Gender-Affirming Care: What Doctors Really Think

Did you know that almost 2% of U.S. high school students identify as transgender?

And that number is growing.

And unfortunately, transgender and non-binary teens are four times more likely to suffer from mental illness when compared to their peers.

Many feel isolated, misunderstood or are outright bullied.

There are medical options to help these teens align with their gender, like puberty blockers and later in life, hormone therapy and surgery.

And preliminary data does suggest that gender affirming care can improve mental wellness.

But many states outright ban transgender care, citing that it's harmful for teens under a certain age.

Now, there's concern about whether or not a young teen can start gender affirming care, such as puberty hormone blockers.

And there's a debate about whether or not a psychological evaluation is needed.

But here's a question.

Can someone under the age of 18 decide for themselves that they're ready?

Being able to be oneself is a very powerful thing.

And I ask people before they start.

What are your goals with hormone therapy?

And nine times out of ten people say, I just want to feel like myself I just want to feel more comfortable in my body.

For many people, medically and physically, transitioning is about along in your body with your gender identity.

But how do we define terms like gender, sex, and anything else that doesn't fit easily into a box?

Simply put, gender is a set of rules and expectations that are defined by society, and those rules and expectations are socially constructed and can evolve over time.

Some people say gender is like a spectrum, but I kind of like to take it step further and say that gender is kind of like an expansive galaxy with infinite possible categories beyond just the binary points of male and female.

While sex is what we're assigned based on our parent anatomy at birth, typically male or female.

But here's where the conflict begins when a person's gender is different from their assigned sex.

It can create an extremely uncomfortable and confusing situation.

And this distress can lead to depression, anxiety, and in some cases, suicide.

Professionals currently diagnose this as gender dysphoria.

Gender dysphoria is a topic of serious debate right now in the medical community.

In order for a person to receive gender-affirming care in most cases, the United States, a diagnosis of gender dysphoria is needed from a board certified psychologist, you can't just run to a doctor and ask for it.

And the guidance on how teenagers and adults are evaluated for gender dysphoria is complex and very different.

In December 2021, the World Professional Association for Transgender Health, WPATH, an international forum of medical experts on transgender health, released a draft of a new set of guidance suggesting that teenagers must have questioned their identity for several years before undergoing gender-affirming care.

Now, for many teens, this can be an excruciating task of living in a body that does not match their gender identity.

Especially if the need for diagnosis prevent a teenager access to gender affirming care such as puberty blockers, which inhibit the production of certain hormones during the phases of puberty.

But the guidance is different for adults.

WPATH suggests that adults don't need the psychological assessment for gender dysphoria to receive gender-affirming care.

And a lot of people praise this as the gold standard for treating transgender patients because it informs what care insurers will cover.

These long established guidelines are well-recognized in the medical community, but they're also widely criticized.

On one hand, you have new laws in many states saying that any kind of gender affirming care should be illegal and doctors and parents should be thrown in prison.

I think male and female children exist, and I think they're very troubled.

And I think trans.

Is a horrible, negative label.

It is not up to you to decide medical care for my child or anybody else's child.

But on the other hand, you have some people saying that the current medical guidelines are actually too restrictive.

They have another idea in mind: informed consent.

More and more people are switching to an informed consent model, which is treats the patient like someone who can make their own decisions and is much like everything else in medicine.

If someone's going to have elective surgery, for example, in almost all cases, we take the patient's word for it that they want that and provide the service to them.

Hormone therapy is less invasive than surgery.

And so in my practice, in many others, certainly for adult patients, they can come see us, we can make that diagnosis and provide the care without them having to jump through multiple hoops, spend lots of money on therapists visits, etc..

So for teens, it's a little bit more complicated, in large part because of all of the controversy around providing care to teens and because they are there younger.

So there are a couple different things that we also think about in providing care for teens.

One is parental consent.

So they need the consent of all of their legal guardians, whether that's their parent or someone else.

Everyone who's responsible for that person has to give their consent and it's just we want to be extra careful that we're doing the right thing with with teenage patients.

So in my practice, it's not an absolute requirement that teens have a letter from a therapist affirming that they do meet the diagnostic criteria for hormones, but it's almost a requirement.

The reason it's not an absolute requirement for me is I have you know, some patients just can't access it.

So what are the options for gender affirming care?

Let's start with the puberty blockers.

Starting in the early stages of puberty.

Puberty blockers can be given to teenagers to prevent the production of certain hormones In effect, they pressed pause on the development of certain physical characteristics until a decision can be made about physical interventions later down the road.

During the early stages of puberty.

