How gender-affirming care affects transgender minors: What’s permanent and what’s not?
About 300,000 people between the ages of 13 and 17 identify as transgender in the United States, according to a 2022 study by UCLA’s Williams Institute. About 8,500 of those youth live in North Carolina.
The estimated number of transgender youth has doubled since 2017, according to Williams Institute, though different means of collecting data were used for the two studies and it’s unclear how that affected the results. No federal data estimates the number of transgender minors younger than 13.
Not all receive gender-affirming medical care, but the best way to provide support and medical care to transgender youth has been outlined by the World Professional Association for Transgender Health.
Except in extenuating cases, surgery is generally not recommended for minors, and it is rare.
Here is what is considered best practice, according to the World Professional Association for Transgender Health.
For prepubescent children
If children display consistent, persistent and insistent behavior, family and friends are encouraged to support the child’s chosen gender.
Psychotherapy is recommended for both the child and their family to better understand “needs, strengths, protective factors, and risks for a specific child and family across environments.” “The goal of psychotherapy should never be aimed at modifying a child’s gender identity, either covertly or overtly,” WPATH says.
Support can include allowing the child to socially transition. That could encompass:
A name change
Pronoun change
Change in sex/gender markers on birth certificate, ID cards, etc.
Participation in chosen gender-segregated programs (such as sports teams or clubs)
Personal expression, including hair style and clothing choice.
For adolescents entering puberty
For any minor entering puberty, gender-affirming care is recommended for anyone who:
Has demonstrated gender diversity/incongruence for a sustained amount of time;
Demonstrates emotional and cognitive maturity required to provide informed consent for the treatment.
Puberty-blocking drugs can be prescribed to halt the production of sex hormones — estrogen or testosterone — so that puberty is blocked or delayed.
The effects of blockers are not permanent, and if medication is stopped, the body will resume making hormones and puberty will continue from where it was stopped. This can happen within a matter of weeks or months.
Other effects of puberty-blocking medications include:
An individual may not get significantly taller because the drugs prevent growth spurts. Most adolescents on these medications continue to grow in height, but not as fast as in puberty.
Delays in bone density are common in young people taking puberty-blocking drugs, but growth and density catch up after puberty is resumed (either by stopping the medication or starting hormone therapy).
If an individual already is well into puberty, they may experience withdrawal effects from their own hormones. That includes hot flashes, mood changes, irritability, headaches and other symptoms. These typically last a few weeks.
The age at which individuals enter puberty varies, so the age at which puberty-blocking drugs can begin also differs from person to person. Stage of puberty is also a factor in deciding between prescribing puberty blockers and affirming hormones. Typically, doctors recommend adolescents remain on puberty-blocking medication for about 2-3 years.
For adolescents transitioning through hormone therapy
WPATH recommends gender-affirming medical or surgical treatments requested by the patient only when the individual meets certain qualifications. These include:
Has persistent gender dysphoria, and has been seen by a psychologist with experience with trans and non-binary youth who feel the patient is appropriate for treatment, which has been communicated via formal letter to the provider;
Consent of both parents;
The absence or management of psychological, medical or social problems that interfere with treatment;
The patient has been informed of the reproductive effects, including the potential loss of fertility and the available options to preserve fertility.
Irreversible surgeries are not recommended until age 18 or older, except for chest mastectomy, which has a recommended age minimum of 16 years.
For patients receiving testosterone therapy, changes to the body take several months to become noticeable and usually between 3-5 years to complete. Permanent changes include:
The pitch of the voice deepens
Increased growth, thickening and darkening of hair on the body
Growth of facial hair
Possible hair loss at the temples and crown of the head (male pattern baldness)
Increase in the size of the clitoris/phallus.
Changes that are not permanent and will likely reverse if testosterone treatment is stopped include:
Menstruation will stop, usually within a few months
Possible weight gain, typically in the abdomen and mid-section rather than buttocks, hips and thighs
Increased muscle mass and upper-body strength
Skin changes, including acne that may be severe
Increased physical energy
Increased sex drive
For patients receiving estrogen and androgen (testosterone) blocking therapy, changes to the body take several months to become noticeable and usually between 3-5 years to complete. Permanent changes include:
Breast growth and development. If a patient stops taking estrogen, breasts may shrink but will not go away completely.
Changes that are not permanent and will likely reverse if testosterone treatment is stopped include:
Testicles will get smaller softer and will produce less sperm
Loss of muscle mass and decreased strength, particularly in the upper body
Decreased metabolism and weight gain. Weight gain will typically occur in the buttocks, hips and thighs.
Facial and body hair will get softer and lighter and grow more slowly, but will not go away
Skin may become softer and existing acne may decrease
Male-pattern baldness on the scalp may slow down or stop, but hair might not regrow
Sex drive might decrease
Changes in mood or thinking.
