanie Roberts, a specialist at Boston Children’s Hospital’s Gender Management Service. For boys transitioning to girls, estrogen-induced breast development is typically permanent, Roberts said.

Research on long-term hormone use in transgender adults has found potential health risks including blood clots and cholesterol changes.

Gender-altering surgery in teens is less common than hormone treatment, but many centers hesitate to give exact numbers.

Guidelines say such surgery generally should be reserved for those aged 18 and older. The World Professional Association for Transgender Health says breast removal surgery is OK for those under 18 who have been on testosterone for at least a year. The Endocrine Society says there isn’t enough evidence to recommend a specific age limit for that operation.

Studies have found some children and teens resort to self-mutilation to try to change their anatomy. And research has shown that transgender youth and adults are prone to stress, depression and suicidal behavior when forced to live as the sex they were assigned at birth.

Opponents of youth transgender medical treatment say there’s no solid proof of purported benefits and cite widely discredited research claiming that most untreated kids outgrow their transgender identities by their teen years or later. One study often mentioned by opponents included many kids who were mistakenly identified as having gender dysphoria and lacked outcome data for many others.

READ MORE: Giving homeless transgender youth a safe haven from the streets

Doctors say accurately diagnosed kids whose transgender identity persists into puberty typically don’t outgrow it. And guidelines say treatment shouldn’t start before puberty begins.

Many studies show the treatment can improve kids’ well-being, including reducing depression and suicidal behavior. The most robust kind of study — a trial in which some distressed kids would be given treatment and others not — cannot be done ethically. Longer term studies on treatment outcomes are underway.

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Services & Specialties Transgender Health Center

Health Services for Transgender Youth

The Living With Change Center at Cincinnati Children’s provides an accepting atmosphere and services for patients 5-24 years old. Our team of specialists is in a unique position to provide medical and psychosocial support for these children and their families.

What Is ‘Transgender’?

Transgender is an umbrella term for people who experience their gender differently from their gender at birth. These individuals experience a consistent and persistent discomfort with gender identity, causing extreme distress. Gender identity is one’s psychological sense of being male, female, some of both or neither.

Learn more about the importance of family acceptance as well as some common concerns that families express about transgender treatment.

To make an appointment, submit a referral or view our treatment locations, please contact us .

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Gender-Affirming Surgeries

What is gender-affirming surgery?

Gender-affirming surgeries change the look and function of your assigned sex to more closely match the gender you identify with. Having a gender-affirming surgery may be part of your journey to becoming more of your true self.

Surgical options for gender-affirmation include facial surgery, voice surgery, and top and bottom surgeries. Patients whose assigned sex and gender identity are different may experience gender dysphoria. Gender-affirming surgery is an important part of the management of patients with gender dysphoria.

Top surgery includes procedures to create or remove breasts. Feminizing bottom surgery includes procedures to remove the penis and testicles and create a new vagina, labia and clitoris. Learn more about feminizing bottom surgery .

Masculinizing bottom surgery includes procedures to remove the uterus or add a penis for intercourse and urinating or a small penis to urinate standing up. Learn more about masculinizing bottom surgery .

We follow the World Professional Association for Transgender Health’s standards when performing gender-affirming surgeries. These guidelines are set for safe, effective physical and mental health care for transgender and gender-nonconforming patients. Requirements for each procedure will vary.

Why choose Ohio State for gender-affirming surgery?

The Ohio State Wexner Medical Center is one of only a few academic health centers in the country to offer bottom gender-affirming surgery. We have a dedicated team of medical experts in every field, and through close collaboration aim to serve the LGBTQ population of Columbus and beyond.

Surgical options for gender-affirmation

• Facial surgery options
• Feminization surgery
• Masculinization surgery
• Meet our gender-affirming care surgical team Meet your surgical team

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Due to the downward trend in respiratory viruses in Maryland, masking is no longer required but remains strongly recommended in Johns Hopkins Medicine clinical locations in Maryland. Read more .

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Center for Transgender and Gender Expansive Health

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The Johns Hopkins Center for Transgender and Gender Expansive Health offers comprehensive, evidence-based and affirming care for transgender and gender diverse youth and adults that is in line with the standards of care set by the World Professional Association for Transgender Health (WPATH).

Creating an environment in which our patients and their families feel safe and confident in the care they receive is central to the mission of Johns Hopkins Medicine. The multidisciplinary care team takes careful consideration of best practices and the appropriate provision of care for transgender and nonbinary individuals.

Request an Appointment: 844-546-5645

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Center collaborators, eligibility criteria, services for adults, dermatology.

Dermatologists at the Center for Transgender and Gender Expansive Health perform laser hair removal for both aesthetic reasons and as preparation for some surgeries.

During laser hair removal, a dermatologist uses a low-energy beam laser, which results in long-term or permanent hair reduction and removal. Usually, a series of laser hair removal appointments are recommended for best results. Discuss an individualized plan with your dermatologist.

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Facial Surgery

In cases where hormone therapy is not enough to achieve  desired gender affirming changes to the face , surgery can help. Feminizing facial surgery includes a variety of procedures, such as reshaping the nose; brow lift (or forehead lift); chin, cheek and jaw reshaping; Adam’s apple reduction; lip augmentation; hairline restoration; and earlobe reduction. Masculinizing facial surgical options including hairline reshaping, jaw augmentation, and thyroid cartilage enhancement are also available. Watch to learn more .  See eligibility requirements . See surgical timeline .

Our specialists at the Fertility Center coordinate with the Center for Transgender and Gender Expansive Health to provide  services for gender affirming fertility preservation, reproduction assistance and contraception . It is recommended that you consider speaking to a specialist before undergoing hormone treatment to review how gender-affirming hormone therapy may affect your fertility options.

• Gyn/Ob Care for Transgender and Gender Expansive Patients

Geriatric Care

Our specialists in Geriatric Care coordinate with the Center for Transgender and Gender Expansive Health to provide the highest quality clinical care to improve the health of older adults and society.

Gynecology, Obstetrics and Family Planning for Gender Diverse Patients

Gyn/Ob specialists provide preventive, gender- affirming gynecologic care throughout your life. This may include routine annual exams/cervical screening for transgender and gender diverse individuals, sexuality and sexual health care, the management of benign gynecologic disorders, transitioning and gender affirmation including menstrual suppression, trauma informed pap smears, local anesthetics for IUD placement and counseling when appropriate. The department also specializes in shared decision making for family planning, care during pregnancy, childbirth and the postpartum period for transgender and gender diverse individuals.

Hormone Treatment

The Center for Transgender and Gender Expansive Health partners with endocrinologists and primary care providers. Both endocrinologists and primary care providers work with each patient to prescribe either gender-affirming hormone treatments. Hormone treatments can be part of a pre-surgical plan, or be a stand-alone service, depending on your desired outcomes. Talk to your doctor about the process and any side effects that you can expect.

Hysterectomy

Hysterectomy  includes the removal of the uterus and ovaries (oophorectomy). Many gender patients are seeking gender affirming hysterectomy as part of their gender journey. Other patients have preexisting conditions such as fibroids, or endometriosis.

Options for oocyte storage and fertility preservation are also available if desired.  See eligibility requirements .  See surgical timeline

Mental Health

The Department of Psychiatry and Behavioral Sciences partners with the Center for Transgender and Gender Expansive Health (CTH) to provide mental health services through the expertise of the Sex and Gender Clinic. Assessments for surgical readiness are available. These involve the completion of a comprehensive mental health evaluation, following WPATH guidelines. Other services include recommendations for ongoing care such as support and guidance preoperatively and postoperatively as well as treatment for co-existing mental health conditions. Support and education for families and significant others are further aspects of the team’s services. The aim of the collaboration between CTH and Psychiatry is to maximize the health, well-being and quality of life of transgender and gender diverse individuals.

Metoidioplasty

Metoidioplasty is a surgical procedure for gender affirmation that is sometimes called a meta procedure or bottom surgery. It is an alternative to phalloplasty .

