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FACT SHEET: Biden- ⁠ Harris Administration Advances Equality and Visibility for Transgender Americans

Today, the Biden-Harris Administration recognizes Transgender Day of Visibility, an annual celebration of the resilience, achievements, and joy of transgender people in the United States and around the world. Every American deserves the freedom to be themselves. But far too many transgender Americans still face systemic barriers, discrimination, and acts of violence. Today, the Administration once again condemns the proliferation of dangerous anti-transgender legislative attacks that have been introduced and passed in state legislatures around the country. The evidence is clear that these types of bills stigmatize and worsen the well-being and mental health of transgender kids, and they put loving and supportive families across the country at risk of discrimination and harassment. As the President has said, these bills are government overreach at its worst, they are un-American, and they must stop. Transgender people are some of the bravest people in our nation. But nobody should have to be brave just to be themselves. Today, the Biden Administration announced new actions to support the mental health of transgender children, remove barriers that transgender people face accessing critical government services, and improve the visibility of transgender people in our nation’s data.

Reinforcing federal protections for transgender kids. The Justice Department announced today that it has issued a letter to all state attorneys general reminding them of federal constitutional and statutory provisions that protect transgender youth against discrimination, including when those youth seek gender-affirming care. Advancing dignity, respect, and self-determination for transgender people by improving the traveler experience. For far too long, transgender, non-binary, and gender non-conforming Americans have faced significant barriers to travelling safely and many have not had their gender identity respected as they travel within the United States and around the world. To create a safer and more dignified travel experience, the Biden Administration is announcing the following changes.

• The Department of State is announcing that beginning on April 11, 2022, all U.S. citizens will be able select an “X” as their gender marker on their U.S. passport application. This is a major step in delivering on the President’s commitment to expand access to accurate identification documents for transgender and non-binary Americans. Information on how to apply will be available at travel.state.gov/gender .
• Implementing enhanced screening technology. The Transportation Security Administration (TSA) will soon begin updating its Advanced Imaging Technology (AIT) body scanners with new technology that will increase security and efficiency by reducing false alarm rates and pat-downs for the traveling public. By replacing the current, gender-based system with this more accurate technology, TSA will improve the customer experience of transgender travelers who have previously been required to undergo additional screening due to alarms in sensitive areas.  This new technology will help to improve the experience of travelers, particularly those who are transgender and non-binary travelers. TSA will begin deploying this new technology in airports throughout the country later this year.
• Expanding airline partnerships to enhance the overall travel experience.  TSA is working closely with air carriers across the nation to promote the use and acceptance of the “X” gender marker to ensure more efficient and accurate passenger processing. As of March 31st, two major domestic air carriers already offer a third gender marker option in their travel-reservation systems, with a third air carrier planning to offer this option in the Fall of 2022.
• Streamlining identity validation. TSA has updated its Standard Operating Procedures to remove gender considerations when validating a traveler’s identification at airport security checkpoints. This ensures that TSOs can accurately and efficiently validate each traveler’s identity while avoiding unnecessary delays.
• Updating TSA PreCheck and CBP Trusted Traveler Programs enrollment to include “X” gender markers. The Department of Homeland Security is beginning the process of adding “X” gender markers options in Trusted Traveler programs and the TSA PreCheck program to enhance access for transgender, non-binary, and gender non-conforming travelers to these programs.

Providing resources for transgender kids and their families. Transgender children are put at higher risk of attempted suicide or mental health challenges when they face bullying, rejection, or denial of health care. The Biden Administration is releasing several new resources to help transgender children and their parents thrive:

• Providing mental health resources for transgender youth.  In recent months, multiple states have removed critical information about mental health resources for LGBTQI+ youth from official state websites. Transgender youth often face significant barriers in accessing supportive resources, and are at greater risk of attempted suicide. In response, the Department of Health and Human Services released a new website that offers resources for transgender and LGBTQI+ youth, their parents, and providers. These resources include best practices for affirming an LGBTQI+ child, and information about suicide prevention services.
• Expanding trainings to support transgender and nonbinary students in schools. The Office of Safe and Supportive Schools in the Department of Education will offer new training for schools with experts and school leaders who will discuss the challenges faced by many transgender and nonbinary students and strategies and actions for providing support.
• Confirming the positive impact of gender affirming care on youth mental health. The Substance Abuse and Mental Health Services Administration (SAMHSA) has posted LGBTQI+ Youth – Like All Americans, They Deserve Evidence-Based Care , in which Miriam Delphin-Rittmon, Ph.D., HHS Assistant Secretary for Mental Health and Substance Use and the leader of SAMHSA, shares how to engage LGBTQI+ youth, the evidence behind the positive effects of gender affirming care, and available resources for LGBTQI+ youth, their families, providers, community organizations, and government agencies.
• Confirming that gender-affirming care is trauma-informed care. The National Child Traumatic Stress Network (NCTSN), which is administered by the Substance Abuse and Mental Health Services Administration, is releasing new information for providers confirming that providing gender-affirming care is neither child maltreatment nor malpractice.
• Providing resources on the importance of gender affirming care for children and adolescents. The Office of the Assistant Secretary for Health has developed a resource to inform parents and guardians, educators, and other persons supporting children and adolescents with information on what is gender-affirming care and why it is important to transgender, nonbinary, and other gender expansive young people’s well-being.

Improving access to federal services and benefits for transgender Americans.  With support and coordination from the U.S. Digital Service, federal agencies are removing barriers to access government services by improving the customer experience of transgender, non-binary, and gender non-conforming Americans:

• Accessing retirement savings. The Social Security Administration is announcing that it is removing the requirement that transgender people show proof of identity such as doctor’s notes in order to update their gender information in their social security record by the fall of 2022. This will significantly improve transgender individuals’ experience in accessing their retirement benefits, obtaining health care, and applying for jobs.
• Filing an employment discrimination complaint . The U.S. Equal Employment Opportunity Commission (EEOC) is announcing that it will promote greater equity and inclusion for members of the transgender community by giving individuals the option to select an “X” gender marker during the voluntary self-identification questions that are part of the intake process for filing a charge of discrimination.
• Applying for federal student aid. The Department of Education plans to propose next month that the 2023-24 FAFSA (Free Application for Federal Student Aid) will include an opportunity for applicants to indicate their gender identity as well as their race/ethnicity when applying for federal financial aid. The questions, which will be posted for public comment, will be in a survey that accompanies the application. This privacy-protected information would help to inform the Department about possible barriers students, including transgender and nonbinary students, face in the financial aid process.
• Visiting the White House.  The White House Office of Management and Administration is announcing that it is beginning the process of implementing updates that will improve the White House campus entry process for transgender, gender non-conforming, and non-binary visitors by adding an “X” gender marker option to the White House Worker and Visitor Entry System (WAVES) system. This change will ensure that transgender, non-binary, and gender nonconforming people can visit the People’s House in a manner that respects and affirms their gender identity.

Advancing inclusion and visibility in federal data. In too many critical federal surveys and data systems, transgender, non-binary, and gender non-conforming people are not fully reflected. To improve visibility for transgender Americans, agencies are announcing new actions to expand the collection and use of sexual orientation and gender identity (SOGI) data.

• The White House announced that the President’s proposed Fiscal Year 23 budget includes $10 million in funding for additional critical research on how to best add questions about sexual orientation and gender identity to the Census Bureau’s American Community Survey, one of our nation’s largest and most important surveys of American households. This data collection will help the federal government better serve the LGBTQI+ community by providing valuable information on their jobs, educational attainment, home ownership, and more.
• The Department of Health and Human Services has released the findings of the federal government’s first-ever user research testing conducted with transgender Americans on how they want to see themselves reflected on Federal IDs. This groundbreaking user research by the Collaborating Center for Question Design and Evaluation Research (CCQDER) at the National Center for Health Statistics (NCHS) directly informed the State Department’s adopted definition of the “X” gender marker.
• The Department of Health and Human Services  has released a comprehensive new consensus study on Measuring Sex, Gender Identity, and Sexual Orientation. This work, commissioned by the National Institutes of Health and carried out by the National Academies of Sciences, Engineering, and Medicine, will inform additional data collections and future research in how to best serve LGBTQI+ Americans.

These announcements build on the Biden-Harris Administration’s historic work to advance equality for transgender Americans since taking office, including: Combatting legislative attacks on transgender kids at the state level.

• Condemning anti-transgender bills. The President has consistently made clear that legislative attacks against transgender youth are un-American, and are bullying disguised as legislation. In his March, 2022 State of the Union Address, the President said, “The onslaught of state laws targeting transgender Americans and their families is wrong. As I said last year, especially to our younger transgender Americans, I will always have your back as your President, so you can be yourself and reach your God-given potential.” The White House has also hosted listening sessions with transgender youth and advocates in states across the country that are impacted by anti-transgender legislative attacks.
• Reaffirming that transgender children have the right to access gender-affirming health care. In March, following state actions that aim to target parents and doctors who provide gender-affirming care to transgender children with child abuse investigations, the Department of Health and Human Services took multiple actions to support transgender children in receiving the care they need and promised to use every tool available to protect LGTBQI+ children and support their families.
• Department of Justice statements of interest and amicus briefs. The Department of Justice’s Civil Rights Division has filed Statements of Interest and amicus briefs in several matters to protect the constitutional rights of transgender individuals, including in Brandt v. Rutledge , a lawsuit challenging legislation restricting access to gender-affirming care for transgender youth; B.P.J. v. West Virginia State Board of Education , a lawsuit challenging legislation restricting participation of transgender students in school sports; Corbitt v. Taylor , a lawsuit challenging legislation restricting the ability to change gender markers on state driver’s licenses; and Adams v. School Board of St. John’s County , which involves the right of a transgender boy to use the boys’ restroom at his school.

Advancing civil rights protections for transgender Americans

• Fighting for passage of the Equality Act.  President Biden  continues to call  on the Senate to pass the Equality Act, legislation which will provide long overdue federal civil rights protections to transgender and LGBTQI+ Americans and their families. As the White House has  said , passing the Equality Act is key to addressing the epidemic levels of violence and discrimination that transgender people face. The Administration’s first Statement of Administration Policy was in support of the Equality Act, and the White House has convened national leaders to discuss the importance of the legislation.
• Signing one of the most comprehensive Executive Orders on LGBTQI+ rights in history.  Within hours of taking office, President Biden signed an  Executive Order  which established that it is the official policy of the Biden-Harris Administration to prevent and combat discrimination against LGBTQI+ individuals, and to fully enforce civil rights laws to prevent discrimination on the basis of gender identity or sexual orientation. This Executive Order is one of the most consequential policies for LGBTQI+ Americans ever signed by a U.S. President. As a result of that Order, the Departments of Health and Human Services , Housing and Urban Development , Education , Consumer Financial Protection Bureau , and Justice have announced that they are expanding non-discrimination protections for transgender people in health care, housing, education, credit and lending services, and community safety programs.

Supporting transgender service members and veterans

• Reversing the discriminatory ban on transgender servicemembers.  In his first week in office, President Biden  signed  an Executive Order reversing the ban on openly transgender servicemembers serving in the Armed Forces, enabling all qualified Americans to serve their country in uniform. President Biden believes that an inclusive military strengthens our national security As a result of his Executive Order, the Department of Defense issued new  policies  which prohibit discrimination against transgender servicemembers, provide a path for transgender servicemembers to access gender-affirming medical care, and require that all transgender servicemembers are treated with dignity and respect.
• Supporting transgender veterans. To ensure that transgender veterans are treated with dignity and respect, the Department of Veterans Affairs (VA) launched an  agency-wide review  of its policies and practices to ensure that transgender veterans and employees do not face discrimination on the basis of gender identity or expression. In June, VA also announced that it is beginning the regulatory process to remove restrictions that prevent transgender veterans from accessing the gender-affirming care they need and deserve.

Responding to the crisis of anti-transgender violence and advancing safety

• Establishing a White House-led interagency working group on anti-transgender violence. To address the crisis of anti-transgender stigma and violence, during Pride Month in 2021 the White House established the first Interagency Working Group on Safety, Opportunity, and Inclusion for Transgender and Gender Diverse Individuals. The Working Group is co-led by the White House Domestic Policy Council and Gender Policy Council. To inform the priorities of the Working Group, throughout the fall of 2021 the White House convened 15 historic listening sessions with transgender and gender diverse people, advocates, and civil rights leaders from across the country and around the world, including a White House roundtable with transgender women of color .
• Releasing a White House report uplifting the voices of transgender people on gender-based violence and discrimination. On Transgender Day of Remembrance, the White House released a  report  sharing the perspectives from White House listening sessions, uplifting the voices and advocacy of transgender people throughout the country, and highlighting over 45 key, early actions the Biden-Harris Administration is taking to address the root causes of anti-transgender violence, discrimination, and denial of economic opportunity.
• Department of Justice civil rights enforcement actions. On September 14, 2021, the Department of Justice announced that it was launching a statewide civil investigation into Georgia’s prisons, which includes a focus on sexual abuse of transgender prisoners by other prisoners and staff. The Department of Justice’s Civil Rights Division and U.S. Attorney’s Office for the District of Puerto Rico also obtained a federal indictment charging three men with hate crimes for assaulting a transgender woman because of her gender identity.
• Ensuring non-discrimination protections in community safety programs. The Department of Justice issued a Memorandum from the Assistant Attorney General for Civil Rights regarding the application of Bostock v. Clayton County to the nondiscrimination provisions of the Safe Streets Act, the Juvenile Justice and Delinquency Prevention Act, the Victims of Crime Act, and the Violence Against Women Act to strengthen non-discrimination protections for transgender and LGBTQI+ individuals in key community safety programs.
• Strengthening protections for transgender individuals who are incarcerated. In January 2022 the Bureau of Prisons revised its manual on serving transgender offenders , improving access to gender-affirming care and access to facility placements that align with an inmate’s gender identity.
• Honoring those lost to violence.  The White House and the Second Gentleman of the United States hosted a first of its kind vigil in the Diplomatic Room of the White House to honor the lives of transgender and gender diverse people killed in 2021, and the countless transgender and gender diverse people who face brutal violence, harassment, and discrimination in the United States and around the world. The President also released a statement honoring the transgender people who lost their lives to violence.
• Advancing safety and justice for transgender and Two-Spirit Indigenous people. LGBTQI+ Native Americans and people who identify as transgender or “Two-Spirit” are often the targets of violent crimes. On November 15, 2021, President Biden signed an Executive Order on Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People. The Executive Order directs federal agencies to work hand in hand with Tribal Nations and Tribal partners to build safe and healthy Tribal communities to address the crisis of Missing and Murdered Indigenous People, including LGBTQI+ and “Two-Spirit” Native Americans.

Advancing health equity and expanding access to gender-affirming health care to support transgender patients

• Protecting transgender patients from health care discrimination. The Department of Health and Human Services (HHS) announced that it would interpret and enforce section 1557 of the Affordable Care Act’s prohibition on discrimination on the basis of sex in certain health programs to prohibit discrimination on the basis of gender identity and sexual orientation.
• Advancing gender-affirming care as an essential health benefit.  In 2021, the Centers for Medicare and Medicaid Services (CMS) approved the first ever application from a state to add additional gender-affirming care benefits to a state’s essential health benefit benchmark plan.
• Advancing health equity research on gender-affirming care.  The National Institutes of Health (NIH) announced that it will increase funding for research on gender-affirming procedures to further develop the evidence base for improved standards of care. Research priorities include a more thorough investigation and characterization of the short- and long-term outcomes on physical and mental health associated with gender-affirming care.
• Ending the HIV crisis among transgender and gender diverse communities.  In December, 2021, in recognition of World AIDS Day, the White House Office of National AIDS Policy released a revised National HIV/AIDS Strategy which now identifies transgender and gender diverse communities as a priority population in the federal government’s strategy to end the HIV epidemic.
• Advancing access to gender-affirming care through Ryan White HIV/AIDS Program. The Health Resources and Services Administration announced that it has released a letter encouraging Ryan White HIV/AIDS Program service providers to provide access to gender affirming care and treatment services to transgender and gender diverse individuals with HIV. The letter reaffirms the importance of providing culturally-affirming health care and social services as a key component to improving the lives of transgender people with HIV.
• Ensuring transgender patients can access birth control. In 2021 HHS issued a final rule to strengthen the Title X family planning program, fulfilling the Biden-Harris Administration’s commitment to restore access to equitable, affordable, client-centered, quality family planning services. The rule requires family planning projects to provide inclusive care to LGBTQI+ persons. Additionally, the rule prohibits discrimination against any client based on sex, sexual orientation, gender identity, sex characteristics, or marital status.

Supporting transgender students and their families

• Ensuring educational environments are free from sex discrimination and protecting LGBTQI+ students from sexual harassment.  President Biden signed an  Executive Order  recommitting the Federal Government to guarantee educational environments free from sex discrimination, including discrimination on the basis of sexual orientation or gender identity. The Executive Order charged the Department of Education with reviewing the significant rates at which students who identify as LGBTQ+ are subject to sexual harassment, including sexual violence. The Department of Education has announced that it intends to propose amendments to its Title IX regulations this year.
• Protecting the rights of transgender and gender diverse students. The Department of Education has affirmed that federal civil rights laws protect all students, including transgender and other LGBTQI+ students, from discrimination. The Department published a notice in the Federal Register announcing that it interprets Title IX’s statutory prohibition on sex discrimination as encompassing discrimination based on sexual orientation and gender identity.
• Department of Justice memorandum on Title IX. The Department of Justice issued a memorandum regarding the application of Bostock to Title IX.
• Speaking directly to transgender students. The Department of Justice, Department of Education, and Department of Health and Human Services issued a joint back to school message for transgender youth.
• Outreach and education to transgender and gender diverse students and their families. The Department of Education has published fact sheets and other resources showing the federal government’s support for transgender students, highlighting the ways schools can support students, reminding schools of their duty to investigate and address harassment based on sexual orientation or gender identity, and informing students how they can assert their rights and file complaints.
• Advancing research to address the harms of so-called conversion therapy.  The Substance Abuse and Mental Health Services Administration (SAMHSA) announced that it will update its 2015 publication  Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth  to reflect the latest research and state of the field. 

Promoting fair housing and ending homelessness for transgender Americans

• Advancing fair housing protections on the basis of gender identity. In February 2021 the Department of Housing and Urban Development (HUD) announced that it would administer and enforce the Fair Housing Act to prohibit discrimination on the basis of gender identity and sexual orientation.
• Ensuring safety and access to services for transgender people experiencing homelessness. In April, HUD withdrew the previous administration’s proposed “Shelter Rule,” which would have allowed for federally funded discrimination against transgender people who seek shelter housing. By withdrawing the previous administration’s proposed rule, the agency has restored protections for transgender people to access shelter in line with their gender identity. HUD has also released new tools for recipients to ensure compliance with these requirements in shelters and other facility settings.

Advancing economic opportunity and protections for transgender workers

• Ensuring nondiscrimination protections for transgender and gender diverse workers. In November 2021, the Department of Labor’s Office of Federal Contract Compliance Programs proposed to rescind the agency’s 2020 rule “Implementing Legal Requirements Regarding the Equal Opportunity Clause’s Religious Exemption,” an important step toward protecting workers from discrimination while safeguarding principles of religious freedom.
• Ensuring equal access to the workforce development system. The Department of Labor is enforcing discrimination prohibitions in workforce development programs funded by the Workforce Innovation and Opportunity Act, protecting workers from discrimination based on their gender identity or transgender status.

Advancing gender equity and transgender equality at home and around the world

• Advancing transgender equality in U.S. foreign policy and foreign assistance. In line with the Presidential Memorandum on Advancing the Human Rights of LGBTQI+ Persons Around the World , the United States is making significant investments to uphold dignity, equality and respect for transgender persons globally.  For example, USAID supports the Global Barometer for Transgender Rights and the LGBT Global Acceptance Index which track progress and setbacks to protecting transgender lives around the world.  The Department of Health and Human Services through the United States President’s Emergency Plan for AIDS Relief supports inclusive health care services for transgender individuals, enabling health clinics to provide care to the transgender community. And through the Department of State’s Global Equality Fund , local transgender rights organizations receive support to document human rights violations and provide critical legal assistance to community members.  
• Establishing the White House Gender Policy Council to Advance Gender Equity and Equality.  President Biden signed an  Executive Order  establishing the White House Gender Policy Council to advance gender equity and equality across the whole of the government, including by addressing barriers faced by LGBTQ+ people, in particular transgender women and girls, across our country.  

Supporting transgender leaders and public servants

• Making the Federal government a model employer for transgender public servants. President Biden signed an  Executive Order  which takes historic new steps to ensure the Federal government is a model employer for all employees – including transgender, gender non-conforming, and non-binary employees. The Executive Order charges agencies with building inclusive cultures for transgender employees by: expanding the availability of gender-neutral facilities in Federal buildings; ensuring that employee services support transgender employees who wish to legally, medically or socially transition; advancing the use of non-binary gender markers and pronouns in Federal employment processes; and expanding access to gender-affirming care and inclusive health benefits.
• Appointing historic transgender leaders. The Biden-Harris Administration includes barrier-breaking LGBTQI+ leaders, including Assistant Secretary for Health Dr. Rachel Levine, who is the first openly transgender person ever confirmed by the U.S. Senate. In October, she was also named a four-star admiral in the U.S. Public Health Service Commissioned Corps, becoming the first openly transgender person to hold that rank in any of the country’s uniformed services. Over 14 percent of Biden-Harris Administration appointees identify as LGBTQI+.

Advancing visibility for transgender Americans

• Issuing the First White House Proclamation for Transgender Day of Visibility.  On March 31, 2021 President Biden became the first U.S. President to issue a  proclamation  commemorating Transgender Day of Visibility.  
• Hosting a White House Virtual Convening on Transgender Equality.  In June, White House Press Secretary Jen Psaki hosted a first-of-its-kind  national conversation  on equality for transgender, gender non-conforming, and non-binary Americans.
• Releasing a toolkit on equality and inclusion for transgender Americans.  The White House released a new  toolkit  with best practices for advancing inclusion, opportunity, and safety for transgender Americans.
• Establishing a National Pulse Memorial. On June 25, 2021, President Biden signed H.R. 49 into law to designate the National Pulse Memorial. As the President acknowledged in his statement on the fifth anniversary of the Pulse nightclub shooting, we must acknowledge gun violence’s particular impact on LGBTQ+ communities across our nation, and we must drive out hate and inequities that contribute to the epidemic of violence and murder against transgender women – especially transgender women of color. As the President has said, Pulse Nightclub is hallowed ground.

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Health Care for Transgender and Gender Diverse Individuals

• Committee Opinion CO
• Number 823
• March 2021

Recommendations and Conclusions

Barriers to health care, creating an inclusive environment, gender transition, fertility, pregnancy, contraception, and abortion, medical transition, surgical transition, cancer screening, additional considerations for preventive care.

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Number 823 (Replaces Committee Opinion 512, December 2011, and Committee Opinion 685, January 2017. Reaffirmed 2024)

Committee on Gynecologic Practice and Committee on Health Care for Underserved Women

This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice and Committee on Health Care for Underserved Women in collaboration with committee members Beth Cronin, MD and Colleen K. Stockdale MD, MS.

ABSTRACT: An estimated 150,000 youth and 1.4 million adults living in the United States identify as transgender. This Committee Opinion offers guidance on providing inclusive and affirming care as well as clinical information on hormone therapy and preventive care; it also cites existing resources for those seeking information on the care of transgender adolescents. The social and economic marginalization of transgender individuals is widespread, which leads to health care inequities and poorer health outcomes for this population. To reduce the inequities experienced by the transgender community, the provision of inclusive health care is essential. Obstetrician–gynecologists should strive to make their offices open to and inclusive for all individuals and should seek out education to address health care disparities, both in their individual practices and in the larger health care system. In order to provide the best care for patients, it is useful to know which health care professionals to include in a referral network for primary care and to have many clinician and surgeon options given the many different therapies available and the different sites at which these therapies are offered. It is important to remember that although hormone therapy is a medically necessary treatment for many transgender individuals with gender dysphoria, not all transgender patients experience gender dysphoria and not everyone desires hormone treatment. Gender-affirming hormone therapy is not effective contraception. Sexually active individuals with retained gonads who do not wish to become pregnant or cause pregnancy in others should be counseled about the possibility of pregnancy if they are having sexual activity that involves sperm and oocytes. Although being knowledgeable about the medications used for gender transition and potential risks and side effects is important, specific certification for prescribing them is not required and should not be a limiting factor in helping patients access care.

The American College of Obstetricians and Gynecologists makes the following conclusions and recommendations regarding health care for transgender and gender diverse individuals:

The American College of Obstetricians and Gynecologists opposes discrimination on the basis of gender identity, urges public and private health insurance plans to cover necessary services for individuals with gender dysphoria, and advocates for inclusive, thoughtful, and affirming care for transgender individuals.

Obstetrician–gynecologists should make their offices inclusive and inviting to all individuals who need obstetric or gynecologic health care. They should take steps to educate themselves and their medical teams about appropriate language and the health care needs of transgender patients.

Fertility and parenting desires should be discussed early in the process of transition, before the initiation of hormone therapy or gender affirmation surgery.

Gender-affirming hormone therapy is not effective contraception. Sexually active individuals with retained gonads who do not wish to become pregnant or cause pregnancy in others should be counseled about the possibility of pregnancy if they are having sexual activity that involves sperm and oocytes.

The majority of medications used for gender transition are common and can be safely prescribed by a wide variety of health care professionals with appropriate training and education, including, but not limited to, obstetrician–gynecologists, family or internal medicine physicians, endocrinologists, advanced practice clinicians, and psychiatrists.

Hysterectomy with or without bilateral salpingo-oophorectomy is medically necessary for patients with gender dysphoria who desire this procedure.

To guide preventive medical care, any anatomical structure present that warrants screening should be screened, regardless of gender identity.

Transgender and gender diverse individuals face harassment, discrimination, and rejection within society. Lack of awareness, knowledge, and sensitivity as well as bias from health care professionals leads to inadequate access to, underuse of, and inequities within the health care system for transgender patients. Throughout this document, the term transgender will be used to refer to anyone who identifies as transgender, gender diverse, and genderqueer , while acknowledging that there are vast individual differences and variations in preferred terminology. Box 1 for related terminology and definitions.) This Committee Opinion provides guidance for obstetrician–gynecologists on both routine screening and transition care. Obstetrician–gynecologists should be aware of the unique needs of transgender individuals and be prepared to assist them with preventive health care, as well as have knowledge of hormone and surgical therapies. The American College of Obstetricians and Gynecologists opposes discrimination on the basis of gender identity, urges public and private health insurance plans to cover necessary services for individuals with gender dysphoria and advocates for inclusive, thoughtful, and affirming care for transgender individuals. Although there is some overlap in clinical and psychosocial care for adolescents and adults, there are some issues specific to adolescents. The American College of Obstetricians and Gynecologists supports the provision of appropriate and evidence-based care for transgender and gender diverse adolescents. For guidance on the medical and surgical care of transgender adolescents, see the World Professional Association for Transgender Health 1 , the Endocrine Society 2 , and the Pediatric Endocrine Society 3 .

Terminology and Definitions

Chestfeeding: Some masculine-identified individuals use this term to describe the act of feeding their child from their chest regardless of whether they have had chest surgery.

Cisgender: A term used to describe a person whose gender identity aligns with those typically associated with the sex assigned to them at birth.

Gender Identity: A person's internal sense of self and how they fit into the world, from the perspective of gender.

Gender Dysphoria: Distress that accompanies the incongruence between one's experienced and expressed gender and one's assigned or natal gender.

Gender Expression: The outward manner in which individuals express or display their gender. This may include choices in clothing and hairstyle or speech and mannerisms. Gender identity and gender expression may differ; for example, a woman (transgender or cisgender) may have an androgynous appearance, or a man (transgender or cisgender) may have a feminine form of self-expression.

Transgender: A person whose gender identity differs from the sex that was assigned at birth. May be abbreviated to trans. A transgender man is someone with a male gender identity and a female birth assigned sex; a transgender woman is someone with a female gender identity and a male birth assigned sex. A nontransgender person may be referred to as cisgender (cis means same side in Latin).

Gender Nonconforming: A person whose gender identity differs from that which was assigned at birth, but may be more complex, fluid, multifaceted, or otherwise less clearly defined than a transgender person.

Genderqueer: Blurring the lines around gender identity and sexual orientation. Genderqueer individuals typically embrace a fluidity of gender identity and sometimes sexual orientation.

Nonbinary: Transgender or gender nonconforming person who identifies as neither male nor female.

Sex: Historically has referred to the sex assigned at birth, based on assessment of external genitalia, as well as chromosomes and gonads. In everyday language is often used interchangeably with gender, however there are differences, which become important in the context of transgender people.

Sexual Orientation: Describes sexual attraction only and is not directly related to gender identity. The sexual orientation of transgender people should be defined by the individual. It is often described based on the lived gender; a transgender woman attracted to other women would be a lesbian, and a transgender man attracted to other men would be a gay man.

Gender Fluidity: Having different gender identities at different times

Agender: “Without gender”; individuals identifying as having no gender identity

Gender Expansiveness: Conveys a wider, more flexible range of gender identity or expression than typically associated with the binary gender system

Transmasculine and Transfeminine: Terms to describe gender nonconforming or nonbinary persons, based on the directionality of their gender identity. A transmasculine person has a masculine spectrum gender identity, with the sex of female listed on their original birth certificate. A transfeminine person has a feminine spectrum gender identity, with the sex of male listed on their original birth certificate. In portions of these Guidelines, in the interest of brevity and clarity, transgender men or women are inclusive of gender nonconforming or nonbinary persons on the respective spectra.

They/Them/Their: Neutral pronouns used by some who have a nonbinary or nonconforming gender identity.

Transsexual: A more clinical term which had historically been used to describe those transgender people who sought medical intervention (hormones, surgery) for gender affirmation. This term is less commonly used in present day; however, some individuals and communities maintain a strong and affirmative connection to this term.

Cross Dresser/Drag Queen/Drag King: These terms generally refer to those who may wear the clothing of a gender that differs from the sex which they were assigned at birth for entertainment, self-expression, or sexual pleasure. Some cross dressers and people who dress in drag may exhibit an overlap with components of a transgender identity. The term transvestite is no longer used in the English language and is considered pejorative.

Adapted from Human Rights Campaign. Glossary of terms. Available at: http://www.hrc.org/resources/glossary-of-terms . Retrieved June 1, 2020; MacDonald T. Transgender parents and chest/breastfeeding. St. Petersburg, FL: KellyMom; 2018. Available at: https://kellymom.com/bf/got-milk/transgender-parentschestbreastfeeding/ . Retrieved June 18, 2020; UCSF Transgender Care. Terminology and definitions. In: Deutsch MB, editor. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. 2nd ed. San Francisco, CA: UCSF Transgender Care; 2016. p. 15-6. Available at: https://transcare.ucsf.edu/guidelines/terminology . Retrieved June 18, 2020; Human Rights Campaign. New Facebook gender options validated by HRC report on gender expansive youth. Washington, DC: HRC; 2014. Available at: https://www.hrc.org/press/newfacebook-gender-options-validated-by-hrc-report-on-gender-expansive-you . Retrieved June 18, 2020; and American Psychiatric Association. What is gender dysphoria? Washington, DC: APA; 2016. Available at: https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria . Retrieved May 28, 2020.

It is important for obstetrician–gynecologists and other health care professionals to be familiar with appropriate terminology when caring for patients. Transgender is a broad term used for people whose gender identity or gender expression differs from their assigned sex at birth. For the purposes of clarity, sex is defined as the presence of specific anatomy or chromosomes. Gender is a social construct, made up of attitudes, feelings, and behaviors that a culture associates with either males or females; terminology often varies by geographic region, culture, and individual preference 4 Box 1 . Gender nonconformity is the extent to which a person’s gender identity, role, or expression differs from the cultural norms described for a specific sex 5 . Sexual orientation refers to sexual attraction only and is separate from gender identity. It is important to differentiate these concepts and terms when caring for patients Figure 1 .

An estimated 150,000 youth (aged 13–17 years) and 1.4 million adults (aged 18 years and older) living in the United States identify as transgender 6 . Analysis of data collected on adults in 19 states by the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System found that 55% of transgender individuals identified as White, 16% identified as African American or Black, 21% identified as Latino or Hispanic, and 8% identified as another race or ethnicity 7 . Although more data on the experiences and needs of the transgender community is now available, there are important gaps in the literature and additional research is needed.

