Should trans kids get puberty blockers and hormones? And if so, how difficult are they to get? Here are some guidelines.

Over the past few years, more than 20 states have passed laws that ban transgender people younger than 18 from receiving gender-affirming medical care, including puberty blockers, hormone treatment and surgeries.

While such a ban has not passed in Wisconsin, there is a bill in the Legislature that would ban gender-affirming medical care for minors. Champions of these bills say that young children are getting gender-affirming surgeries and that children's access to puberty blockers and hormones is too easy.

But advocates for transgender people say there is a lot of misinformation driving these bills. Here is more about transgender people and the process trans youth and their families go through in Wisconsin to get gender-affirming medical care.

What does it mean to be transgender?

According to the American Psychological Association, "transgender" is an “umbrella term for persons whose gender identity, gender expression or behavior does not conform to that typically associated with the sex to which they were assigned at birth.”

A transgender woman is someone who was assigned male at birth but whose gender identity is that of a woman.

A transgender man is someone who was assigned female at birth but whose gender identity is that of a man.

Gender nonbinary or genderqueer people, the APA says, “identify their gender as falling outside the binary constructs of ‘male’ and female.’ They may define their gender as falling somewhere on a continuum between male and female, or they may define it as wholly different from these terms.”

What is the difference between sex and gender?

According to the American Psychological Association, “sex is assigned at birth, refers to one’s biological status as either male or female, and is associated primarily with physical attributes such as chromosomes, hormone prevalence, and external and internal anatomy.”

A person’s sex is not necessarily binary, as intersex people are born with chromosomes, genitals or reproductive organs that do not match binary classifications of male or female.

According to the American Psychological Association, “gender refers to the socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for boys and men or girls and women.”

A person’s gender identity is determined by their internal sense of feeling male or female or somewhere else on the gender identity spectrum.

What happens when a child identifies as transgender?

Major medical and psychological associations, including the American Academy of Pediatrics, American Medical Association, American Psychiatric Association and the Endocrine Society, recommend that adults affirm children and adolescents' gender identity.

Gender clinics generally follow the World Professional Association for Transgender Health standards of care for support of people who are transgender. That includes the Children’s Wisconsin Gender Health Clinic. Children who are transgender and their parents can consult with an interdisciplinary team at Children's Wisconsin, which generally includes doctors, nurses, endocrinologists and mental health practitioners.

What is gender-affirming care for a child who has not yet reached puberty?

For children who have not yet reached puberty, WPATH recommends individualized psychological therapy for the whole family; it also recommends that “parents/caregivers and health care professionals respond supportively to children who desire to be acknowledged as the gender that matches their internal sense of gender identity.”

This type of support is generally referred to as social transition and, according to WPATH, those who want to be supportive of trans children should support them in their chosen names and pronouns, change in sex/gender markers on legal documents, participation in sports teams and the usage of bathrooms and locker rooms that match the child’s gender identity, personal expression through clothing and hair styles, and communication of the affirmed gender to other people or institutions in the child’s life.

WPATH also recommends that health care providers start the conversation about the benefits and risks of puberty blockers so an informed choice can be made when the child reaches puberty. No medical interventions are recommended before a child reaches puberty.

What are puberty blockers, and why would they be recommended?

When a trans child reaches puberty, WPATH recommends a process for determining whether they should take puberty blockers, which delay puberty by stopping the body from making sex hormones.

Puberty blockers are reversible, meaning that once a child stops taking them, they will generally start puberty. Puberty blockers provide a transgender adolescent with more time to live in their gender identity before they decide whether they want to take gender-affirming hormones.

Treatment with puberty blockers is also seen as a way to prevent some of the psychological distress that can be experienced when secondary sex characteristics start to occur that don’t match the adolescent’s gender identity.

However, not all people experience this gender dysphoria, and not all transgender people decide to pursue medical interventions, which is why an individualized approach to gender-affirming care is recommended.

For adolescent transgender people, WPATH continues to recommend interdisciplinary care from medical and psychological providers as well as support in how the person expresses their gender identity.

It also recommends against conversion therapy which would try to "change a person’s gender and lived gender expression to become more congruent with the sex assigned at birth,” noting that such efforts have been found to be both ineffective and to decrease the mental well-being of transgender people.

There are several criteria WPATH recommends a transgender adolescent’s interdisciplinary team determine exist in the adolescent before any medical treatment should be undertaken:

• They meet the diagnostic criteria for gender incongruence (“a marked and persistent incongruence between an individual’s experienced gender and the assigned sex, which often leads to a need to ‘transition’ to live and be accepted as a person of the experienced gender.”)

• The experience of gender incongruence is “marked and sustained over time.”

• The adolescent is emotionally and cognitively mature enough to provide informed consent.

• Any mental health concerns that would impair the person’s ability to provide informed consent have been addressed.

• Possible reproductive effects of treatment (including a loss of fertility) have been presented to the person and are understood.

• The adolescent has reached the stage of puberty when outward physical signs of puberty start to occur.

• The transgender person should have at least 12 months of hormone therapy before receiving any gender-affirming surgery.

Children’s Wisconsin's gender clinic notes that doctors will discuss risks, benefits and expectations with the adolescent and their parents before puberty blockers are recommended. The clinic also encourages the family to continue care with a mental health provider.

Medical monitoring is also required when a child is on puberty blockers, with Children’s requiring medical appointments every three to six months.

When would a transgender adolescent take gender-affirming hormones?

The Endocrine Society notes that it is not until age 16 that most adolescents are generally thought to be ready to start hormone therapy.

Before an adolescent starts to receive gender-affirming hormones (testosterone for transgender males and estrogen for transgender females) through the Children’s Wisconsin clinic, the requirements are:

• “A written ‘letter of support’ from a knowledgeable mental health provider.”

• “Reasonable control of any medical and mental health problems” the child may have.

• “The support and informed written consent of the child’s legal guardian(s).”

To ensure that informed consent exists, clinicians will talk through the benefits and risks of hormone therapy, including effects on fertility. There will also be physical exams, blood tests and meetings with mental health providers.

Minors who receive hormones are required to be seen by practitioners at the clinic every three months for the first year and every six months thereafter.

Do transgender adolescents typically receive gender-affirming surgeries?

It is rare for transgender teenagers to receive gender-affirming surgeries.

The Endocrine Society recommends against gender-affirming genital surgery for those younger than 18.

There is no age recommendation for breast surgeries for transgender males, although, as with any stage of gender-affirming medical care, it is not recommended without the consultation of an interdisciplinary team, the ability of the transgender person to give informed consent and the consent of parents or guardians if the person is younger than 18.

Contact Amy Schwabe at amy.schwabe@jrn.com.

This article originally appeared on Milwaukee Journal Sentinel: Medical and psychological standards for gender-affirming care