Pelvic Physical Therapy

Our pelvic health physical therapists are specially trained to evaluate and treat different types of pelvic floor dysfunction and treat a variety of pelvic floor symptoms after performing a complete assessment to best suit your needs. They can also assist with pre and post-operative exercises for genital surgery, and assist with dilation teaching.

Pelvic Floor Physical Therapy

Occupational Therapy

General Physical Therapy

Penile construction (phalloplasty)

Phalloplasty  can include removal of the vagina (vaginoplasty), reconstruction of the urethra, scrotoplasty, penile and testicular implants, and penile construction. Surgeons will use tissue from another part of the body to construct the penis.  See eligibility requirements .  See surgical timeline .

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Primary care for gender diverse patients.

The comprehensive services offered through the Center for Transgender and Gender Diverse Health include connecting transgender patients with primary care providers across Johns Hopkins Medicine who are trans affirming. These providers can manage a patient’s general health care needs as well as specific transgender-health-related needs such as initiating and managing hormone therapy in most cases. Our primary care team members are vital partners in providing holistic care that leverages the resources of our academic medical health care system.

Top surgery (chest feminization or chest masculinization)

Top surgery is surgery that removes or augments breast tissue and reshapes the chest to create a more masculine or feminine appearance for transgender and nonbinary people.  See eligibility requirements . See surgical timeline .

At the Center for Transgender and Gender Expansive Health, you will receive care from doctors in the Johns Hopkins Department of Urology who have experience in the range of gender-affirming surgeries.

The urology team works closely with the Department of Plastic and Reconstructive Surgery and other members of our integrated team to provide the most up-to-date gender affirmation procedures and ongoing care. Services provided include robot assisted vaginoplasty, orchiectomy, and insertion of penile prostheses. Follow-up visits with urology are available for prostate screening or urological issues.  See eligibility requirements . See surgical timeline .

Vaginoplasty

This surgical procedure  is a single stage procedure during which our skilled surgeons may remove the penis (penectomy) and the testes (orchiectomy), if still present, and use tissues from the penis to construct the vagina (vaginoplasty), the clitoris (clitoroplasty) and the labia (labiaplasty).  See eligibility requirements . See surgical timeline .

Voice Therapy

The Center for Transgender and Gender Expansive Health works with otolaryngologists who specialize in voice therapy, which some transgender individuals find beneficial. Intervention is designed to meet the individual needs of the person who is transitioning and may include diagnostic evaluation, treatment or surgical intervention. Our team works together to assist in the voice transition. Specifically, we provide a supportive and guided environment to maximize total communication, including aspects of voice such as conversational pitch and inflection, as well as nonverbal communication.

The initial evaluation will include a case history and assessment of voice and speech prosody. All clients are initially screened for any laryngeal pathology to ensure optimal vocal fold health. An individualized treatment plan is created with the client based on the assessment findings and the client’s perceived needs. Some aspects the voice pathologist may choose to address include:

• Habitual speaking pitch
• Inflection (the melodic ups and downs of the voice)
• Rate of speech (how fast or slow the person speaks)
• Non-verbal communication
• Volume/intensity
• Articulation
• Pragmatics (social rules of communication)

Sometimes, voice therapy alone is not enough to achieve your desired outcome. In cases like this, vocal cord surgery is an option and is usually done as an outpatient procedure. Talk to your doctor about surgical options to achieve the vocal identity that is right for you. 

Insurance coverage for voice therapy often differs among providers. It is important for the patient to be familiar with their specific contract coverage for this service.

Emerge Gender Diversity Clinic

The Emerge Gender Diversity Clinic for Children, Adolescents and Young Adults offers fully integrated and interdisciplinary expertise and clinical services in pediatrics, adolescent and young adult medicine, endocrinology, nursing, social work, child and adolescent psychiatry, and mental health care designed to improve the health and well-being of gender variant, gender diverse and transgender youth and young adults.

Through a collaborative relationship with endocrinology and psychiatry, we work to provide comprehensive services for all youth. Clinical services are available for children, adolescents and young adults 5–25 years old and include education, family and individual support, pubertal blockade, cross-hormonal therapy and mental health support and treatment. The clinic additionally provides referrals for gender affirmation surgery for adolescents and young adults, 18 years and older, according to the Johns Hopkins Center for Transgender and Gender Expansive Health guidelines. 

• Puberty blockade
• Cross sex hormones
• Psychosocial support
• Complex care needs (e.g., autism spectrum, complex family, etc.)
• Menstrual suppression and management, family planning services
• Sexual and reproductive/contraceptive health care sexually transmitted infection (STI), HIV, Pre-exposure prophylaxis (PrEP) testing and care
• Substance use treatment

Primary Care Sites

Psychiatric services include mental health treatment with Psychiatry Community mental health providers.

Pediatric Endocrine

Pediatric endocrine services include pubertal blockade, cross sex hormones, and underlying endocrine disorder.

Reproductive Endocrine/Urology

 Johns Hopkins Community Physicians works to provide the best reproductive endocrine and urology services.

Sexual and Reproductive Health Care

Sexual and reproductive health care services include sexually transmitted infection (STI) and HIV testing. 

Center for Adolescent and Young Adult Health

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• Chase Brexton
• Whitman Walker
• Johns Hopkins Community Physicians
• East Baltimore Medical Campus
• Johns Hopkins University Student Clinics

Our team is committed to providing high-quality, compassionate care that is in line with the standards of care outlined by the World Professional Association for Transgender Health (WPATH), including  mental health criteria for surgical services . 

Gender affirming surgery is only offered to patients aged 18+.

Surgical Services Timeline

It all starts with a phone call..

First, call 844-546-5645 for an initial intake interview via phone with a clinical specialist. This is your first point of contact with the clinical team, where you will review your medical history, discuss which procedures you’d like to learn more about and what is required, and develop a plan for next steps.

After intake, you'll receive next steps to schedule a consult appointment. Depending on your specific surgery, you'll likely need to prepare the following documentation:

• Mental Health Evaluations and Surgical Readiness referral letters from mental health providers documenting their assessment and evaluation
• Pharmacy records and medical records documenting your hormone therapy
• Medical records from your primary physician (these will be requested by the clinical team)
• Information about which prescription and over-the-counter medications you are currently taking
• Insurance information

Meeting with your surgeon.

The consult will be your first appointment with your new healthcare provider. These appointments typically include:

• Assessment of your medical health status and readiness for major surgical procedures;
• Discussion of your long-term gender affirmation goals and assessment of which procedures may be most appropriate to help you in your journey;
• Specific details about the procedures you and your surgeon identify, including the risks, benefits and what to expect after surgery.

After the consult, you'll receive next steps for scheduling the surgery.

Getting ready for surgery.

After your consult with the surgical team, you will receive information regarding next steps. Next steps can include a variety of things, to include:

• Medical Clearance tests and/or notes from other providers
• Additional imaging
• Updated mental health evaluation letters
• Hair removal, or other pre-operative readiness

Once all these things have been completed, you will receive a surgery date.

A preoperative anesthesia and medical evaluation.

Your surgeon may need to meet with you before surgery to finalize your surgical plan and go over any questions you may have before the morning of your procedure. You may also be asked to complete these evaluations at the hospital, which ensure that you are healthy enough for surgery.

Your surgery.

On the day of your procedure, you'll arrive at the hospital two hours prior to surgery. You will be brought back to the pre-op area where you'll change into a surgical gown and nursing staff will begin your check in. This involves asking questions, taking blood samples, starting an IV for fluids, and monitoring your vital signs with a blood pressure cuff and oxygen monitor.

In addition to the nurse that checks you in, you will see your surgeon, our PA, anesthesiologists, and possibly other surgical attending’s and surgical residents who assist in the operating room. Together everyone works as a team to ensure the best possible outcome.

Read FAQs for more information about what you can expect during your hospital experience at either the Johns Hopkins Outpatient Center or the Harry and Jeanette Weinberg Building.