The World Professional Association for Transgender Health (an international, multidisciplinary professional society representing the specialties of medicine, psychology, social sciences, and law) released the following statement in 2010: “the expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally diverse human phenomenon [that] should not be judged as inherently pathological or negative” 8 . Although a diagnosis of gender dysphoria as defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, currently is the only way for many individuals to obtain insurance coverage for necessary services, many experts agree that gender dysphoria is not a psychological condition and does not necessarily belong in the Diagnostic and Statistical Manual of Mental Disorders Box 2 . Gender dysphoria can result in psychologic dysfunction, depression, suicidal ideation, and even death 9 . It is important to remember that although some gender nonconforming people will experience gender dysphoria at some point in their lives, not all will; and for many, dysphoria is not persistent if appropriately addressed. The term “gender incongruence” is slated to replace “gender dysphoria” in the International Classification of Diseases, 11th edition.

The American Psychiatric Association’s Diagnostic Criteria for Gender Dysphoria in Adolescents and Adults

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, 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).

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Reprinted from American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

The social and economic marginalization of transgender individuals is widespread, which leads to health care inequities and poorer health outcomes for this population. The 2015 National Transgender Discrimination Survey, comprised of 27,715 participants from throughout the United States who identified as transgender, trans, genderqueer, nonbinary, and other identities on the transgender identity spectrum, reported that 29% of respondents were currently living in poverty, compared with 14% of the general U.S. population 10 . Thirty percent had experienced homelessness during their lifetime and 12% did so during the past year. Notably, homeless transgender individuals may be denied access to shelters or placed in inappropriate housing because of their gender; 26% of homeless respondents reported avoiding shelters because of fear of being mistreated, and 70% of those using shelters reported some form of mistreatment. Additionally, 20% of respondents reported experience in sex work, drug sales, and other work currently criminalized 10 .

To reduce the inequities experienced by the transgender community, the provision of inclusive health care is essential. Obstetrician–gynecologists should strive to make their offices open to and inclusive for all individuals and should seek out education to address health care disparities, both in their individual practices and in the larger health care system.

Transgender individuals face substantial barriers to accessing health care, including health care professionals’ bias and lack of general knowledge about best practices, as well as the failure of many health insurance plans to cover the cost of hormone therapy and supplies, mental health services, or gender affirmation surgery and restrictions on care imposed by prohibitive health care systems. One in four respondents to the Transgender Discrimination Survey had experienced insurance coverage obstacles, such as coverage denials for care related to gender transition or routine care. More than half (55%) had been denied coverage for transition-related surgery, and 25% were denied coverage for hormone therapy 10 . These barriers exist despite evidence that such interventions are safe, effective, and medically necessary. The consequences of inadequate care are substantial. Providing accessible, inclusive, gender-affirming care helps to reduce barriers and allow more individuals to obtain the care they need.

Creating a safe and affirming health care environment for all patients, including transgender individuals, is essential. Transgender individuals face discrimination from health care professionals and staff. One-third of respondents reported having at least one negative experience in a health care office related to being transgender, such as being refused care or verbally harassed or having to teach the health care professional about transgender people in order to get appropriate care. In addition, some respondents have experienced physical or sexual abuse in this setting 10 . Even higher rates of negative experiences were reported for transgender individuals with disabilities and American Indian, Middle Eastern, and multiracial transgender individuals. For instance, in 2015, 23% of the respondents did not see a doctor when they needed to because of fear of being mistreated as a transgender person 10 . Individuals concerned about the way they may be treated by a health care professional are more likely to obtain hormones from friends or unlicensed sources, putting them at risk of inappropriate dosing and the subsequent sequelae. Accessing care from an obstetrician–gynecologist is specifically challenging because these offices have generally been very gendered, women-specific environments, which can be perceived and experienced as exclusive.

Presenting to a health care office can be stressful and anxiety provoking for a transgender individual. Obstetrician–gynecologists and office staff can create an inclusive environment for transgender patients that will encourage patients to be forthcoming with their concerns and confident that they will be able to obtain the care that they need.

Increase health care professional knowledge of and comfort with providing care for transgender and gender nonconforming individuals. This includes avoiding making assumptions about patients’ sexual orientation, sexual practices, and surgeries and being cognizant of what questions are appropriate (eg, is the question relevant to the care being provided?).

Train and empower front desk staff, nursing staff, phone staff, billing staff, and others who interact with patients on appropriate ways to ask about names and pronouns Box 3 .

Review the office space to ensure that images chosen for signage, educational materials, and artwork represent all individuals who may seek health care services.

Ask all patients what pronouns they use Box 3 .

Clearly post a sign with the office’s nondiscrimination policy.

Ensure that at least one restroom is gender neutral and accessible to all patients.

Use patient forms that include check boxes for all gender and sexual orientation options, include blanks for patients to write in their responses, or both. Both the Institute of Medicine (now the National Academies of Sciences, Engineering, and Medicine 11 ) and the Joint Commission 12 recommend collection of sexual orientation and gender identity data. Studies demonstrate that patients want to be asked these questions because they feel it is important for their health care professionals to have this information 13 .

Create a system where names used by patients (if other than their legal names), gender markers (eg, on medical charts), and pronouns are used for every patient every time.

Examine the electronic health record system available in offices and hospitals to determine a universal process to ease the communication process for all staff. The Fenway Institute has an excellent resource to guide this process. 14 . The patient’s name, if different from the individual’s legal name, and pronouns used should be noted in the electronic health record.

Train employees how to apologize for mistakes if they happen.

Obstetrician–gynecologists should ask patients about their name and which pronouns they use. Asking all patients routinely for their gender identity and gender pronouns normalizes the interaction and allows patients to disclose without being targeted; good practice includes reciprocal disclosure (eg, “Hello, I am Dr. X and I use she/her pronouns. Is the name on your chart what you would like me to call you? What pronouns do you use?”).

The patient’s pronouns should be documented in the patient chart.

She/her/hers

They/them/their: Neutral pronouns used by some who have a nonbinary or diverse gender identity.

Other gender-neutral pronouns include zie (ze) or hir.

Each individual patient will desire different outcomes. Not all patients will want hormone therapy, and not everyone will desire surgery. Some transmasculine patients may desire only masculinizing chest surgery, and other patients will desire hysterectomy and phalloplasty in addition to chest surgery. Medication and surgery are not required parts of transition and should not be required for legally changing one’s name or gender marker on official documents (eg, birth certificate, passport, driver’s license). Legal transition will vary depending on state laws. Some patients may request letters of support for changing their name or sex on legal documents, and these should be provided. It is important to remember that although hormone therapy is a medically necessary treatment for many transgender individuals with gender dysphoria, not all transgender patients experience gender dysphoria and not everyone desires hormone treatment.

Historically, a referral letter from a mental health professional was required before initiating a patient’s gender-affirming hormone therapy. However, current consensus is that an informed consent process without a separate letter from a mental health care professional is more than adequate for initiating therapy for those patients who wish to medically transition. The majority of medications used for gender transition are common and can be safely prescribed by a wide variety of health care professionals with appropriate training and education, including, but not limited to, obstetrician–gynecologists, family or internal medicine physicians, endocrinologists, advanced practice clinicians, and psychiatrists. Although being knowledgeable about the medications used for gender transition and potential risks and side effects is important, specific certification for prescribing them is not required and should not be a limiting factor in helping patients access care. Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People , published by the World Professional Association for Transgender Health, is an important resource for health care professionals working with transgender patients 15 .

Health care professionals’ knowledge and awareness about reproductive options need improvement. Pregnancies are possible after transitioning, and perhaps, most important, contraceptive counseling is crucial to prevent undesired pregnancies. Fertility and parenting desires should be discussed early in the process of transition, before the initiation of hormone therapy or gender affirmation surgery. Fertility preservation options for transgender individuals are the same as for those cisgender individuals who desire preservation before gonadotoxic cancer therapy or for elective preservation. These options include sperm banking, oocyte preservation, embryo preservation, and in some cases, ovarian or testicular tissue cryopreservation. In addition to the expected pregnancy outcomes with these procedures, patients should be informed of the potential for out-of-pocket costs, which vary by state and insurance coverage.

Transmasculine Individuals

Transmasculine individuals taking testosterone who desire biologically related children may safely achieve pregnancy after the cessation of testosterone. Whether they choose insemination from partner or donor sperm and carry a pregnancy themselves or in vitro fertilization with embryo transfer to a partner or surrogate, transgender masculine individuals have many options for facilitating pregnancy. A 2013 survey of 41 transgender men who experienced pregnancy after transitioning found that two-thirds had used testosterone before pregnancy, with 81% using their own oocytes. Many of the respondents became pregnant within 4 months of stopping testosterone therapy and 32% of these pregnancies were unintended 16 . As with cisgender patients, obstetrician–gynecologists should discuss pregnancy intention and prepregnancy health, if appropriate, with transgender patients. The Society of Family Planning provides guidance on contraceptive counseling for transgender and gender diverse people who were assigned female sex at birth 17 . Given that contraception can be underutilized in this population because of concerns about adverse effects or access to care, undesired pregnancy is a substantial concern. Abortion access is a critical component to comprehensive reproductive health care for transgender individuals. The 2013 survey also demonstrated that patients experienced low levels of health care professional awareness and knowledge of the needs of transgender individuals 16 .

Obstetrician–gynecologists and other health care professionals who care for transmasculine individuals during pregnancy should keep in mind that pregnancy is a gendered experience and pregnancy may trigger feelings of dysphoria or isolation for some patients 18 . In addition, some postpartum transgender individuals may not identify as “mothers;” thus, obstetrician–gynecologists and other health care professionals should be mindful of the language they use. It may be appropriate to use a more neutral term, such as “parent.” Some patients may benefit from referral to mental health care professionals with experience in this area. A recent study of patients’ experiences recommends providing affirming and inclusive care from prepregnancy through the postpartum period 18 . During the postpartum period, patients will need to decide when to restart testosterone. For those making the decision to chestfeed , there is little evidence that testosterone passes into breast milk; however, because testosterone may suppress milk production, its use is not recommended until after chestfeeding is complete. Individuals who have had top surgery may still be able to lactate and chestfeed with the help of a support device. Some individuals may have worsening symptoms of dysphoria with lactation, and management of lactation suppression with cabergoline can be discussed with those individuals 19 .

Transfeminine Individuals

For those transfeminine individuals preferring to retain their gonads, some may need to use assisted reproductive technologies to achieve pregnancy and others may have return of fertility within months of ceasing hormone therapy. For transfeminine individuals wishing to use their sperm for a pregnancy in a partner or surrogate, some data indicate that long-term estrogen exposure may be associated with testicular damage 20 ; however, discontinuing hormones for a few months may lead to the return of normal sperm counts. It is best practice to encourage sperm banking before initiation of hormones. Transfeminine individuals who wish to breastfeed may have success with induction of lactation using modifications to the Newman-Goldfarb method 21 . A 2018 case report described a transgender woman successfully inducing lactation and continuing breastfeeding at 6 months follow-up 22 .

Contraception

Gender-affirming hormone therapy is not effective contraception. Sexually active individuals with retained gonads who do not wish to become pregnant or cause pregnancy in others should be counseled about the possibility of pregnancy if they are having sexual activity that involves sperm and oocytes. Transmasculine individuals should be counseled that lack of menses does not mean they are unable to conceive. All patients should be counseled on barrier use for prevention of sexually transmitted infections. For transmasculine individuals interested in hormonal contraception, testosterone is not a specific contraindication to using any form of contraception. Many transmasculine patients prefer to avoid estrogen-containing methods because they do not want to add estrogen to their system; however, little change is seen in masculinization when these methods are used. Many patients will choose hormonal intrauterine device, contraceptive implant or, depot medroxyprogesterone acetate injection.

Identifying the patient’s goals before initiating masculinizing or feminizing hormone therapy is important. Hormone therapy can be provided in the office, and obstetrician–gynecologists can broaden their skill sets by educating themselves on the provision of transition care. For more details on the provision of hormone therapy for these populations, obstetrician–gynecologists should see resources from the World Professional Association for Transgender Health 8 and the Endocrine Society 20 .

Masculinizing Therapy

For many patients, goals of masculinization therapy will include the development of facial hair, deepening of the voice, and increasing body hair and muscle mass. Other effects of masculinizing hormone therapy include the redistribution of subcutaneous fat, change in sweat and odor patterns, and hairline recession, including possible male pattern baldness. Patients also may experience increased libido, cessation of menses, vaginal atrophy, and increased clitoral size. Although testosterone generally causes temporary, and possibly permanent, decreased fertility, discussion about the possibility of continued ovulation is important for those patients with sexual practices that leave them with the potential for pregnancy. Patients should be counseled on current contraception options and their future reproductive life plan. The only absolute contraindications to masculinizing hormone therapy are current pregnancy, unstable coronary artery disease, and polycythemia (hematocrit greater than 55%) 15 . Lipid profiles should be monitored in transmasculine patients receiving testosterone therapy 23 . High-density lipoprotein levels decrease and triglycerides increase in transmasculine individuals receiving testosterone therapy. Studies have not shown an increased risk of cardiovascular events despite these adverse changes in the lipid profile.

There are many testosterone preparations available in the United States, including injectables, gels, creams, patches, and implantable pellets. Injectable testosterone cypionate is most commonly used subcutaneously, which allows for use of a smaller, less painful needle, but other formulations may be used based on patient preferences or adverse effects. Target ranges for testosterone levels are in the normal physiologic male range (typically 320–1,000 ng/dL) 20 . See Table 1 for details on formulations and dosing. In addition to standard health care screening, it is recommended that testosterone levels and hematocrit be monitored every 3 months for the first year and then once or twice a year thereafter.

Patients should be counseled that menses likely will cease within a few months after initiating hormone therapy. If bleeding continues, the obstetrician–gynecologist may consider adding progesterone therapy to facilitate amenorrhea for patients who wish to avoid hysterectomy or endometrial ablation. Testosterone commonly will cause vaginal tissues to atrophy, similar to what is experienced by postmenopausal cisgender women. These tissues may be more susceptible to small amounts of tearing and changes in microbial environment, resulting in increased risk of bacterial vaginosis, cystitis, cervicitis, or dyspareunia 4 . In these situations, obstetrician–gynecologists should consider topical treatments such as lubricants, vaginal moisturizers, and topical estrogen. Patients can be counseled that topical estrogen will have minimal systemic absorption and will not interfere with testosterone therapy.

Feminizing Therapy

Feminizing effects of hormone therapy include decreased erectile function, decreased testicular size, breast growth, and increased body fat percentage. Although there are no absolute contraindications to feminizing therapy, risks include venous thromboembolic embolism (VTE), hypertriglyceridemia, development of gallstones, and elevated liver enzymes. Patients on feminizing hormone therapy should be counseled to decrease risk factors for cardiovascular disease, such as smoking. Ethinyl estradiol, which provides better cycle control, may increase the risk of VTE; therefore, because cycle control is unnecessary for transgender women, its use is not indicated. Transdermal preparations of estradiol typically used for hormone replacement therapy are recommended for those with risk factors. If using oral estrogens, 17-β estradiol preparations are preferred 23 . In general, prescribing the smallest dose possible to achieve desired effects is recommended. See Table 2 for preparation and dosing suggestions.

Antiandrogens, such as spironolactone, cyproterone acetate, gonadotropin-releasing hormone agonists, and 5-α reductase inhibitors, are used to reduce endogenous testosterone levels, which will decrease masculine characteristics and the amount of estrogen needed 15 . Cyproterone is not available in the United States because of concern for hepatotoxicity. Gonadotropin-releasing hormone agonists are often expensive, so are not widely used. Spironolactone, which directly inhibits secretion of testosterone and androgen receptor binding, is the most commonly used antiandrogen in the United States. Because of the risk of hyperkalemia with these medications, it is important to monitor patients’ blood pressure and potassium levels 23 .

Although currently available data do not provide clear guidance on titration of dosing, it generally should be based on patient goals. Doses should be titrated to physiologic effects, while adjusting estrogen and antiandrogen dosing until in female physiologic range; then, dosing can be modified to focus on further increasing androgen blocking. The goals are to maintain estradiol levels at the mean daily levels for premenopausal women (less than 200 ng/ml) and testosterone in female range (less than 55 ng/dl) 20 . Progestins may increase breast development as well as improve libido and mood in some patients. Recommended laboratory surveillance includes estradiol and total testosterone levels, sex hormone binding globulin, and albumin levels every 3 months in the first year to titrate estrogen dosing. After the first year, laboratory tests are necessary only if there are patient or health care professional concerns about adverse effects or after a change in dosage. Patients taking spironolactone also should be tested for potassium and creatinine levels every 3 months for first year and then yearly.

Notably, feminizing hormones do not result in substantial changes to voice. Vocal pitch is secondary to the size and mass of folds of the vocal cords, which are not reversed by the addition of estrogen. Patients with concerns that their voice is incongruent with their gender can be referred to a speech language pathologist who has specific training in this area. If speech therapy does not adequately help, surgical procedures can be considered.

Some of the surgical procedures described here may not be considered within the scope of practice for an obstetrician–gynecologist, but this section may provide education for clinicians who care for transgender patients before and after surgery. As with any surgical procedure, the quality of care provided before, during, and after surgery greatly affects patient outcomes. Many insurance companies that cover gender affirmation procedures will require a mental health assessment letter before authorization for surgery. Box 4 provides an overview of surgical procedures. For additional information on postoperative care for patients who have had gender-affirming surgery, obstetrician–gynecologists can see resources from the University of San Francisco’s Center of Excellence for Transgender Health 4 .

Surgical Procedures for Transgender Individuals

Breast or chest surgery: subcutaneous mastectomy, creation of a male chest

Genital surgery: hysterectomy with or without salpingo-oophorectomy, reconstruction of the fixed part of the urethra, which can be combined with a metoidioplasty or with a phalloplasty (employing a pedicled or free vascularized flap), vaginectomy, scrotoplasty, and implantation of erection or testicular prostheses

Nongenital, nonbreast surgical interventions: voice surgery (rare), liposuction, lipofilling, pectoral implants, and various aesthetic procedures

Breast or chest surgery: augmentation mammoplasty (implants/lipofilling)

Genital surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, vulvoplasty

Nongenital, nonbreast surgical interventions: facial feminization surgery, liposuction, lipofilling, voice surgery, thyroid cartilage reduction, gluteal augmentation (implants/lipofilling), hair reconstruction, and various aesthetic procedures

Reprinted from World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people. 7th version. Minneapolis (MN): WPATH; 2012.

Masculinizing Surgery

Transmasculine individuals may choose chest reconstruction, hysterectomy with or without salpingo-oophorectomy, or metoidioplasty, phalloplasty, or both. The U.S. Transgender Survey reported that the majority (97%) of patients had or wanted masculinizing chest surgery; similarly, a majority (79%) of patients had undergone or wanted a hysterectomy. When asked about genital surgeries, only 4% had had metoidioplasty and 53% wanted the procedure in the future; for phalloplasty, 2% had had the procedure and 27% desired it in the future 10 . The lower percentage of patients wanting these surgeries is likely multifactorial; limited insurance coverage is one issue. Masculinizing chest surgery, sometimes referred to as “top surgery,” generally includes a subcutaneous mastectomy and recontouring to develop a masculine-appearing chest. Factors such as surgeon expertise, body habitus, skin quality, and breast shape and size will influence the surgical approach.

Metoidioplasty to create a neophallus is generally chosen by patients who want genital surgery but are not interested in phalloplasty. Metoidioplasty involves releasing the clitoris, lengthening the urethra to the tip of the phallus, and covering the phallus with neighboring skin. It is possible to have concurrent vaginectomy and scrotoplasty. Patients who choose urethral lengthening will be able to void when standing if they are close to ideal body weight. If a patient desires scrotoplasty, rotational flaps of the labia majora are used to place the scrotum in an anatomic male position. Implants can be placed approximately 6 months later. Phalloplasty generally takes tissue from a donor site, which is shaped into a phallus, allowing for later penile implant to facilitate penetrative intercourse. Most commonly, tissue is taken from the radial forearm, latissimus dorsi, or anterolateral thigh. The decision on the location of the tissue donor site is based on surgeon technique and desired patient outcomes.

Hysterectomy with or without bilateral salpingo-oophorectomy is medically necessary for patients with gender dysphoria who desire this procedure. The route of hysterectomy should be based on clinical findings as well as surgeon and patient preference. Although vaginal hysterectomy will allow for recovery without abdominal scarring, some surgeons may find it to be technically difficult given likely lack of uterine descent and severe vaginal atrophy with a narrow introitus; however, it can be accomplished if desired 24 . A genital examination may be challenging and worsen dysphoria for some patients. In these cases, it may be appropriate to conduct the examination under anesthesia before initiating the surgical procedure. Whether the ovaries are removed at the time of hysterectomy will be informed by the patient’s fertility desires, long-term plans for hormonal use, and personal preferences and should be considered within a shared decision-making model. Patients should be offered consultation with a fertility specialist before surgical removal of ovaries. Counseling about bone health and cardiovascular protection is challenging because of limited data. Testosterone may have an anabolic effect on cortical bone, and if provided in adequate doses will prevent bone demineralization. No studies have found an increase in the occurrence of cardiovascular events in transmasculine individuals 23 , so unless the patient is planning to stop taking testosterone in the future, it is unlikely that the ovaries are necessary to maintain bone or cardiovascular health. More research is needed in this area. Notably while some patients may not plan to stop testosterone, they may do so because of issues such as lack of access. Engaging in shared decision making and counseling regarding the risks and benefits of ovarian preservation before hysterectomy is important.

Feminizing Surgery

Although desire for surgical transition varies depending on the individual, the U.S. Transgender Survey reported that 74% of respondents had either undergone breast augmentation or wanted it in the future. One quarter had undergone orchiectomy and 61% desired it in the future; 87% had undergone vaginoplasty or wanted to do so in the future 10 . Potential procedures for transfeminine individuals include breast augmentation, orchiectomy, vaginoplasty, and facial feminization surgeries. It generally is recommended that patients wait at least 6 months after initiating feminizing hormone therapy before undergoing breast augmentation; other experts suggest waiting 2–3 years to maximize hormonal effects 4 . Breast augmentation typically is performed with implants, either subglandular or subpectoral depending on a patient’s body habitus and desire.

Vaginoplasty involves penile inversion and the creation of a vaginal vault between the rectum and urethra. The vagina is lined with penile skin and labia are created using scrotal skin after orchiectomy is completed. The glans penis is used to create the clitoris. If there is not enough skin available to provide adequate depth, a skin graft is performed. Preoperative electrolysis of the scrotum is recommended to prevent hair from growing in the neovagina.

Successful recovery from this procedure requires patient commitment to a dilation regimen (up to three times per day) to maintain depth and width of the neovagina. Given the limited number of centers providing these procedures, it is not uncommon for a patient to present to their local obstetrician–gynecologist for ongoing postoperative care. The vagina is lined by skin, not mucosa; therefore, it will not lubricate naturally. For patients who are struggling with dilation, they should be counseled to increase the amount of lubricant used and to consider using a smaller-sized dilator to allow for more frequent and deeper dilation; patients can then gradually increase the size of the dilator. Individuals with persistent pain or discomfort with dilation may benefit from a referral to a pelvic floor physical therapist. For individuals presenting with vaginal discharge and odor, sources are most likely sebum, dead skin, or retained semen or lubricant. Those patients should be counseled to clean or douche with soap and water; the addition of vinegar may be considered if strong odor is noted. Patients may present with bleeding or discharge consistent with granulation tissue; this often can be easily treated with silver nitrate.

There are insufficient data to determine whether transgender individuals are at increased risk of malignancy compared with the general population. To guide preventive medical care, any anatomical structure present that warrants screening should be screened regardless of gender identity. It may be useful to comprehensively label laboratory specimens (eg, “male with cervix”) to ensure they are appropriately processed.

For transmasculine individuals, screening includes breast cancer screening for patients who have breast tissue and cervical cancer screening for those who have a cervix. Before ceasing breast cancer screening, it is important to review operative reports to ensure that mastectomy was performed and not just breast reduction. For those individuals who have undergone mastectomy and reconstruction, there are limited data to support clinical chest examinations in the absence of patient concern 4 . The American College of Obstetricians and Gynecologists recommends genetic counseling before surgery for those with a personal or family history of breast cancer or ovarian cancer 25 .

Cervical cancer screening should be performed according to age-related guidelines 26 27 28 . Self-collected human papillomavirus (HPV) specimens may be appropriate for those patients who otherwise may not access screening or for whom speculum insertion may be physically difficult or emotionally traumatic; though, to date, there is no patient-collected HPV test approved by the U.S. Food and Drug Administration. Atrophy secondary to testosterone may make cervical cancer screening more challenging. Transmasculine individuals have a 10-fold higher rate of unsatisfactory Pap tests (samples that cannot be evaluated by the laboratory due to a lack of sufficient cells or obscuring factors such as blood) compared with cisgender individuals 29 . A 2018 study of transmasculine patients aged 21–64 years reported a high patient preference for self-collected vaginal HPV swabs (greater than 90% preference over swabs collected by health care professionals) and accurate self-collected results consistent with previous studies in cisgender female patients. There was a 71.4% concordance of self-collected samples compared with samples collected by health care professionals (15 of 21 cases detected) 30 .

Similar to cisgender women, routine screening for endometrial cancer is not recommended for transmasculine individuals who still have a uterus. Although for transmasculine individuals there is a theoretical concern for increased risk of hyperplasia or malignancy because of the aromatization of exogenous testosterone to estrogen with anovulation leading to unopposed estrogen, there are no data to support this. In fact, most studies demonstrate that the endometrium is atrophic secondary to testosterone use. Therefore, on the basis of limited data, recommendations for screening for endometrial cancer for transmasculine individuals are no different than for cisgender women. Additionally, evaluation of transmasculine individuals with abnormal uterine bleeding are the same as those for cisgender women 31 .

A neovagina does not require routine cytologic screening. Prostate cancer screening for transfeminine individuals should follow the recommendations for cisgender men 32 . Although there are some case reports of prostate cancer in transfeminine individuals, most of these were in individuals who started hormone therapy after 50 years of age; these individuals likely had preexisting lesions before initiating hormone therapy 33 . It is likely that transfeminine individuals have a lower risk of breast cancer than cisgender women. A retrospective study of Dutch transfeminine individuals found an estimated breast cancer incidence of 4.1 in 100,000 person-years in comparison with 155 in 100,000 person-years in the cisgender female population 34 . This decreased risk is likely because of a substantially decreased length of lifetime exposure to estrogen. However, it is notable that a study of 50 transfeminine individuals found 60% had dense or very dense breasts on mammography, leading to increased rates of false-negative mammogram results 35 . General consensus is that screening should begin after 50 years of age and a minimum of 5 years of feminizing hormone use, with a health care professional-patient discussion about the potential harms of over screening 4 .

As for all patients, transgender individuals should be counseled about the importance of routine preventive health care. All individuals should be routinely screened for intimate partner violence, depression, substance use, cancer, and other health care needs and should be screened for sexually transmitted infections and counseled about appropriate immunizations based on age and risk factors, including HPV vaccination. As with the general population, screening for intimate partner violence in transgender patients is important and should be performed. A 2017 study found a higher report rate of intimate partner violence in transfeminine individuals (12.1%) when compared with cisgender women (2.7%), transmasculine individuals (6.6%), nonbinary individuals (8.2%), and transgender or gender diverse individuals who did not report a gender identity (9.1%) 36 . Screening for mental health issues should be part of standard practice. Forty percent of transgender individuals have attempted suicide at some point during their lifetime 10 .

Obstetrician–gynecologists should take a careful and thoughtful medical, family, and surgical history for all patients. Risk assessment for sexually transmitted infections should be based on a patient’s behaviors and present anatomy. When performing the physical examination, it is important to remember that patients may have had traumatic examinations in the past. Self-collected vaginal and rectal swabs as well as the option for urine specimens may be appropriate alternatives to physical examination. Obstetrician–gynecologists should follow guidance for transgender individuals in the Centers for Disease Control and Prevention’s 2015 STD Treatment Guidelines, endorsed by the American College of Obstetricians and Gynecologists 37 . Screening for human immunodeficiency virus (HIV) in at-risk individuals is of high importance. Among those respondents to the Transgender Discrimination Survey, 1.4% were living with HIV; this is five times higher than the rate of the general U.S. population. The rate in transfeminine individuals was 3.4%, and 19% of Black transfeminine individuals reported living with HIV 10 . Obstetrician–gynecologists should counsel patients at high risk of HIV infection on safer sex practices and other prevention methods, as well as the option of preexposure prophylaxis 38 .

Accessing health care as a transgender individual often is challenging. Obstetrician–gynecologists may provide comprehensive care for transgender patients at various times in their lives. Obstetrician–gynecologists should make their offices inclusive and inviting to all individuals who need obstetric or gynecologic health care. They should take steps to educate themselves and their medical teams about appropriate language and the health care needs of transgender patients. Putting the patient in the role of educator of the health care professional diminishes the patient-physician relationship. In order to provide the best care for patients, it is useful to know which health care professionals to include in a referral network for primary care and to have many clinician and surgeon options given the many different therapies available and the different sites at which these therapies are offered. Connecting with trans-friendly colleagues is a way to expand access to care for the transgender individuals in the community.