Gonadotropin-releasing hormones trigger the production of follicle-stimulating hormone, FSH and LUTEINIZING hormone, or LH.

Both of these hormones are responsible for stimulating the production of estrogen and testosterone.

Puberty blockers interrupt the production of FSH and LH and in effect halt the production of estrogen and testosterone without the production of estrogen and testosterone.

Things like breast development, facial hair and menstruation are delayed puberty blockers can be given a shot in intervals of three to six months.

Or as an implant that might last a year.

One note about puberty blockers they fall into a category of drugs called Gonadotropin-releasing hormone agonists, GnRH agonists.

Typically, these are prescribed to children who are experiencing puberty at an early age.

This means that prescribing puberty blockers to transgender teens is technically considered off-Label.

The term off label is common in the medical world.

It just means that the medication prescribed is used in a way that was not approved by the FDA.

But this can cause some insurance companies to deny coverage of certain puberty blockers.

That's an issue.

And that can be costly.

And there are some medical risks associated with using puberty blockers.

When used for short periods of time, like one to three years.

They're completely reversiblable.

They have no long term adverse effects.

They don't affect fertility.

They don't affect growth.

They don't they don't have any adverse effects.

The problem comes in if you use them for periods of time longer than they were supposed to be used.

If you use these for more than about five years.

You do get some permanent effects, potentially permanent effects, bone density doesn't develop properly with puberty blockers.

And for a few years, that's fine.

You catch right up as soon as they're stopped with you.

You know, once you start having estrogen or testosterone in your body, that helps with bone development and people catch up within a year or two.

But if they're used for prolonged periods of time, it's unclear if people catch up fully.

And there are a lot of other adverse effects of having someone be pre-pubescent for that long.

For example, if someone's in high school or junior or senior in high school and still in the body of someone who hasn't started puberty yet and has a brain of someone who hasn't started puberty yet, that puts them completely off course with their peers, let alone causes health problems.

Recent study from 2022 suggests that after just one year, transgender kids on puberty blockers saw an overall improvement of their mental wellness.

The other options for gender affirming care are more long term forms of hormone therapy and surgery.

This regimen is given after puberty.

Gender-affirming hormones or GAH can be prescribed to promote the physical traits that align with one's gender identity.

So masculinizing hormone therapy increases testosterone while feminizing hormone therapy blocks testosterone and increases estrogen.

And the levels for the hormone prescriptions would match that of the hormone levels of a cisgender person of the same gender.

And hormone therapy medication needs to be taken for the extent of one's lifetime, or at least for as long as someone wants to continue receiving the effects of hormones.

So I've been on testosterone for seven years now.

I started when I was 25, and it's been great.

The best decision of my life, really.

It just feels so good to feel at home in my body and confident.

And this isn't true for all trans people, but being read correctly as male feels so affirming to me.

And it's just great to, like, not feel like my transness is constantly weighing me down.

I can just kind of go on with my life without having to think about it all the time.

And there is gender-affirming surgery, a.k.a.

surgical intervention.

There is a wide range of surgical procedures, including top surgery, which shapes or, removes breast tissue and bottom surgery, reconstructing the genitalia, as well as tracheal shaving, a procedure aimed to reduce the size of the Adam's apple.

There's facial reconstruction and hair removal.

However, the WPATH guidance recommends a transgender person has a well-documented history of persistently and consistently questioning their gender identity and has undergone at least a year of hormone therapy.

The requirements for surgical intervention are in sharp contrast to someone who is cisgender or not a part of the trans population.

For example, procedures such as breast augmentation for someone whose gender matches the sex they were assigned at birth.

Those are elective and do not require assessment by a medical provider.

These body modifications are generally safe or at least as safe as major surgery, but they will be costly as much as $100,000 in some cases, and sometimes insurance will not cover it.

But access to gender affirming care has hit a boiling point in the United States.

As of March 2022, 15 U.S. states have either enacted or considering legislation restricting access to gender-affirming care.

Additionally, several states have opened investigations looking into gender affirming care as a form of child abuse.

The concern over puberty blockers is at the front of the conversation as puberty blockers are given to minors.

Some think that the decision to give teenagers access to life altering drugs such as puberty blockers, should happen when a child hits adulthood or developmentally appropriate age.

Despite some of the pressures we're facing politically right now to to not provide this care, I think there's a real interest in from the next generation of physicians coming.

So I think eventually my hope and I do think this will happen, it'll become basically routine primary care that any doctor can provide.

Jackson real talk.

Thank you so much for joining us today and just telling us all your stories.

Without you, without your insight, this episode would not have been possible.

So appreciate you stopping by.

Well, thank you so much for having me.

This has been an absolute blast.

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