Read more about preparing for gender affirmation surgery

What can you expect after gender affirming surgery?

For specific questions, please refer to the post-operative instructions you received from your surgical team.

If you have any of the following signs and symptoms, please call us: temperature greater than 101.5˚F; redness or rapidly changing shape of the surgical area; pus and/or large quantities of drainage from your incision or drain site; continuing inability to urinate; severe and unremitting pain not relieved by maximum doses of pain medications.

If you have any questions or concerns during regular business hours between 8:00 am and 5:00 pm, please call 844-546-5645 to reach the Center for Transgender and Gender Expansive Health. If you have questions or concerns after regular business hours, please call 410-955-5000 and ask for the “Plastic Surgery Resident On Call” to be paged. A doctor is available and present in the hospital 24/7/365 in case of emergencies.

For life-threatening symptoms such as shortness or breath, difficulty breathing, dizziness or fainting, chest pain, or mental status changes, call 9-1-1 or go to your nearest emergency department immediately.

We're here for you.

When you’ve finished the surgical aspects of your gender affirmation, we encourage you to follow up with your primary care physician to make sure that they have the latest information about your health. Your doctor can create a custom plan for long-term care that best fits your needs.

Among other changes, you may consider updating your name and identification. This collection of resources for transgender and gender-nonconforming individuals can help you in this process.

Browse Resources

Patient story The Joy of Being Yourself

In a little more than a year, the Center for Transgender and Gender Expansive Health has provided gender affirming surgeries that changed the lives of about 150 people. Here are the stories of best friends Dylan Ballerstadt and Kez Hall, and Dariel Peay.

Putting numbers on the rise in children seeking gender care

By ROBIN RESPAUT and CHAD TERHUNE

Filed Oct. 6, 2022, 11 a.m. GMT

Thousands of children in the United States now openly identify as a gender different from the one they were assigned at birth, their numbers surging amid growing recognition of transgender identity and rights even as they face persistent prejudice and discrimination.

As the number of transgender children has grown, so has their access to gender-affirming care, much of it provided at scores of clinics at major hospitals.

Reliable counts of adolescents receiving gender-affirming treatment have long been guesswork – until now. Reuters worked with health technology company Komodo Health Inc to identify how many youths have sought and received care. The data show that more and more families across the country are grappling with profound questions about what type of care to pursue for their children, placing them at the center of a vitriolic national political debate over what it means to protect youth who identify as transgender.

Diagnoses of youths with gender dysphoria surge

In 2021, about 42,000 children and teens across the United States received a diagnosis of gender dysphoria, nearly triple the number in 2017, according to data Komodo compiled for Reuters. Gender dysphoria is defined as the distress caused by a discrepancy between a person’s gender identity and the one assigned to them at birth.

Overall, the analysis found that at least 121,882 children ages 6 to 17 were diagnosed with gender dysphoria from 2017 through 2021. Reuters found similar trends when it requested state-level data on diagnoses among children covered by Medicaid, the public insurance program for lower-income families.

Gender-affirming care for youths takes several forms, from social recognition of a preferred name and pronouns to medical interventions such as hormone therapy and, sometimes, surgery. A small but increasing number of U.S. children diagnosed with gender dysphoria are choosing medical interventions to express their identity and help alleviate their distress.

These medical treatments don’t begin until the onset of puberty, typically around age 10 or 11.

For children at this age and stage of development, puberty-blocking medications are an option. These drugs, known as GnRH agonists, suppress the release of the sex hormones testosterone and estrogen. The U.S. Food and Drug Administration has approved the drugs to treat prostate cancer, endometriosis and central precocious puberty, but not gender dysphoria. Their off-label use in gender-affirming care, while legal, lacks the support of clinical trials to establish their safety for such treatment.

Over the last five years, there were at least 4,780 adolescents who started on puberty blockers and had a prior gender dysphoria diagnosis.

This tally and others in the Komodo analysis are likely an undercount because they didn’t include treatment that wasn’t covered by insurance and were limited to pediatric patients with a gender dysphoria diagnosis. Practitioners may not log this diagnosis when prescribing treatment.

By suppressing sex hormones, puberty-blocking medications stop the onset of secondary sex characteristics, such as breast development and menstruation in adolescents assigned female at birth. For those assigned male at birth, the drugs inhibit development of a deeper voice and an Adam’s apple and growth of facial and body hair. They also limit growth of genitalia.

Without puberty blockers, such physical changes can cause severe distress in many transgender children. If an adolescent stops the medication, puberty resumes.

The medications are administered as injections, typically every few months, or through an implant under the skin of the upper arm.

After suppressing puberty, a child may pursue hormone treatments to initiate a puberty that aligns with their gender identity. Those for whom the opportunity to block puberty has already passed or who declined the option may also pursue hormone therapy.

At least 14,726 minors started hormone treatment with a prior gender dysphoria diagnosis from 2017 through 2021, according to the Komodo analysis.

Hormones – testosterone for adolescents assigned female at birth and estrogen for those assigned male – promote development of secondary sex characteristics. Adolescents assigned female at birth who take testosterone may notice that fat is redistributed from the hips and thighs to the abdomen. Arms and legs may appear more muscular. The brow and jawline may become more pronounced. Body hair may coarsen and thicken. Teens assigned male at birth who take estrogen may notice the hair on their body softens and thins. Fat may be redistributed from the abdomen to the buttocks and thighs. Their testicles may shrink and sex drive diminish. Some changes from hormone treatment are permanent.

Hormones are taken in a variety of ways: injections, pills, patches and gels. Some minors will continue to take hormones for many years well into adulthood, or they may stop if they achieve the physical traits they want.

Hormone treatment may leave an adolescent infertile, especially if the child also took puberty blockers at an early age. That and other potential side effects are not well-studied, experts say.

The ultimate step in gender-affirming medical treatment is surgery, which is uncommon in patients under age 18. Some children’s hospitals and gender clinics don’t offer surgery to minors, requiring that they be adults before deciding on procedures that are irreversible and carry a heightened risk of complications.

The Komodo analysis of insurance claims found 56 genital surgeries among patients ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021. Among teens, “top surgery” to remove breasts is more common. In the three years ending in 2021, at least 776 mastectomies were performed in the United States on patients ages 13 to 17 with a gender dysphoria diagnosis, according to Komodo’s data analysis of insurance claims. This tally does not include procedures that were paid for out of pocket.

A note on the data

Komodo’s analysis draws on full or partial health insurance claims for about 330 million U.S. patients over the five years from 2017 to 2021, including patients covered by private health plans and public insurance like Medicaid. The data include roughly 40 million patients annually, ages 6 through 17, and comprise health insurance claims that document diagnoses and procedures administered by U.S. clinicians and facilities.

To determine the number of new patients who initiated puberty blockers or hormones, or who received an initial dysphoria diagnosis, Komodo looked back at least one year prior in each patient’s record. For the surgery data, Komodo counted multiple procedures on a single day as one procedure.

For the analysis of pediatric patients initiating puberty blockers or hormones, Komodo searched for patients with a prior gender dysphoria diagnosis. Patients with a diagnosis of central precocious puberty were removed. A total of 17,683 patients, ages 6 through 17, with a prior gender dysphoria diagnosis initiated either puberty blockers or hormones or both during the five-year period. Of these, 4,780 patients had initiated puberty blockers and 14,726 patients had initiated hormone treatment.

Youth in Transition

By Robin Respaut and Chad Terhune

Photo editing: Corrine Perkins

Art direction: John Emerson

Edited by Michele Gershberg and John Blanton

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Other Reuters investigations

Pediatric & Adolescent Care for Transgender and Gender-Diverse Youth

If your child identifies as transgender or gender non-binary or is exploring their gender identity or expression, you can find the answers and support you need at UChicago Medicine. Here, we strive to provide a safe, welcoming environment for your entire family.