• World Professional Association for Transgender Health . Standards of care for the health of transsexual, transgender, and gender nonconforming people. 7th version . Minneapolis, MN : WPATH ; 2012 . Available at: https://www.wpath.org/publications/soc . Retrieved June 1, 2020. Article Locations: Article Location
• Endocrine Society . Clinical practice guideline: gender dysphoria/gender incongruence guideline resources . Washington, DC : Endocrine Society ; 2017 . Available at: https://www.endocrine.org/clinical-practice-guidelines/gender-dysphoria-gender-incongruence . Retrieved October 14, 2020. Article Locations: Article Location
• Pediatric Endocrine Society . Guidelines of care, consensus statements, reviews . Available at: https://www.pedsendo.org/education_training/healthcare_providers/consensus_statements/index.cfm . Retrieved June 2, 2020. Article Locations: Article Location
• Deutsch MB , editor. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people . 2nd ed . San Francisco, CA : UCSF Transgender Care ; 2016 . Available at: https://transcare.ucsf.edu/guidelines . Retrieved June 1, 2020. Article Locations: Article Location Article Location Article Location Article Location Article Location Article Location
• Institute of Medicine . The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding . Washington, DC : National Academies Press ; 2011 . Article Locations: Article Location
• Herman JL , Flores AR , Brown TN , Wilson BD , Conron KJ . Age of individuals who identify as transgender in the United States . Los Angeles, CA : The Williams Institute ; 2017 . Article Locations: Article Location
• Flores AR , Brown TN , Herman JL . Race and ethnicity of adults who identify as transgender in the United States . Los Angeles, CA : The Williams Institute ; 2016 . Article Locations: Article Location
• The difference between gender nonconformity and gender dysphoria . In: Coleman E , Bockting W , Botzer M , Cohen-Kettenis P , DeCuypere G , Feldman J , et al , editors. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7 . Minneapolis, MN : World Professional Association for Transgender Health ; 2012 : 4 – 6 . Article Locations: Article Location Article Location
• American Psychiatric Association . Diagnostic and statistical manual of mental disorders . 5th ed . Arlington, VA : APA ; 2013 . Article Locations: Article Location
• James SE , Herman JL , Rankin S , Keisling M , Mottet L , Anafi M . The report of the 2015 U.S. transgender survey . Washington, DC : National Center for Transgender Equality ; 2016 . Article Locations: Article Location Article Location Article Location Article Location Article Location Article Location Article Location Article Location Article Location
• Institute of Medicine . Sexual orientation and gender identity data collection in electronic health records: a workshop . Washington, DC : National Academies Press ; 2012 . Article Locations: Article Location
• The Joint Commission . Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: a field guide . Oak Brook, IL : The Joint Commission ; 2011 . Article Locations: Article Location
• Cahill S , Singal R , Grasso C , King D , Mayer K , Baker K , et al . Do ask, do tell: high levels of acceptability by patients of routine collection of sexual orientation and gender identity data in four diverse American community health centers . PLoS One 2014 ; 9 : e107104 . Article Locations: Article Location
• National LGBT Health Education Center . Ready, set, go! Guidelines and tips for collecting patient data on sexual orientation and gender identity . Boston, MA : National LGBT Health Education Center ; 2020 . Available at: https://www.lgbtqiahealtheducation.org/publication/ready-set-go-guidelines-tips-collecting-patient-data-sexual-orientation-gender-identity/ . Retrieved February 1, 2021. Article Locations: Article Location
• Coleman E , Bockting W , Botzer M , Cohen-Kettenis P , DeCuypere G , Feldman J , et al . Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7 . Int J Transgend 2012 ; 13 : 165 – 232 . Article Locations: Article Location Article Location Article Location
• Light AD , Obedin-Maliver J , Sevelius JM , Kerns JL . Transgender men who experienced pregnancy after female-to-male gender transitioning . Obstet Gynecol 2014 ; 124 : 1120 – 7 . Article Locations: Article Location Article Location
• Bonnington A , Dianat S , Kerns J , Hastings J , Hawkins M , De Haan G , et al . Society of Family Planning clinical recommendations: contraceptive counseling for transgender and gender diverse people who were female sex assigned at birth [published online April 15, 2020] . Contraception . DOI: 10.1016/j.contraception.2020.04.001 . Article Locations: Article Location
• Ellis SA , Wojnar DM , Pettinato M . Conception, pregnancy, and birth experiences of male and gender variant gestational parents: it's how we could have a family . J Midwifery Womens Health 2015 ; 60 : 62 – 9 . Article Locations: Article Location Article Location
• Yang Y , Boucoiran I , Tulloch KJ , Poliquin V . Is cabergoline safe and effective for postpartum lactation inhibition? A systematic review . Int J Womens Health 2020 ; 12 : 159 – 70 . Article Locations: Article Location
• Hembree WC , Cohen-Kettenis PT , Gooren L , Hannema SE , Meyer WJIII , Murad MH , et al . Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society Clinical practice guideline [published errata appear in J Clin Endocrinol Metab 2018;103:2758–59; J Clin Endocrinol Metab 2018;103:699] . J Clin Endocrinol Metab 2017 ; 102 : 3869 – 903 . Article Locations: Article Location Article Location Article Location Article Location
• Goldfarb L , Newman J . The protocols for induced lactation: a guide for maximizing breastmilk production . Available at: http://www.asklenore.info/breastfeeding/induced_lactation/protocols4print.shtml . Retrieved October 15, 2020. Article Locations: Article Location
• Reisman T , Goldstein Z . Case report: induced lactation in a transgender woman . Transgend Health 2018 ; 3 : 24 – 6 . Article Locations: Article Location
• Unger CA . Hormone therapy for transgender patients . Transl Androl Urol 2016 ; 5 : 877 – 84 . Article Locations: Article Location Article Location Article Location Article Location
• Obedin-Maliver J , Light A , de Haan G , Jackson RA . Feasibility of vaginal hysterectomy for female-to-male transgender men . Obstet Gynecol 2017 ; 129 : 457 – 63 . Article Locations: Article Location
• Hereditary breast and ovarian cancer syndrome. Practice Bulletin No. 182. American College of Obstetricians and Gynecologists . Obstet Gynecol 2017 ; 130 : e110 – 26 . Article Locations: Article Location
• Fontham ET , Wolf AM , Church TR , Etzioni R , Flowers CR , Herzig A , et al . Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society [published online July 30, 2020] . CA Cancer J Clin . DOI: 10.3322/caac.21628 . Article Locations: Article Location
• Curry SJ , Krist AH , Owens DK , Barry MJ , Caughey AB , Davidson KW , et al . Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. U.S. Preventive Services Task Force . JAMA 2018 ; 320 : 674 – 86 . Article Locations: Article Location
• Cervical cancer screening and prevention. Practice Bulletin No. 168. American College of Obstetricians and Gynecologists . Obstet Gynecol 2016 ; 128 : e111 – 30 . Article Locations: Article Location
• Peitzmeier SM , Reisner SL , Harigopal P , Potter J . Female-to-male patients have high prevalence of unsatisfactory Paps compared to non-transgender females: implications for cervical cancer screening . J Gen Intern Med 2014 ; 29 : 778 – 84 . Article Locations: Article Location
• Reisner SL , Deutsch MB , Peitzmeier SM , White Hughto JM , Cavanaugh TP , Pardee DJ , et al . Test performance and acceptability of self-versus provider-collected swabs for high-risk HPV DNA testing in female-to-male trans masculine patients . PLoS One 2018 ; 13 : e0190172 . Article Locations: Article Location
• Endometrial cancer. Practice Bulletin No. 149. American College of Obstetricians and Gynecologists . Obstet Gynecol 2015 ; 125 : 1006 – 26 . Article Locations: Article Location
• Grossman DC , Curry SJ , Owens DK , Bibbins-Domingo K , Caughey AB , Davidson KW , et al . Screening for prostate cancer: US Preventive Services Task Force recommendation statement [published erratum appears in JAMA 2018;319:2443] . JAMA 2018 ; 319 : 1901 – 13 . Article Locations: Article Location
• Trum HW , Hoebeke P , Gooren LJ . Sex reassignment of transsexual people from a gynecologist's and urologist's perspective . Acta Obstet Gynecol Scand 2015 ; 94 : 563 – 7 . Article Locations: Article Location
• Gooren LJ , van Trotsenburg MA , Giltay EJ , van Diest PJ . Breast cancer development in transsexual subjects receiving cross-sex hormone treatment . J Sex Med 2013 ; 10 : 3129 – 34 . Article Locations: Article Location
• Weyers S , Villeirs G , Vanherreweghe E , Verstraelen H , Monstrey S , Van den Broecke R , et al . Mammography and breast sonography in transsexual women . Eur J Radiol 2010 ; 74 : 508 – 13 . Article Locations: Article Location
• Valentine SE , Peitzmeier SM , King DS , O'Cleirigh C , Marquez SM , Presley C , et al . Disparities in exposure to intimate partner violence among transgender/gender nonconforming and sexual minority primary care patients . LGBT Health 2017 ; 4 : 260 – 7 . Article Locations: Article Location
• Workowski KA , Bolan GA . Sexually transmitted diseases treatment guidelines, 2015. Centers for Disease Control and Prevention [published erratum appears in MMWR Recomm Rep. 2015;64:924] . MMWR Recomm Rep 2015 ; 64 ( RR-03 ): 1 – 137 . Article Locations: Article Location
• Preexposure prophylaxis for the prevention of human immunodeficiency virus. Committee Opinion No. 595. American College of Obstetricians and Gynecologists . Obstet Gynecol 2014 ; 123 : 1133 – 6 . Article Locations: Article Location

Published online on February 18, 2021.

Copyright 2021 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

American College of Obstetricians and Gynecologists 409 12th Street SW, Washington, DC 20024-2188

Health care for transgender and gender diverse individuals. ACOG Committee Opinion No. 823. American College of Obstetricians and Gynecologists. Obstet Gynecol 2021;137:e75–88.

This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on acog.org or by calling the ACOG Resource Center.

While ACOG makes every effort to present accurate and reliable information, this publication is provided "as is" without any warranty of accuracy, reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither ACOG nor its officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

All ACOG committee members and authors have submitted a conflict of interest disclosure statement related to this published product. Any potential conflicts have been considered and managed in accordance with ACOG’s Conflict of Interest Disclosure Policy. The ACOG policies can be found on acog.org . For products jointly developed with other organizations, conflict of interest disclosures by representatives of the other organizations are addressed by those organizations. The American College of Obstetricians and Gynecologists has neither solicited nor accepted any commercial involvement in the development of the content of this published product.

Figures & Tables

Figure 1. Concepts of Sex and Gender. Reprinted from Concepts of sex and gender. Mayo Clinic. Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved. https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/transgender-facts/art-20266812 .

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Gender reassignment discrimination and the NHS

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NHS bodies, in their roles as both employer and service provider, increasingly find themselves subject to complaints of discrimination on the grounds of gender reassignment, due to a growing awareness and understanding within the trans community of their rights as employees and patients.

It is therefore important that NHS bodies ensure that they have adequate training and policies in place for the prevention of discrimination against transgender employees or service users.

The two key pieces of legislation that protect transsexual people are the Equality Act 2010 (EqA 2010) and the Gender Recognition Act 2004 (GRA 2004).

The Equality Act 2010

Discrimination under the eqa 2010.

The EqA 2010 provides legal protection from discrimination and harassment. Gender reassignment is one of the nine protected characteristics covered by the Act. A person has the protected characteristic of gender reassignment if that person is proposing to undergo, is undergoing or has undergone a process (or part of a process) for the purpose of reassigning their sex by changing physiological or other attributes of sex.

Under the Act, a reference to a person who has the protected characteristic of gender reassignment is a reference to a transsexual person. Therefore, a woman making the transition to being a man and a man making the transition to being a woman both share the characteristic of gender reassignment.

A key point to note about the definition of gender reassignment under the EqA 2010, is that a person who ‘is proposing to undergo’ the process of changing their sex is protected i.e. they need not have undertaken any actual steps towards the process of transitioning. Further, a person living in the opposite gender without having undergone any medical procedures will be protected. Unlike earlier legislation, there is no requirement to be under medical supervision to qualify for protection under the EqA 2010.

There are five types of prohibited discrimination in respect of gender reassignment:

• Direct discrimination – when a transsexual person is treated less favourably than others because of gender reassignment
• Indirect discrimination – where a transsexual person is particularly disadvantaged by a provision, criterion or practice which applies to everyone
• Harassment – when unwanted conduct related to gender reassignment causes an intimidating, hostile, humiliating or offensive environment for that person
• Victimisation – when a person is subjected to a detriment because they have made or supported a complaint about gender reassignment discrimination
• Absences from work – where an employee is treated less favourably in relation to absences from work because of gender reassignment. This is the only type of prohibited discrimination specific to transsexual people

Case example

One issue that employers are likely to face in relation to transsexual employees is use of single-sex facilities. For example, it is likely, and understandably so, that person will want to use the toilet facilities of the gender to which they are transitioning. In the leading authority on this issue Croft -v- Royal Mail Group plc [2003], the Court of Appeal upheld a decision of an employment tribunal that it was not discrimination to require a pre-operative male to female transsexual employee to use the disabled toilet as opposed to the female toilet facilities during the transition process.

However, the approach in this case should not be regarded as best practice. The recruitment and retention of transgender staff guidance issued by the Government Equalities Office (GEO) Guide states that a trans person should be free to select the facilities appropriate to the gender in which they present and that when a trans person starts to live in their acquired gender role on a full-time basis they should have the right to use the facilities for that gender. Further, the Department of Health Guidance for NHS Trusts sets out that it is not good practice to require a transsexual person to use the disabled facilities and it is not acceptable to require a transsexual person to use the facilities of their assigned gender.

Exceptions: when gender reassignment discrimination may be lawful

Gender reassignment discrimination may be permitted in certain limited circumstances. The EqA 2010 provides for an ‘occupational requirement’ exception that employers can rely on in discrimination claims. This enables employers, in limited circumstances, to require that, having regard to the nature or context of the work, only people who are not transsexuals can do the job. The explanatory notes in the EqA 2010 give the following example of an occupational requirement; ‘a counsellor working with victims of rape might have to be a woman and not a transsexual person, even if she has a gender recognition certificate, in order to avoid causing victims further distress.’ This may also apply to NHS staff employed to help victims of rape or other sexual assault.

Application to the NHS

In addition to NHS employees, patients must not be subjected to discrimination by NHS Trusts. The EqA 2010 prohibits discrimination by a service provider (concerned with the provision of a service to the public) against a person requiring the service. Therefore, NHS trusts must not discriminate against transsexual patients because they have the protected characteristic of gender reassignment.

However, there is an exception in the Act for single-sex only services (for example, a group counselling session provided only for female victims of sexual assault) but NHS trusts must be certain that the provision of separate services is a proportionate means of achieving a legitimate aim.

NHS bodies must also have regard to the Public Sector Equality Duty set out in Section 149 EqA 2010, which sets out that they must have due regard to eliminating discrimination prohibited by the EqA 2010 and advancing equality of opportunity and fostering good relations between those who share a protected characteristic and people who do not share it.

Gender Recognition Act 2004

The Gender Recognition Act 2004 (the Act) allows transsexual people to gain legal recognition of their acquired gender by registering for a Gender Recognition Certificate (GRC). The application is made to the Gender Recognition Panel who will determine whether a GRC should be issued on the basis that the applicant has lived in their acquired gender for two years and intends to live the acquired gender until death. An applicant does not have to have had gender reassignment surgery, but have been diagnosed as gender dysphoric. Where a full GRC has been issued to a person, their gender becomes for all purposes the acquired gender.

Prohibition on disclosure of information

The Act has important implications for NHS trusts, particularly in relation to the provisions on prohibition of disclosure of information relating to a person’s application for a GRC or, if a GRC is issued, their previous gender. Under section 22 of the Act, it is a criminal offence for a person who has acquired, in an official capacity, protected information regarding an individual’s gender identity to disclose that information to any other person. This clearly affects NHS bodies as employers and in the supply of services to the public, as they are likely to acquire such information in relation to their employees or patients.

An example provided by the workplace and gender reassignment: Guide for staff and managers (a:gender Guide) is of someone working in HR with access to an employee’s personal file, disclosing the fact that the employee was born a different gender, without the employee’s prior consent.

Potential defences

There are a number of defences to this prohibition set out in section 22(4) of the Act. These include where the information does not enable that person to be identified and where the person has agreed to the disclosure of the information.

In addition, there is a further defence which will have particular importance to NHS bodies as service providers. The Gender Recognition (Disclosure of Information) (England, Wales and Northern Ireland) (No2) Order 2005 provides a defence in relation to disclosure for medical purposes. It will not be an offence under section 22 of the Act to disclosure protected information if the disclosure is made to a health professional, for medical purposes, and the person making the disclosure reasonably believes that the subject has given consent to the disclosure or cannot give such consent.

Practical considerations for NHS bodies

The a:gender Guide states that ‘it is the antithesis of the intentions of the privacy provision included in the GRA 2004 to ask or expect an individual to evidence they have gender recognition. Given the wider privacy protection applicable to all, it is best practice to assume any transsexual person has gender recognition and treat them accordingly’.

Care should be taken to use appropriate names and terminology in HR and patient records in relation to transsexual people. Where a person is transgender, it is important not to refer to this fact in patient or HR records unless the person has consented to it. In respect of employees, this may involve issuing them with a new set of HR records.

In relation to transgender patients, NHS/Department of Health guidance is that they should be issued with a new set of medical records to reflect their new gender status. NHS trusts may find themselves in a difficult position when there are medical reasons why a transgender patient’s previous gender needs to be referred to. In these circumstances, the medical professionals should seek consent from the patient for their gender history being recorded in their notes and steps should be taken to ensure that access to those notes is limited to those who need to be aware of the patient’s gender history for clinical reasons.

Department of Health guidance recommends that all staff are trained on these issues in relation to transgender patients and employees. Our specialist employment team can provide training on the legislation in this area and its implications for NHS bodies.

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Outlawing Trans Youth: State Legislatures and the Battle over Gender-Affirming Healthcare for Minors

Chapter One

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As soon as I realized that I was not happy in my body, I went up to my parents to fix it. And it felt as natural as going up and being like, “Hey, I’m hungry.” I was just kind of like, “Hey, when’s the girl thing happening? ”

— Nicole Maines, actress and transgender activist, on coming out as transgender as a child 1

More than one-third of transgender high school students attempt suicide in a given year. 2 This alarming statistic underscores the importance of providing transgender youth 3 with access to medically necessary healthcare to bring their bodies into alignment with their gender identities. 4 Fortunately, medical science and understanding have advanced such that trans youth can safely and effectively transition under the supervision of medical professionals. 5 Obstacles remain, to be sure. 6 But information about, and access to, gender-affirming care for trans youth is more widespread than ever before. 7

Over the last few years, however, a growing political tide has threatened to reverse this progress. Gender-affirming healthcare 8 for minors has become a new frontier in the culture war. In the first months of 2020 alone, legislators in at least fifteen states introduced bills that would have prohibited and, in many cases, criminalized providing gender-affirming healthcare services to minors. 9 None of these bills became law. 10 But the fight over gender-affirming healthcare for minors is far from over; as of January 2021, at least nine states were considering gender-affirming care bans, 11 with more sure to follow, and a recent court decision in the United Kingdom effectively banning hormone treatments for trans youth under sixteen is likely to embolden the stateside opposition even further. 12 This Chapter shines light on attempts to outlaw necessary gender-affirming medical treatment for minors, drawing on scientific evidence and legal doctrine to show why such legislative efforts are harmful, prejudiced, and unconstitutional. Section A will outline the current medical standard of care for trans youth and argue that access to gender-affirming care provides critical and empirically demonstrable psychological, social, and legal benefits for trans youth. Section B will describe the 2020 bills, 13 critique their foundational premises, and analyze how their paternalistic narratives represent new rhetorical strategies of opposition to trans youth. Section C will offer two constitutional arguments against the bans, one based in the Equal Protection Clause and one based in parental due process rights.

The Importance of Gender-Affirming Healthcare for Trans Youth

The prevalence and availability of gender-affirming healthcare for trans youth have increased considerably since the 1990s, when transitioning before adulthood was quite rare. 14 A 2017 survey found that almost two percent of American public high school students in ten states and nine large urban school districts identified as transgender, 15 and although not all trans youth seek out gender-affirming healthcare, exponentially greater numbers of trans youth are pursuing this care. 16 This section describes the current medical standard of gender-affirming healthcare for trans youth and explains the importance of gender-affirming healthcare to the mental and social well-being and legal recognition of trans youth.

1. The Current Standard of Care.

The purpose of gender-affirming healthcare is usually to treat gender dysphoria (“dysphoria”), or “discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth.” 17 Physical and social transition through the use of gender-affirming healthcare is clinically shown to reduce dysphoria by aligning a transgender person’s physical body and gender presentation with their gender identity. 18 Thus, every major U.S. medical association recognizes that gender-affirming healthcare is medically necessary treatment for dysphoria. 19

Gender-affirming healthcare for trans youth is typically admin-istered pursuant to Standards of Care published by the World Professional Association for Transgender Health (WPATH SOC), an international body of experts in transgender healthcare. 20 The WPATH SOC represent the authoritative medical consensus on treatment for dysphoria in transgender people. 21

The first step in gender-affirming treatment for trans youth is therapy and counseling. The WPATH SOC recommend that trans youth be diagnosed with gender dysphoria and referred by a gender therapist before they begin physical transition. 22 After the initial diagnosis, gender-affirming therapists help trans youth process their gender identities and cope with distress associated with dysphoria and coexisting sources of stress, and support them in taking future steps in physical and social transition. 23

Trans youth who are diagnosed with dysphoria sometimes begin hormone treatments, depending on their age and stage of physical development. Trans youth who have reached the early stages of puberty may be prescribed puberty blockers, which prevent the further progression of assigned-sex puberty and the development of associated secondary sex characteristics. 24 Halting puberty is typically done to give trans youth more time to process their identity and decide whether to pursue further steps in transition, 25 and to prevent irreversible physical changes that conflict with their desired gender presentation and increase dysphoria. 26

Beginning at around age sixteen, 27 trans youth can be prescribed hormone replacement therapy (HRT), which causes development of secondary sex characteristics associated with the trans youth’s identified gender. 28 For trans girls, HRT involves suppressing endogenous testosterone and taking estrogen, 29 a regimen that typically causes breast growth, softer skin, and reduction in body hair, 30 while for trans boys, it involves taking testosterone, 31 which typically causes muscle growth, an increase in body and facial hair, and a deeper voice. 32 Some nonbinary youth also seek HRT, but there are currently no formal standards of care for nonbinary people and there is little research as to clinical outcomes outside the binary context. 33 The WPATH SOC and Endocrine Society typically require parental consent before doctors may prescribe HRT to minors. 34

Gender confirmation surgery (GCS), which involves changing a transgender person’s reproductive anatomy to the anatomy usually associated with their identified gender, is rarely performed for trans youth because the WPATH SOC require the patient to have attained the age of majority to be eligible for surgery. 35 Additionally, insurance coverage usually requires GCS patients to be eighteen or older. 36 However, GCS is not the only type of gender-affirming surgery. Transgender men may undergo surgery to remove breast tissue (“top surgery”), and the WPATH SOC allow this surgery to be performed on patients under eighteen on a case-by-case basis. 37

2. Why Trans Youth Need Access to Gender-Affirming Healthcare .

Access to these gender-affirming healthcare services is essential — even lifesaving — for trans youth. There is a vast disparity in traditional measures of quality of life between trans youth with untreated dysphoria and their cisgender peers. A wealth of empirical research confirms that, although it does not erase this gap, medical transition narrows it considerably. This section summarizes the benefits of gender-affirming care for trans youth in three spheres: mental health, social acceptance, and legal rights. Although they are categorized separately for organizational purposes, these spheres often intersect and complement one another in practice.

(a) Mental Health. — Untreated dysphoria in trans youth is associated with severe mental health problems, including depression, social anxiety, and suicidal thoughts and behavior. 38 A study of baseline (pre-transition) psychological characteristics of trans youth revealed that twenty percent had “moderate to extreme” depressive symptoms, and that their reported rate of suicidal thoughts and attempts was at least three times higher than that of the general youth population. 39 Over half reported having thought about suicide, and a third reported at least one attempt. 40

Conversely, a large body of research demonstrates that trans youth who receive gender-affirming healthcare to treat their dysphoria show decreased anxiety, depression, suicidal behavior, and psychological distress, 41 and increased quality of life. 42 Trans children who are allowed to socially transition before puberty have relatively normal rates of depression and anxiety, “in striking contrast” with nontransitioned trans children. 43 A longitudinal study of trans adolescents before and after they received gender-affirming care found that psychological functioning steadily improved throughout treatment and that overall well-being after treatment was “comparable to [that of] same-age peers.” 44 And a study of transgender adults found that subjects who had received puberty blockers in childhood had a significantly lower incidence of suicidal ideation than did those who had wanted puberty blockers but did not receive them. 45 Of course, gender dysphoria is not the sole cause of psychological distress and mental health problems in trans youth, nor is access to gender-affirming healthcare a panacea. But, in the words of the preeminent professional association of pediatric psychiatry in the United States, “[r]esearch consistently demonstrates that gender diverse youth . . . have better mental health outcomes” when they have access to gender-affirming healthcare. 46

(b) Social Integration. — Middle school and high school are stressful for many young people, but they are often particularly difficult social environments for trans youth. Not only are trans students disproportionately bullied and alienated by their peers, 47 but they may also have problems fitting in due to the frequent mental health issues associated with untreated dysphoria 48 and feelings of not “belonging” with cisgender students. 49 This trauma only intensifies with the onset of assigned-sex puberty, which causes trans youth to develop secondary sex characteristics (such as breasts in trans boys and facial hair in trans girls) that are inconsistent with their gender identities. 50 Because of this process, trans youth who undergo assigned-sex puberty often experience decreased self-esteem and increased body image issues, which can cause further social and educational impairment. 51 Physical changes from puberty may also make it harder for trans youth to “pass” as the gender with which they identify, 52 meaning they are more likely to experience psychological problems 53 and to face discrimination and abuse. 54

Puberty blockers and HRT allow trans youth to avoid many of these challenges. Trans youth who start puberty blockers or HRT in childhood or adolescence are spared the hardships of navigating school and peer relationships while presenting as a gender with which they do not identify. Because of this relief, medically transitioned trans youth are often more confident and socially well-adjusted than their nontransitioned peers. 55 Undergoing medical transition at an earlier age also allows many trans youth to “pass” more easily as their identified gender, 56 and avoid many of the challenges associated with being visibly transgender. 57

(c) Legal Status. — Gender-affirming medical care often mediates the availability of legal rights and protections for trans youth. Most notably, many states require medical evidence like a diagnosis of gender dysphoria, HRT, or GCS to change a transgender person’s gender on identity documents such as driver’s licenses and birth certificates. 58 Misalignment between a trans youth’s gender presentation and their gender on identity documents is not an isolated indignity; it can have serious collateral consequences. For example, many colleges and universities do not allow students to use their preferred names or genders in school records if they have not legally changed them on identity documents. 59

Access to gender-affirming care is also critical for many trans youth to participate in competitive school sports. The National Collegiate Athletic Association and some state high school athletic associations allow trans girls to play on girls’ sports teams only after they have taken HRT for a certain period, out of concern that their assigned sex gives them an “unfair” advantage. 60 Trans boys typically do not have to meet specific medical criteria in order to play on boys’ teams, 61 but in practice it will often be difficult for trans boys to compete with other boys without the physiological benefits of testosterone. 62

Finally, lack of access to gender-affirming care continues to mitigate trans youths’ access to sex-segregated school bathrooms and locker rooms. The Biden Administration is expected to reinstate the Obama Administration’s 2016 Title IX guidance that required schools to allow students to use facilities consistent with their gender identities. 63 Even so, there are reasons to think access to gender-affirming medical care is still relevant to determining trans youths’ access to such facilities. First, trans youth may be less comfortable coming out as transgender to their peers and school officials if they have not started medical transition. Second, school districts and courts may be more willing to accept in practice a trans student’s use of facilities consistent with their identified gender if they have provided evidence of being diagnosed with dysphoria or undergoing gender-affirming medical treatment. 64

Proposed State Legislation Banning Gender-Affirming Healthcare for Trans Youth

1. background and legislative context..

A custody battle in a Dallas suburb is an unlikely spark for a political brushfire. But in October 2019, a dispute in Texas family court over parental rights for a seven-year-old transgender girl ignited outrage in conservative circles. 65 The girl’s father, Jeffrey Younger, petitioned for full custody based on his disagreement with her mother’s gender-affirming parenting approach, accusing the mother of “emotional abuse” for allowing the girl to express her gender identity. 66 Unfolding amid a frenzy of media coverage and vocal opposition to the mother’s gender-affirming stance from conservatives, 67 the Younger case shined a national spotlight on the issue of gender-affirming medical care for minors and prompted calls for legislative action from Texas Republicans. 68

In truth, the Younger case and the ensuing media controversy did not begin the political movement against gender-affirming healthcare for minors so much as add fuel to a campaign already broiling within conservative lobbying groups. The Heritage Foundation, one of the most influential conservative think tanks in the United States, 69 hosted a series of events on the “medical risks” of gender-affirming healthcare for trans youth at its DC headquarters throughout 2019. 70 These events proved foundational to later legislative efforts; attendees at the conferences authored several of the bans, 71 and a policy manager at Family Policy Alliance, a Christian conservative lobbying group that cohosted one of the Heritage events, confirmed that her organization “work[ed] with legislators all over the country” to distribute “model” gender-affirming care bans to be introduced during states’ 2020 legislative sessions. 72

With help from these groups, legislators in fifteen states introduced bills between January and March 2020 banning medical professionals from providing gender-affirming healthcare to minors. 73 The bills are tellingly similar in substance and language. 74 Almost every bill (with some minor deviations 75 ) bans all medical professionals in the state from administering puberty blockers or HRT to, or performing gender-affirming surgery on, anyone under the age of eighteen, with notable exceptions for minors with “medically verifiable” developmental disorders or intersex conditions. 76 Most of the proposals make providing gender-affirming care a crime; on the extreme end, violation of Idaho’s prohibition is a felony punishable by a life sentence. 77 Because they would prevent any state-licensed medical providers from administering gender-affirming care, the bans would effectively prohibit trans youth from accessing that care unless they were able to travel out of state. Thus, they would disproportionately burden trans youth from disadvantaged socioeconomic backgrounds and communities of color, who are less likely to have the resources to travel across state lines or to relocate for care. 78

None of the fifteen bills introduced in early 2020 became law, 79 al-though bills in Alabama and South Dakota passed by large margins in individual state houses. 80 But the fact that no bills passed during the 2020 legislative session may not be a meaningful indication of whether they will pass in the future. The COVID-19 lockdowns in the United States in March 2020 forced many state legislatures to adjourn regular sessions before important committee votes on the bills. 81 Additionally, a wave of early failures does not necessarily rule out future success; “bathroom bills” banning trans people from using public bathrooms and changing facilities consistent with their identified genders failed in at least ten states between 2013 and 2015 82 before North Carolina infamously passed House Bill 2 in March 2016. 83 Finally, a recent High Court decision in the United Kingdom severely inhibiting administration of puberty blockers to trans youth under age sixteen is likely to invigorate opponents of gender-affirming care for trans youth in the United States. 84

2. Explaining Gender-Affirming Healthcare Bans.

Legal and political battles over gender-affirming healthcare have persisted for decades, 85 and are somewhat ubiquitous today. 86 Nevertheless, the gender-affirming care bans deserve particular attention because they mark a subtle yet important rhetorical pivot in the broader political opposition to trans youth. To understand the larger sociopolitical significance of the gender-affirming care bans, as well as to lay the foundation for constitutional arguments against them, this section deconstructs the bans’ underlying purposes and rationales.

Some of the bills included statements of legislative purpose that provide useful starting points. For example, the Mississippi Senate bill’s “Legislative findings and intent” section states in part that “the decision to pursue [gender-affirming care] should not be presented to or determined for minors who are incapable of comprehending the negative implications and life-altering difficulties attending to these interventions.” 87 Similar language subsists throughout the proposals, revealing a consistent, surface-level legislative intent to “protect” trans youth from gender-affirming medical interventions. 88

This paternalistic rhetoric represents a narrative shift that has surfaced in the wake of widespread rejection of preexisting justifications for discrimination against trans youth. The most prominent political crusade against trans youth, the bathroom scare of the mid-to-late 2010s, portrayed trans youth as predatory, deviant, and mentally unstable, 89 and their rights to use sex-segregated spaces as intrusions on the privacy and safety of cisgender children. 90 These strategies have largely failed both in courts of law 91 and in the court of public opinion. 92 Even many conservatives have cautioned that overt fearmongering about trans people intruding on others in public spaces is not a winning political strategy. 93

But prejudice dies hard. When one justification for negative treatment of a disfavored group falls out of favor with the public or the legal system, opponents of that group often translate their prejudice into new rhetorical forms that are more palatable. 94 The shift from the stigmatization and vilification of trans youth in the bathroom bills to the victimization narrative embodied in the gender-affirming care bans illustrates how opponents of trans identity are adapting their rhetoric in response to changing legal and social attitudes towards transgender children. Courts, media, and the public should not be fooled. The paternalistic arguments underlying gender-affirming care bans reflect the same underlying prejudices arising from the same individuals and groups, 95 and are directed towards the same ends — erasing trans youth by stigmatizing transgender identity and fortifying the gender binary 96 — as bathroom bills and similar transparently vindictive campaigns. In translating their hostility to trans youth into a more socially acceptable language of “protecting” trans youth from the supposedly fraught choice of whether to transition, 97 cultural conservatives play both sides of the ball. They moderate their image by appealing to fundamental paternalistic impulses while continuing to work toward eradication of transgender identity in children by blocking access to medical services that make transition possible. 98

Their pretextual nature does not — as the UK case illustrated 99 — mean the paternalistic justifications can be ignored. The argument that trans youth should not receive gender-affirming medical care must be vigorously discredited on its own terms as a fallacious rationalization of ingrained prejudices that contradicts both empirical data and the experiences of thousands of children. For one thing, the bills’ central justification, that trans youth lack the capacity for self-reflection necessary to accurately perceive their gender identities, 100 is flatly untrue. Trans youth are quite secure in their gender identities by the time hormonal interventions become physiologically appropriate. 101 A related claim, that trans youth should have to wait until adulthood to transition because many young children who display gender nonconforming behavior “desist,” or do not grow up to be transgender, 102 has questionable empirical support 103 and, more fundamentally, equivocates gender expression with gender identity. There is a meaningful difference between a child who exhibits gender-atypical behavior and a child who persistently identifies as another gender, and the fact that the former child may not be transgender does nothing to invalidate the latter child’s entitlement to access medically necessary gender-affirming care. And gender nonconforming children who later “desist” from expressing the binary gender opposite to their assigned sex may not necessarily identify as cisgender; they may be nonbinary or possess another gender identity. Presuming that all of these persons are cisgender thus erases nonbinary experiences. 104 Second, the implied premise that trans youth have unilateral control over whether and when they transition is empirically untrue because the current standards of care recommend both parental consent and a medical diagnosis of gender dysphoria before a minor can receive puberty blockers or HRT. 105 This “gatekeeping” model, far from uncritically acceding to trans youths’ wishes, privileges caution and deliberation over ease of access. 106 Finally, even if one accepts that a certain number of cisgender youth will mistakenly transition if gender-affirming healthcare is available (which is itself a dubious proposition), that number is likely dwarfed by the number of trans youth who will suffer the opposite, equivalent harm — being unable to transition even though transition is right for them — if gender-affirming healthcare is not available.

