Here are some things we know about gender-affirming health care: We know that the number of young patients being seen by gender clinics has increased, and that the gender balance of these young patients has changed, with more female-assigned youth seeking care. (We don’t see the same gender imbalance outside of clinics, where young people identify as trans in roughly equal numbers regardless of birth-assigned sex.) We also know that autism is more common in trans youth than in the broader population.
We don’t know why these things are true. Nonetheless, these facts have helped spur a wave of coverage and concern around gender-affirming health care for young people experiencing gender dysphoria. This concern presents itself on the front page of the New York Times, in New York magazine, in the account of a woman who used to work at a gender clinic. At the heart of this concern—among good-faith debaters, those who are not merely trying to ban access for all trans people—is the idea that young people today who are identifying as trans may grow out of it, and come to deeply regret treatments like cross-sex hormones or surgeries. (It’s worth saying upfront that only a minority of young people who experience gender dysphoria are even receiving these treatments.)
We know that research on gender-affirming care for tweens and teens has shown generally positive results, and that side effects are usually mild (and that medical treatments always pose trade-offs). We know that accessing gender-affirming care can be extremely difficult. But it’s true that we don’t know how teens who are treated today with, say, puberty blockers will feel about that treatment 50 years from now.
There are—speaking extremely broadly—two things to do about the unknowns in gender-affirming care, and the expanding, and underserved, patient population. We could work to increase access and reduce barriers, to help patients have access to a promising treatment. We could do this with the understanding that medical choices always involve a highly personal calculus of benefit versus downsides and risks. Or, we could react to the increase in patients seeking treatment with broad-brush skepticism, positing that the new patients won’t necessarily benefit the way previous, but much smaller, cohorts have. We can make minimizing any chance of regret in pursuing gender-affirming medicine and procedures the centerpiece of our policies. The first side wants to reduce standardized gatekeeping around procedures, leaving the matter of the right age at which to, say, undergo top surgery up to the doctor, parents, and teen. Guidance in this case looks like providing doctors with some general things to consider, such as how long the teen has identified as another gender, how much distress they’re experiencing, and whether there are other mental health concerns. The second side worries that allowing access to top surgery for young people at all is reckless, and could lead to regret.
Advocates for the first approach believe increased visibility and acceptance of trans people is leading more young people to feel comfortable coming out as trans. They point to the rapid increase in left-handedness as social stigma waned as a precedent for this, and the increase in the number of people willing to openly identify as lesbian, gay, or bi in recent years. They note that tightly controlling care with an eye toward minimizing any possible regret would entail accepting serious harm to trans youth who need that care.
Advocates for the second approach believe many of the new patients may be falsely and temporarily believing themselves to have gender dysphoria due to the influence of transgender peers, either in person or on social media. This idea, which holds that the new patients are suffering from a “social contagion,” is related to the phenomenon of cultural concepts of distress, where mental illness may be mediated through culture and result in symptoms specific to the environment a person finds themself in. They point to the higher incidence of eating disorders in the West, or the fact that suicide is more common in some cultures than others, as precedents.
As a trans man and a journalist who has spent years covering these issues, it makes more sense to me to remain in the first camp until evidence has been provided to back up the second. If you find yourself at all in the second—perhaps unwittingly!—I hope you’ll consider my thinking on this. I think it is all too easy to dismiss people advocating for more care as warm, fuzzy activists, and not careful people who have evaluated the evidence, the risks, and the unknowns, and decided that more care is the best-informed course of action at this time.
Much of the recent coverage of gender-affirming care has focused on laying out the criticisms of the status quo (doctors seeking to provide gender-affirming care) that are being made by proponents of the social contagion idea (commentators, and even some providers, who worry that gender-affirming care is being provided to people who do not need it, and may in fact be harmed by it). Gender-affirming care is portrayed as something incredibly easy to access, with doctors giving it out quickly and with little discretion. An extreme version of this can be found in the caricature provided by former gender clinic worker Jamie Reed. “The center’s working assumption was that the earlier you treat kids with gender dysphoria, the more anguish you can prevent later on,” Reed writes. She claims that doctors were pushing parents and children into treatments after only two or three visits, without giving patients and families adequate information, and regardless of any other mental health concerns. Something similar can be found in an article for the New York Times about teens who are accessing top surgery (by all accounts still an exceedingly rare practice), which described a doctor who has performed some surgeries on minors as “proudly flouting professional mores in favor of connecting with hundreds of thousands of followers.” In an interview with Reuters, a Dutch psychiatrist who is in favor of more stringent assessments frames the dilemma as being whether to abide by the “the do-not-harm principle of medical intervention” or whether to privilege “the transgender right or child’s right.”