Our pediatric endocrinologists (hormone specialists), behavioral health specialists, social workers and sexual health experts are dedicated to delivering gender-affirming care. This may include providing puberty blocking treatment according to current guidelines for pre-teens and adolescents who have been diagnosed with gender dysphoria by a mental health professional.

Our caring team of social workers also can assist with name changes or other social issues that may arise.

Pediatric & Adolescent Care Services

At UChicago Medicine, we offer a variety of services including:

• Puberty blocking therapy
• Gender-affirming hormone therapy
• Sexually transmitted infection (STI) prevention and treatment
• HIV pre-exposure prophylaxis (PrEP)
• HIV post-exposure prophylaxis (PEP)

Adolescent Sexual Health Care

The Care2Prevent (C2P) program at UChicago Medicine provides care for people of all ages (including trans-identified youth) who are living with HIV or who want to stay HIV-negative.

Through Care2Prevent, you can receive free or low-cost HIV/STI testing and basic medical care. We also provide case management services if you are living with HIV, including helping you find educational opportunities, employment and medical insurance.

Behavioral Health Support for Trans-identified Youth

The caring therapists in our Care2Prevent program provide social, emotional and spiritual support to young people on Chicago’s South Side who are diagnosed with HIV or who are at risk for HIV. Many of our clients are young people of color who identify as transgender or non-binary.

Our goal is to provide a space for healing in which you are fully accepted. By working together, we can help you:

• Adjust to a new HIV/STI diagnosis
• Offer support if you are struggling with sexual trauma
• Help you find treatment for substance abuse
• Address family challenges such as acceptance
• Connect you with other trans-friendly organizations on the South Side

We also offer workshops and support groups for families in an affirming space. You may access these services at no cost if you are uninsured or underinsured.

Frequently Asked Questions

When can my child start puberty blocking treatment.

Puberty blockers delay unwanted body changes and can give your child or teen more time to explore their gender identity. The best time to start therapy is different for each child, although we want to ensure that young people have the support they need before beginning treatment.

At UChicago Medicine, we follow guidelines from the Pediatric Endocrine Society , the Endocrine Society and the World Professional Association of Transgender Health (WPATH) on using these medications safely and appropriately.

Are the effects of puberty blockers permanent?

No, the medications used to block puberty only have temporary effects. In other words, they delay puberty so children and teens have more time to explore their identity. If they choose to stop taking medications, their puberty will resume following their assigned sex at birth.

Why do we talk so much about sexually transmitted infections (STI) and HIV when discussing care for transgender youth?

Here at UChicago Medicine, we take a holistic approach to providing care that meets our patients’ needs, including their sexual and reproductive health. Research has shown that trans-identified youth are at a higher risk for acquiring HIV and STIs. This risk is even greater in young people of color. Our providers are passionate about offering thorough, confidential prevention and treatment services so that our patients can live their best, healthiest lives.

What is PrEP for prevention, and am I a candidate?

PrEP is a once-daily pill you can take to prevent HIV if you are HIV-negative and are at risk for HIV infection. PrEP is free in the state of Illinois, and our team can help to determine if PrEP is right for you and how to access the medication.

Can I get condoms from you?

Yes, our team can provide safe-sex kits, which include condoms and lube as well as information about our testing program.

I need other types of support. Can you help?

In many cases, yes. We routinely help young people (especially those living with HIV or who want to stay HIV-negative) in our community find health insurance and employment opportunities. We may also be able to help you if you are looking to complete your GED or need help with food or transportation.

If I come to you for behavioral health support or HIV services, how do you protect my privacy?

We follow strict confidentiality rules to honor your right to privacy. For example, what you discuss during a session with your therapist is confidential. We also take additional steps to protect your privacy in our therapy records, which can only be seen by your direct care team. And if you receive HIV-related services through Care2Prevent, we take extra precautions to not disclose your HIV status to other providers, unless they are part of your care team.

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Gender Transition Medications and Surgeries for Children in the U.S.

Key takeaways.

The U.S. currently has the most permissive laws surrounding transgender treatments for children compared to peer Western and Northern European nations.

Only 12–27% of children with gender dysphoria—a condition where one’s perceived gender identity differs from their biological sex—carry it into adulthood, yet many children in the U.S. are still eligible for irreversible therapies and surgeries.

Many puberty blockers given to children are prescribed for off-label (unapproved) use and can have dangerous side effects, including lowered bone density, stunted growth, and permanent infertility. There is limited research on the long-term effects of transgender interventions on children and little evidence of mental health benefits.

Policymakers should adopt policies to protect children from potentially harmful and irreversible sex reassignment surgeries and medications.

Executive Summary: 

Rates of transgenderism in children have rapidly increased in recent years in the U.S., which has sparked discussions between parents, schools, policymakers, and medical professionals alike over how to discuss and treat the issue. On one end of the spectrum, activist groups and a vocal subset of the medical establishment have promoted what is euphemistically known as “gender-affirming care,” whereby children with transgender inclinations are being encouraged to undertake potentially irreversible surgical and hormonal interventions with unknown long-term consequences. The interventions range from preventing normal pubertal development to surgical procedures removing healthy breast tissue and genitalia. Recognizing the potential for significant harm, and with over 300,000 youths between the ages of 13–17 in the U.S. now identifying as transgender, some states are setting policies designed to protect children from such irreversible treatments made at a critical time in their physical, mental, and emotional development ( Herman, Flores, & O’Neil, 2022 ). 

By castigating those who disagree with these procedures as “transphobic,” the people calling for the immediate normalization of these surgeries and treatments have dismissed valid concerns. Many important questions have arisen based on emerging evidence from systematic reviews, whistleblowers, detransitioners, and findings of a new clinical phenomenon of rapid onset of the condition in adolescence rather than early childhood. The fervor of the argument for “gender-affirming care” is not matched by any strength of evidence establishing that such treatments are either safe or effective for promoting long-term well-being. On the contrary, Americans have significant reasons to be instead concerned about the effects of such radical interventions undertaken on children.  

Indeed, the American people recognize the riskiness of such treatments on children, with most registered voters believing that “gender-affirming care” for children should be illegal. Moreover, around 85% of children with gender dysphoria do not carry this condition into adolescence—making the notion of using permanent treatments to address temporary conditions quite troubling ( Hembree et al., 2017 ). Nevertheless, many medical professionals in the U.S. are using an “affirm-early/affirm-often” approach when it comes to dealing with children who have gender dysphoria, and they often recommend puberty blockers, cross-sex hormones, and/or sex-change surgeries.  

Though other nations have shied away from such an approach in recent years, a recent review of eligibility criteria for sex-reassignment surgery found that children in the U.S. have access to the procedure at younger ages than minors in Western and Northern Europe ( Do No Harm, 2023a ). The same holds true with the prescription of puberty blockers and cross-sex hormones. Today, some states in the U.S. have more permissive laws than Western and Northern European nations. Not only is there little evidence that some of these “treatments” do anything to benefit the mental health of a child, but studies have shown mounting evidence that transgender drugs and surgical procedures have negative side effects for children. Moreover, many of the drugs prescribed to children for such procedures are prescribed for unapproved use.  

A contrasting approach to the prevailing “gender-affirming” philosophy of interventions does exist. It can be described as the “first, do no harm” model, which holds that the risks of medical and surgical interventions outweigh the benefits, and states that doctors should focus on other options, such as exploratory psychotherapy, while ensuring strong mental and social support ( Schwartz, 2021 ; SEGM, 2021a ). The non-profit “Do No Harm,” which consists of numerous physicians and healthcare professionals, has started an education campaign to protect minors from gender ideology and has, like other non-profit groups, concluded that it is appropriate for state lawmakers to now intervene ( Do No Harm, 2023a ; Do No Harm, 2023b ; Do No Harm, 2023c ; Brown & Stathatos, 2022 ). The Society for Evidence Based Gender Medicine (SEGM) has also highlighted the lack of quality evidence and recommended that the medical community urgently address concerns with current practices while endorsing the approach to “first, do no harm” ( SEGM, 2023 ; SEGM, 2021b ). Policymakers in the U.S. should consider all of this data and adopt policies that protect children from potentially harmful and irreversible procedures. 