Constitutional Arguments Against Gender-Affirming Care Bans

Gender-affirming care bans are not only harmful and founded on false premises, they are also unconstitutional. This section sketches two constitutional arguments against these proposed bans: one based in the Equal Protection Clause of the Fourteenth Amendment, and one based in the parental rights strand of substantive due process jurisprudence.

1. Equal Protection.

The Equal Protection Clause ensures the right of all citizens to enjoy “the equal protection of the laws,” 107 or to be free from unjustified, government-imposed discrimination. 108 An equal protection challenge against a facially discriminatory law usually proceeds in two stages: First, the plaintiff must show that the law discriminates or classifies based on the plaintiff’s membership in a protected class. 109 Second, the burden shifts to the government to show that the classification is justified by an adequate government interest, and the extent of the government’s burden depends on the tier of scrutiny applied to the type of classification at issue. 110

(a) Protected Class. — In the last few years, a growing number of courts of appeals have found that discrimination against transgender people violates equal protection. 111 Some courts have held that transgender status is a protected class in its own right, 112 while others have found that antitransgender discrimination is sex discrimination. 113 Across-the-board bans on gender-affirming healthcare for trans youth would likely receive heightened scrutiny under either framing. Gender-affirming care bans discriminate based on transgender status because they prohibit providing HRT and GCS to minors for the specific purpose of affirming a trans youth’s gender identity, thus facially discriminating against transgender identity, and because in most cases they include exceptions allowing that same care to be provided to cisgender minors for the purpose of treating intersex conditions or “disorder[s] of sexual development.” 114 It may be argued that the bans do not facially discriminate based on transgender status, because they simply bar conduct associated with being transgender . But this formalistic status/conduct distinction was hardly convincing in the context of sexual orientation discrimination and is similarly unpersuasive in the context of antitransgender discrimination. 115

The per se transgender status argument may no longer be necessary, however, in light of the Supreme Court’s recent decision in Bostock v. Clayton County , 116 which held that discrimination against transgender people is sex discrimination under Title VII. 117 Justice Gorsuch’s majority opinion applied a but-for causation standard to find that “discrimination based on . . . transgender status necessarily entails discrimination based on sex.” 118 Although Bostock ’s holding formally reached only Title VII, Justice Alito’s dissent and several courts of appeals recognized that its analysis applies just as clearly to equal protection claims. 119 Just as an employer discriminates “because of sex” when it “intentionally penalizes a person [assigned] male at birth for traits or actions that it tolerates in an employee [assigned] female at birth,” 120 bans on gender-affirming care for minors discriminate because of sex when they deny minors assigned one sex at birth access to certain medical procedures for gender-affirming purposes, but allow those same procedures to be performed for minors assigned the other sex at birth for non-gender-affirming purposes. 121

(b) Government Interest. — To survive heightened scrutiny, the government’s interest must at least be “important” and the law must be “substantially related” to the advancement of the interest. 122 Gender-affirming care bans fail this means-ends inquiry along both dimensions. First, the alleged purpose of the bans — to protect children from receiving gender-affirming healthcare — is fundamentally inconsistent with the empirical evidence and the lived experiences of many trans youth showing the efficacy and safety of these treatments, 123 and is based in faulty logic. 124 It is hard to argue that “protecting” children from medically necessary healthcare that is endorsed by nearly every professional medical association in the country 125 and validated by a near-unanimous consensus in peer-reviewed literature 126 is an interest sufficiently “legitimate” to pass rational basis review, much less one “important” enough to satisfy heightened scrutiny. 127 Second, the bans fail the “substantially related” test because they are considerably underinclusive: even as they identify gender-affirming medical interventions as “dangerous and uncontrolled human medical experiment[s],” 128 they allow the same procedures to be performed on children who have “medically verifiable disorder[s] of sex development.” 129 If the bans are actually motivated by concern over the supposed dangers of puberty blockers, HRT, and GCS, providing an exception allowing those treatments to be performed for practically any medical condition other than gender dysphoria 130 is hardly “substantially related” to abating these alleged harms.

If their purposes are taken at face value, the gender-affirming care bans cannot survive heightened scrutiny. But they also fail under rational basis review, since, as section A explained, their real purpose is preventing transgender children from expressing their transgender identity, 131 an expression of animus against transgender people that cannot be a legitimate government interest in the first place. 132 Animus can be demonstrated in a number of ways: based on inference from the structure of the law and through direct evidence that the law was motivated by prejudice. 133 As the Supreme Court held in City of Cleburne v. Cleburne Living Center, Inc ., 134 the structure of a classification can provide inferential evidence of animus when the alleged government interest does not support targeting the particular group over and above other similarly situated groups. 135 Thus, when state governments profess that bans on gender-affirming medical treatments are meant to protect children from invasive and life-changing medical procedures, but only ban procedures that are performed for the purpose of affirming a trans youth’s gender identity, the arbitrariness of the classification suggests the stated interests are pretext for animus. 136

Ultimately, however, this structural analysis is probably unneeded because there is abundant direct evidence of animus against transgender people surrounding the bans. 137 For example, during a private meeting, the Florida bill’s sponsor told a nonbinary opponent of the bill that transgender people “manufacture” their identities. 138 The author of the South Dakota legislation labeled medical transition in minors a “crime against humanity” and analogized it to medical experimentation at Auschwitz. 139 The lead sponsor of the Colorado bill admitted he was “not concerned” about the potential impact of the bill on the mental health of trans youth in the state, but was disturbed by “a progression of acceptance of young kids being sterilized.” 140 The organizations that promoted these bills also demonstrate clear animus towards transgender identity. YouTube removed the video of the October 2019 Heritage Foundation event that inspired many of the bills after determining that the Heritage panelists’ incendiary comments violated the YouTube hate speech policy. 141 And the Family Policy Alliance, which helped draft many of the bills, declares prominently on its website that it “oppose[s] . . . attempts to normalize” being transgender, “especially amongst impressionable children.” 142

2. Due Process and Parental Rights.

The gender-affirming care bans also arguably violate the Fourteenth Amendment’s due process guarantee of parents ’ rights to make decisions about the upbringing of their children. The due process right to freedom in child rearing is one of the foundational rights protected under substantive due process doctrine, dating back to the early twentieth century 143 and consistently reaffirmed since then. 144 It protects parents’ ability to make important decisions about “the care, custody, and control of their children” free from government interference, 145 based on the presumption that a parent, not the state, is in the best position to determine their child’s best interests. 146 The Supreme Court has never explicitly held that the due process right to freedom in child rearing encompasses the right to direct a child’s medical care, but has implied as much in at least one case. 147 Many other courts and commentators have presumed that parents’ common law right to supervise their children’s healthcare is constitutionally protected. 148 Gender-affirming care bans would likely violate this right. Prohibiting parents from authorizing medically necessary treatment for their children when they believe this care is in their children’s best interests is just the kind of intrusive government conduct that parental due process rights guard against.

Of course, parental rights are not absolute. The state can limit parental autonomy in medical decisionmaking in order to prevent injury to children’s health and well-being. 149 For example, many states have passed bans on conversion therapy for minors based on the nearly unanimous medical consensus that such treatment is harmful and dangerous. 150 Courts have upheld these bans against due process challenges on the ground that “the fundamental rights of parents do not include the right to choose . . . a specific medical or mental health treatment that the state has reasonably deemed harmful.” 151

The test is whether the treatment is actually harmful or reasonably believed to be harmful, which depends on the weight of scientific evidence for the legislature’s judgment. Conversion therapy bans do not violate due process because a considerable scientific consensus views conversion therapy as harmful and senseless. 152 The crucial difference in the case of gender-affirming care bans is that the weight of the scientific supermajority, 153 along with a growing canon of empirical research 154 and the lived experiences of thousands of trans youth who benefit from gender-affirming care, is against the legislatures’ judgments that gender-affirming care is harmful.

None of this is to say that challenges to gender-affirming healthcare bans on due process grounds are certain to prevail. Courts often fail to interrogate the factual underpinnings of a legislature’s judgment because their focus is more directly trained on rooting out the motivations of the legislature than on checking the lawmakers’ work in an empirical sense, 155 or because they are distracted by their moral preconceptions of an issue. 156 This failure is unfortunately commonplace in transgender rights cases, 157 though recent decisions have shown improvement in this regard. 158 There is also a risk that parental due process arguments could be turned against trans youth who seek to use state resources to obtain access to gender-affirming care against the wishes of unaccepting parents. Detailed exploration of this question is not possible here, but it is doubtful that the best-interests presumption applies if the parent’s decision not to accept their child’s transgender identity or desire to transition is motivated by prejudice, to which “the law cannot, directly or indirectly, give . . . effect.” 159

Anxiety about gender-affirming medical interventions for trans youth is understandable in many respects. Puberty blockers, HRT, and GCS are dramatic and life-changing decisions. However, a failure to intervene can be equally consequential. In other words, foregoing gender-affirming care “is not a neutral option” 160 for trans youth: it is a choice that imposes significant risks of physical, mental, social, and legal harms. Even so, this Chapter does not argue that every trans youth must transition before adulthood. Although evidence suggests this is the best option in many cases, every trans youth is different, and many transgender people live happy and healthy lives after transitioning as adults. Nor does this Chapter have the scope to opine on the ideal distribution of agency in these decisions between doctors, parents, and trans youth, beyond the observation that parents’ animus or prejudice against transgender people should not inhibit a youth’s access to care. 161 Ultimately, “protecting” trans youth requires allowing them to access medical care that permits them to live according to their own definitions of themselves, rather than the definitions ascribed to them by politicians whose goal is not protection, but suppression of children whose identities threaten their worldview. Perhaps lawmakers will one day realize this. But for now, the issue of gender-affirming healthcare for trans youth remains a heated battleground in the culture war, with the rights of thousands of children once again subject to political will.

^ Pam O’Brien, How Nicole Maines Is Paving the Way for the Next Generation of LGBTQ Youth , Shape (Aug. 15, 2019), <a href=" https://www.shape.com/celebrities/interviews/nicole-maines-transgender-activist-supergirl ">https://www.shape.com/celebrities/interviews/nicole-maines-transgender-activist-supergirl">https://www.shape.com/celebrities/interviews/nicole-maines-transgender-activist-supergirl [ https://perma.cc/5QET-8948 ].

^ See Michelle M. Johns et al., Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students — 19 States and Large Urban School Districts, 2017 , 68 Morbidity & Mortality Wkly. Rep . 67, 70 (2019).

^ Hereinafter “trans youth,” which this Chapter defines as transgender children and adolescents between roughly twelve and eighteen years of age.

^ This Chapter assumes basic familiarity with terms like “transgender” and “cisgender” and with the difference between assigned sex at birth and gender identity. For an introductory explanation of these concepts, see Understanding Gender , Gender Spectrum , <a href=" https://genderspectrum.org/articles/understanding-gender ">https://genderspectrum.org/articles/understanding-gender">https://genderspectrum.org/articles/understanding-gender [ https://perma.cc/U635-823E ].

^ See Jason Rafferty, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents , Pediatrics , Oct. 2018, at 1, 4–5.

^ See generally, e.g ., Emily Ikuta, Note, Overcoming the Parental Veto: How Transgender Adolescents Can Access Puberty-Suppressing Hormone Treatment in the Absence of Parental Consent Under the Mature Minor Doctrine , 25 S. Cal. Interdisc. L.J. 179 (2016) (describing the problems that arise when the parent of a trans youth refuses to provide consent to gender-affirming treatment for their child, and how minors can argue for the right to consent).

^ See, e.g ., Diane Ehrensaft, Gender Nonconforming Youth: Current Perspectives , 8 Adolescent Health Med. & Therapeutics 57, 57–58 (2017). This increased research and attention has largely centered on the experiences of youth who transition from one binary gender to the other, and has neglected the experiences of nonbinary youth. Abbie E. Goldberg et al., Health Care Experiences of Transgender Binary and Nonbinary University Students , 47 Counseling Psych . 59, 86 (2019). For more on the experiences of nonbinary youth in transgender healthcare, see, for example, Gary E. Butler, Child and Adolescent Endocrinology , in Genderqueer and Non-binary Genders 171, 177–79 (Christina Richards, Walter Pierre Bouman & Meg-John Barker eds., 2017); and Goldberg et al., supra , at 86–90.

^ This Chapter uses the umbrella term “gender-affirming healthcare” to describe the range of medical services that trans youth use to bring their bodies and lived experiences into alignment with their gender identities (“transition”).

^ See Past Legislation Affecting LGBT Rights Across the Country , ACLU (Mar. 20, 2020), https://www.aclu.org/past-legislation-affecting-lgbt-rights-across-country-2020 [ https://perma.cc/KQ6T-KDR2 ] [hereinafter ACLU Legislation Tracker ]; H.B. 3515, 101st Gen. Assemb., Reg. Sess. (Ill. 2019). The Illinois bill was originally introduced in 2019, but changed sponsors in 2020. See Bill Status of HB 3515 , Ill. Gen. Assembly , https://www.ilga.gov/legislation/BillStatus.asp?DocNum=3515&GAID=15&DocTypeID=HB&SessionID=108&GA=101 [ https://perma.cc/6S5R-6SX9 ].

^ See ACLU Legislation Tracker , supra note 9; Bill Status of HB 3515 , supra note 9.

^ See H.B. 1, 2021 Leg., Reg. Sess. (Ala. 2021); S.B. 224, 122d Gen. Assemb., 1st Reg. Sess. (Ind. 2021); H. File 193, 89th Gen. Assemb., Reg. Sess. (Iowa 2021); H.B. 33, 101st Gen. Assemb., 1st Reg. Sess. (Mo. 2021); H.B. 113, 67th Leg., Reg. Sess. (Mont. 2021); H.B. 68, 167th Gen. Ct., Reg. Sess. (N.H. 2021); S.B. 676, 58th Leg., 1st Reg. Sess. (Okla. 2021); H.B. 92, 64th Leg., Gen. Sess. (Utah 2021); H.B. 68, 87th Leg., Reg. Sess. (Tex. 2020). For an up-to-date list of gender-affirming care bans filed in 2021, see Legislative Tracker: Anti-transgender Medical Care Bans , Freedom for All Ams ., <a href=" https://freedomforallamericans.org/legislative-tracker/medical-care-bans ">https://freedomforallamericans.org/legislative-tracker/medical-care-bans/">https://freedomforallamericans.org/legislative-tracker/medical-care-bans [ https://perma.cc/JX3V-J3US ].

^ See Bell v. Tavistock [2020] EWHC (Admin) 3274 [151] (Eng.).

^ Because the rationales and legal errors underlying the 2021 bills were substantially the same as the 2020 bills, and because the 2021 bills were rapidly evolving and changing at the time of publication, this Chapter focuses its critique on the 2020 bills rather than the 2021 bills.

^ See, e.g ., Hallie Horowitz, Introduction to Just Evelyn, Mom, I Need to Be a Girl 4, 4 (1998), <a href=" https://ai.eecs.umich.edu/people/conway/TS/Evelyn/Mom_I_need_to_be_a_girl.pdf ">http://ai.eecs.umich.edu/people/conway/TS/Evelyn/Mom_I_need_to_be_a_girl.pdf">https://ai.eecs.umich.edu/people/conway/TS/Evelyn/Mom_I_need_to_be_a_girl.pdf [ https://perma.cc/LD34-7MYX ] (describing “one of the first” adolescent transitions in the mid-1990s).

^ Johns et al., supra note 2, at 68. 1.6 percent said they were “not sure.” Id .

^ See Ehrensaft, supra note 7, at 57–58.

^ World Pro. Ass’n for Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People 5 (7th ed. 2012) [hereinafter WPATH SOC]. Importantly, dysphoria is a psychological condition that results from a difference between gender identity and assigned sex at birth; transgender identity is not itself a psychological condition or mental illness. See id . at 5–6.

^ See id . at 8.

^ Kellan E. Baker, The Future of Transgender Coverage , 376 New Eng. J. Med. 1801 , 1801 (2017); see Professional Organization Statements Supporting Transgender People in Health Care , Lambda Legal (Sept. 17, 2018), https://www.lambdalegal.org/sites/default/files/publications/downloads/resource_trans-professional-statements_09-18-2018.pdf [ https://perma.cc/5HTA-PUHR ] (collecting statements of medical necessity). “Medically necessary” — and the closely related term “medical necessity” — is a term of art used to describe “[h]ealth care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.” Medically Necessary , HealthCare.gov , <a href=" https://www.healthcare.gov/glossary/medically-necessary ">https://www.healthcare.gov/glossary/medically-necessary/">https://www.healthcare.gov/glossary/medically-necessary [ https://perma.cc/Y6K7-HAKL ].

^ See WPATH SOC, supra note 17, at 1–2; Rafferty, supra note 5, at 6. Other medical associations also provide guidance to clinicians in specific areas of care such as hormone treatment. See, e.g ., Wylie C. Hembree et al., Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline , 102 J . Clinical Endocrinology & Metabology 3869, 3874 (2017).

^ See Am. Med. Ass’n House of Delegates, Resolution: 122, Subject: Removing Financial Barriers to Care for Transgender Patients 1 (2008), <a href=" https://www.imatyfa.org/assets/ama122.pdf ">http://www.imatyfa.org/assets/ama122.pdf">https://www.imatyfa.org/assets/ama122.pdf [ https://perma.cc/T6RY-7LZN ]; Edmo v. Corizon, Inc., 935 F.3d 757, 769 (9th Cir. 2019) (citing case law and medical authority recognizing the WPATH SOC as the prevailing medical standard).

^ See WPATH SOC, supra note 17, at 14, 18–19.

^ See Johanna Olson, Catherine Forbes & Marvin Belzer, Management of the Transgender Adolescent , 165 Archives Pediatric & Adolescent Med . 171, 174 (2011) (stating that the majority of gender specialists follow this affirming approach); Leigh A. Spivey & Laura Edwards-Leeper, Future Directions in Affirmative Psychological Interventions with Transgender Children and Adolescents , 48 J. Clinical Child & Adolescent Psych . 343, 347–48 (2019).

^ See Simone Mahfouda et al., Review, Puberty Suppression in Transgender Children and Adolescents , 5 Lancet Diabetes & Endocrinology 816, 817–18 (2017).

^ Id . at 816; see WPATH SOC, supra note 17, at 19.

^ See WPATH SOC, supra note 17, at 19; Mahfouda et al., supra note 24, at 817–18.

^ See Hembree et al., supra note 20, at 3884–85.

^ See WPATH SOC, supra note 17, at 33–34.

^ Id . at 48.

^ Id . at 38 tbl.1B.

^ Id . at 49.

^ Id . at 37 tbl.1A.

^ See Butler, supra note 7, at 179; Anna Martha Vaitses Fontanari et al., Gender Affirmation Is Associated with Transgender and Gender Nonbinary Youth Mental Health Improvement , 7 LGBT Health 237, 243 (2020).

^ See WPATH SOC, supra note 17, at 20; Hembree et al., supra note 20, at 3878 tbl.5. But see generally Ikuta, supra note 6 (describing a strategy for minors in the United States to obtain HRT without parental consent).

^ See WPATH SOC, supra note 17, at 21, 54–55; see also Olson, Forbes & Belzer, supra note 23, at 176.

^ See, e.g ., Clinical Policy Bulletin, Gender Affirming Surgery , Aetna (Jan. 12, 2021), <a href="https://www.aetna.com/cpb/medical/data/600_699/0615.html ">https://www.aetna.com/cpb/medical/data/600_699/0615.html [ https://perma.cc/C5ZK-VZAR ].

^ WPATH SOC, supra note 17, at 21; see also Masculinizing Chest Reconstruction (“Top Surgery”) , UCSF Transgender Care , <a href=" https://transcare.ucsf.edu/masculinizing-chest-reconstruction-top-surgery ">https://transcare.ucsf.edu/masculinizing-chest-reconstruction-top-surgery/">https://transcare.ucsf.edu/masculinizing-chest-reconstruction-top-surgery [ https://perma.cc/6HM2-UV5W ].

^ See, e.g ., Trevor Project, National Survey on LGBTQ Youth Mental Health 2020 , at 3 (2020), <a href=" https://www.thetrevorproject.org/wp-content/uploads/2020/07/The-Trevor-Project-National-Survey-Results-2020.pdf ">https://www.thetrevorproject.org/wp-content/uploads/2020/07/The-Trevor-Project-National-Survey-Results-2020.pdf">https://www.thetrevorproject.org/wp-content/uploads/2020/07/The-Trevor-Project-National-Survey-Results-2020.pdf [ https://perma.cc/WXM5-JVG6 ]; Johanna Olson et al., Baseline Physiologic and Psychosocial Characteristics of Transgender Youth Seeking Care for Gender Dysphoria , 57 J. Adolescent Health 374, 375, 378 tbl.5 (2015).

^ Olson et al., supra note 38, at 379.

^ Id .; see also Johns et al., supra note 2, at 69 tbl.2 (finding that 43.9% of transgender high school students considered attempting and 34.6% attempted).

^ See, e.g ., Rosalia Costa et al., Psychological Support, Puberty Suppression, and Psychosocial Functioning in Adolescents with Gender Dysphoria , 12 J. Sexual Med . 2206, 2212 (2015); Annelou L.C. de Vries et al., Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment , Pediatrics , Oct. 2014, at 1, 6–7; Fontanari et al., supra note 33, at 243; Kristina R. Olson et al., Mental Health of Transgender Children Who Are Supported in Their Identities , Pediatrics , Mar. 2016, at 1, 5; Jack L. Turban et al., Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation , Pediatrics , Feb. 2020, at 1, 5; Anna I.R. van der Miesen et al., Psychological Functioning in Transgender Adolescents Before and After Gender-Affirmative Care Compared with Cisgender General Population Peers , 66 J. Adolescent Health 699, 703 (2020).

^ See de Vries et al., supra note 41, at 7. See generally What Does the Scholarly Research Say About the Effect of Gender Transition on Transgender Well-Being? , Cornell Univ.: What We Know Project , <a href=" https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-well-being-of-transgender-people ">https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-well-being-of-transgender-people">https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-well-being-of-transgender-people [ https://perma.cc/RZ6H-4JC8 ] [hereinafter What We Know Project ] (collecting over fifty studies showing improvements in quality of life for transgender people after gender-affirming care).

^ Lily Durwood, Katie A. McLaughlin & Kristina R. Olson, Mental Health and Self-Worth in Socially Transitioned Transgender Youth , 56 J. Am. Acad. Child & Adolescent Psychiatry 116, 116 (2017).

^ de Vries et al., supra note 41, at 7 (finding that transitioned youth exhibited “quality of life, satisfaction with life, and subjective happiness” scores similar to those of cisgender youth).

^ See Turban et al., supra note 41, at 5.

^ AACAP Statement Responding to Efforts to Ban Evidence-Based Care for Transgender and Gender Diverse Youth , Am. Acad. Child & Adolescent Psychiatry (Nov. 8, 2019), <a href=" https://www.aacap.org/AACAP/Latest_News/AACAP_Statement_Responding_to_Efforts-to_ban_Evidence-Based_Care_for_Transgender_and_Gender_Diverse.aspx ">https://www.aacap.org/AACAP/Latest_News/AACAP_Statement_Responding_to_Efforts-to_ban_Evidence-Based_Care_for_Transgender_and_Gender_Diverse.aspx">https://www.aacap.org/AACAP/Latest_News/AACAP_Statement_Responding_to_Efforts-to_ban_Evidence-Based_Care_for_Transgender_and_Gender_Diverse.aspx [ https://perma.cc/WXH9-5AKY ] [hereinafter AACAP Statement ]; see also Endocrine Soc’y & Pediatric Endocrine Soc’y, Transgender Health Position Statement (2020), <a href=" https://www.endocrine.org/-/media/endocrine/files/advocacy/position-statement/position_statement_transgender_health_pes.pdf ">https://www.endocrine.org/-/media/endocrine/files/advocacy/position-statement/position_statement_transgender_health_pes.pdf">https://www.endocrine.org/-/media/endocrine/files/advocacy/position-statement/position_statement_transgender_health_pes.pdf [ https://perma.cc/JQ9S-TAQ2 ].

^ See, e.g ., Johns et al., supra note 2, at 69 tbl.2 (showing significantly higher rates of in-person and online bullying and feelings of unsafety at school compared to cisgender students); cf . Trevor Project , supra note 38, at 7 (showing high levels of violence and discrimination against transgender youth).

^ See sources cited supra notes 38–40 and accompanying text.

^ See Goldberg et al., supra note 7, at 7.

^ See Hembree et al., supra note 20, at 3880–81 (listing various “[i]rreversible and . . . undesirable sex characteristics” that develop during assigned-sex puberty, id . at 3881); Turban et al., supra note 41, at 6.

^ See Jenifer K. McGuire et al., Body Image in Transgender Young People: Findings from a Qualitative, Community Based Study , 18 Body Image 96, 103 (2016) (noting that transgender young people feel social stress when they exhibit physical characteristics associated with their assigned sexes); Developments in the Law — Sexual Orientation & Gender Identity , 127 Harv. L. Rev . 1680, 1726 (2014) (noting the “severe negative impact” of discrimination on trans students’ educational outcomes and that socially transitioned trans youth “report a healthier sense of belonging than their peers who are not able to express and embrace their transgender identities”).

^ See, e.g ., Laura Kuper , IMPACT LGBT Health & Dev. Program , Puberty Blocking Medications 8 (2014), <a href=" https://www.impactprogram.org/wp-content/uploads/2014/12/Kuper-2014-Puberty-Blockers-Clinical-Research-Review.pdf ">https://www.impactprogram.org/wp-content/uploads/2014/12/Kuper-2014-Puberty-Blockers-Clinical-Research-Review.pdf">https://www.impactprogram.org/wp-content/uploads/2014/12/Kuper-2014-Puberty-Blockers-Clinical-Research-Review.pdf [ https://perma.cc/78G8-PAZW ] (“[I]t is more difficult to align the body with one’s affirmed gender once physical changes in [puberty] occur . . . .”). It should be noted, however, that the concept of “passing” as one’s identified gender may not apply to nonbinary individuals, whose gender identities may not align with a binary mode of gender presentation. Cf . Christina Richards, Psychology , in Genderqueer and Non-binary Genders , supra note 7, at 141, 147 (noting that the genders of nonbinary people may be “socially unintelligible” such that they “find themselves in the trap of either seeming to be what they aren’t and so being accepted, or seeming to be what they are and so facing opprobrium”).

^ See Margaret To et al., Visual Conformity with Affirmed Gender or “Passing”: Its Distribution and Association with Depression and Anxiety in a Cohort of Transgender People , 17 J. Sexual Med . 2084, 2088 (2020).

^ See id . at 2089; Brynn Tannehill, For Many Trans People, Not Passing Is Not an Option , Slate (June 27, 2018, 11:54 AM), <a href=" https://slate.com/human-interest/2018/06/not-passing-or-blending-is-dangerous-for-many-trans-people.html ">https://slate.com/human-interest/2018/06/not-passing-or-blending-is-dangerous-for-many-trans-people.html">https://slate.com/human-interest/2018/06/not-passing-or-blending-is-dangerous-for-many-trans-people.html [ https://perma.cc/3EPP-6ZNS ].

^ See Costa et al., supra note 41, at 2212 (stating that use of puberty blockers results in “improvement in many aspects of . . . psychosocial functioning, such as mood improvement and school integration”); McGuire et al., supra note 51, at 105 (reporting increased confidence, self-acceptance, and social adjustment in trans youth who transition).

^ See, e.g ., Kuper , supra note 52, at 8; Ikuta, supra note 6, at 213.

^ See To et al., supra note 53, at 2089; Tannehill, supra note 54.

^ See Nat’l Ctr. for Transgender Equal., Summary of State Birth Certificate Gender Change Laws (2020), <a href=" https://transequality.org/sites/default/files/docs/resources/Summary of State Birth Certificate Laws Jan 2020.pdf"><a href="https://transequality.org/sites/default/files/docs/resources/Summary%20of%20State%20Birth%20Certificate%20Laws%20Jan%202020.pdf ">https://transequality.org/sites/default/files/docs/resources/Summary%20of%20State%20Birth%20Certificate%20Laws%20Jan%202020.pdf [ https://perma.cc/PP39-SYZ2 ]; Identity Document Laws and Policies , Movement Advancement Project (Feb. 11, 2021), <a href=" https://www.lgbtmap.org/equality-maps/identity_document_laws ">https://www.lgbtmap.org/equality-maps/identity_document_laws">https://www.lgbtmap.org/equality-maps/identity_document_laws [ https://perma.cc/E2BP-4HB7 ].

^ See Abbie E. Goldberg, Genny Beemyn & JuliAnna Z. Smith, What Is Needed, What Is Valued: Trans Students’ Perspectives on Trans-Inclusive Policies and Practices in Higher Education , 29 J. Educ. & Psych. Consultation 27, 31–32 (2019).

^ Jacob Gershman, States Weigh Measures to Stop Transgender Athletes from Competing in Women’s Sports , Wall St. J . (Jan. 7, 2020, 5:30 AM), <a href=" https://www.wsj.com/articles/states-weigh-measures-to-stop-transgender-athletes-from-competing-in-womens-sports-11578393001 ">https://www.wsj.com/articles/states-weigh-measures-to-stop-transgender-athletes-from-competing-in-womens-sports-11578393001">https://www.wsj.com/articles/states-weigh-measures-to-stop-transgender-athletes-from-competing-in-womens-sports-11578393001 [ https://perma.cc/SX58-6ERN ]; see NCAA Off. of Inclusion, NCAA Inclusion of Transgender Student-Athletes 13 ( 2011) , <a href=" https://www.ncaa.org/sites/default/files/Transgender_Handbook_2011_Final.pdf ">http://www.ncaa.org/sites/default/files/Transgender_Handbook_2011_Final.pdf">https://www.ncaa.org/sites/default/files/Transgender_Handbook_2011_Final.pdf [ https://perma.cc/RG7X-HHJ2 ]. Along with their campaigns against gender-affirming healthcare, see infra section B.1, pp. 2172–75, state legislatures have launched a parallel nationwide offensive against trans girls’ participation in women’s sports, see Gershman, supra ; see also , e.g ., Hecox v. Little, No. 20-cv-00184, 2020 WL 4760138, at *15, *39 (D. Idaho Aug. 17, 2020) (granting preliminary injunction against one such athletics ban on trans girls).

^ See, e.g ., NCAA Off. of Inclusion , supra note 60, at 13 (“A trans male (FTM) student-athlete who is not taking testosterone related to gender transition may participate on a men’s or women’s team.”).

^ Cf . David J. Handelsman, Angelica L. Hirschberg & Stephanie Bermon, Circulating Testosterone as the Hormonal Basis of Sex Differences in Athletic Performance , 39  Endocrine Revs . 803, 823 (2018) (finding that higher testosterone explains “most, if not all, the sex differences in sporting performance”).

^ See The Biden Plan to Advance LGBTQ+ Equality in America and Around the World , Biden for President , <a href=" https://joebiden.com/lgbtq-policy ">https://joebiden.com/lgbtq-policy/">https://joebiden.com/lgbtq-policy [ https://perma.cc/8TDP-C4UD ]; Dear Colleague Letter on Transgender Students from Catherine E. Lhamon, Assistant Sec’y for C.R., U.S. Dep’t of Educ. & Vanita Gupta, Principal Deputy Assistant Att’y Gen. for C.R., U.S. Dep’t of Just. 3 (May 13, 2016), https://www2.ed.gov/about/offices/list/ocr/letters/colleague-201605-title-ix-transgender.pdf [ https://perma.cc/85P9-GFHP ].

^ Cf., e.g ., Adams ex rel . Kasper v. Sch. Bd., 318 F. Supp. 3d 1293, 1326 (M.D. Fla. 2018), aff’d , 968 F.3d 1286 (11th Cir. 2020) (crediting evidence of the plaintiff’s “social, medical, and legal transitions” in determining he had a right to use the boys’ restroom at school).

^ See Teo Armus, A Texas Man Says His 7-Year-Old Isn’t Transgender. Now His Custody Fight Has Reached the Governor’s Office ., Wash. Post (Oct. 24, 2019, 6:13 AM), <a href=" https://www.washingtonpost.com/nation/2019/10/24/james-younger-luna-transgender-greg-abbott ">https://www.washingtonpost.com/nation/2019/10/24/james-younger-luna-transgender-greg-abbott/">https://www.washingtonpost.com/nation/2019/10/24/james-younger-luna-transgender-greg-abbott [ https://perma.cc/WSH8-BDJF ].