Many people who specialize in gender-affirming care do feel great love for the trans community, and for transgender kids. Given the stigma and hardship that come with being trans, adults in a trans child’s life often try to mitigate the cruelty of the outside world by showing them kindness and approval rather than skepticism. But showing empathy and care for vulnerable children doesn’t mean that professionals who work with trans youth are in a hurry to suggest medical treatments, ignore co-occurring mental health concerns, or fail to stay abreast of the most recent research. Rather than cheerleaders, these are professionals who have looked at the evidence and come to a different conclusion than proponents of the social contagion idea—the conclusion that kids are accurate reporters of their trans and nonbinary identities. This is an empirical idea that has so far been borne out by data, and may, like all scientific ideas, be disproven with yet more data.
In medicine, you have to take the best available evidence and make decisions with it. Doctors are doing that by administering treatment after careful evaluations and discussions of side effects, on timelines that are tailored to the patient’s particular case. Reed’s allegations have been directly contradicted in multiple local news outlets by parents, patients, and former co-workers at the clinic where she worked, who describe a slow, methodical process. A child who walked in at age 12 asking for hormones and surgery was told to “give it time”; he went to nearly 100 appointments with a therapist, and his dad dove into the medical literature and generally came around the idea of gender-affirming care.
But consider that it also could have made medical sense for a child to be offered medical interventions much sooner than that. For some parents whose children have already been socially transitioned for many years, the months of waiting and dozens of appointments feel excessive for their particular child’s needs, especially if they’ve only sought treatment because puberty has commenced. Reducing some of these requirements, particularly for patients whose identity has been stable for years before they first see a doctor, is an example of what the reduced-gatekeeping side hopes to see.
Caution and circumspection are warranted with any kind of ongoing medical intervention, particularly when it involves kids. But the research on gender-affirming care provides ample reason to believe that most kids who present with gender dysphoria in a clinical setting will become trans adults, and that puberty blockers and hormones are helpful for these youth. Many of the studies are small, and the positive effects tend to be weak, but the overall evidence isn’t dissimilar to that for other much less controversial medical interventions, including every known treatment for obesity in youth. This is due to well-known practical barriers to studying kids. More research is still needed, but as studies have come in in drips and drops, the picture has pointed toward the stability of kids’ identities and the benefits from early intervention, and away from there being reason to deny care. This has led many in the field to shift their focus away from exploring whether the treatments work and toward reducing barriers to ensure that kids who need them can access these meds.
“We have to be really thoughtful about the structural barriers that we are creating ourselves as providers,” Dr. Gina Sequeira, a co-director of the Seattle Children’s Gender Clinic, told Sabrina Imbler for a 2021 New York Times story on barriers faced by trans youth. (Unlike a recent wave of stories that have garnered criticism, this one didn’t make the front page.) “The majority of the kids I see have already overcome many, many barriers.”
In addition to those studies, there’s some circumstantial support for the idea that more—not fewer—young people would benefit from gender-affirming care. The New York Times has reported that about 1.4 percent of 13- to 17-year-olds in America say they’re transgender. The number of patients who are currently being treated medically for gender dysphoria remains quite small. Reporting by Reuters produced the best estimate yet, using a comprehensive look at insurance claims. They found 121,882 youth had been diagnosed with gender dysphoria between 2017 and 2021, and 17,683 (or about 14.5 percent of those diagnosed) had been given prescriptions for puberty blockers or hormones during that time. (This is likely to be a slight undercount because some families may pay for treatment out of pocket.)
Adults identify as transgender at a rate of 0.5 percent. Taking the more conservative figure—assuming that the entire increase in trans youth is due to a social contagion and there are no adults suppressing their identities due to widespread stigma and shame—we’d expect 130,000 American youth, 0.5 percent of those between 12 and 17, to grow up to be transgender adults.
While every adult who identifies as trans does not pursue medical transition, most do, and very, very few regret it. According to the United States Transgender Survey, a large, wide-ranging survey of trans adults conducted in 2015, 84 percent of respondents said they were either currently living as a different gender than the one on their birth certificate, or wanted to do so. Seventy-eight percent said they wanted hormone therapy (though only 49 percent said they’d received it). It’s therefore downright conservative to believe that somewhere between 65,000 and 100,000 young people between the ages of 12 and 17 would benefit from transitioning young. It’s also entirely plausible to imagine a number significantly higher than that, if you think trans identities are more common among youth because of reduced stigma, not social contagion effects.
Either way, the youth who are receiving hormones and blockers now represent only a fraction of the adult trans population seeking medical care for gender dysphoria. In the absence of more data on long-term regret rates for this particular cohort of trans youth, it’s entirely reasonable to make the empirical argument that the numbers support helping more kids get treatment by cutting down wait times and barriers whenever possible.
The debate around trans youth—when it happens in good faith—isn’t, at its core, about whether to believe trans youth because it’s the kind thing to do. It’s about whether believing trans youth will lead to better outcomes for more patients, or not. The side wanting to reduce gatekeeping is supported by at least as much evidence, if not more, than the side that has predicted that a coming wave of detransitions due to insufficient gatekeeping has been just over the horizon for many years now, and has yet to materialize in any actual results.