This report builds upon the foundation set by Do No Harm and SEGM by compiling knowledge from a diversified set of resources to understand the history and diagnosis of gender dysphoria, explore different treatment models for the condition, and investigate how other countries approach the issue relative to how it is dealt with in the U.S. Finally, this report reviews how the American people perceive this issue and then outlines state actions to protect children.   

Section One: Defining Gender Dysphoria and Understanding the Role of the Diagnostic and Statistical Manual of Mental Disorders 

To fully understand pediatric gender medicine, it is critical to start with the diagnostic history of gender dysphoria and the evolution of the primary tool used by clinicians to make the diagnosis. Originally published in 1952 by the American Psychiatric Association (APA), the Diagnostic and Statistical Manual of Mental Disorders (DSM) is considered the “go-to” reference for the characterization and diagnosis of mental disorders in the U.S. and much of the world ( Kawa & Giordano, 2012 ).  

The DSM is translated into over 20 languages and is the leading mental disorder diagnostic resource, exerting heavy influence in the field of psychiatry and across society over the last 70 years ( Kawa & Giordano, 2012 ). This resource is used by clinicians, researchers, policymakers, courts, and insurance companies alike. The DSM is now on volume five, with each edition reflecting a change of definitions and inclusions intended to represent current medical thinking—some with significant impact. As an example, between DSM-II to DSM-III, the number of mental disorder categories rose from 182 to 265, partly due to a shift from considering mental disorders as psychological states to considering them discrete disease categories based on symptoms—a shift one source noted as “an attempt to ‘re-medicalize’ American psychiatry” ( Kawa & Giordano, 2012 ). The most recent version, DSM-5 (the version updated its notation from Roman numerals to numbers), included nearly 300 mental disorders and took 14 years of planning and preparation to publish ( Suris et al. 2016 ). 

It was not until DSM-III (1980) that any term related to gender dysphoria was included. The term used in the DSM-III was “transsexualism,” and then was later changed to “gender identity disorder in adults and adolescents” in the DSM-IV released in 1994. In 2013, the DSM-5 was released and again changed the term to “gender dysphoria” ( APA, 2017 ). Given the above history regarding the DSM, it is also important to note that the symptom-based disease categorization of the DSM-III led to an increase in psychopharmacological interventions.  

The revised text version of the DSM-5, the DSM-5-TR, was published in 2022. This edition included significant updates, notably the direction to use “culturally-sensitive language,” such as changing “desired gender” to “experienced gender” and changing “cross-sex medical procedure” to “gender-affirming medical treatment” ( APA, 2022a ).  

The DSM-5-TR definition of gender dysphoria in adolescents and adults is as follows:  

“ … a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two of the following: 

A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics) 

A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) 

A strong desire for the primary and/or secondary sex characteristics of the other gender 

A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender) 

A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender) 

A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender),” 

( APA, 2022b ). 

Additionally, the DSM-5-TR definition of gender dysphoria in children is as follows:  

“ … a marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least 6 months, as manifested by at least six of the following (one of which must be the first criterion): 

A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender) 

In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing 

A strong preference for cross-gender roles in make-believe play or fantasy play 

A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender 

A strong preference for playmates of the other gender 

In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities 

A strong dislike of one’s sexual anatomy 

A strong desire for the physical sex characteristics that match one’s experienced gender,” 

Notably, the diagnostic criteria for both include association of the condition with clinically significant distress or impairment in social, occupational, or other important areas of functioning ( APA, 2022b ). 

Because of the millions of lives impacted by the DSM, researchers have raised concerns about potential political and financial biases of authors contributing to the clinical reference book. The Society for Humanistic Psychology has been a leader in elevating concerns over the DSM-5 and was critical in launching a petition of over 15,000 concerned mental health professionals and groups from around the world ( Kamens, Elkins,  & Robbins, 2017 ). Topping the list of their concerns is a conflict of interest among the authors. Many DSM panel members have direct financial ties to the pharmaceutical industry, and several of the disorders call for pharmacological treatment as the first-line intervention ( Cosgrove & Krimsky, 2012 ).  

It is also worth noting that the DSM-5-TR included other considerable “cultural changes.” Published in 2022 as a text revision to the latest DSM-5, the DSM-5-TR changed (among other things) the term “race/racial” to “racialized” to underscore that race is a social construct ( Blanchfield, 2022 ). It also changed “Latino/Latina” to “Latinx” to promote gender equality and discontinued the use of “minority” and “non-White” to avoid creating a social hierarchy ( Blanchfield, 2022 ).  

The DSM-5 was designed to include cultural, racial, and gender considerations. As a part of their review and rationale for updating the DSM-5, “a DSM-5 Culture and Gender Study Group was appointed to provide guidelines for the work group literature reviews and data analyses that served as the empirical rationale for draft changes” to ensure that cultural factors were included in revisions ( Regier et al. 2013 ). Although these considerations were included in the DMS-5, updates were made in the DSM-5-TR in “response to concerns that race, ethnoracial differences, racism and discrimination be handled appropriately” ( APA,  2022c ). The strategies used to address these concerns were 1) a 19-person review committee on cultural issues and 2) a 10-person Ethnoracial Equity and Inclusion Work Group made up of practitioners from diverse backgrounds ( APA,  2022c ). Given that the DSM is the mental disorder diagnostic tool used in much of the world, it is critical to note the changes that have been made in response to social, cultural, and political pressures rather than a change in medical data and scientific evidence.  

Section Two: The Treatment of Gender Dysphoria  

Today, U.S. government agencies and many medical professional groups have signaled their support for these types of treatments. Under the Biden Administration, the U.S. Department of Health and Human Services states that for children, “early gender-affirming care is crucial to overall health and well-being” ( HHS Office of Population Affairs, n.d.). Many medical professionals in the U.S. accept an “affirm-only/affirm-early” approach to gender transition, which strives to implement interventions (including hormonal or surgical) to help a child better align with his or her “gender identity” ( Do No Harm, 2023a ). Though surgery and hormonal treatments are permanent, evidence indicates that about 85% of cases of children with gender dysphoria do not persist into adolescence ( Hembree et al., 2017 ). Nevertheless, the American Academy of Pediatrics (AAP) embraces the approach of early medical intervention for children and adolescents  ( Rafferty et al., 2018 ). 

Along with the AAP, multiple medical professional guidelines explain that the appropriate treatment of gender dysphoria in children and adolescents should be used in a “gender-affirmative care model” (GACM) and may include: 

Psychotherapy;  

Hormone or Puberty Blockers; 

Cross-Sex Hormone Therapy; and/or 

Sex Reassignment Surgery 

The GACM allows youth to progress through some or all interventions depending on timing and pubertal maturity ( Brown & Stathatos, 2022 ; Rafferty et al., 2018 ). Psychotherapy has an important distinction; it has a primary role in another model of care known as “first, do no harm” ( Rafferty et al., 2018 ; Schwartz, 2021 ). In this model, medical and surgical interventions are considered to carry greater risk than benefit for youth, a position well summarized by psychologist David Schwartz, Ph.D.:  

 … in the treatment of children and adolescents, no matter what the diagnosis, encouraging mastectomy, ovariectomy, uterine extirpation, penile disablement, tracheal shave, the prescription of hormones which are out of line with the genetic make-up of the child, or puberty blockers, are all clinical practices which run an unacceptably high risk of doing harm ( SEGM, 2021 ). 