^ See, e.g ., Senator Ted Cruz (@SenTedCruz), Twitter (Oct. 23, 2019, 7:01 PM), <a lang="en"" href=" https://twitter.com/sentedcruz/status/1187157024888496128 ">https://twitter.com/sentedcruz/status/1187157024888496128?lang=en">https://twitter.com/sentedcruz/status/1187157024888496128 [ https://perma.cc/X67V-3LQZ ] (accusing the mother of “child abuse”).

^ María Méndez, Could Transgender Kids’ Care Be Next “Bathroom Bill” for Texas Republicans? , Dall. Morning News (Oct. 25, 2019, 11:57 AM), <a href=" https://www.dallasnews.com/news/politics/2019/10/25/could-transgender-kids-care-be-next-bathroom-bill-for-texas-republicans ">https://www.dallasnews.com/news/politics/2019/10/25/could-transgender-kids-care-be-next-bathroom-bill-for-texas-republicans/">https://www.dallasnews.com/news/politics/2019/10/25/could-transgender-kids-care-be-next-bathroom-bill-for-texas-republicans [ https://perma.cc/7MCJ-DWYA ].

^ See About Heritage , Heritage Found ., <a href=" https://www.heritage.org/about-heritage/impact ">https://www.heritage.org/about-heritage/impact">https://www.heritage.org/about-heritage/impact [ https://perma.cc/TPW2-KYPQ ].

^ See, e.g ., Summit on Protecting Children from Sexualization , Heritage Found ., at 2:12:28 (Oct. 9, 2019), <a href=" https://www.heritage.org/marriage-and-family/event/summit-protecting-children-sexualization ">https://www.heritage.org/marriage-and-family/event/summit-protecting-children-sexualization">https://www.heritage.org/marriage-and-family/event/summit-protecting-children-sexualization [ https://perma.cc/DN2P-RRXZ ] [hereinafter Summit ]; see also Brianna January, Anti-LGBTQ Group Heritage Foundation Has Hosted Four Anti-trans Panels So Far in 2019 , Media Matters for Am . (Apr. 18, 2019, 9:18 AM), <a href=" https://www.mediamatters.org/heritage-foundation/anti-lgbtq-group-heritage-foundation-has-hosted-four-anti-trans-panels-so-far ">https://www.mediamatters.org/heritage-foundation/anti-lgbtq-group-heritage-foundation-has-hosted-four-anti-trans-panels-so-far">https://www.mediamatters.org/heritage-foundation/anti-lgbtq-group-heritage-foundation-has-hosted-four-anti-trans-panels-so-far [ https://perma.cc/Q7SK-D5DT ].

^ See Sydney Bauer, The New Anti-trans Culture War Hiding in Plain Sight , New Republic (Feb. 11, 2020), <a href=" https://newrepublic.com/article/156539/new-anti-trans-culture-war-hiding-plain-sight ">https://newrepublic.com/article/156539/new-anti-trans-culture-war-hiding-plain-sight">https://newrepublic.com/article/156539/new-anti-trans-culture-war-hiding-plain-sight [ https://perma.cc/ZC7X-JK3E ]; Chris Johnson, Advocates Prepare for Fight as Anti-trans Youth Legislation Advances in S.D ., Wash. Blade (Jan. 31, 2020, 2:22 PM), <a href=" https://www.washingtonblade.com/2020/01/31/advocates-prepare-for-fight-as-anti-trans-youth-legislation-advances-in-s-d ">https://www.washingtonblade.com/2020/01/31/advocates-prepare-for-fight-as-anti-trans-youth-legislation-advances-in-s-d/">https://www.washingtonblade.com/2020/01/31/advocates-prepare-for-fight-as-anti-trans-youth-legislation-advances-in-s-d [ https://perma.cc/85YF-JHX3 ].

^ See Bauer, supra note 71; Summit , supra note 70. Model legislation is often a symptom of pervasive interest group influence in state legislatures. See Rob O’Dell & Nick Penzenstadler, You Elected Them to Write New Laws. They’re Letting Corporations Do It Instead ., USA Today (June 19, 2019, 5:56 PM), <a href=" https://www.usatoday.com/in-depth/news/investigations/2019/04/03/abortion-gun-laws-stand-your-ground-model-bills-conservatives-liberal-corporate-influence-lobbyists/3162173002 ">https://www.usatoday.com/in-depth/news/investigations/2019/04/03/abortion-gun-laws-stand-your-ground-model-bills-conservatives-liberal-corporate-influence-lobbyists/3162173002/">https://www.usatoday.com/in-depth/news/investigations/2019/04/03/abortion-gun-laws-stand-your-ground-model-bills-conservatives-liberal-corporate-influence-lobbyists/3162173002 [ https://perma.cc/3ACT-WP3W ].

^ See sources cited supra note 9. Although a Utah Representative was considering a bill to ban HRT and GCS, he changed course and drafted a bill geared toward exploratory research into gender-affirming healthcare. See Connor Richards, Utah House Rejects Bill to Study Effects of Hormone Therapy on Transgender Minors , Daily Herald (Mar. 10, 2020), https://www.heraldextra.com/news/local/govt-and-politics/legislature/utah-house-rejects-bill-to-study-effects-of-hormone-therapy-on-transgender-minors/article_2fc144a0-9573-50fc-a6e7-60841a6d8632.html [ https://perma.cc/M4CH-44DC ]. The fifteen-state count thus does not include the Utah bill.

^ For a database containing links to the text, sponsors, and status of the 2020 bills, see ACLU Legislation Tracker , supra note 9. For the bills introduced so far in 2021, see sources cited supra note 11; Legislation Affecting LGBT Rights Across the Country , ACLU (Feb. 11, 2021), https://www.aclu.org/legislation-affecting-lgbt-rights-across-country [ https://perma.cc/RD96-UXDP ].

^ Tennessee’s bill banned all gender-affirming care for minors who have not started puberty, but allowed minors who have begun puberty to receive gender-affirming care upon the recommendation of three physicians. See H.B. 2576, 111th Gen. Assemb., Reg. Sess. § 1(b) (Tenn. 2020). In addition, Missouri’s, Oklahoma’s, and South Carolina’s bills did not contain a “medically verifiable” exception, see H.B. 1721, 100th Gen. Assemb., 2d Reg. Sess. (Mo. 2020); S.B. 1819, 57th Leg., 2d Reg. Sess. (Okla. 2020); H.B. 4716, 123d Gen. Assemb, Reg. Sess. (S.C. 2020), and Mississippi’s and South Dakota’s bills did not follow the eighteen-year cutoff, see S.B. 2490, 2020 Leg., Reg. Sess. § 3(b) (Miss. 2020) (defining minors as below age twenty-one); H.B. 1057, 95th Gen. Assemb., Reg. Sess. (S.D. 2020) (defining minors as below age sixteen).

^ See, e.g ., S. File 2213, 88th Gen. Assemb., Reg. Sess. § 1 (3) (Iowa 2020); H.B. 513, 133d Gen. Assemb., Reg. Sess. § 1, sec. 5128.03(C)(1) (Ohio 2020).

^ See H.B. 465, 65th Leg., 2d Reg. Sess. (Idaho 2020). The law would have defined gender-affirming care as “genital mutilation of a child,” which carries a maximum life sentence under the state criminal code. See id .; Idaho Code § 18-1506B(6) (2020).

^ Cf . Annamarie Forestiere, America’s War on Black Trans Women , Harv. C.R.-C.L. L. Rev. Amicus Blog (Sept. 23, 2020), <a href=" https://harvardcrcl.org/americas-war-on-black-trans-women ">https://harvardcrcl.org/americas-war-on-black-trans-women/">https://harvardcrcl.org/americas-war-on-black-trans-women [ https://perma.cc/DRD4-RHXY ] (noting that high poverty and homelessness rates among Black trans women affect their ability to travel); La’Tasha D. Mayes, Black Women Are Dying from a Lack of Access to Reproductive Health Services , TIME (Jan. 19, 2018, 11:53 AM), <a href=" https://time.com/5109797/black-women-dying-reproductive-health ">https://time.com/5109797/black-women-dying-reproductive-health/">https://time.com/5109797/black-women-dying-reproductive-health [ https://perma.cc/LY33-M8JL ] (showing how similar laws restricting reproductive healthcare access disparately affect people of color).

^ See ACLU Legislation Tracker , supra note 9.

^ See Bauer, supra note 71; Nico Lang, Alabama Moves Closer to Transgender Health Care Ban for Minors , NBC News (Mar. 10, 2020, 4:21 PM), <a href=" https://www.nbcnews.com/feature/nbc-out/alabama-moves-closer-transgender-health-care-ban-minors-n1154791 ">https://www.nbcnews.com/feature/nbc-out/alabama-moves-closer-transgender-health-care-ban-minors-n1154791">https://www.nbcnews.com/feature/nbc-out/alabama-moves-closer-transgender-health-care-ban-minors-n1154791 [ https://perma.cc/3KDX-HYYE ].

^ See Changes to State Legislative Session Dates in Response to the Coronavirus (COVID-19) Pandemic, 2020 , Ballotpedia (Jan. 21, 2021), https://ballotpedia.org/Changes_to_state_legislative_session_dates_in_response_to_the_coronavirus_(COVID-19)_pandemic,_2020 [ https://perma.cc/JK26-WYNM ]; ACLU Legislation Tracker , supra note 9 (showing that several bills died in committee in mid-March).

^ See Joellen Kralik, “ Bathroom Bill” Legislative Tracking , Nat’l Conf. of State Legislatures (Oct. 24, 2019), <a href=" https://www.ncsl.org/research/education/-bathroom-bill-legislative-tracking635951130.aspx ">https://www.ncsl.org/research/education/-bathroom-bill-legislative-tracking635951130.aspx">https://www.ncsl.org/research/education/-bathroom-bill-legislative-tracking635951130.aspx [ https://perma.cc/5JH4-QPZA ] (listing the states).

^ See Elena Schneider, The Bathroom Bill that Ate North Carolina , Politico Mag . (Mar. 23, 2017), <a href=" https://www.politico.com/magazine/story/2017/03/the-bathroom-bill-that-ate-north-carolina-214944 ">https://www.politico.com/magazine/story/2017/03/the-bathroom-bill-that-ate-north-carolina-214944">https://www.politico.com/magazine/story/2017/03/the-bathroom-bill-that-ate-north-carolina-214944 [ https://perma.cc/5E4M-VHQC ]; see also N.C. Gen. Stat . § 143-760(b), (d) (repealed 2017).

^ See Bell v. Tavistock [2020] EWHC (Admin) 3274 (Eng.). The court ruled that puberty blockers are presumptively inappropriate for adolescents under sixteen, id . at [151], and that court authorization may be necessary for sixteen- and seventeen-year-olds, id . at [152].

^ See, e.g ., G.B. v. Lackner, 145 Cal. Rptr. 555, 556, 559 (Ct. App. 1978) (reversing state health department’s denial of insurance coverage for GCS).

^ See, e.g ., Whitman-Walker Clinic, Inc. v. U.S. Dep’t of Health & Hum. Servs., No. CV 20-1630, 2020 WL 5232076, at *1 (D.D.C. Sept. 2, 2020) (challenging the Trump Administration’s rescission of an Obama Administration policy banning discrimination against transgender people in healthcare). For an overview of other legal battles surrounding gender-affirming healthcare, see generally Judson Adams et al., Transgender Rights and Issues , 21 Geo. J. Gender & L . 479, 494–507 (2020).

^ S.B. 2490, 2020 Leg., Reg. Sess. § 2(1)(a) (Miss. 2020).

^ See, e.g ., id . § 2(2); H.B. 3515, 101st Gen. Assemb., Reg. Sess. § 10 (Ill. 2019). Indeed, many of the bills even share a version of the same title: “Vulnerable Child Protection Act.” See, e.g ., H.B. 303, 2020 Leg., Reg. Sess. § 1 (Ala. 2020); H.B. 1365, 2020 Leg., Reg. Sess. (Fla. 2020); H.B. 513, 133d Gen. Assemb., Reg. Sess. § 2 (Ohio 2020).

^ See Amy L. Stone, Gender Panics About Transgender Children in Religious Right Discourse , 15 J. LGBT Youth 1, 1–3 (2018).

^ See, e.g ., Grimm v. Gloucester Cnty. Sch. Bd., 972 F.3d 586, 613–14 (4th Cir. 2020); id . at 626 (Wynn, J., concurring); Doe ex rel . Doe v. Boyertown Area Sch. Dist., 897 F.3d 518, 526 (3d Cir. 2018); see also Note, Constitutional Privacy and the Fight Over Access to Sex-Segregated Spaces , 133 Harv. L. Rev . 1684, 1685 (2020).

^ See, e.g ., Grimm , 972 F.3d at 620; Doe , 897 F.3d at 538.

^ See Gabby Orr, The Wedge Issue That’s Dividing Trumpworld , Politico Mag . (Aug. 7, 2020, 7:08 AM), <a href=" https://www.politico.com/news/magazine/2020/08/07/wedge-issue-dividing-trumpworld-392323# ">https://www.politico.com/news/magazine/2020/08/07/wedge-issue-dividing-trumpworld-392323">https://www.politico.com/news/magazine/2020/08/07/wedge-issue-dividing-trumpworld-392323# [ https://perma.cc/M2H2-JTBL ] (noting that “public opinion [is] moving dramatically in favor” of transgender rights); Schneider, supra note 83 (detailing the backlash to House Bill 2 in North Carolina).

^ See, e.g ., Orr, supra note 92 (detailing a sharply divided opinion within the Trump reelection campaign concerning whether to embrace an explicitly antitransgender platform).

^ Professor Reva Siegel has termed this phenomenon “preservation-through-transformation.” Reva B. Siegel, “ The Rule of Love”: Wife Beating as Prerogative and Privacy , 105 Yale L.J . 2117, 2180 (1996); see id . at 2179 (“[T]he manner in which a legal system enforces social stratification . . . evolve[s] over time, changing shape as it is contested.”).

^ See Editorial, Lawmakers Reach New Low with Latest Transgender Bill , Argus Leader (Jan. 27, 2020, 10:14 AM), <a href=" https://www.argusleader.com/story/opinion/editorials/2020/01/23/south-dakota-legislature-transgender-bill-fred-deutsch/4551350002 ">https://www.argusleader.com/story/opinion/editorials/2020/01/23/south-dakota-legislature-transgender-bill-fred-deutsch/4551350002/">https://www.argusleader.com/story/opinion/editorials/2020/01/23/south-dakota-legislature-transgender-bill-fred-deutsch/4551350002 [ https://perma.cc/EHA6-QVMU ] (noting that the chief sponsor of the 2020 South Dakota gender-affirming care ban also introduced the state’s failed bathroom bill in 2016); Chase Strangio, Conservative Legislators Want Transgender Kids’ Lives as the New Battlefield in Their Culture War , NBC News (Jan. 17, 2021, 3:30 AM), <a href=" https://www.nbcnews.com/think/opinion/conservative-legislators-want-transgender-kids-lives-new-battlefield-their-culture-ncna1254483 ">https://www.nbcnews.com/think/opinion/conservative-legislators-want-transgender-kids-lives-new-battlefield-their-culture-ncna1254483">https://www.nbcnews.com/think/opinion/conservative-legislators-want-transgender-kids-lives-new-battlefield-their-culture-ncna1254483 [ https://perma.cc/8AXG-39EJ ].

^ See Nancy J. Knauer, The Politics of Eradication and the Future of LGBT Rights , 21 Geo. J. Gender & L . 615, 655 (2020); Strangio, supra note 95.

^ See Clifford J. Rosky, Fear of the Queer Child , 61 Buff. L. Rev . 607, 638–39 (2013) (noting that paternalistic justifications for opposing LGBTQ youth are “more appealing to a wide audience and more challenging for LGBT advocates to rebut,” id . at 639).

^ See Strangio, supra note 95; see also Knauer, supra note 96, at 637 (“By focusing on the element of choice and the ability to change, anti-LGBT advocates . . . attempt to not only destabilize LGBT identities, but to eradicate them completely because they believe that being LGBT is not a choice that anyone should make.”).

^ See Bell v. Tavistock [2020] EWHC (Admin) 3274 (Eng.). Immediately after the High Court upheld a challenge to the National Health Service (NHS) gender-affirming treatment protocol for minors, framing the decision as an exercise of “the protective role of the court,” id . at [149], the defendant NHS trust announced a moratorium on new referrals for puberty blockers, see Owen Bowcott, Puberty Blockers: Under-16s “Unlikely to Be Able to Give Informed Consent ,” The Guardian (Dec. 1, 2020, 12:18 AM), <a href=" https://www.theguardian.com/world/2020/dec/01/children-who-want-puberty-blockers-must-understand-effects-high-court-rules ">https://www.theguardian.com/world/2020/dec/01/children-who-want-puberty-blockers-must-understand-effects-high-court-rules">https://www.theguardian.com/world/2020/dec/01/children-who-want-puberty-blockers-must-understand-effects-high-court-rules [ https://perma.cc/L4CR-4KJ7 ].

^ See supra p. 2175.

^ See Rafferty, supra note 5, at 4 (“[C]hildren who are prepubertal and assert [a trans identity] know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender . . . .”); see also Anne A. Fast & Kristina R. Olson, Gender Development in Transgender Preschool Children , 89 Child Dev . 620, 631–32 (2018) (finding that “[a]cross all measures of preference, behavior, stereotyping, and identity . . . preschool-age socially transitioned transgender children never significantly differed from their [cisgender] peers,” id . at 631).

^ See Jesse Singal, When Children Say They’re Trans , The Atlantic (July/Aug. 2018), <a href=" https://www.theatlantic.com/magazine/archive/2018/07/when-a-child-says-shes-trans/561749 ">https://www.theatlantic.com/magazine/archive/2018/07/when-a-child-says-shes-trans/561749/">https://www.theatlantic.com/magazine/archive/2018/07/when-a-child-says-shes-trans/561749 [ https://perma.cc/P7RZ-CH57 ].

^ See Julia Temple Newhook et al., A Critical Commentary on Follow-Up Studies and “Desistance” Theories About Transgender and Gender-Nonconforming Children , 19 Int’l J. Transgenderism 212, 212–13 (2018) (claiming that the studies showing “desistance” of gender dysphoria are methodologically flawed).

^ See id . at 218 (noting that “desistance” arguments concerning gender nonconforming youth “reinforce [a] limited binary perspective on gender and sexuality” and that “if we find that people do not fit our categories, then it is the categories that must change”); see also Goldberg et al., supra note 7, at 92.

^ See WPATH SOC , supra note 17, at 14, 18–19.

^ See Singal, supra note 102; see also WPATH SOC, supra note 17, at 18 (“Before any physical interventions are considered for adolescents, extensive exploration of psychological, family, and social issues should be undertaken . . . .”).

^ U.S. Const . amend . XIV , § 1.

^ See City of Cleburne v. Cleburne Living Ctr., Inc., 473 U.S. 432, 439–40 (1985).

^ See, e.g ., Grimm v. Gloucester Cnty. Sch. Bd., 972 F.3d 586, 607 (4th Cir. 2020).

^ See, e.g ., Cleburne , 473 U.S. at 440–42; Grimm , 972 F.3d at 608; see also Ashutosh Bhagwat, Purpose Scrutiny in Constitutional Analysis , 85 Calif. L. Rev . 297, 303–04 (1997).

^ See, e.g ., Grimm , 972 F.3d at 607; Adams ex rel . Kasper v. Sch. Bd., 968 F.3d 1286, 1296, 1304 (11th Cir. 2020); Whitaker ex rel . Whitaker v. Kenosha Unified Sch. Dist. No. 1 Bd. of Educ., 858 F.3d 1034, 1051–52 (7th Cir. 2017).

^ See, e.g ., Grimm , 972 F.3d at 610; Karnoski v. Trump, 926 F.3d 1180, 1201 (9th Cir. 2019); see also Kevin M. Barry et al., A Bare Desire to Harm: Transgender People and the Equal Protection Clause , 57 B.C. L. Rev . 507, 551–67 (2016) (arguing that transgender status satisfies the four-factor test for whether a group should receive protected status).

^ See, e.g ., Whitaker , 858 F.3d at 1051; Glenn v. Brumby, 663 F.3d 1312, 1317 (11th Cir. 2011); Smith v. City of Salem, 378 F.3d 566, 568, 577 (6th Cir. 2004).

^ H.B. 321, 2020 Gen. Assemb., Reg. Sess. § 1(3) (Ky. 2020); see, e.g ., id . § 1(2); H.B. 303, 2020 Leg., Reg. Sess. § 4 (Ala. 2020). Even the bills that do not specifically except treatment of intersex or developmental conditions from the prohibitions imply through their language that the bans only apply to use of the prohibited services as gender-affirming medical treatment. See, e.g ., H.B. 2210, 100th Gen. Assemb., 2d Reg. Sess. § A(1) (Mo. 2020) (prohibiting medical providers from “administering any hormonal treatment or performing any surgical treatment for the purpose of gender reassignment ” (emphasis added)); see also S.B. 1819, 57th Leg., 2d Reg. Sess. § 1(C) (Okla. 2020).

^ See, e.g ., Christian Legal Soc’y Chapter of the Univ. of Cal., Hastings Coll. of the Law v. Martinez, 561 U.S. 661, 689 (2010) (“A tax on wearing yarmulkes is a tax on Jews.” (quoting Bray v. Alexandria Women’s Health Clinic, 506 U.S. 263, 270 (1993))).

^ 140 S. Ct. 1731 (2020).

^ See id . at 1754.

^ Id . at 1747.

^ See id . at 1783 (Alito, J., dissenting) (“By equating discrimination because of sexual orientation or gender identity with discrimination because of sex, the Court’s decision will be cited as a ground for subjecting all three forms of discrimination to [heightened scrutiny].”); see also, e.g ., Adams ex rel . Kasper v. Sch. Bd., 968 F.3d 1286, 1296 (11th Cir. 2020) (applying Bostock to find that a school board policy discriminating against transgender students was sex discrimination warranting heightened scrutiny).

^ Bostock , 140 S. Ct. at 1741.

^ See Flack v. Wis. Dep’t of Health Servs., 328 F. Supp. 3d 931, 948 (W.D. Wis. 2018) (observing that a Medicaid exclusion for gender-affirming healthcare was “a straightforward case of sex discrimination” because “if plaintiffs’ natally assigned sexes had matched their gender identities, their requested, medically necessary surgeries to reconstruct their genitalia or breasts would be covered”).

^ United States v. Virginia, 518 U.S. 515, 524 (1996) (citations omitted); see Bhagwat, supra note 110, at 304. While this test for “intermediate scrutiny” has been used for gender-based classifications, courts apply a more searching “strict scrutiny” test for certain other classifications. See id .

^ See supra section A.2, pp. 2167–72.

^ See supra section B.2, pp. 2175–78.

^ See sources cited supra note 19.

^ See, e.g ., What We Know Project , supra note 42 (stating that, of more than fifty studies published between 1991 and 2017, ninety-three percent “found that gender transition improves the overall well-being of transgender people,” and that there were “no studies concluding that gender transition causes overall harm”) ; see also sources cited supra notes 41–42. But see infra pp. 2184–85 (describing concerns with judicial analysis of scientific evidence).

^ See Bhagwat, supra note 110, at 303 (discussing rational basis review).

^ H.B. 303, 2020 Leg., Reg. Sess. § 2(1) (Ala. 2020).

^ Id . § 4(b). The Alabama bill defines “medically verifiable” conditions to include “external biological sex characteristics that are irresolvably ambiguous . . . , [such as] having both ovarian and testicular tissue,” and “[ab]normal sex chromosome structure, sex steroid hormone production, or sex steroid hormone action.” Id .

^ See, e.g ., Romer v. Evans, 517 U.S. 620, 634 (1996) (explaining that “a bare . . . desire to harm a politically unpopular group cannot constitute a legitimate government interest” (citation omitted)); City of Cleburne v. Cleburne Living Ctr., Inc., 473 U.S. 432, 446–47 (1985); Susannah W. Pollvogt, Unconstitutional Animus , 81 Fordham L. Rev . 887, 888 (2012).

^ See Pollvogt, supra note 132, at 926–27.

^ 473 U.S. 432.

^ See id . at 447–50. In Cleburne , the Court held that a city’s denial of a special zoning permit to a group home for people with intellectual disabilities violated equal protection because it was founded on “irrational prejudice” against such people. Id . at 450. The Court inferred prejudice in part because the city imposed special permitting requirements on the group home for reasons such as density, traffic congestion, and exposure to litigation risk that applied equally to other high-density residential uses, such as nursing homes and dormitories, for which special permits were not required. See id . at 447–50.

^ Cf . Romer , 517 U.S. at 635; Cleburne , 473 U.S. at 450.

^ See Jessica A. Clarke, Explicit Bias , 113 Nw. U. L. Rev . 505, 511 (2018) (defending the probative value of explicit statements of bias as evidence of discriminatory intent); Pollvogt, supra note 132, at 927.

^ Jeff Taylor, Florida Lawmaker Told Nonbinary Candidate He’s “Manufacturing” His Identity , NewNowNext (Feb. 4, 2020), <a href=" https://www.newnownext.com/florida-republican-sabatini-gender-nonbinary-manufacturing-identity/02/2020 ">http://www.newnownext.com/florida-republican-sabatini-gender-nonbinary-manufacturing-identity/02/2020/">https://www.newnownext.com/florida-republican-sabatini-gender-nonbinary-manufacturing-identity/02/2020 [ https://perma.cc/3NTT-LSBB ].

^ Katie Shepherd, A GOP Lawmaker, the Son of an Auschwitz Survivor, Compared Doctors Treating Transgender Children to Nazis. He Regrets It ., Wash. Post (Jan. 28, 2020, 11:45 AM), <a href=" https://www.washingtonpost.com/nation/2020/01/28/deutsch-transgender-doctors-nazi ">https://www.washingtonpost.com/nation/2020/01/28/deutsch-transgender-doctors-nazi/">https://www.washingtonpost.com/nation/2020/01/28/deutsch-transgender-doctors-nazi [ https://perma.cc/7AJH-AMJX ]. To his credit, Rep. Deutsch later apologized. Id .

^ John Herrick, Anti-LGBTQ Bills Doomed to Die. Advocates Say They Still Take a Toll ., Colo. Indep . (Feb. 13, 2020), <a href=" https://www.coloradoindependent.com/2020/02/13/gop-anti-lgbtq-transgender-youth ">https://www.coloradoindependent.com/2020/02/13/gop-anti-lgbtq-transgender-youth/">https://www.coloradoindependent.com/2020/02/13/gop-anti-lgbtq-transgender-youth [ https://perma.cc/GQP4-8AJP ].

^ See Emily Jashinsky, Exclusive: Man Tried to Share His Regrets About Transgender Life. YouTube Censored It , Federalist (June 19, 2020), https://thefederalist.com/2020/06/19/exclusive-man-tried-to-share-his-regrets-about-transgender-life-youtube-censored-it [ https://perma.cc/9JEM-M7NJ ]; see also, e.g ., Summit , supra note 70, at 2:15:20 (panelist describing the pioneers of gender-affirming treatment for minors as “pedophile activist[s]”).

^ Transgenderism & Gender Dysphoria , Fam. Pol’y All . (internal quotation marks omitted), <a href=" https://familypolicyalliance.com/issues/sexuality/transgender ">https://familypolicyalliance.com/issues/sexuality/transgender/">https://familypolicyalliance.com/issues/sexuality/transgender [ https://perma.cc/77QD-7FMA ]; see Bauer, supra note 71.

^ See Pierce v. Soc’y of Sisters, 268 U.S. 510, 534–35 (1925); Meyer v. Nebraska, 262 U.S. 390, 399 (1923).

^ See, e.g ., Troxel v. Granville, 530 U.S. 57, 65–66 (2000); Planned Parenthood of Se. Pa. v. Casey, 505 U.S. 833, 851 (1992); Moore v. City of East Cleveland, 431 U.S. 494, 499 (1977); Stanley v. Illinois, 405 U.S. 645, 651 (1972).

^ Troxel , 530 U.S. at 65.

^ See id . at 69–70.

^ See Parham v. J.R., 442 U.S. 584, 603–04 (1979) (recognizing “parents’ authority to decide what is best for the[ir] child” in the medical context, id . at 604); see also Kanuszewski v. Mich. Dep’t of Health & Hum. Servs., 927 F.3d 396, 418–19 (6th Cir. 2019).

^ See, e.g ., Kanuszewski , 927 F.3d at 418–19; PJ ex rel . Jensen v. Wagner, 603 F.3d 1182, 1197 (10th Cir. 2010); Restatement of the Law, Children and the Law § 2.30 (Am. L. Inst ., Tentative Draft No. 1, 2018) ; Alicia Ouellette, Shaping Parental Authority over Children’s Bodies , 85 Ind. L.J . 955, 966–68 (2010).

^ See Prince v. Massachusetts, 321 U.S. 158, 166–67 (1944).

^ See, e.g ., Cal. Bus. & Prof. Code § 865.1 (West 2021); Editorial, A Nationwide Ban Is Needed for “Anti-gay Therapy ,” Sci. Am . (Jan. 1, 2020), <a href=" https://www.scientificamerican.com/article/a-nationwide-ban-is-needed-for-anti-gay-therapy ">https://www.scientificamerican.com/article/a-nationwide-ban-is-needed-for-anti-gay-therapy/">https://www.scientificamerican.com/article/a-nationwide-ban-is-needed-for-anti-gay-therapy [ https://perma.cc/BV37-ZYVH ].

^ Pickup v. Brown, 740 F.3d 1208, 1236 (9th Cir. 2014); see also, e.g ., Doe ex rel . Doe v. Governor of N.J., 783 F.3d 150, 156 (3d Cir. 2015) (same).

^ See Doe , 783 F.3d at 152–53; Pickup , 740 F.3d at 1231–32.

^ Compare, e.g ., Policy Statement, Conversion Therapy , Am. Acad. Child & Adolescent Psychiatry (2018), <a href=" https://www.aacap.org/AACAP/Policy_Statements/2018/Conversion_Therapy.aspx ">https://www.aacap.org/AACAP/Policy_Statements/2018/Conversion_Therapy.aspx">https://www.aacap.org/AACAP/Policy_Statements/2018/Conversion_Therapy.aspx [ https://perma.cc/LV4U-SV3P ] (confirming that conversion therapy “lack[s] scientific credibility and clinical utility”), and Editorial, supra note 150 (noting that various medical associations characterize conversion therapy as “useless and injurious”), with, e.g ., AACAP Statement , supra note 46 (stating that “AACAP strongly opposes any efforts . . . to block access” to “evidence-based [gender-affirming] care”), and Endocrine Soc’y & Pediatric Endocrine Soc’y, supra note 46, at 2 (describing gender-affirming care for minors as “effective, relatively safe when appropriately monitored, and . . . the standard of care” (parentheses omitted)).

^ See Joseph Landau, Broken Records: Reconceptualizing Rational Basis Review to Address “Alternative Facts” in the Legislative Process , 73 Vand. L. Rev . 425, 443–44 (2020) (noting that the doctrinal framework for judicial review of legislative purposes is ill-equipped to protect marginalized groups from “distorted legislative records” based on “alternative facts,” id . at 443).

^ See, e.g ., Gonzales v. Carhart, 550 U.S. 124, 179–82 (2007) (Ginsburg, J., dissenting) (describing the majority’s “bewildering,” id . at 179, rejection of the “significant medical authority,” id . at 180 (quoting Stenberg v. Carhart, 530 U.S. 914, 932 (2000)), supporting the use of a late-term abortion procedure to protect the patient’s health in some circumstances); id . at 182 (“Ultimately, the Court admits that moral concerns are at work . . . .” (quotation marks omitted)).

^ See, e.g ., Gibson v. Collier, 920 F.3d 212, 223 (5th Cir. 2019) (“There is no medical consensus that sex reassignment surgery is a necessary or even effective treatment for gender dysphoria.”).

^ See, e.g ., Edmo v. Corizon, Inc., 935 F.3d 757, 803 (9th Cir. 2019) (holding that prison officials’ denial of medically necessary gender-affirming medical care violated the Eighth Amendment).

^ Palmore v. Sidoti, 466 U.S. 429, 433 (1984).

^ WPATH SOC, supra note 17, at 21.

^ See Ikuta, supra note 6, at 227–28.

• Health Care Law
• LGBT Rights

April 12, 2021

More from this Issue

Reframing the harm: religious exemptions and third-party harm after little sisters.