Many of the puberty blockers and cross-sex hormone therapies used to treat gender dysphoria in children are prescribed off-label (for a purpose not approved by the U.S. Food and Drug Administration (FDA)). Therefore, they can pose a greater risk, including the risk of unknown long-term effects, to the children who receive them. In 2021, the Texas Attorney General launched an investigation into two pharmaceutical companies for allegedly advertising and promoting the off-label use of puberty blockers without disclosing any of their risks ( Attorney General of Texas, 2021 ). In 2022, the FDA also issued a new warning for commonly used puberty blockers, including “recommendations to monitor patients taking GnRH agonists for signs and symptoms of pseudotumor cerebri, including headache, papilledema, blurred or loss of vision, diplopia, pain behind the eye or pain with eye movement, tinnitus, dizziness and nausea” ( FDA, 2022 ). Despite these facts, a growing number of children are being prescribed these drugs for unapproved uses.  

There are significant side effects and limited research on the long-term impacts and efficacy of various treatments used in a GACM of gender dysphoria in children. Patients and parents are advised that the use of puberty blockers in children may be associated with lower bone density, stunted growth, fertility issues, and underdevelopment of genital tissue ( Mayo Clinic, 2022 ; St. Louis Children’s Hospital, n.d.; Brown & Stathatos, 2022 ). Moreover, a study conducted in England demonstrated similar negative side effects, such as lowered bone density and stunted growth, without showing a change in the psychological well-being of the children studied ( Carmichael et al., 2021, p. 18 ; Brown & Stathatos, 2022 ). Cross-sex hormones prescribed to children also demonstrated a plethora of side effects, including blood clots in veins and permanent infertility ( CDC, n.d .; NHS England, 2016, p. 8 ; Brown & Stathatos, 2022 ). Importantly, cross-sex hormones can result in the development of secondary sex characteristics such as the development of breasts in male-to-female patients and deepening of the voice in female-to-male patients that, though desired at the time, are irreversible ( NHS England, 2020b ; Brown & Stathatos, 2022 ). Moreover, the neurocognitive effects of pubertal suppression are unknown. International experts are in consensus about the need to assess long-term effects and have stated that: “Taken as a whole, the existing knowledge about puberty and the brain raises the possibility that suppressing sex hormone production during this period could alter neurodevelopment in complex ways—not all of which may be beneficial” ( Chen et al. 2020 ).  

Proponents of a GACM frequently claim that it is the only way to improve mental health and reduce suicide risk in youth. However, a 40-year cohort study from Sweden on transsexual individuals undergoing sex-reassignment surgery—one of the most comprehensive long-term studies available—found that high suicide risk persisted after surgical procedures at a rate 19.1 times higher than the general population ( Dhejne et al., 2011 ). Another Swedish population study with one of the largest cohorts established to date evaluated (in a corrected analysis from the original publication) mental health outcomes among transgender individuals who received surgical interventions and those who did not and found “no advantage of surgery in relation to subsequent mood or anxiety disorder-related health care visits or prescriptions or hospitalizations following suicide attempts” ( Branstrom, & Pachankis, 2019 ; Kalin, 2020 ). 

Treatment protocols for gender dysphoria often follow the guidelines of the World Professional Association for Transgender Health (WPATH), the Endocrine Society (an international medical professional association), and the American Association of Pediatrics (AAP). However, a recent review article from the Manhattan Institute outlined significant flaws with the recommendations from each organization based on the evidence available in the academic literature and from best practices in other countries ( Sapir, 2022 ). Notably, the AAP position paper, which supported early affirmation and treatment of gender dysphoria in childhood, was fact-checked by psychologist James Cantor, Ph.D., of the Toronto Sexuality Center. Dr. Cantor found that the AAP position paper omitted information regarding the low frequency of gender dysphoria persisting from childhood to adolescence ( Cantor, 2020 ). He also found that the AAP paper, when rejecting “watchful waiting,” misrepresented citations regarding the approach that aims to put pharmacologic or surgical intervention on hold while the patient receives other supportive care and counseling ( Cantor, 2020 ).  

Additionally, the Endocrine Society’s “clinical practice guideline” from 2017 assesses the quality of evidence for each of its recommendations ( Hembree et al., 2017 ). All six recommendations specifically related to treatment for adolescents found only a “low” or “very low” quality of evidence ( Hembree et al., 2017 ). One recommendation (2.5) that is listed as a weak recommendation with a very low quality of evidence is particularly concerning:  

We recognize that there may be compelling reasons to initiate sex hormone treatment prior to the age of 16 years in some adolescents with GD [gender dysphoria] / gender incongruence, even though there are minimal published studies of gender-affirming hormone treatments administered before age 13.5 to 14 years. As with the care of adolescents 16 years of age, we recommend that an expert multidisciplinary team of medical and MHPs [mental health providers] manage this treatment ( Hembree et al., 2017 ). 

The WPATH guidelines rely heavily on the experience of a specific Dutch protocol, but there are many methodological concerns with how conclusions are supported and how they apply to the current clinical reality ( Coleman et al., 2022 ; Sapir, 2022 ). A recent review of the Dutch protocol methodology outlines the following three primary concerns:  

(1) subject selection assured that only the most successful cases were included in the results; (2) the finding that “resolution of gender dysphoria” was due to the reversal of the questionnaire employed; (3) concomitant psychotherapy made it impossible to separate the effects of this intervention from those of hormones and surgery ( Abbruzzese, Levine, & Mason, 2023).  

Importantly, there have been challenges replicating the Dutch protocol results largely due to concerns of significant selection bias ( Abbruzzese, Levine, & Mason, 2023) . This fact and the forthcoming discussion about the changing demographics of youth gender dysphoria in the U.S. lend credence to the position that the Dutch protocol cannot adequately justify the current practice patterns in America. 

Further, political biases exist within WPATH and appear to be reflected in their guidelines. Dr. Bowers, a transgender woman and world-renowned gender surgeon who is on the board of WPATH, was asked if the organization had been welcoming to a wide variety of doctors’ viewpoints. In response, Dr. Bowers said: “There are definitely people who are trying to keep out anyone who doesn’t absolutely buy the party line that everything should be affirming and that there’s no room for dissent” ( Shrier, 2021, para. 12 ; Brown & Stathatos, 2022 ). A second doctor on the board of WPATH, Dr. Erica Anderson, submitted a co-authored op-ed to the New York Times expressing concerns that transgender children were receiving reckless healthcare and that WPATH was recommending puberty blockers too early in puberty, but the Times declined to publish her piece ( Shrier, 2021, para. 6, 7, & 50 ; Brown & Stathatos, 2022 ). The piece, which was titled “The mental health establishment is failing trans kids: Gender-exploratory therapy is a key step. Why aren’t therapists providing it?” was later published in the Washington Post ( Edwards-Leeper & Anderson, 2021 ). It was co-authored with another clinical psychologist and member of the WPATH, Dr. Laura Edwards-Leeper,  with the core message that rushed medical treatment without proper evaluation and therapy puts children at risk ( Edwards-Leeper & Anderson, 2021 ). 

In addition to the Do No Harm group, other groups of medical professionals have alternative views on the ideal way to proceed in this area. SEGM is a group made up of over 100 clinicians and researchers from a range of disciplines who are concerned about the quality of evidence being used to recommend medical and surgical interventions as first-line treatment for young patients with gender dysphoria ( SEGM, n.d.(b) ). They offer an alternative clinical position based on their expertise and review of the current evidence:  

SEGM firmly believes that medical decisions must remain between patient and clinicians, without political interference. However, we also believe that it is incumbent on US medical societies to urgently examine the evidence base for hormonal and surgical interventions for youth using rigorous systematic research methods. Given the results of the recent systematic evidence review conducted by NICE, which concluded that the evidence of benefits of these interventions is of very low certainty and the risk/benefit profile is unclear, SEGM believes that exploratory psychotherapy should be first-line treatment for gender dysphoric people age 25 and under ( SEGM, n.d.(a) ).  

Section Three:  A Comparison: Trends in the U.S. vs. Other Nations on the Treatment of Gender Dysphoria in Children and Adolescents 

 A recent study estimated that nearly 1.6 million people ages 13+ identified as transgender in the U.S. and denoted a generational shift because rates of transgenderism in children are growing at a much faster rate than in adults ( Herman, Flores, & O’Neil, 2022 ). In fact, now nearly 20% of people who identify as transgender are aged 13–17, meaning around 300,000 children are now identifying as transgender ( Herman, Flores, & O’Neil, 2022 ). For added perspective, one must consider that nearly 20% of all people who identify as transgender in the U.S. are children 13–17, yet that age range only makes up 8% of the U.S. population ( Herman, Flores, & O’Neil, 2022 ). Additionally, the number of children known to be on puberty blockers or cross-sex hormones in the U.S. more than doubled in just four years—from 2,394 in 2017 to 5,063 in 2021 ( Do No Harm, 2023a ; Terhune, Respaut, & Conlin, 2022 ). Furthermore, one study found that more than 120,000 children in the U.S. were diagnosed with gender dysphoria during the same four-year period ( Respaut & Terhune, 2022 ). Experts and researchers in the field are concerned with rates in a specific sub-group—adolescent girls—and have called for a greater understanding of “rapid onset gender dysphoria” as a distinct clinical phenomenon ( Sinai, 2022 ). 

As noted above, the medical community in the U.S. has opted to broadly take an “affirm-early/affirm-often” approach when it comes to treating gender dysphoria in children. By labeling the full spectrum of interventions used to transition youth—from social to puberty-blocking to cross-sex hormones and to surgery—as “affirming,” many have tried to categorize all other treatments into a binary category of “non-affirming.” In doing so, they have framed it as harmful, thereby limiting valid alternatives such as psychotherapy ( D’Angelo et al., 2020 ). More than 60 pediatric gender clinics and more than 300 clinics that provide hormonal interventions to children in the U.S. now exist ( Do No Harm, 2023a , p. 12). When measured against other Western and Northern European countries, the U.S. has the most clinics providing treatment for the gender transition of children and the most permissive laws regarding the legal and medical gender transition of children ( Do No Harm, 2023a , p. 3 & p. 12). Below is a chart from Do No Harm that outlines the laws regarding sex-assignment surgery in the U.S. in comparison to the laws in Western and Northern European nations: 

This data clearly demonstrate that the U.S. allows doctors to perform sex-reassignment surgery on children at a younger age than most comparable nations (12 years old in some cases in the U.S.) ( Do No Harm, 2023a , p. 11). Most Western and European nations protect minor children from sex-reassignment surgeries by requiring patients to reach age 18 ( Do No Harm, 2023a , p. 11). The U.S. is in a similar position regarding puberty blockers for children, which clinical guidelines do not recommend until puberty ( Do No Harm, 2023a , p. 9). Nevertheless, many U.S. physicians are prescribing puberty blockers as early as 8 years old (reportedly at the earliest sign of puberty), and, in some states, parental consent for these drugs is not needed. ( Do No Harm, 2023a , p. 9). In Oregon, children 15 and over do not need parental consent, and taxpayers pay for puberty blockers for children through Medicaid ( Do No Harm, 2023a , p. 9). This practice appears to be an outlier in comparison to many other countries where puberty blockers are typically not given until children reach a specific stage of puberty (Tanner Stage II) or until they reach the age of 12 ( Do No Harm, 2023a , p. 9).  

The use of cross-sex hormones is likewise another area where some states in the U.S. have more permissive policies than many other countries in the world ( Do No Harm, 2023a , p. 10). Cross-sex hormones have been given to some children in the U.S. under 13 years old (state laws vary on this), and Oregon again has the most permissive laws for this treatment ( Do No Harm, 2023a , p. 10). It now allows for these drugs to be used at the age of 15 without consent and with taxpayer funding ( Do No Harm, 2023a , p. 10). In contrast, the vast majority of other countries examined in the Do No Harm report do not allow for these hormones until age 16 ( Do No Harm, 2023a , p. 10).  

In recent years, the path of the U.S. has diverged significantly from the path of other countries. While the U.S. has continued to loosen protocols around puberty blockers, cross-sex hormones, and sex-reassignment surgeries, other countries have begun tightening their protocols and shifting away from the “affirm-early/affirm-often” approach based on emerging evidence from thorough and systematic evidence reviews. In June 2020, Finland recommended psychosocial support to treat gender dysphoria in minors ( Council for Choice in Health Care in Finland, 2020 ). If youth go on to experience severe and persistent gender-related anxiety, they can then be referred to centralized research clinics on gender identity where hormonal treatment through a research protocol is considered on a case-by-case basis only if strict criteria are met ( Council for Choice in Health Care in Finland, 2020 ). Importantly, the Finnish guidelines do not allow surgical treatments stating that they “are not part of the treatment methods for dysphoria caused by gender-related conflicts in minors” ( Council for Choice in Health Care in Finland, 2020 ). Also in 2020, the Tavistock Gender Identity Development Service of England released a study stating that children receiving puberty blockers for gender dysphoria experienced little to no change in their psychological well-being ( Barnes & Cohen, 2020 ; Carmichael et al., 2021 ; Brown & Stathatos, 2022 ). A study completed by England’s National Institute for Health and Care Excellence (NICE) in October 2020 found the studies evaluating the use of puberty blockers to have “very low certainty” in the “critical outcomes of gender dysphoria and mental health” ( NICE, 2020 a p. 45; Brown & Stathatos, 2022 ). In 2022, the Swedish National Board of Health and Welfare updated its recommendations for the care of children and adolescents with gender dysphoria assessing that “the risks of puberty blockers and gender-affirming treatment are likely to outweigh the expected benefits of these treatments” and cautions the healthcare system regarding their use (National Board of Health and Welfare, 2022 p. 3 ; Brown & Stathatos, 2022 ). 

In addition to systematic reviews, emerging evidence in the academic literature and in mainstream news about the experience of “detransitioners” is leading to more questions than answers. Detransitioners are defined as those individuals who revert back to living as their biological sex after transitioning, and many medical professionals and the general public are now asking more questions about the care these children and adolescents receive. In a key study of 100 detransitioners, more than half (55%) did not have an adequate evaluation from a doctor or mental health professional before starting to transition, and just one in four (24%) told their clinician they had detransitioned ( Littman, 2021 ).  

The U.S. has clearly taken a radical stance regarding the treatment of gender dysphoria in children, while other countries are simultaneously questioning the data and evidence that support the use of hormone therapy and puberty blockers in children. Given the irreversible nature of these treatments, emerging evidence that high numbers of people regret undergoing them as minor children, and rising international awareness that an “affirm-only/affirm-early” approach may be causing inadvertent harm, medical policymakers in the U.S. should strongly consider adopting a more cautious approach. 

Section Four: The Position of the American People on “Gender-Affirming Care”  

A series of national polls from Scott Rasmussen throughout 2022 demonstrates that the plurality of Americans surveyed does not align with the medical community’s current recommendations. The findings may be largely based on a common-sense approach and informed by other societal norms to protect children from potentially damaging and irreversible decisions until they reach adulthood. Current examples are the legal drinking age of 21 years old, voluntary military participation at 18 years old, and informed parental consent for all aspects of daily life—from field trip permission slips to major medical interventions. 

Scott Rasmussen National Survey of Registered Voters    

October 25–27, 2022  

When given a choice between two candidates for Congress, 56% of registered voters responded that they would vote for the candidate who said it should be illegal to provide surgery to help children transition from one gender to another. 25% of registered voters responded that they would vote for the candidate who said it would be immoral to restrict surgery that helps children transition from one gender to another. 

October 18–20, 2022  

72% of registered voters do not believe schools should teach children that they can change their gender. 

59% of registered voters believe it should be against the law to provide “gender-affirming care” to children, which involves puberty blockers or surgery to help transition a boy to a girl or a girl to a boy. 

56% of registered voters believe conducting gender-transition surgery on children is a form of child abuse. 

73% of registered voters either strongly or somewhat disagree with people who advocate that children should be allowed to receive “gender-affirming care,” including puberty blockers and surgery, without the permission of their parents. 