Chapter Two

The Legal Infrastructure of Childbirth

Chapter Three

Conditions of Confinement, COVID-19, and the CDC

Chapter Four

• Introduction
• Conclusions
• Article Information

Outcomes are estimated from bivariate and multivariable generalized estimating equation models. aOR, indicates adjusted odds ratio; GAD-7, Generalized Anxiety Disorder 7-item scale; PHQ-9, Patient Health Questionnaire 9-item scale; whiskers, 95% CIs.

eTable 1. Survey Instruments

eTable 2. Prevalence of Exposure Over Time

eTable 3. Prevalence of Outcomes Over Time by Exposure Group

eTable 4. E-Value Calculation for Association Between Puberty Blockers or Gender-Affirming Hormones and Mental Health Outcomes

eTable 5. Examining Association Between Puberty Blockers or Gender-Affirming Hormones and Mental Health Outcomes Separately

eTable 6. Bivariate Model Restricted to Youths Ages 13 to 17 Years

eTable 7. Multivariable Model Restricted to 90 Youths Ages 13 to 17 Years

eTable 8. Sensitivity Analyses using Patient Health Questionnaire 8-item Scale Score of 10 or Greater for Moderate to Severe Depression

eFigure 1. Schematic of Generalized Estimating Equation Model

eFigure 2. Association Between Receipt of Gender-Affirming Hormones or Puberty Blockers and Mental Health Outcomes

eReferences

• Medical Groups Defend Patient-Physician Relationship and Access to Adolescent Gender-Affirming Care JAMA Medical News & Perspectives April 19, 2022 This Medical News article discusses physicians’ advocacy to protect patients and the patient-physician relationship amid efforts by politicians to limit access or criminalize gender-affirming care. Bridget M. Kuehn, MSJ
• As Laws Restricting Health Care Surge, Some US Physicians Choose Between Fight or Flight JAMA Medical News & Perspectives June 13, 2023 In this Medical News article, 13 physicians and health care experts spoke with JAMA about the increasing efforts to criminalize evidence-based medical care in the US. Melissa Suran, PhD, MSJ
• Data Errors in eTables 2 and 3 JAMA Network Open Correction July 26, 2022
• Improving Mental Health Among Transgender and Gender-Diverse Youth JAMA Network Open Invited Commentary February 25, 2022 Brett Dolotina, BS; Jack L. Turban, MD, MHS

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Tordoff DM , Wanta JW , Collin A , Stepney C , Inwards-Breland DJ , Ahrens K. Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care. JAMA Netw Open. 2022;5(2):e220978. doi:10.1001/jamanetworkopen.2022.0978

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Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care

• 1 Department of Epidemiology, University of Washington, Seattle
• 2 Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
• 3 School of Medicine, University of Washington, Seattle
• 4 Department of Psychiatry and Behavioral Medicine, Department of Adolescent and Young Adult Medicine, Seattle Children’s Hospital, Seattle, Washington
• 5 University of California, San Diego School of Medicine, Rady Children's Hospital
• 6 Division of Adolescent Medicine, Department of Pediatrics, Seattle Children’s Hospital, Seattle, Washington
• Invited Commentary Improving Mental Health Among Transgender and Gender-Diverse Youth Brett Dolotina, BS; Jack L. Turban, MD, MHS JAMA Network Open
• Medical News & Perspectives Medical Groups Defend Patient-Physician Relationship and Access to Adolescent Gender-Affirming Care Bridget M. Kuehn, MSJ JAMA
• Medical News & Perspectives As Laws Restricting Health Care Surge, Some US Physicians Choose Between Fight or Flight Melissa Suran, PhD, MSJ JAMA
• Correction Data Errors in eTables 2 and 3 JAMA Network Open

Question   Is gender-affirming care for transgender and nonbinary (TNB) youths associated with changes in depression, anxiety, and suicidality?

Findings   In this prospective cohort of 104 TNB youths aged 13 to 20 years, receipt of gender-affirming care, including puberty blockers and gender-affirming hormones, was associated with 60% lower odds of moderate or severe depression and 73% lower odds of suicidality over a 12-month follow-up.

Meaning   This study found that access to gender-affirming care was associated with mitigation of mental health disparities among TNB youths over 1 year; given this population's high rates of adverse mental health outcomes, these data suggest that access to pharmacological interventions may be associated with improved mental health among TNB youths over a short period.

Importance   Transgender and nonbinary (TNB) youths are disproportionately burdened by poor mental health outcomes owing to decreased social support and increased stigma and discrimination. Although gender-affirming care is associated with decreased long-term adverse mental health outcomes among these youths, less is known about its association with mental health immediately after initiation of care.

Objective   To investigate changes in mental health over the first year of receiving gender-affirming care and whether initiation of puberty blockers (PBs) and gender-affirming hormones (GAHs) was associated with changes in depression, anxiety, and suicidality.

Design, Setting, and Participants   This prospective observational cohort study was conducted at an urban multidisciplinary gender clinic among TNB adolescents and young adults seeking gender-affirming care from August 2017 to June 2018. Data were analyzed from August 2020 through November 2021.

Exposures   Time since enrollment and receipt of PBs or GAHs.

Main Outcomes and Measures   Mental health outcomes of interest were assessed via the Patient Health Questionnaire 9-item (PHQ-9) and Generalized Anxiety Disorder 7-item (GAD-7) scales, which were dichotomized into measures of moderate or severe depression and anxiety (ie, scores ≥10), respectively. Any self-report of self-harm or suicidal thoughts over the previous 2 weeks was assessed using PHQ-9 question 9. Generalized estimating equations were used to assess change from baseline in each outcome at 3, 6, and 12 months of follow-up. Bivariate and multivariable logistic models were estimated to examine temporal trends and investigate associations between receipt of PBs or GAHs and each outcome.

Results   Among 104 youths aged 13 to 20 years (mean [SD] age, 15.8 [1.6] years) who participated in the study, there were 63 transmasculine individuals (60.6%), 27 transfeminine individuals (26.0%), 10 nonbinary or gender fluid individuals (9.6%), and 4 youths who responded “I don’t know” or did not respond to the gender identity question (3.8%). At baseline, 59 individuals (56.7%) had moderate to severe depression, 52 individuals (50.0%) had moderate to severe anxiety, and 45 individuals (43.3%) reported self-harm or suicidal thoughts. By the end of the study, 69 youths (66.3%) had received PBs, GAHs, or both interventions, while 35 youths had not received either intervention (33.7%). After adjustment for temporal trends and potential confounders, we observed 60% lower odds of depression (adjusted odds ratio [aOR], 0.40; 95% CI, 0.17-0.95) and 73% lower odds of suicidality (aOR, 0.27; 95% CI, 0.11-0.65) among youths who had initiated PBs or GAHs compared with youths who had not. There was no association between PBs or GAHs and anxiety (aOR, 1.01; 95% CI, 0.41, 2.51).

Conclusions and Relevance   This study found that gender-affirming medical interventions were associated with lower odds of depression and suicidality over 12 months. These data add to existing evidence suggesting that gender-affirming care may be associated with improved well-being among TNB youths over a short period, which is important given mental health disparities experienced by this population, particularly the high levels of self-harm and suicide.

Transgender and nonbinary (TNB) youths are disproportionately burdened by poor mental health outcomes, including depression, anxiety, and suicidal ideation and attempts. 1 - 5 These disparities are likely owing to high levels of social rejection, such as a lack of support from parents 6 , 7 and bullying, 6 , 8 , 9 and increased stigma and discrimination experienced by TNB youths. Multidisciplinary care centers have emerged across the country to address the health care needs of TNB youths, which include access to medical gender-affirming interventions, such as puberty blockers (PBs) and gender-affirming hormones (GAHs). 10 These centers coordinate care and help youths and their families address barriers to care, such as lack of insurance coverage 11 and travel times. 12 Gender-affirming care is associated with decreased rates of long-term adverse outcomes among TNB youths. Specifically, PBs, GAHs, and gender-affirming surgeries have all been found to be independently associated with decreased rates of depression, anxiety, and other adverse mental health outcomes. 13 - 16 Access to these interventions is also associated with a decreased lifetime incidence of suicidal ideation among adults who had access to PBs during adolescence. 17 Conversely, TNB youths who present to care later in adolescence or young adulthood experience more adverse mental health outcomes. 18 Despite this robust evidence base, legislation criminalizing and thus limiting access to gender-affirming medical care for minors is increasing. 19 , 20

Less is known about the association of gender-affirming care with mental health outcomes immediately after initiation of care. Several studies published from 2015 to 2020 found that receipt of PBs or GAHs was associated with improved psychological functioning 21 and body satisfaction, 22 as well as decreased depression 23 and suicidality 24 within a 1-year period. Initiation of gender-affirming care may be associated with improved short-term mental health owing to validation of gender identity and clinical staff support. Conversely, prerequisite mental health evaluations, often perceived as pathologizing by TNB youths, and initiation of GAHs may present new stressors that may be associated with exacerbation of mental health symptoms early in care, such as experiences of discrimination associated with more frequent points of engagement in a largely cisnormative health care system (eg, interactions with nonaffirming pharmacists to obtain laboratory tests, syringes, and medications). 25 Given the high risk of suicidality among TNB adolescents, there is a pressing need to better characterize mental health trends for TNB youths early in gender-affirming care. This study aimed to investigate changes in mental health among TNB youths enrolled in an urban multidisciplinary gender clinic over the first 12 months of receiving care. We also sought to investigate whether initiation of PBs or GAHs was associated with depression, anxiety, and suicidality.

This cohort study received approval from the Seattle Children’s Hospital Institutional Review Board. For youths younger than age 18 years, caregiver consent and youth assent was obtained. For youths ages 18 years and older, youth consent alone was obtained. The 12-month assessment was funded via a different mechanism than other survey time points; thus, participants were reconsented for the 12-month survey. The study follows the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We conducted a prospective observational cohort study of TNB youths seeking care at Seattle Children’s Gender Clinic, an urban multidisciplinary gender clinic. After a referral is placed or a patient self-refers, new patients, their caregivers, or patients with their caregivers are scheduled for a 1-hour phone intake with a care navigator who is a licensed clinical social worker. Patients are then scheduled for an appointment at the clinic with a medical provider.

All patients who completed the phone intake and in-person appointment between August 2017 and June 2018 were recruited for this study. Participants completed baseline surveys within 24 hours of their first appointment and were invited to complete follow-up surveys at 3, 6, and 12 months. Youth surveys were used to assess most variables in this study; caregiver surveys were used to assess caregiver income. Participation and completion of study surveys had no bearing on prescribing of PBs or GAHs.

We assessed 3 internalizing mental health outcomes: depression, generalized anxiety, and suicidality. Depression was assessed using the Patient Health Questionnaire 9-item scale (PHQ-9), and anxiety was assessed using the Generalized Anxiety Disorder 7-item scale (GAD-7). We dichotomized PHQ-9 and GAD-7 scores into measures of moderate or severe depression and anxiety (ie, scores ≥10). 26 , 27 Self-harm and suicidal thoughts were assessed using PHQ-9 question 9 (eTable 1 in the Supplement ).

Participants self-reported if they had ever received GAHs, including estrogen or testosterone, or PBs (eg, gonadotropin-releasing hormone analogues) on each survey. We conducted a medical record review to capture prescription of androgen blockers (eg, spironolactone) and medications for menstrual suppression or contraception (ie, medroxyprogesterone acetate or levonorgestrel-releasing intrauterine device) during the study period.

We a priori considered potential confounders hypothesized to be associated with our exposures and outcomes of interest based on theory and prior research. Self-reported gender was ascertained on each survey using a 2-step question that asked participants about their current gender and their sex assigned at birth. If a participant’s self-reported gender changed across surveys, we used the gender reported most frequently by a participant (3 individuals identified as transmasculine at baseline and as nonbinary on all follow-up surveys). We collected data on self-reported race and ethnicity (available response options were Arab or Middle Eastern; Asian; Black or African American; Latinx; Native American, American Indian, or Alaskan Native or Native Hawaiian; Pacific Islander; and White), age, caregiver income, and insurance type. Race and ethnicity were assessed as potential covariates owing to known barriers to accessing gender-affirming care among transgender youth who are members of minority racial and ethnic groups. For descriptive statistics, Asian and Pacific Islander groups were combined owing to small population numbers. We included a baseline variable reflecting receipt of ongoing mental health therapy other than for the purpose of a mental health assessment to receive a gender dysphoria diagnosis. We included a self-report variable reflecting whether youths felt their gender identity or expression was a source of tension with their parents or guardians. Substance use included any alcohol, marijuana, or other drug use in the past year. Resilience was measured by the Connor-Davidson Resilience Scale (CD-RISC) 10-item score developed to measure change in an individual’s state resilience over time. 28 Resilience scores were dichotomized into high (ie, ≥median) and low (ie, <median). Prior studies of young adults in the US reported mean CD-RISC scores ranging from 27.2 to 30.1. 29 , 30

We used generalized estimating equations to assess change in outcomes from baseline at each follow-up point (eFigure 1 in the Supplement ). We used a logit link function to estimate adjusted odds ratio (aOR) for the association between variables and each mental health outcome. We initially estimated bivariate associations between potential confounders and mental health outcomes. Multivariable models included variables that were statistically significant in bivariate models. For all outcomes and models, statistical significance was defined as 95% CIs that did not contain 1.00. Reported P values are based on 2-sided Wald test statistics.

Model 1 examined temporal trends in mental health outcomes, with time (ie, baseline, 3, 6, and 12 months) modeled as a categorical variable. Model 2 estimated the association between receipt of PBs or GAHs and mental health outcomes adjusted for temporal trends and potential confounders. Receipt of PBs or GAHs was modeled as a composite binary time-varying exposure that compared mean outcomes between participants who had initiated PBs or GAHs and those who had not across all time points (eTable 2 in the Supplement ). All models used an independent working correlation structure and robust standard errors to account for the time-varying exposure variable.

We performed several sensitivity analyses. Because our data were from an observational cohort, we first considered the degree to which they were sensitive to unmeasured confounding. To do this, we calculated the E-value for the association between PBs or GAHs and mental health outcomes in model 2. The E-value is defined as the minimum strength of association that a confounder would need to have with both exposure and outcome to completely explain away their association (eTable 4 in the Supplement ). 31 Second, we performed sensitivity analyses on several subsets of youths. We separately examined the association of PBs and GAHs with outcomes of interest, although we a priori did not anticipate being powered to detect statistically significant outcomes owing to our small sample size and the relatively low proportion of youths who accessed PBs. We also conducted sensitivity analyses using the Patient Health Questionnaire 8-item scale (PHQ-8), in which the PHQ-9 question 9 regarding self-harm or suicidal thoughts was removed, given that we analyzed this item as a separate outcome. Lastly, we restricted our analysis to minor youths ages 13 to 17 years because they were subject to different laws and policies related to consent and prerequisite mental health assessments. We used R statistical software version 3.6.2 (R Project for Statistical Computing) to conduct all analyses. Data were analyzed from August 2020 through November 2021.

A total of 169 youths were screened for eligibility during the study period, among whom 161 eligible youths were approached. Nine youths or caregivers declined participation, and 39 youths did not complete consent or assent or did not complete the baseline survey, leaving a sample of 113 youths (70.2% of approached youths). We excluded 9 youths aged younger than 13 years from the analysis because they received different depression and anxiety screeners. Our final sample included 104 youths ages 13 to 20 years (mean [SD] age, 15.8 [1.6] years). Of these individuals, 84 youths (80.8%), 84 youths, and 65 youths (62.5%) completed surveys at 3, 6, and 12 months, respectively.

Our cohort included 63 transmasculine youths (60.6%), 27 transfeminine youths (26.0%), 10 nonbinary or gender fluid youths (9.6%), and 4 youths who responded “I don’t know” or did not respond to the gender identity question on all completed questionnaires (3.8%) ( Table 1 ). There were 4 Asian or Pacific Islander youths (3.8%), 3 Black or African American youths (2.9%); 9 Latinx youths (8.7%); 6 Native American, American Indian, or Alaskan Native or Native Hawaiian youths (5.8%); 67 White youths (64.4%); and 9 youths who reported more than 1 race or ethnicity (8.7%). Race and ethnicity data were missing for 6 youth (5.8%).

At baseline, 7 youths had ever received PBs or GAHs (including 1 youth who received PBs, 4 youths who received GAHs, and 2 youths who received both PBs and GAHs). By the end of the study, 69 youths (66.3%) had received PBs or GAHs (including 50 youths who received GAHs only [48.1%], 5 youths who received PBs only [4.8%], and 14 youths who received PBs and GAHs [13.5%]), while 35 youths had not received either PBs or GAHs (33.7%) (eTable 3 in the Supplement ). Among 33 participants assigned male sex at birth, 17 individuals (51.5%) had received androgen blockers, and among 71 participants assigned female sex at birth, 25 individuals (35.2%) had received menstrual suppression or contraceptives by the end of the study.

A large proportion of youths reported depressive and anxious symptoms at baseline. Specifically, 59 individuals (56.7%) had baseline PHQ-9 scores of 10 or more, suggesting moderate to severe depression; there were 22 participants (21.2%) scoring in the moderate range, 11 participants (10.6%) in the moderately severe range, and 26 participants (25.0%) in the severe range. Similarly, half of participants had a GAD-7 score suggestive of moderate to severe anxiety at baseline (52 individuals [50.0%]), including 20 participants (19.2%) scored in the moderate range, and 32 participants (30.8%) scored in the severe range. There were 45 youths (43.3%) who reported self-harm or suicidal thoughts in the prior 2 weeks. At baseline, 65 youths (62.5%) were receiving ongoing mental health therapy, 36 youths (34.6%) reported tension with their caregivers about their gender identity or expression, and 34 youths (32.7%) reported any substance use in the prior year. Lastly, we observed a wide range of resilience scores (median [range], 22.5 [1-38], with higher scores equaling more resiliency). There were no statistically significant differences in baseline characteristics by gender.

In bivariate models, substance use was associated with all mental health outcomes ( Table 2 ). Youths who reported any substance use were 4-fold as likely to have PHQ-9 scores of moderate to severe depression (aOR, 4.38; 95% CI, 2.10-9.16) and 2-fold as likely to have GAD-7 scores of moderate to severe anxiety (aOR, 2.07; 95% CI, 1.04-4.11) or report thoughts of self-harm or suicide in the prior 2 weeks (aOR, 2.06; 95% CI, 1.08-3.93). High resilience scores (ie, ≥median), compared with low resilience scores (ie, <median), were associated with lower odds of moderate or severe anxiety (aOR, 0.51; 95% CI, 0.26-0.999).

There were no statistically significant temporal trends in the bivariate model or model 1 ( Table 2 and Table 3 ). However, among all participants, odds of moderate to severe depression increased at 3 months of follow-up relative to baseline (aOR, 2.12; 95% CI, 0.98-4.60), which was not a significant increase, and returned to baseline levels at months 6 and 12 ( Figure ) prior to adjusting for receipt of PBs or GAHs.

We also examined the association between receipt of PBs or GAHs and mental health outcomes in bivariate and multivariable models (eFigure 2 in the Supplement ). After adjusting for temporal trends and potential confounders ( Table 4 ), we observed that youths who had initiated PBs or GAHs had 60% lower odds of moderate to severe depression (aOR, 0.40; 95% CI, 0.17-0.95) and 73% lower odds of self-harm or suicidal thoughts (aOR, 0.27; 95% CI, 0.11-0.65) compared with youths who had not yet initiated PBs or GAHs. There was no association between receipt of PBs or GAHs and moderate to severe anxiety (aOR, 1.01; 95% CI, 0.41-2.51). After adjusting for time-varying exposure of PBs or GAHs in model 2 ( Table 4 ), we observed statistically significant increases in moderate to severe depression among youths who had not received PBs or GAHs by 3 months of follow-up (aOR, 3.22; 95% CI, 1.37-7.56). A similar trend was observed for self-harm or suicidal thoughts among youths who had not received PBs or GAHs by 6 months of follow-up (aOR, 2.76; 95% CI, 1.22-6.26). Lastly, we estimated E-values of 2.56 and 3.25 for the association between receiving PGs or GAHs and moderate to severe depression and suicidality, respectively (eTable 4 in the Supplement ). Sensitivity analyses obtained comparable results and are presented in eTables 5 through 8 in the Supplement .

In this prospective clinical cohort study of TNB youths, we observed high rates of moderate to severe depression and anxiety, as well as suicidal thoughts. Receipt of gender-affirming interventions, specifically PBs or GAHs, was associated with 60% lower odds of moderate to severe depressive symptoms and 73% lower odds of self-harm or suicidal thoughts during the first year of multidisciplinary gender care. Among youths who did not initiate PBs or GAHs, we observed that depressive symptoms and suicidality were 2-fold to 3-fold higher than baseline levels at 3 and 6 months of follow-up, respectively. Our study results suggest that risks of depression and suicidality may be mitigated with receipt of gender-affirming medications in the context of a multidisciplinary care clinic over the relatively short time frame of 1 year.

Our findings are consistent with those of prior studies finding that TNB adolescents are at increased risk of depression, anxiety, and suicidality 1 , 11 , 32 and studies finding long-term and short-term improvements in mental health outcomes among TNB individuals who receive gender-affirming medical interventions. 14 , 21 - 24 , 33 , 34 Surprisingly, we observed no association with anxiety scores. A recent cohort study of TNB youths in Dallas, Texas, found that total anxiety symptoms improved over a longer follow-up of 11 to 18 months; however, similar to our study, the authors did not observe statistically significant improvements in generalized anxiety. 22 This suggests that anxiety symptoms may take longer to improve after the initiation of gender-affirming care. In addition, Olson et al 35 found that prepubertal TNB children who socially transitioned did not have increased rates of depression symptoms but did have increased rates of anxiety symptoms compared with children who were cisgender. Although social transition and access to gender-affirming medical care do not always go hand in hand, it is noteworthy that access to gender-affirming medical care and supported social transition appear to be associated with decreased depression and suicidality more than anxiety symptoms.

Time trends were not significant in our study; however, it is important to note that we observed a transient and nonsignificant worsening in mental health outcomes in the first several months of care among all participants and that these outcomes subsequently returned to baseline by 12 months. This is consistent with findings from a 2020 study 36 in an academic medical center in the northwestern US that observed no change in TNB adolescents’ GAD-7 or PHQ-9 scores from intake to first follow-up appointment, which occurred a mean of 4.7 months apart. Given that receipt of PBs or GAHs was associated with protection against depression and suicidality in our study, it could be that delays in receipt of medications is associated with initially exacerbated mental health symptoms that subsequently improve. It is also possible that mental health improvements associated with receiving these interventions may have a delayed onset, given the delay in physical changes after starting GAHs.

Few of our hypothesized confounders were associated with mental health outcomes in this sample, most notably receipt of ongoing mental health therapy and caregiver support; however, this is not surprising given that these variables were colinear with baseline mental health, which we adjusted for in all models. Substance use was the only variable associated with all mental health outcomes. In addition, youths with high baseline resilience scores were half as likely to experience moderate to severe anxiety as those with low scores. This finding suggests that substance use and resilience may be additional modifiable factors that could be addressed through multidisciplinary gender-affirming care. We recommend more granular assessment of substance use and resilience to better understand support needs (for substance use) and effective support strategies (for resilience) for TNB youths in future research.

This study has a number of strengths. This is one of the first studies to quantify a short-term transient increase in depressive symptoms experienced by TNB youths after initiating gender-affirming care, a phenomenon observed clinically by some of the authors and described in qualitative research. 37 Although we are unable to make causal statements owing to the observational design of the study, the strength of associations between gender-affirming medications and depression and suicidality, with large aOR values, and sensitivity analyses that suggest that these findings are robust to moderate levels of unmeasured confounding. Specifically, E-values calculated for this study suggest that the observed associations could be explained away only by an unmeasured confounder that was associated with both PBs and GAHs and the outcomes of interest by a risk ratio of 2-fold to 3-fold each, above and beyond the measured confounders, but that weaker confounding could not do so. 31

Our findings should be interpreted in light of the following limitations. This was a clinical sample of TNB youths, and there was likely selection bias toward youths with supportive caregivers who had resources to access a gender-affirming care clinic. Family support and access to care are associated with protection against poor mental health outcomes, and thus actual rates of depression, anxiety, and suicidality in nonclinical samples of TNB youths may differ. Youths who are unable to access gender-affirming care owing to a lack of family support or resources require particular emphasis in future research and advocacy. Our sample also primarily included White and transmasculine youths, limiting the generalizability of our findings. In addition, the need to reapproach participants for consent and assent for the 12-month survey likely contributed to attrition at this time point. There may also be residual confounding because we were unable to include a variable reflecting receipt of psychotropic medications that could be associated with depression, anxiety, and self-harm and suicidal thought outcomes. Additionally, we used symptom-based measures of depression, anxiety, and suicidality; further studies should include diagnostic evaluations by mental health practitioners to track depression, anxiety, gender dysphoria, suicidal ideation, and suicide attempts during gender care. 2

Our study provides quantitative evidence that access to PBs or GAHs in a multidisciplinary gender-affirming setting was associated with mental health improvements among TNB youths over a relatively short time frame of 1 year. The associations with the highest aORs were with decreased suicidality, which is important given the mental health disparities experienced by this population, particularly the high levels of self-harm and suicide. Our findings have important policy implications, suggesting that the recent wave of legislation restricting access to gender-affirming care 19 may have significant negative outcomes in the well-being of TNB youths. 20 Beyond the need to address antitransgender legislation, there is an additional need for medical systems and insurance providers to decrease barriers and expand access to gender-affirming care.

Accepted for Publication: January 10, 2022.

Published: February 25, 2022. doi:10.1001/jamanetworkopen.2022.0978

Correction: This article was corrected on July 26, 2022, to fix minor errors in the numbers of patients in eTables 2 and 3 in the Supplement.

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2022 Tordoff DM et al. JAMA Network Open .

Corresponding Author: Diana M. Tordoff, MPH, Department of Epidemiology, University of Washington, UW Box 351619, Seattle, WA 98195 ( [email protected] ).

Author Contributions : Diana Tordoff had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Diana Tordoff and Dr Wanta are joint first authors. Drs Inwards-Breland and Ahrens are joint senior authors.

Concept and design: Collin, Stepney, Inwards-Breland, Ahrens.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Tordoff, Wanta, Collin, Stepney, Inwards-Breland.

Critical revision of the manuscript for important intellectual content: Wanta, Collin, Stepney, Inwards-Breland, Ahrens.

Statistical analysis: Tordoff.

Obtained funding: Inwards-Breland, Ahrens.

Administrative, technical, or material support: Ahrens.

Supervision: Wanta, Inwards-Breland, Ahrens.

Conflict of Interest Disclosures: Diana Tordoff reported receiving grants from the National Institutes of Health National Institute of Allergy and Infectious Diseases unrelated to the present work and outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported Seattle Children’s Center for Diversity and Health Equity and the Pacific Hospital Preservation Development Authority.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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The adult trans care pathway

The adult trans care pathway focuses on the care of people with:

• variations of sex characteristics (VSC)
• trans people aged 17 years and older and transitioning their gender
• non-binary people aged 17 years and older and transitioning their gender

The trans care pathway refers mainly to patients transitioning gender medically, rather than socially or legally.

People with VSC, trans and non-binary people may be particularly vulnerable to receiving poor care. This may be for reasons such as a lack of training for staff, inefficient monitoring of trans status, and potential transphobia.

The General Medical Council (GMC) has produced guidance on trans care . It states that trans and non-binary people experience the same health problems as everyone else and that healthcare professionals must assess, provide treatment for and refer trans patients in the same way as other patients.

Terminology

• Transgender is usually shortened to ‘trans’. It describes people whose felt sense of gender (gender identity) is not the same as the gender assigned at birth on the basis of genital appearance
• Non-binary is an umbrella term to describe gender identities that are not only masculine or only feminine. They are outside the ‘gender binary’ of male and female. Not all non-binary people identify as trans.
• Gender affirmation is the process a transgender person goes through to change their physical sexual characteristics to match their gender identity. This typically involves a combination of surgical procedures and hormone treatment.
• Gender reassignment (wording of the Act to mean trans status) is one of the nine protected characteristics under the Equality Act 2010. The Act recognises prejudice and discrimination that trans and non-binary people may face in receiving both services and employment.
• Gender variance is an umbrella term to describe gender identity, expression, or behaviour that falls outside culturally defined norms associated with a specific assigned gender.
• Cisgender relates to a person whose sense of gender identity corresponds with their sex assigned at birth.

When we assess health and care services, we consider equality and whether services are providing high-quality care for all people, including people on the trans care pathway. We judge whether services are meeting the equality aspects of the Health and Social Care Act regulations, particularly:

• Regulation 9 (Person centred care)
• Regulation 10 (Dignity and Respect)

When we assess services, we will look at how they provide care for people who are on the trans care pathway, where this is relevant. This will take into account the local access arrangements to gender services.

Adult trans care pathway: what CQC expects from GP practices

Adult trans care pathway: what CQC expects from maternity and gynaecology services

Adult trans care pathway: what CQC expects from speech and language services

Further information

• How to find a gender identity clinic (NHS England)
• Inclusive language (NHS Digital Service Manual)
• Transgender issues in later life (Age UK)
• Trans healthcare (General Medical Council)
• Support for GPs and trans patients (LGBT Foundation/NHS in Greater Manchester)
• Gender Dysphoria Clinical Programme (NHS England)
• The role of the GP in caring for gender-questioning and transgender patients (Royal College of General Practitioners)
• Fair care for trans and non-binary people (Royal College of Nursing)
• The Royal College of Psychiatrists position statement Supporting transgender and gender diverse people
• LGBT in Britain: Trans report (Stonewall and YouGov)
• Standards of care for the Health of Transsexual, Transgender, and Gender Nonconforming People: Version 7 (World Professional Association for Transgender Health)

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• v.104(3); Mar 2014

The State of Transgender Health Care: Policy, Law, and Medical Frameworks

I review the current status of transgender people’s access to health care in the United States and analyze federal policies regarding health care services for transgender people and the limitations thereof. I suggest a preliminary outline to enhance health care services and recommend the formulation of explicit federal policies regarding the provision of health care services to transgender people in accordance with recently issued medical care guidelines, allocation of research funding, education of health care workers, and implementation of existing nondiscrimination policies. Current policies denying medical coverage for sex reassignment surgery contradict standards of medical care and must be amended.

The term transgender is an adjective that has been widely adopted to describe people whose gender identity, gender expression, or behavior does not conform to what is socioculturally accepted as, and typically associated with, the legal and medical sex to which they were assigned at birth. 1 Gender nonconformity, or a desire to express gender in ways that differ from gender-cultural norms linked to sex assigned at birth, was until very recently considered a mental pathology by the psychiatric community. 2 Although recognition and classification of gender nonconformity appeared in Western medicine in the 1920s, gender identity disorder (GID) first appeared as a distinct diagnosis in the American Psychiatric Association’s (APA’s) third edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM ) in 1980 2 and remained a category until the newest edition of the DSM (the DSM-5 ). 3 Over the past few decades, after professional as well as public debates, the APA has moved toward differentiating gender nonconformity from mental illness. On December 1, 2012, the board of the APA approved changing the diagnosis of GID to that of gender dysphoria in the DSM-5, 3 a significant move toward depathologizing gender variance. Psychiatrists increasingly agree that being transgender is not an illness to be cured or overcome (nor, for that matter, a state that can be altered). However, those who suffer because of the misalignment of their physical characteristics with their gender identity may benefit from treatment. 4

Current estimates have suggested that 0.3% of US adults, or close to 1 million people, identify as transgender. 5 (Other estimates have varied widely from a high prevalence of 1:500 or more 6 to 1:11 900–1:45 000 for male-to-female individuals and 1:30 400–1:200 000 for female-to-male individuals. 7–10 ) Demographic studies to date have been limited 7 because national surveys have not included questions recognizing gender identity. Furthermore, important methodological debates remain unresolved, including those about conflation of terms (e.g., differentiation among gender, gender identity, and sex ) and appropriate ways to accurately describe the transgender population (e.g., according to self-identification, gender expression, gender identity, or wish for medical treatment). 8 One way of estimating the proportion of transgender people in the population is through data on medical care, specifically medical assistance in the process of adapting gender presentation to align with identity, a process known as transitioning. However, this approach does not identify transgender people who have not opted for or who have faced insurmountable obstacles in accessing such care. Even using the conservative estimate of 0.3%, the number of people living in the United States who identify as transgender is nearly 1 million. Health care for this population has historically been, and continues to be, overlooked by governmental, health care, and academic establishments.