60% of registered voters believe it is a form of child abuse when a teacher or school encourages students to change their gender identity. 

Scott Rasmussen National Survey of Registered Voters   

July 12–13, 2022  

When asked, “Should a child under 18 be encouraged to explore and define his or her own gender identity, or should he or she be encouraged to accept the gender that aligns with his or her biological sex?” 49% said a child should accept the gender that aligns with his or her biological sex. 32% said a child should define his or her own gender identity, and 19% were not sure.  

March 10–12, 2022  

When asked, “Some people advocate “gender-affirming care” which involves surgery to alter a person’s physical and sexual characteristics to match their gender identity, which can be used to transition a boy to a girl or a girl to a boy. Should it be against the law to perform such a surgery on young children?” 63% of registered voters said “yes.” 

66% of registered voters said it should be against the law to perform such a surgery on anyone under 18. 

Section Five: State Actions to Protect Children  

The regulation of medical care is under the purview of states, and states have started to take action to protect children. The combination of concerning safety evidence and international trends outlined above supports the need for restrictions on medical and surgical gender transition interventions in children and adolescents. One option states can take is to delegate this responsibility to the state medical board, which could evaluate all the evidence and provide guidance to enact restrictions. Florida implemented this approach in 2022—first with guidance from the Department of Health in April and then with a report from the Agency for Health Care Administration in June ( FL DOH, 2022a , FL ACHA, 2022 ). These releases were immediately followed by a letter from the Surgeon General to Members of the Board asking them to review the evidence and guidance to establish a standard of care for “these complex and irreversible procedures” ( FL DOH 2022b ). The Florida Board of Medicine voted in November 2022 to ban the hormonal and surgical treatment of gender dysphoria in children (Izaguirre, 2022). This approach is a policy lever to preserve the delegative nature of the nuanced medical decision-making to medical experts. However, as seen in the COVID-19 pandemic, state medical boards do not always make evidence-based decisions when providing guidance, which indicates a need for additional policy options for state lawmakers ( Tahir, 2022 ). 

In 2021, Arkansas became the first state to pass such restrictions into law with the Save Adolescents from Experimentation (SAFE) Act ( HB 1570, 2021 ; Bryan, 2021 ; Brown & Stathatos, 2022 ). The American Civil Liberties Union (ACLU) quickly filed suit resulting in a preliminary injunction on the restrictions, and the case is currently awaiting a decision in the 8th Circuit Court of Appeals ( ACLU, n.d. ). At least 18 other states are considering similar actions, and Utah became the first state to enact legislation to protect children in 2023 ( Associated Press, 2023 ).  

After recently blowing the whistle on The Washington University Transgender Center at St. Louis Children’s Hospital, Jamie Reed began cooperating with the Missouri Attorney General to investigate the center. Following four years of working as a case manager in the clinic, she stated “… I could no longer participate in what was happening there. By the time I departed, I was certain that the way the American medical system is treating these patients is the opposite of the promise we make to ‘do no harm.’ Instead, we are permanently harming the vulnerable patients in our care” ( Reed, 2023 ). Now, Ms. Reed is working with Missouri Attorney General Andrew Bailey, who has launched a multi-agency investigation into the St. Louis Transgender Center on February 9, 2023, for harming hundreds of children ( MO Attorney General’s Office, 2023 ). The investigation is based on Ms. Reed’s sworn affidavit signed on February 7, 2023 ( MO Attorney General’s Office, 2023 ). Missouri is one of several states considering legislative action this session that would create more than one mechanism to resolve the disturbing issues raised by Ms. Reed. Though this is largely a state issue, Ms. Reed, who is self-described as “politically left of Bernie Sanders,” believes there should be a national moratorium on these interventions for children and adolescents until the American people know more ( Reed, 2023 ). 

Another high-profile story on youth sex-reassignment surgeries at Vanderbilt University Medical Center (VUMC) led Tennessee Governor Bill Lee to call for an investigation of the pediatric transgender clinic in September 2022 ( Kruesi, 2022a ). VUMC subsequently paused the surgeries in October of 2022 to review their practices ( Kruesi, 2022b ). Tennessee lawmakers in both chambers have prioritized legislation this session that protects children by banning gender transition interventions for minors—Senate Bill 1 has already passed, and House Bill 1 is expected to pass imminently ( Brown, 2023 ). 

Although critics argue that these state policies limit necessary medical care and risk the mental health of transgender youth, all should understand that the restrictions on gender transition interventions do not limit the mental health and supportive treatments available for vulnerable children and adolescents. Instead, the policies seek to increase the “first, do no harm” principle of healthcare and protect children from an area of uncertain science with emerging evidence that is rapidly changing international best practices. Indeed, an evidence review completed for the National Health Service in England found that “any potential benefits of gender-affirming hormones must be weighed against the largely unknown long-term safety profile of these treatments in children and adolescents with gender dysphoria,” ( NICE, 2020 b, p. 14). 

National policymakers and, specifically, public health officials would be wise to both listen to Ms. Reed and follow the example of Florida Surgeon General Dr. Ladapo in independently gathering data and taking action to ensure the safety of America’s children.  

Conclusion 

The U.S. is an outlier among peer European nations in its “affirm-early/affirm-often” approach to medical and surgical interventions for gender dysphoria in children. The low-quality evidence of the current clinical practice guidelines and the unknown long-term consequences merit additional safety measures for children. State policymakers can implement solutions through their medical boards, through legal action, and in their 2023 legislative sessions, while the medical community should more broadly adopt a “first, do no harm” model when treating children with gender dysphoria. 

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South Carolina Gov. McMaster signs bill outlawing transgender care for trans youth

South Carolina Gov. Henry McMaster signed a bill banning certain medical care for transgender youth on Tuesday.

House Bill 4624, called the “Help not Harm” bill by legislators, prohibits anyone under the age of 18 from receiving gender reassignment surgery or any form of puberty-blocking or hormone therapy. The bill became effective immediately.

The bill also makes it a felony to perform gender reassignment surgery on those under the age of 18.

McMaster said a ceremonial bill signing with legislators would take place in the Upstate next week.

Under the new bill, minors can still be prescribed puberty blockers or hormone therapy to treat certain conditions like precocious puberty or endometriosis.

The new law also bans the South Carolina Medicaid program from providing coverage for gender reassignment surgery or hormone therapy to adults and minors.

The bill passed on the last day of the legislative session after the House agreed to accept the Senate’s changes to the law. The Senate's major change was an amendment requiring public school principals and vice principals to report students to parents if their child informed officials that they were identifying as a different gender from their assigned sex or using different pronouns.

More: As SC legislature winds down, bill banning transgender youth medical care returns to House

Opponents of the amendment argued the measure would be a forced outing and worried it could put a child in an uncomfortable or potentially dangerous situation if their parent or guardian were not accepting. Supporters of the amendment said parents have a right to know if their children are identifying as transgender or requesting to change their pronouns.

Dr. Elizabeth Mack, president of the South Carolina chapter of the American Academy of Pediatrics testified against the bill during a Senate medical affairs subcommittee in February, noting there are “less than 2,000 trans kids in the state.”

Still, supporters of the bill pushed for it, saying its intention was to protect children, while others say it does the opposite.

“We stand in grief and solidarity with LGBTQ South Carolinians, who are increasingly under attack by our own government,” Executive Director of ACLU South Carolina Jace Woodrum said in a statement on X, formerly known as Twitter. “We can put to rest the notion that the government cares about limited government and personal freedom. With a stroke of a pen, he (McMaster) has chosen to insert the will of politicians into healthcare decisions, trample on the liberties of trans South Carolinians, and deny the rights of the parents of trans minors.”

South Carolina joins 25 states to outlaw transgender care for minors. It was also one of the only states that did not have a ban on transgender care in the South, with Virginia now being the lone Southern state with access.

Savannah Moss covers politics for the Greenville News. Reach her at [email protected] or follow her on X @Savmoss.