Transgender people have a unique set of mental and physical health needs. These needs are compounded by prejudices against transgender people within both the medical system and society at large. These prejudices create barriers to accessing timely, culturally competent, medically appropriate, and respectful care. 9,11,12 These societal and medical barriers are associated with increased risk of violence, suicide, and sexually transmitted infections. 11 Additionally, transgender people may have health needs related to gender transition, including hormonal therapy and surgery, that can create an undesired and unavoidable dependency on the medical system for basic identity expression. This combination of high medical needs and barriers to accessing appropriate care may give rise to a self-perpetuating cycle of risk exposure, stigmatization, prejudice, and eventually poor health outcomes.

Transition-related medical care, otherwise referred to as gender-confirming therapy , is designed to assist an individual with the adjustment of primary and secondary sexual characteristics to align with gender identity. 9,13 Such therapy may include hormonal therapy, surgical therapy, or both depending on individual needs and wishes, as well as ability to access such services. Procedures for gender confirmation may include breast or chest surgery, hysterectomy, genital reconstruction, facial hair removal, and plastic reconstruction, as appropriate to the particular person. 14

Denial of, or severely limited access to, medical care for transgender people, whether explicitly by refusal of coverage or implicitly by prejudice and lack of knowledge among health care workers, may have detrimental effects on both short- and longer term health and well-being of transgender people. Moreover, the failure to comprehensively address the medical needs of transgender people stands in contradiction to the medical profession’s prized values of equity and respect. 15 As such, I argue that a new approach is urgently needed: one that not only recognizes the unique health care needs of this group of people, but does so in an ethical, principled, and timely manner.

TRENDS IN DATA COLLECTION

Over the past few decades, a growing body of research has been published regarding lesbian, gay, bisexual, and transgender (LGBT) health. 16,17 However, most of the literature and published data have involved sexual minorities (i.e., lesbians, gays, and bisexuals) or the LGBT community as a whole, leaving unaddressed specific needs, issues, and barriers faced by transgender and gender-nonconforming people. Although a growing body of literature has addressed the overall health and health indicators of transgender people, 12,18,19 the evidence-based work on gender-confirming treatment (medical and surgical transition care) is still limited. For example, few high-quality systematic studies have been conducted 20 ; of those conducted, many are observational in nature. 4,11,21 (Because of the relative availability of funding for HIV/AIDS-related research and high HIV prevalence among transgender people, 11 much of the research to date regarding transgender health policy has focused on HIV/AIDS; see also Brennan et al. 21 ) Further compounding the lack of rigorous research and data, the limited body of published work includes examples of research that may be construed as objectifying and may lead to misunderstanding or prejudice by readers (including authors’ use of assigned rather than chosen gender pronouns 22 ), which brings with it the risk of perpetuating or deepening misconceptions and unconscious prejudices among health care professionals.

In the past few years, several key public health bodies have recognized the lack of robust data on health indicators and on what constitutes medically appropriate care and the negative effect it has had on the quality of care provided to sexual and gender minorities; attempts to address these knowledge gaps have resulted in recent reports on LGBT health, for example, by the Institute of Medicine 17 and Healthy People 2020. 23

In a recently published response to the Institute of Medicine report on LGBT health, the National Institute of Health’s LGBT Research Coordinating Committee found that most LGBT health research

is focused in the areas of Behavioral and Social Sciences, HIV (human immunodeficiency virus)/AIDS, Mental Health, and Substance Abuse. Relatively little research has been done in several key health areas for LGBT populations including the impact of smoking on health, depression, suicide, cancer, aging, obesity, and alcoholism. 24 (p8)

In this same report, the LGBT Research Coordinating Committee called for increased research on transgender-specific health needs, including those associated with transitioning and the safety and efficacy of surgical sex reassignment procedures, as well as mental health and routine clinical care.

On June 29, 2011, US Department of Health and Human Services Secretary Kathleen Sibelius announced that the department would begin collecting data in its population health surveys that would facilitate identification of health issues and reduction of health disparities among LGBT populations. 25 These data will be collected by integrating questions regarding sexual orientation and gender identity into the National Health Interview Survey and, as an initial step toward the creation of a governmental standard for LGBT health data collection, under Section 4302 (nondiscrimination) of the Patient Protection and Affordable Care Act (ACA). 26 Starting in January 2013, the National Health Interview Survey has included a sexual-orientation specific question. HHS is currently testing survey questions on gender identity with the express purpose of capturing data about transgender people. 27

MEDICAL NEEDS

Transgender people, particularly low-income transgender people and transgender people of color, have reported even higher rates of discrimination in accessing competent and comprehensive care than other sexual minorities. 28 In 2008, the National Center for Transgender Equality and the National Gay and Lesbian Task Force partnered to conduct the first large-scale, national survey of transgender people, funded by the Network for LGBT Health Equity (formerly the Network for LGBT Tobacco Control). The study’s overarching objective was to map out the needs of and the issues faced by transgender people. 11 The 70-question survey was developed by an interdisciplinary team of social and health science researchers, grassroots and national transgender rights advocates, expert lawyers, statisticians, and LGBT movement leaders. The survey was completed online or in paper form and returned by more than 7500 respondents recruited through community organizations and community e-mail distribution lists, with direct outreach through organizations serving hard-to-reach populations, such as rural, homeless, and low-income transgender and gender-nonconforming people. The responses of 6456 people were included in the analysis, with a geographical distribution representative of the US population.

The landmark survey confirmed and expanded existing knowledge regarding areas of increased risk and specific difficulties that transgender people face in navigating the health care system. 11 It found that 19% of respondents reported having been denied health care by a provider because of their gender identity, and 28% reported verbal harassment in a medical setting. More than a quarter (28%) of respondents postponed care because of discrimination and disrespect, and a third (33%) postponed preventive care. Nineteen percent of respondents reported that they lacked insurance coverage (compared with 15% of the general population at that time 29 ), and a lower proportion of insured people received employment-based insurance than in the general population, which is likely attributable to high rates of job loss resulting from bias (as reported in the survey). 11

Looking at specific vulnerabilities, the survey reported that transgender people have a particularly high likelihood of being HIV-positive and using drugs, alcohol, or smoking as a mechanism to cope with discrimination compared with the general population. The lifetime suicide attempt rate was 41% of the respondent population (compared with 1.6% in the general population). 11 Each of these vulnerabilities was enhanced among racial minorities and among those participating in sex work, drug use and sales, or both. The survey reported that 75% of transgender women (i.e., female-identified or male-to-female transgender people) and more than 90% of transgender men (i.e., male-identified or female-to-male transgender people) either had or wanted to have surgical treatment, and 85% of transgender people either had or hoped to have hormonal treatment. 11

A modest but growing body of research has examined the efficiency of medical treatment. Gender-confirming surgery, often referred to as sex reassignment surgery (SRS), 1 has been shown to be beneficial in alleviating gender dysphoria (the distress associated with the difference between an individual’s expressed or experienced gender and socially assigned gender). 4,30,31 A 1992 study reported that hormone therapy improves quality of life as assessed by the Short Form-36 (SF-36) Health Survey, a 36-question validated survey assessing measures of health and well-being. 32 Increasingly, the overall consensus among those providing medical care to transgender people is that

sex reassignment generally, and SRS specifically, is associated with a high degree of patient satisfaction, a low prevalence of regrets, significant relief of gender dysphoria, and aggregate psychosocial outcomes that are usually no worse and are often substantially better than before sex reassignment. 33 (pp423–424)

Medical professional associations are increasingly publicly supporting inclusion of health care for transgender people and opposing the commonly held but slowly changing notion that such care is frivolous, cosmetic, experimental, or unnecessary. Since the early 1980s, the World Professional Association for Transgender Health (WPATH, formerly known as the Harry Benjamin International Gender Dysphoria Association) has been publishing standards of care (SOC). 9 Both SRS and hormonal therapy are endorsed by the SOC as necessary care for gender dysphoria, being both effective and often life saving. 9 Other professional societies, including the American College of Obstetricians and Gynecologists, 34 the Endocrine Society, 35 the American Medical Association, 36,37 and the American Psychological Association, 38 have endorsed these recommendations. They have each published statements encouraging care for transgender patients and urging public and private health insurance coverage for treatment of gender dysphoria.

In terms of costs, the American Medical Association has estimated provision of health care to transgender people to be nearly cost saving (incremental cost-effectiveness estimate = $500). 37 In 2001, San Francisco, California, became the first US city and county to remove transgender access exclusions from its employee health plan; in 2006, employee surcharges to cover these benefits were dropped because costs of reimbursement proved to be significantly lower than previously estimated. 39

Beyond insurance coverage, access to care is limited by the dearth of physicians who focus on, or are comfortable with, providing care for transgender people. A stark example is the paucity of surgeons performing genital reconstructive surgery: As of 2012, only 6 identified surgeons in the United States performed genital reconstructive surgery (Eric Plemons, PhD, written communication, January 3, 2013), thus limiting options for people seeking this surgery.

Other issues that transgender people often encounter in their interaction with the health care system include lack of respect and acceptance of chosen gender by health care staff, privacy and safety, 1 cultural appropriateness and understanding, and adequate knowledge of some of their specific medical needs. 11,12,40 (For example, while breach of confidentiality is always a serious matter, it can have particularly far-reaching consequences for the safety of transgender people when it leads to involuntary “outing,” or exposure of transgender identity.) Given the widespread lack of knowledge about transgender populations, and the absence of transgender health issues from most medical school curricula, 41 much remains to be done to shape a medical workforce that is well informed regarding the needs of this population and capable of providing appropriate care. Therefore, educating health practitioners about these issues is crucial. Of utmost importance is education of primary care providers, along with specialists in fields of particular relevance (including endocrinology, urology, obstetrics and gynecology, and plastic and reconstructive surgery, as well as emergency medicine). However, because physicians from all specialties treat transgender people, the basics of transgender health care should be addressed in medical, physician assistant, and nursing schools on a national scale.

US REGULATORY AND POLICY LANDSCAPE

Among issues of access to care that must be addressed nationally, that of insurance coverage and affordability of care has primary importance.

Federal Agencies and Regulations

As the US population ages, an increasing proportion of the population, including the transgender population, will become dependent on Medicare for access to care. Although Medicare covers both routine care (through parts B and 1) and hormonal treatment (part D), SRS is not covered. The specific language used by the Center for Medicare and Medicaid Services in explaining this lack of coverage is telling:

Transsexual surgery, also known as sex reassignment surgery or intersex surgery, is the culmination of a series of procedures designed to change the anatomy of transsexuals to conform to their gender identity. Transsexuals are persons with an overwhelming desire to change anatomic sex because of their fixed conviction that they are members of the opposite sex. For the male-to-female, transsexual surgery entails castration, penectomy and vulva-vaginal construction. Surgery for the female-to-male transsexual consists of bilateral mammectomy, hysterectomy and salpingo-oophorectomy, which may be followed by phalloplasty and the insertion of testicular prostheses. Transsexual surgery for sex reassignment of transsexuals is controversial. Because of the lack of well controlled, long term studies of the safety and effectiveness of the surgical procedures and attendant therapies for transsexualism, the treatment is considered experimental. Moreover, there is a high rate of serious complications for these surgical procedures. For these reasons, transsexual surgery is not covered by Medicare. 42 (sect140.3)

Several issues arise from this language. First, SRS is neither controversial nor experimental; rather, it is a well-recognized therapy advocated for by leading medical associations. This claim cannot serve as a basis for denying coverage for necessary treatment. The terminology and definitions in this statement are inaccurate, outdated, and inconsistent with current APA guidelines. The statement conflates intersexuality with being transgender and fails to acknowledge the wide range of possible gender expressions. Neither does it address the high rate of serious sequelae of failing to treat transgender people who have a need for gender-confirming surgery. Risk of complication is not sufficient grounds for rejecting treatment. As with any other procedure, one must evaluate the potential risk of complication in the context of the condition being treated and the risks of failure to treat.

In June 2011, in an effort to standardize care for transgender veterans, the Veterans Health Administration in the US Department of Veterans Affairs (VA) published directives regarding provision of care to transgender (and intersex) veterans (Patrick Paschall, JD, policy counsel, National Gay and Lesbian Task Force, oral communication, January 8, 2013). The directives state that

medically necessary care is provided to enrolled or otherwise eligible intersex and transgender Veterans including hormonal therapy, mental health care, preoperative evaluation, and medically necessary post-operative and long-term care following sex reassignment surgery. 43 (p2)

This policy clarifies the obligation of VA medical providers to extend comprehensive care to transgender veterans. The directives, however, deny coverage of SRS on the basis of a VA regulation excluding gender alterations from the medical benefits package, 44 despite the recognition of such alterations as part of care. Furthermore, these directives also contradict VA policy to provide “care and treatment to Veterans that is compatible with generally accepted standards of medical practice.” 34,35,37,43 (p2) However, an increasing commitment to LGBT inclusion in the VA, particularly through the recently founded Office for Diversity and Inclusion, has led to significant progress in health care delivery for transgender people. In June 2011, the Veterans Health Administration added protections based on gender identity to Equal Employment Opportunity Commission protections for employees, 45 and it is currently providing training for health care providers in services for transgender veterans. 46

High rates of unemployment in the transgender population are also a major barrier to maintaining health and appropriate health care. 2 Accordingly, employment of transgender people in the health care workforce is recommended because it offers an important avenue to address some of the challenges and barriers this population faces in the health care system. Although the burden of educating medical professionals should not rest on transgender people, increasing participation of transgender people in the health care workforce can facilitate and catalyze education and increase the understanding of issues faced by transgender people. This, in turn, has the potential to create safer and welcoming spaces for transgender people who seek medical care. Regarding employment more generally, in April 2012 the Equal Employment Opportunity Commission ruled that the Civil Rights Act’s prohibition against sex employment discrimination (title VII) applies to transgender people. See Macy v Holder. 47

In July 2012, in response to a letter from LGBT organizations, the US Department of Health and Human Services issued a statement clarifying that the ban on sex discrimination in section 1557 (nondiscrimination) of the ACA includes discrimination on the basis of gender identity. 48 This federal policy statement, the 1st of its kind, has wide implications, including for Medicare and Medicaid. This statement, along with the Equal Employment Opportunity Commission ruling, should not only increase access of transgender people to appropriate health care but also help alleviate concerns about discrimination and promote active participation in the health care system.

Some additional protections for transgender people are expected with implementation of the ACA. Standards for qualified health providers (QHPs) participating in the exchange programs ban discrimination in any of their activities, including on the basis of sexual orientation or gender identity:

Non-discrimination. A QHP issuer must not, with respect to its QHP, discriminate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation. 49 (p916)

Additionally, coverage denial based on being transgender as a preexisting condition will be banned under the ACA starting in 2014. To what extent and how promptly these protections will be implemented, and whether they will lead to higher rates of coverage for mental health services, cross-sex hormone therapy, or gender affirmation surgery, remains to be seen. These advances do not, however, provide an explicit and directed protection of transgender people within the health care system, nor do they address coverage of specific treatments that transgender people may need.

The Ending LGBT Health Disparities Act, a federal bill introduced in 2009, proposed the addition of a sexual orientation and gender identity nondiscrimination clause to all Medicaid, Medicare, and Children’s Health Insurance programs, with gender identity meaning

the gender-related identity, appearance, or mannerisms, or other gender-related characteristics of an individual, with or without regard to the individual's designated sex at birth. 50

The bill included federal grants to improve access and health promotion to gender and sexual minorities, in part through dedicated LGBT health centers, research related to gender and sexual minorities’ health disparities, and a requirement that sexual orientation and gender identity be included in federally funded health surveys. It also aimed to amend the Public Health Services Act by setting national standards for cultural competency of health care service to include sexual and gender minority cultural competency. Also important, the bill included a prohibition against discrimination on the basis of sexual orientation or gender identity under the health benefits program for federal employees and in the provision of health care and other benefits for members of the armed forces and veterans. This bill, though it did not directly relate to treatment coverage, would not only have increased access to care for all those directly affected by it, but may also have helped create a positive and inclusive climate for transgender people as full members of the population whose health is of concern. The bill was not passed, however, and so developments in enabling access to care for transgender people remain dependent on incremental advances within the current legal frameworks.

Court Decisions and Treatment Coverage

Given prisoners’ restriction of liberties, it is perhaps not surprising that some of the most serious limitations on transgender people’s access to health care have been in the US prison system. In most states, either incarcerated transgender people are housed according to their external genitals or no specific policy exists regarding their treatment and housing. 51,52 More surprising, perhaps, is that these abuses coexist alongside some of the most important advancements in protection of these rights. In several instances, federal courts have upheld the rights of transgender prisoners to receive both hormonal and surgical treatment. These decisions were based on the WPATH standards of care and on expert opinions that transition care (both hormonal and surgical) is medically necessary. The courts reasoned that the denial of transition care amounts to cruel and unusual punishment, a violation of the Eighth Amendment.

A landmark case is Fields v Smith. 53 In 2005, Wisconsin passed the Inmate Sex-Change Prevention Act, prohibiting funding of transition therapy (both hormonal and surgical) for transgender prisoners. 54 Several transgender women whose care was abruptly cut off filed against this law, claiming unconstitutionality on the basis of both the Eighth Amendment (cruel and unusual punishment) and the Equal Protection Clause. A federal district court found that the law constituted deliberate indifference to the plaintiffs’ medical needs in violation of the Eighth Amendment and violated the plaintiffs’ right to equal protection. The Seventh Circuit court affirmed the district court’s order.

In Adams v Federal Bureau of Prisons 55 in 2010, a federal district court judge denied a motion to dismiss the complaint of Vanessa Adams, who was denied hormonal treatment. Though Adams was by that time receiving care, the Federal Bureau of Prisons had not changed its policy of refusing hormone therapy for transgender people. The case resulted in a reversal of policy that denied inmates initiation of treatment of GID. In Kosilek v Spencer 52 in 2012, the District of Massachusetts Court ruled in favor of Michelle Kosilek, requiring the Massachusetts Department of Corrections to provide SRS for Kosilek. The court based its ruling on doctors’ expert opinions stating that in severe cases SRS is medically necessary; in this case, Justice Wolf, citing the WPATH Standards of Care, upheld previous rulings that GID is a severe medical condition requiring treatment. Justice Wolf also underscored that treatment cannot be denied on the basis of cost, because prisoners routinely receive care that is perceived as expensive. As Levi 56 pointed out, more than asserting the right or need for treatment of GID or limits to treatment within the prison system, the Kosilek ruling relates to what she called transgender exceptionalism, or the fear of controversy as a guiding principle for decisions made by government officials. In O’Donnabhain v Commissioner in 2010, the US Tax Court ruled in a manner similar to the rulings regarding prisoners’ right to transition care. 57 The court found that SRS and hormonal therapy are tax deductible under the Internal Revenue Code because they constitute necessary medical treatment.

Given these affirmations by the judicial system of the medical necessity for transition care, I argue that the federal Medicaid program should require participating states to cover gender-confirming treatment. 58 Although according to the statute governing the Medicaid programs (Title XIX of the Social Security Act, 42 USC § 1396), states “may place appropriate limits on a service based on such criteria as medical necessity,” 59 (p273) they may also not arbitrarily deny benefits solely on the basis of “diagnosis, type of illness, or condition.” 59 (p273) In fact, as early as 1980, the US Court of Appeals (Eighth Circuit) found that denial of coverage for SRS is an

arbitrary denial of benefits based solely on the diagnosis, type of illness, or condition where physician and hospital care are mandatory services and such surgery is “the only successful treatment known to medical science.” 60

A previously used measure for the reasonableness of the legislature’s standards has been general acceptability by the professional medical community as an “effective and proven treatment.” 61 Thus, although coverage of treatment must ultimately depend on particular need, as prescribed by the treating physician, it seems clear that as a category of treatment, gender-confirming care should be covered by individual states’ Medicaid programs, as by other publicly funded programs.

Many states currently have laws that explicitly deny Medicaid coverage of gender-confirming therapies, either specifically (e.g., Iowa, 62 Massachusetts 63 ) or because it is included in the category of cosmetic and experimental surgery (e.g., Missouri 64 and Illinois 65 ). 58 Legal challenges to the legislation have been successful in those states that did not have a statute or regulation explicitly excluding transition treatment from being covered; existing treatment exclusions have consistently been upheld. 58 After such challenges, Iowa and Minnesota added provisions excluding SRS from Medicaid coverage; currently, only California covers SRS under Medi-Cal. 58 However, True 58 suggested that the O’Donnabhain ruling may affect Medicaid coverage of SRS because upheld exclusions were based on the premise of lack of medical necessity for SRS. As medical opinion confirms that SRS is necessary, effective, nonexperimental, and without a comparable substitute; this opinion becomes even more widely echoed in the medical literature and court decisions; and the WPATH standards of care gain recognition as the professionally accepted guidelines for treatment of gender dysphoria, the provisions and statutes excluding coverage of gender-confirming surgery are likely to become increasingly harder to defend. I would contend that the argument for such provisions to be found invalid by the courts under the Federal Medicaid Act will be increasingly strong because they appear to be based on invalid rationales, put unreasonable restrictions on medically necessary treatment, and discriminate on the basis of diagnosis, which is in violation of the Federal Medicaid Act. Successful challenges to the legality of Medicaid coverage denial may also affect denial under Medicare and in the VA.

DIAGNOSES AND THEIR EFFECT ON CARE

In the United States, the medical establishment follows the APA definition as set out in the DSM for diagnosis and care of transgender people. In the fourth edition, text revision, of the DSM ( DSM-IV-TR ), diagnostic criteria for GID included strong and persistent cross-gender identification, persistent discomfort with the current sex, or sense of inappropriateness in the gender role of that sex. 66 More importantly, the discomfort must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. In the DSM-5, GID has been replaced with the term gender dysphoria. 3 The new classification emphasizes gender incongruence rather than cross-gender identification in an effort to reflect the individual’s felt sense of incongruence with natal gender, as opposed to pathologizing gender-atypical behavior. (Despite the APA’s stated intention, the new criteria seem to retain diagnosis based on gender nonconformity and fail to differentiate between distress caused by societal prejudice and that caused by a mental disorder.) Additionally, gender dysphoria is now separated from the chapters on sexual dysfunctions and paraphilias. In contrast to the dichotomized DSM - IV-TR GID diagnosis, the type and severity of gender dysphoria can be inferred from the number and type of indicators and from the severity measures.

At the outset, I must state that the inclusion of gender identity and transgender-related matters in the DSM reflects an inherent problem. Although diagnostic coding is necessary to facilitate access to medical and surgical transition care, the pathologizing and stigmatizing suggested by its designation as a mental disorder is not. Such designation gives rise to an inherent contradiction in terms: what is presented as a mental condition has recognized medical and surgical treatment:

Gender Dysphoria is a unique condition in that it is a diagnosis made by mental health care providers, although a large proportion of the treatment is endocrinological and surgical. 3 (p14)

These treatments are aimed not at affecting or changing mental state but rather at addressing the physical components that lead to the dysphoria. Such logic makes GID or gender dysphoria a unique case of surgically treatable mental illness, which is an oxymoron.

When the category of gender dysphoria was proposed, several LGBT and transgender organizations, including Lambda Legal, urged the APA to prioritize coverage of transitional treatment of transgender people as a medical necessity for a recognized condition over demedicalizing and depathologizing transgender people. 67 The current changes reflect an effort to strike a balance between stigmatization and the need to maintain access to care. 68

Future deliberations as to how to enable coverage of transgender-related care without designating a mental condition might consider an approach similar to that taken toward pregnancy and preventive care. Pregnancy is a condition that is recognized clinically and coded under the World Health Organization’s International Classification of Diseases. 69 It is treated, billed, and covered accordingly (with various policy options related to coverage of what is medically deemed necessary) without being pathologized. Similarly, preventive care is offered and routinely covered and is often considered necessary, independent of any diagnosis. So, too, I would suggest, can need for SRS be covered for transgender people without necessitating a DSM diagnosis.

RECOMMENDATIONS

Given the widespread acknowledgment of the health care needs of transgender people, action must be taken to ensure timely access to appropriate care. Such action includes, first and foremost, a requirement that all governmentally funded programs, including the VA, Medicaid and Medicare, Children’s Health Insurance Program, and Indian Health Services, include coverage of transition care and a requirement to ensure safe, appropriate, and sensitive care in federally funded health centers.

Private insurance may ultimately follow adoption of full coverage by federally funded programs, but until it does, federal guidelines protecting transgender people from discrimination by private insurance companies is warranted, including a ban on the practice of denying medical care coverage by linking the care to transition (which is not covered under most policies). To what extent the inclusion of gender identity in the ACA nondiscrimination clause will lessen this type of denial remains to be seen. Continued monitoring is necessary. More importantly, because a relatively high proportion of transgender people are uninsured, the expansion of Medicaid after implementation of the ACA significantly increases transgender people’s access to medical care (beyond transition care and SRS).

As work to enhance access to medical care progresses, the need for appropriate care will also increase. Models of care for marginalized minority populations with particular health needs can be based on existing general health care systems or implemented through specialized clinics and health care centers. Spurred by the AIDS epidemic and its toll on the gay community, dedicated LGBT health centers have been active in the United States since the 1980s. Although only a handful of centers are, at present, dedicated explicitly and exclusively to transgender patients, LGBT community health centers have provided care and often been active participants in and drivers of knowledge accumulation and dissemination regarding transgender health and treatment. These centers include the Fenway Center in Boston, Massachusetts; the Callen Lorde Community Health Clinic in New York City; and the Lyon-Martin Health Services in San Francisco. Achieving widespread access to acceptable, competent, appropriate, and affordable care, while promoting centers of clinical and research excellence in transgender health care, will require a combination of creating and strengthening dedicated centers as well as addressing transgender people’s health needs within the general health system.

Bias against transgender people takes an enormous toll on their health through direct harm, lack of appropriate care, and a hostile environment and through transgender people’s avoidance of the medical system as a result of discrimination and lack of respect. The medical establishment has a duty, and an ability, to protect transgender patients from such harms. Transgender-sensitive care must be incorporated into medical, nursing, and paramedical curricula, as has been done with other cultural competencies. Clear guidelines for all federally funded health centers, in line with the WPATH standards of care, need to be drafted and adopted by leading medical societies, including guidelines related to appropriate language, adoption of gender-neutral bathrooms, health records respectful of names and gender pronouns, and other safe environment measures.

Federal grants should be offered for programs teaching postgraduate-level care of transgender patients, including SRS. The ACA has taken a first positive step in that direction by providing funding for LGBT cultural competency trainings, which have already been implemented in big-city health departments, with training underway for staff of the National Health Service Corps.

Such measures are not only essential for the creation of an equitable health system, but will also likely result in improved health outcomes for the transgender population as barriers to access are removed and knowledge is enhanced. Incorporation of questions regarding gender identity into health surveys will also enable monitoring of progress and effects of these measures.

National surveys and health-related data sets must start to gather information about populations of transgender people by including questions pertaining to gender identity and sexual orientation. Several approaches are possible (including self-identification and identification of gender expression), and although none are perfect and all raise potential issues related to disclosure and the tension between identity and behavior, inclusion of such questions is a necessary step toward building a foundation of knowledge regarding the health and needs of transgender people. Though the National Transgender Discrimination Survey is an immense step forward in gathering data on health needs as transgender people perceive them, a need remains for data collection on outcomes, both through incorporating gender-identity identifiers into existing national surveys and through directed research. Last, it is essential that those who are caring for transgender patients collect and publish their data, in order to improve care for transgender people. It goes without saying that all such research must be conducted with sensitivity and respect toward participants.

Acknowledgments

I thank Diana Bowman, LLB, PhD, for her encouragement, guidance, and help. I also thank Alicia Cohen, MD, for her incisive and insightful comments. Last, I am grateful to Rachel Neis for her support, careful readings, and thoughtful discussions and comments.

Human Participant Protection

Human participant protection was not required because this study involved no participants.

Addressing Healthcare Inequities: Improving Specialty Care for Transgender and Gender-Diverse Patients

By William Borges

In recent years, transgender and gender-diverse healthcare has been brought to the forefront of public discourse. Discussions have shed light on the unique challenges faced by the transgender and gender-diverse (TGD) community. Some progress has been made in addressing these challenges but there are still critical gaps in our healthcare system. While mental health and primary care are often discussed as major gaps in TGD care, his article will focus on the gaps that exist in specialty care affecting the community. Low-quality urological and gynecological care poses a risk to the health and well-being of TGD individuals. To guarantee adequate urological and gynecological care for TGD patients, experts should focus on improving medical education and training, research on health disparities, TGD-focused clinics, standardized national clinical protocols, TGD provider and patient representation, and integration with emerging technology platforms.

According to data from national surveys, approximately 1 in every 250 adults in the United States is transgender. 1  Despite comprising a substantial number of Americans, TGD individuals have reported negative experiences in healthcare settings. Around 33 percent of TGD patients have reported at least one negative experience with medical providers related to gender identity and around 23 percent avoided seeking care due to fear of mistreatment. 2  TGD patients can often be made to feel neglected and invisible in critical aspects of their healthcare, such as urological and gynecological care. Such experiences can foster distrust of healthcare providers among TGD individuals and lead to negative health outcomes. 

Distrust in providers has been experienced by TGD patients historically experiencing discrimination in healthcare settings. Prior research has explored the negative encounters TGD patients report, such as being refused care due to their gender identity or facing insensitivity from staff. 2  This discrimination relates to the minority stress model, which posits that stigma, prejudice, and discrimination create a hostile social environment that causes excess stress and health problems for minority groups. The chronic experiences of discrimination and hypervigilance in healthcare settings have severe psychological impacts and act as barriers to TGD patients seeking necessary medical care.

This year, the American Cancer Society (ACS) released its annual Statistics Report, which included, for the first time, a section on cancer in people who identify as Lesbian, Gay, Bisexual, Transgender, Queer, or Gender Nonconforming. This section highlighted the available data on prostate and gynecological cancer disparities impacting the TGD population but concluded that the disparities remain inadequately studied and addressed. 3  Cancer disparities encountered by populations with intersectional identities, e.g., TGD patients of color are particularly understudied.  

The ACS report highlighted the available data on prostate cancer disparities in the TGD population. Researchers hypothesize that estrogen-based gender-affirming hormone therapy (GAHT) may play a role in preventing prostate cancer development in transgender women. 4 In 2023, the University of California, San Francisco, and Cedars-Sinai conducted the most extensive retrospective study to date. Published in the Journal of the American Medical Association, their research revealed that transgender women undergoing gender-affirming hormone therapy (GAHT) had notably lower rates of prostate cancer diagnosis compared to cisgender men. 5   However, the results suggested a higher prevalence of aggressive prostate cancer in transgender women, potentially attributable to transgender women on GAHT having delayed prostate cancer diagnosis. 5 Another study published in European Urology found that transgender women have a lower prevalence of PSA screening, which was likely attributed to a lack of prostate cancer risk awareness, stigma, and inadequate inclusion of the transgender male population in prostate cancer screening guidelines. 6  More research is needed to determine the true extent of the underlying disparities in prostate cancer among transgender women. Importantly, future research should isolate the likely intersectional causes of disparities, such as language barriers, lack of insurance, poverty, structural racism, and medical stigma, and develop interventions to address the causes. 

The ACS report also highlighted the available data on gynecological cancer disparities in the TGD population. Transgender men remain at risk for gynecological cancers as evidenced by reports of endometrial, ovarian, and cervical cancers. 7 While it has been theorized that testosterone-based GAHT increases the risk of hormone-responsive endometrial and ovarian cancers because it can get converted to estrogen in the body, population-based incidence data including transgender individuals is unavailable to support this. 7 The American Cancer Society data reveals that transgender men have a lower rate of cervical cancer screening compared to cisgender women, which may leave transgender men at a higher risk for cervical cancer. 3  This disparity in cervical cancer screening rates could be explained by TGD discrimination by providers, discomfort with female sex organs, and fear of receiving a gynecological exam, although more epidemiological data is needed for a definitive answer. Fears of disclosing sensitive medical information and being mistreated may mean that transgender men delay diagnosis, leading to worse health outcomes. 

In addition to gynecological cancers, disparities in outcomes among TGD patients may extend to other urological malignancies such as bladder, kidney, and testicular cancer. To date, there is little data exploring population-level cancer disparities among TGD patients with these other urological malignancies.  It is important to keep in mind that the evidence for prostate and gynecological cancer disparities among TGD patients is also limited, and more substantial research is needed before making any definitive population-level conclusions. Future research efforts should identify cancer disparities among TGD patients, determine their intersectional causes, and propose interventions to address the disparities. 

Urologic and gynecological problems, including cancers, grow as populations age, increasing the demand for relevant specialists. Worryingly, only 38 percent of American counties have practicing urologists and there is a projected 46 percent shortage of urologists by 2035. 8 It is also projected that there will be a similar 40 percent shortage of gynecologists by 2030. 9  With the increasing disease burden, TGD specialty care will likely be sidelined as the limited number of providers deal with the increasing volume of non-TGD urological and gynecological issues. Without proper advocacy efforts to improve the current and future state of TGD specialty care, TGD patients will be severely negatively impacted. A significant effort is necessary to increase the supply of medical specialists available to adequately address the future population’s urological and gynecological needs, particularly within the TGD population. Various models are available to address provider shortages including increasing incentives for medical students to specialize in urology and gynecology, integrating emerging technologies like artificial intelligence to extend provider reach, and training more cost-effective mid-level providers like certified nurse assistants and physician assistants.

Most medical providers do not feel well-equipped to provide TGD specialty care, despite expressing interest in providing such care. Medical specialists in Urology and Gynecology must be prepared to address transition-related genitourinary procedures (e.g., vaginoplasty, phalloplasty, and orchiectomy), fertility, urinary and sexual function, urinary tract infections/sexually transmitted infections, lifestyle medicine, and malignancies like prostate cancer and gynecological cancers. However, according to a 2018 multi-specialty survey published in the Canadian Journal of Medical Education, 100 percent of urology residents surveyed would not feel competent enough to provide urology-specific TGD care by the end of their residency and 100 percent felt their training was inadequate to provide care for this population. 10 Moreover, more than 50 percent of residents in psychiatry, endocrinology, and family medicine indicated an interest in providing TGD care in their future practice, whereas only 29 percent of residents in urology felt the same way. 10  A cross-sectional survey of obstetrics and gynecology residents published in Transgender Health revealed that overall, residents felt an intermediate level of comfort and competency in caring for patients who identified as TGD. 11 Despite inadequate preparation, the residents expressed a high level of interest in caring for TGD patients. 10  Providers reporting low confidence in their ability to address the needs of TGD patients highlights the need for improved cultural competency training across specialties. Incentives should also be implemented to increase trainees’ interest in providing care to TGD patients.  

The lack of preparedness for TGD specialty care may be traced back to medical school. Based on a study published in the Journal of Primary Care Community Health in 2023, only 27 percent of medical students surveyed in the US reported confidence in their knowledge of the health needs of transgender patients. 12  Based on the data, this lack of provider preparedness for providing TGD care has to be addressed starting in medical school. Without confronting gaps in education regarding TGD health, intersectional factors, and care standards, providers will remain ill-equipped to deliver compassionate care.

Plenty can be done to improve TGD specialty care access and delivery. The following are some material policy recommendations:

• Medical school curricula should be redesigned to include more information about TGD patients. Redesigned curricula should include education on historical barriers to access for TGD patients, intersectionality, minority stress, risk factors, pronouns, gender identity, and standards of care for common TGD procedures. 
• Governments and healthcare systems should invest in clinics and community health centers that deliver high-quality, specialized care tailored to the needs of TGD patients. This may help address provider limitations in TGD-competent care. 
• More large-scale research should be conducted to evaluate the true extent of health disparities among TGD patients, especially in cancer. It is imperative that research also addresses the root causes of disparities so that follow-up studies can propose and validate interventions to address identified disparities.
• TGD patients should be proportionally included in standardized national clinical protocols, such as screening protocols for prostate and cervical cancer, to minimize negative health outcomes from inadequate or discriminatory treatment.  
• Representation of TGD providers should be increased in medical education and leadership positions. This would combat stigma while improving cultural understanding of TGD communities. 
• TGD patient advocates should be engaged by healthcare systems to provide input on improving TGD patient experiences and reducing discrimination. Involving more TGD patient advocates would likely help normalize a broad range of patient backgrounds, including TGD patients of different disability statuses, races, income levels, and sexual orientations. 
• Emerging technology platforms, such as those being developed by startups like Plume and Folx, 13  should be promoted. These platforms can achieve substantial scale and help improve patient access to TGD-competent navigation, resources, and telehealth services. 

Policies such as the ones proposed above are a positive first step but should be evaluated as to whether they reduce discrimination-induced stresses experienced by TGD patients in healthcare settings and empower providers to deliver compassionate and competent care to TGD patients. 

In a time where it is legal for medical providers to refuse care to TGD patients in nine US states based on gender and sexual identity, leaders in medicine should consider work to safeguard adequate care for vulnerable TGD patient populations. 14  Negative experiences, structural barriers, and a lack of navigation support or TGD-competent providers have historically led TGD patients to delay or avoid specialty care. Specialized clinics, advocacy services, and technology platforms are urgently needed to help TGD patients overcome discrimination and access appropriate urological or gynecological care. Most importantly, medical providers must work together with policymakers and institutional leaders to ensure the healthcare system is addressing the healthcare needs of TGD patients.

• Meerwijk EL, Sevelius JM. Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples. Am J Public Health. 2017;107(2):e1-e8. doi:10.2105/AJPH.2016.303578 
• James SE, Herman JL, RAnkin S, Keisling M, Mottet L, Anafi M.  The Report of the 2015 U.S. Transgender Survey . National Center for Transgender Equality; 2016. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf
• Dizon DS, Kamal AH. Cancer statistics 2024: All hands on deck.  CA: A Cancer Journal for Clinicians . Published online January 17, 2024. doi: https://doi.org/10.3322/caac.21824
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• Farnoosh Nik-Ahd, De AM, Butler C, et al. Prostate Cancer in Transgender Women in the Veterans Affairs Health System, 2000-2022. Published online April 29, 2023. doi: https://doi.org/10.1001/jama.2023.6028
• Nik-Ahd F, Jarjour A, Figueiredo J, et al. Prostate-Specific Antigen Screening in Transgender Patients.  European Urology . Published online November 4, 2022:S0302-2838(22)026379. doi: https://doi.org/10.1016/j.eururo.2022.09.007
• Stenzel AE, Moysich KB, Ferrando CA, Starbuck KD. Clinical needs for transgender men in the gynecologic oncology setting.  Gynecologic Oncology . 2020;159(3):899-905. doi: https://doi.org/10.1016/j.ygyno.2020.09.038
• Nam CS, Daignault-Newton S, Kraft KH, Herrel LA. Projected US Urology Workforce per Capita, 2020-2060.  JAMA Network Open . 2021;4(11):e2133864. doi: https://doi.org/10.1001/jamanetworkopen.2021.33864
• Satiani B, Williams T, Landon M, Ellison C, Gabbe S. A Critical Deficit of OBGYN Surgeons in the U.S by 2030.  Surgical Science . 2011;02(02):95-101. doi: https://doi.org/10.4236/ss.2011.22020
• Coutin A, Wright S, Li C, Fung R. Missed opportunities: are residents prepared to care for transgender patients? A study of family medicine, psychiatry, endocrinology, and urology residents.  Canadian medical education journal . 2018;9(3):e41-e55. Accessed February 24, 2024. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6104317/
• Qin LA, Estevez SL, Radcliffe E, Shan WW, Rabin JM, Rosenthal DW. Are Obstetrics and Gynecology Residents Equipped to Care for Transgender and Gender Nonconforming Patients? A National Survey Study.  Transgender Health . Published online September 22, 2020. doi: https://doi.org/10.1089/trgh.2020.0063
• Karpel H, Sampson A, Charifson M, et al. Assessing Medical Students’ Attitudes and Knowledge Regarding LGBTQ Health Needs Across the United States.  Journal of Primary Care & Community Health . 2023;14. doi: https://doi.org/10.1177/21501319231186729
• Axios. LGBTQ health startups see funding surge as need grows. February 2, 2021.  https://www.axios.com/2021/02/02/lgbtq-health-startups-funding . Accessed January 23, 2024.
• Equality Maps: Religious Exemption Laws. Movement Advancement Project. Accessed July 25, 2023. https://www.lgbtmap.org/equality-maps/religious_exemption_laws

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• Keuroghlian AS, et al., eds. Basic principles of trauma-informed and gender-affirming care. In: Transgender and Gender Diverse Health Care: The Fenway Guide. McGraw Hill; 2022. https://accessmedicine.mhmedical.com. Accessed Dec. 19, 2022.
• Coleman E, et al. Primary care. In: Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People. 8th version. World Professional Association for Transgender Health; 2022. https://www.wpath.org/publications/soc. Accessed Dec. 19, 2022.
• Feldman J, et al. Primary care of transgender individuals. https://www.uptodate.com/contents/search. Accessed Dec. 15, 2022.
• American College of Obstetricians and Gynecologists. Committee Opinion No. 823: Health care for transgender and gender diverse individuals. Obstetrics & Gynecology. 2021; doi:10.1097/AOG.0000000000004294.
• Erickson-Schroth L, ed. General, sexual and reproductive health. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Dec. 21, 2022.

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The Role of Mental Health Professionals in Gender Reassignment Surgeries: Unjust Discrimination or Responsible Care?

• Letter to the Editor
• Experimental/Special Topics
• Published: 25 October 2014
• Volume 38 , pages 1177–1183, ( 2014 )

Cite this article

• Gennaro Selvaggi 1 &
• Simona Giordano 2  

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Recent literature has raised an important ethical concern relating to the way in which surgeons approach people with gender dysphoria (GD): it has been suggested that referring transsexual patients to mental assessment can constitute a form of unjust discrimination. The aim of this paper is to examine some of the ethical issues concerning the role of the mental health professional in gender reassignment surgeries (GRS).

The role of the mental health professional in GRS is analyzed by presenting the Standards of Care by the World Professional Association of Transgender Health, and discussing the principles of autonomy and non-discrimination.

Purposes of psychotherapy are exploring gender identity; addressing the negative impact of GD on mental health; alleviating internalized transphobia; enhancing social and peer support; improving body image; promoting resilience; and assisting the surgeons with the preparation prior to the surgery and the patient’s follow-up. Offering or requesting psychological assistance is in no way a form of negative discrimination or an attack to the patient’s autonomy. Contrarily, it might improve transsexual patients’ care, and thus at the most may represent a form of positive discrimination. To treat people as equal does not mean that they should be treated in the same way, but with the same concern and respect, so that their unique needs and goals can be achieved.

Conclusions

Offering or requesting psychological assistance to individuals with GD is a form of responsible care, and not unjust discrimination.

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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There are various other ways of referring to similar procedures: “gender reaffirming” surgery, “gender confirming” surgery, “sex reassignment surgery,” and “gender realignment” surgery are the most common. Some terms, such as “confirming” or “realignment,” seem to suggest that perceived gender is innate, and surgery is meant to re-align the body to the “real” gender of the person. We will not examine in great detail the terminological issues; partly, people’s preference for one term rather than the other depends on views relating to how gender identity develops. For theories on gender identity development, see Giordano S, Children with Gender Identity Disorder, Routledge, 2012, Chapter 2. For ease, in this paper, we opt for “gender reassignment surgery.” We opt for “gender” rather than “sex,” because the latter refers to the genital area only.

Wherever possible, we shall privilege the terms “medical interventions” and “medical procedures” over the terms “medical treatments” or “therapies”, in that they might imply a difference between these and “cosmetic” procedures. The terms “procedures” or “interventions,” in fact, would apply to all areas of medical care. We shall also refer particularly to surgery, but what is said is also relevant to other areas of healthcare for people with GD.

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Selvaggi, G., Giordano, S. The Role of Mental Health Professionals in Gender Reassignment Surgeries: Unjust Discrimination or Responsible Care?. Aesth Plast Surg 38 , 1177–1183 (2014). https://doi.org/10.1007/s00266-014-0409-0

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DOI : https://doi.org/10.1007/s00266-014-0409-0

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Gender Reassignment Discrimination

Anne morris.

• 7 September 2020

IN THIS SECTION

As an employer, it is illegal to treat someone unfairly at work because they intend to undergo, are undergoing or have undergone gender reassignment. It is also unlawful to fail to take timely and appropriate action when others at work discriminate against, or bully or harass someone else, because they are transsexual.

Below we look at what the law says about gender reassignment discrimination in the workplace, including what happens when employers get this wrong and the steps that you can put in place to help prevent this type of discrimination .

This is a developing area of law, with a recent tribunal decision finding that protection of non-binary and gender-fluid individuals falls within the scope of gender reassignment under the Equality Act.

What is gender reassignment discrimination?

Gender reassignment discrimination is where someone is treated unfairly because they are ‘transsexual’, ie; someone whose gender identity is different from the gender assigned to them when they were born. Other more commonly used terminology could include transgender, trans male/female, or simply trans.

The unfair treatment could be a one-off action or series of actions, or even as a result of a workplace rule or policy that is applied equally to everyone but puts a transsexual or trans person at a particular disadvantage.

To be protected from gender reassignment discrimination, a person does not need to have undergone any specific treatment or surgery to change from their birth sex to their preferred gender. This is because changing their physiological or other gender attributes is a personal process rather than a medical one.

What is the law on gender reassignment discrimination?

The law relating to gender reassignment discrimination is set out under the Equality Act 2010. The Act makes it unlawful for a person to be discriminated against, or harassed or victimised , because of one or more of the nine protected characteristics , where gender reassignment is one of these.

All transsexual or trans people share the common characteristic of gender reassignment. This could be where someone who was born male has made the decision to spend the rest of her life as a woman, or vice versa.

To be afforded the protection from discrimination, harassment and victimisation, the person can be at any stage in the transition process, from planning to reassign their gender, to undergoing or having completed this process. This includes anyone who has started the process but then decided not to continue.

Protection is also afforded to anyone dressing in a certain way to express their chosen gender, although those who only choose to temporarily adopt the appearance of the opposite gender, such as transvestites, are not protected under the legislation. This is because their cross-dressing is not part of the process of transitioning to live as their non-birth gender.

What employment protections do transsexual employees have?

Under the Equality Act, all transsexual employees are afforded protection from four main types of discriminatory behaviour in the workplace:

• Direct discrimination: where you treat an employee less favourably than you treat or would treat others because they are proposing to undergo, is undergoing or has undergone all or part of a process for the purpose of reassigning their sex by changing physiological or other gender attributes.
• Indirect discrimination : where a workplace provision, criterion or practice that applies equally to everyone puts a transsexual employee at a disproportionate disadvantage when compared with others.
• Harassment: where a transsexual employee is subjected to unwanted conduct at work because of their gender reassignment, and this has the purpose or effect of violating their dignity or creating an intimidating, hostile, degrading, humiliating or offensive environment.
• Victimisation: where someone suffers from detrimental treatment at work because they have made or supported a complaint about harassment or gender reassignment discrimination at work, or it is believed they have or may make or support such a complaint.

The Act applies to all employees, as well as job applicants, trainees, contract workers and office holders, such as company directors and partners. The Act also covers all areas of employment including recruitment, training and promotion, terms and conditions of employment, redundancy and dismissal.

Examples of gender reassignment discrimination

Direct gender reassignment discrimination.

Direct gender reassignment discrimination is where you treat someone at work worse than another person in a similar situation because they are trans. For example, having found out that an employee intends to spend the rest of their life living as a different gender, you decide to transfer them into another position, against their wishes, so they no longer have a customer-facing role.

Direct discrimination also covers the following scenarios:

• Discrimination by perception: where you discriminate against a person because you believe they are trans, even if that perception is incorrect, for example, where they occasionally cross-dress or is gender variant.
• Discrimination by association : where you discriminate against a person for being connected with someone who is, or is wrongly thought to be, transsexual. This could include a co-worker, family member or friend.

Indirect gender reassignment discrimination

Indirect gender reassignment discrimination refers to the application of a rule or policy at work that, on the face of it, applies equally to persons who are not transsexual but which particularly disadvantages transsexual or trans people.

An example of indirect discrimination might be where you have a company policy for an employee’s ID tag to always feature their photograph as it appeared on the day they joined the company. However, because they have changed their gender since then, this might cause them significant embarrassment.

Harassment because of gender reassignment

The definition of harassment under the Act is wide enough to include all types of unwanted conduct because of gender reassignment. This could include nicknames, insults, abusive language, threats, jokes, banter, gossip, asking intrusive or inappropriate questions, excluding or ignoring someone, or even excessive monitoring or excessive criticism of someone’s work.

It does not matter if the harassment is intentional or unintentional, and doesn’t necessarily need to be aimed at the person witnessing it. Examples of this might include the telling or tolerating of trans-phobic jokes and the use of derogatory trans-phobic terms as part of an accepted workplace culture.

As an employer, you are potentially liable for the discriminatory acts of your employees where those employees are acting in the course of their employment. This is known as vicarious liability. You are also liable for the harassment of your staff by third parties, such as clients, customers or suppliers.

This means that if you are aware that a trans person is being harassed at work, either by a member of staff or a third party, and you fail to take reasonable steps to prevent this from happening again, you may be breaking the law.

Victimisation because of gender reassignment

This is where someone at work is subjected to a detriment because they have made, tried to make, helped someone else to make or assumed to have made, a complaint or grievance of discrimination on the grounds of gender reassignment.

A detriment could include, for example, an employee being denied a pay rise or promotion because they have made allegations of gender reassignment discrimination, or where they have given evidence in support of a complaint made by a transsexual person, even though they themselves are not transsexual.

What are the special protections relating to absences from work?

Under the Equality Act 2010, there are special protections relating to absences from work because of gender reassignment.

This means that if someone is absent from work because of gender reassignment you cannot treat that person less favourably than you would treat any other person off work due to sickness or injury, or due to some other reason and it is not reasonable to treat the transsexual person less favourably.

For example, if you refuse, without good reason, to let someone have time off work to undergo treatment for gender reassignment, or you permit them to take time off but pay that person less than they would have received if they were off sick, this is likely to amount to direct discrimination under the Act.

This protection extends to any medical appointment associated with the gender reassignment process, including taking time off for counselling.

Can gender reassignment discrimination ever be justified?

Direct gender reassignment discrimination, harassment and victimisation can never be justified. However, there are certain circumstances in which indirect discrimination can be objectively justified , as long as you can show that the treatment is a proportionate means of achieving a legitimate aim.

The process of determining whether discrimination is justified involves weighing up the legitimate needs of your business against the discriminatory effect on the group of employees who are trans. Where the same aim could have been achieved in a less discriminatory way, the discrimination cannot be justified.

In rare cases, there may also be strict occupational requirements that preclude a transsexual person from applying, although you would need to show that ‘not being trans’ is crucial to the role. This could be, for example, roles in organised religion, where being trans would not comply with the doctrines of that religion.

Equally, there may be cases where a person is required to be transsexual, for example, a gender identity support leader, although again, ‘being trans’ in this instance, must be crucial and not just one of many important factors.

It is also important to note that you can take positive steps to support transgender people who are under-represented in your workforce or otherwise disadvantaged. This could be by way of encouraging applications from trans people or providing special training. This is known as taking positive action .

What are the consequences of gender reassignment discrimination?

If you get the law wrong in relation to gender reassignment discrimination, even if you are trying to take positive steps to assist transsexual people, or you unintentionally discriminate against a trans person, you may find yourself facing a claim for unlawful discrimination before an employment tribunal.

The importance of understanding and preventing all forms of discrimination at work should never be underestimated. The cost to your business in terms of reputational damage and legal proceedings can be significant.

The Equality Act does not require any minimum length of employment, or any employment at all in the case of a job applicant, for an unlawful discrimination claim to be made. The tribunal also has the power to award one or more of the following three remedies if it finds there has been discrimination:

• A declaration setting out the rights of the parties
• An uncapped award of damages, including an award for injury to feelings and to compensate the individual for any financial loss suffered
• A recommendation that you should take certain steps to remove or reduce the discrimination in your workplace

How can employers prevent gender reassignment discrimination?

Employers should take steps to help prevent gender reassignment discrimination and minimise the possibility of workplace issues, grievances or tribunal claims.

These steps could include a programme of equality and diversity training for all your staff on how different forms of gender reassignment discrimination can arise; putting in place appropriate procedures to deal with grievances, both informally and formally; and reviewing your workplace policies on equal opportunities, dignity at work, and bullying and harassment.

In this way you will help to create a positive workplace culture in which gender reassignment discrimination is not tolerated, and victims or witnesses of discrimination feel able to report any complaints without fear of reprisal.

Need assistance?

DavidsonMorris’ employment lawyers can help with all aspects of workplace discrimination. Working closely with our specialists in HR , we can advise on steps to improve diversity and equality in your organisation, while minimising the legal risk of discrimination claims. For help and advice, speak to our experts .

Gender reassignment discrimination FAQs

Gender reassignment discrimination takes place when someone is treated unfairly on the basis of their actual or proposed gender reassignment. The unfair treatment could be a one-off action or a blanket workplace rule or policy that puts a transsexual or trans person at a particular disadvantage.

What are the different types of gender reassignment discrimination?

There are four main types of gender reassignment discrimination set out under the Equality Act 2010. These include direct discrimination, indirect discrimination, harassment and victimisation. The Act also affords trans people special protection from being treated less favourably in cases of absences from work because of gender reassignment.

What discrimination rights do trans employees have?

Trans employees have the right not to be treated less favourably at work, put at a disadvantage, or harassed or victimised, because they are transsexual, or perceived to be or connected with someone who is trans.

Last updated: 7 September 2020

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What is on this page?

What is gender reassignment discrimination, what the equality act says about gender reassignment discrimination, different types of gender reassignment discrimination, circumstances when being treated differently due to gender reassignment is lawful, who is this page for.

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On this page we have used plain English to help explain legal terms. This does not change the meaning of the law.

The Equality Act 2010 uses the term ‘transsexual’ for individuals who have the protected characteristic of gender reassignment. We recognise that some people consider this term outdated, so we have used the term ‘trans’ to refer to a person who has the protected characteristic of gender reassignment. However, we note that some people who identify as trans may not fall within the legal definition.

This page is subject to updates due to the evolving nature of some of the issues highlighted. 

This is when you are treated differently because you are trans in one of the  situations covered by the Equality Act . The treatment could be a one-off action or as a result of a rule or policy. It doesn’t have to be intentional to be unlawful.

There are some circumstances when being treated differently due to being trans is lawful. These are explained below.

See more videos like this in the equality law: discrimination explained playlist on YouTube (opens in new window) .

The Equality Act 2010 says that you must not be discriminated against because of gender reassignment.

In the Equality Act, gender reassignment means proposing to undergo, undergoing or having undergone a process to reassign your sex.

To be protected from gender reassignment discrimination, you do not need to have undergone any medical treatment or surgery to change from your birth sex to your preferred gender.

You can be at any stage in the transition process, from proposing to reassign your sex, undergoing a process of reassignment, or having completed it. It does not matter whether or not you have applied for or obtained a Gender Recognition Certificate, which is the document that confirms the change of a person's legal sex. 

For example, a person who was born female and decides to spend the rest of their life as a man, and a person who was born male and has been living as a woman for some time and obtained a Gender Recognition Certificate, both have the protected characteristic of gender reassignment. 

There are four types of gender reassignment discrimination.

Direct discrimination

This happens when someone treats you worse than another person in a similar situation because you are trans. For example:

• you inform your employer that you intend to spend the rest of your life living as the opposite sex. If your employer alters your role against your wishes to avoid you having contact with clients, this would be direct gender reassignment discrimination.

The Equality Act says that you must not be directly discriminated against because:

• you have the protected characteristic of gender reassignment. A wide range of people identify as trans. However, you are not protected under the Equality Act unless you have proposed, started or completed a process to change your sex.
• someone thinks you have the protected characteristic of gender reassignment. For example, because you occasionally cross-dress or do not conform to gender stereotypes (this is known as discrimination by perception).
• you are connected to a person who has the protected characteristic of gender reassignment, or someone wrongly thought to have this protected characteristic (this is known as discrimination by association).

Absences from work

If you are absent from work because of your gender reassignment, your employer cannot treat you worse than you would be treated if you were absent:

• due to an illness or injury. For example, your employer cannot pay you less than you would have received if you were off sick.
• due to some other reason. However, in this case it is only discrimination if your employer is acting unreasonably. For example, if your employer would agree to a request for time off for someone to attend their child’s graduation ceremony, then it may be unreasonable to refuse you time off for part of a gender reassignment process. This would include, for example, time off for counselling.

Indirect discrimination

This happens when an organisation has a particular policy or way of working that puts people with the protected characteristic of gender reassignment at a disadvantage.

Sometimes indirect gender reassignment discrimination can be permitted if the organisation or employer is able to show that there is a good reason for the discrimination. This is known as  objective justification . For example: 

• An employer has a practice of starting induction sessions for new staff with an ice-breaker designed to introduce everyone in the room to each other. Each worker is required to provide a picture of themselves as a toddler. One worker is a trans woman who does not wish her colleagues to know that she was brought up as a boy, so she does not bring her photo and is criticised by the employer in front of the group for not joining in. The same approach is taken for all new staff, but it puts people with the protected characteristic of gender reassignment at a particular disadvantage.  This would be unlawful indirect discrimination unless the employer could show that the practice was justified.

Harassment is when someone makes you feel humiliated, offended or degraded for reasons related to gender reassignment. For example:

• a person who has undergone male-to-female gender reassignment is having a drink in a pub with friends and the landlord keeps calling her ‘sir’ or ‘he’ when serving drinks, despite her complaining about it.

Harassment can never be justified. However, if an organisation or employer can show it did everything it could to prevent people who work for it from harassing you, you will not be able to make a claim for harassment against the organisation, only against the harasser.

Victimisation

This is when you are treated badly because you have made a complaint of gender reassignment discrimination under the Equality Act. It can also occur if you are supporting someone who has made a complaint of gender reassignment discrimination. For example:

• a person proposing to undergo gender reassignment is being harassed by a colleague at work. He makes a complaint about the way his colleague is treating him and is sacked.

A difference in treatment may sometimes be lawful. This will be the case where the circumstances fall under one of the exceptions in the Equality Act that allow organisations to provide different treatment or services on the basis of gender reassignment. For example:

• competitive sports: a sports organisation restricts participation because of gender reassignment. For example, the organisers of a women’s triathlon event decide to exclude a trans woman with a Gender Recognition Certificate as they think her strength or stamina gives her an unfair advantage. However, the organisers would need to be able to show that this was necessary to make the event fair or safe for everyone.
• a service provider provides single-sex services. The Equality Act allows a lawfully established separate or single-sex service provider to prevent, limit or modify people’s access on the basis of gender reassignment in some circumstances. However, limiting or modifying access to, or excluding a trans person from, the separate or single-sex service of the gender in which they present will be unlawful if you cannot show such action is a proportionate means of achieving a legitimate aim. This applies whether or not the person has a Gender Recognition Certificate.

Updated: 23 Feb 2023

• Removed paragraph on language recommendations made by Women and Equalities Committee (WEC) in 2016
• Removed the term ‘transsexual’ as per WEC 2016 recommendations
• Added paragraph explaining use of plain English in the guidance
• Removed a paragraph on intersex people not being explicitly protected from discrimination by the Equality Act

Last updated: 23 Feb 2023

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The role of mental health professionals in gender reassignment surgeries: unjust discrimination or responsible care?

Affiliation.

• 1 Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gröna Stråket 8, 41345, Gothenburg, Sweden, [email protected].
• PMID: 25344469
• DOI: 10.1007/s00266-014-0409-0

Objective: Recent literature has raised an important ethical concern relating to the way in which surgeons approach people with gender dysphoria (GD): it has been suggested that referring transsexual patients to mental assessment can constitute a form of unjust discrimination. The aim of this paper is to examine some of the ethical issues concerning the role of the mental health professional in gender reassignment surgeries (GRS).

Method: The role of the mental health professional in GRS is analyzed by presenting the Standards of Care by the World Professional Association of Transgender Health, and discussing the principles of autonomy and non-discrimination.

Results: Purposes of psychotherapy are exploring gender identity; addressing the negative impact of GD on mental health; alleviating internalized transphobia; enhancing social and peer support; improving body image; promoting resilience; and assisting the surgeons with the preparation prior to the surgery and the patient's follow-up. Offering or requesting psychological assistance is in no way a form of negative discrimination or an attack to the patient's autonomy. Contrarily, it might improve transsexual patients' care, and thus at the most may represent a form of positive discrimination. To treat people as equal does not mean that they should be treated in the same way, but with the same concern and respect, so that their unique needs and goals can be achieved.

Conclusions: Offering or requesting psychological assistance to individuals with GD is a form of responsible care, and not unjust discrimination.

Level of evidence v: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

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Lydia Polgreen

The Strange Report Fueling the War on Trans Kids

By Lydia Polgreen

Opinion Columnist

I n its upcoming term, the Supreme Court will once again hear a case that involves a highly contentious question that lies at the heart of personal liberty: Who should decide what medical care a person receives? Should it be patients and their families, supported by doctors and other clinicians, using guidelines developed by the leading experts in the field based on the most current scientific knowledge and treatment practice? Or does the Constitution permit lawmakers to place themselves, and courts, in the middle of some of the most complex and intimate decisions people will make in their lives?

The case, United States v. Skrmetti , has been brought by the Biden administration to challenge a ban in Tennessee on gender-affirming care for adolescents that all major American medical organizations support. Tennessee is one of some two dozen states that have passed laws limiting gender-affirming care for young people. The appeal argues that these bans are an unconstitutional form of sex discrimination: They forbid long-used treatments for transgender adolescents that are also given to children who are not transgender for different reasons.

The Tennessee law, called the Protecting Children From Gender Mutilation Act, prohibits the use of puberty-blocking medications for transgender adolescents, for example, but permits them for children who go into puberty at an early age. It bans the use of sex hormones like testosterone in transgender adolescents but allows it for other health issues, such as for children assigned male at birth. It bans gender-affirming surgeries for transgender adolescents — such surgeries are extremely rare — but allows similar surgical procedures that affirm the sex a child is assigned at birth, even on infants who are intersex.

The Supreme Court ruled in 2020 — somewhat surprisingly given its conservative majority — that differential treatment of transgender and gay people is impermissible under civil rights law. “It is impossible,” Justice Neil Gorsuch wrote in his decision in that landmark employment discrimination case, “to discriminate against a person for being homosexual or transgender without discriminating against that individual based on sex.” Lawyers seeking to overturn gender-affirming-care bans will urge the court to follow the logic of that ruling and declare the Tennessee law and others like it unconstitutional.

Lawyers arguing in favor of these bans have taken a sharply different approach. In a striking echo of the arguments used to challenge medical abortion, they have asserted , against the consensus of the mainstream medical science, that the standard treatments for transgender children are not based in evidence and represent a grave risk to the health and well-being of young people.

This argument has been floating around conservative circles in the United States for some time, and some European government health care systems have embraced it, too, with some limiting access to gender-affirming care for young people, citing doubts about the evidence supporting it. The argument has been supercharged in recent months by an unlikely ally on the other side of the Atlantic Ocean: the British pediatrician Hilary Cass.

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Court Says BCBSIL Cannot Exclude Coverage of Gender-Affirming Care

Bcbsil is a third-party administrator for an employer-sponsored health plan that denied coverage of gender-affirming care for an employee’s transgender son..

• Victoria Bailey, Assistant Editor

A United States district court has ruled against Blue Cross Blue Shield of Illinois (BCBSIL), stating that the payer cannot exclude coverage for medically necessary gender-affirming care in its employer-sponsored ERISA health plans.

Lambda Legal and Sirianni Youtz Spoonemore Hamburger PLLC filed a class action lawsuit against BCBSIL on behalf of a 17-year-old transgender man, CP, and his parents. According to the lawsuit, the payer administered discriminatory exclusions of gender-affirming care, violating the anti-discrimination of the Affordable Care Act (ACA), known as Section 1557 .

The class action follows a class certification by the US District Court for the Western District of Washington on November 9, 2022, comprised of individuals who were, are, or will be denied pre-authorization or coverage of gender-affirming care as a result of BCBSIL’s categorical exclusions.

CP’s mother receives healthcare coverage through her employer under the Catholic Health Initiatives (CHI) Medical Plan, and CP is enrolled in the plan as her dependent. BCBSIL acts as the third-party claims administrator for the self-funded health plan.

CP sought gender-affirming care, including hormone therapy and chest reconstruction surgery, on the recommendation of his healthcare providers. However, BCBSIL denied the claims for the services on the exclusion that the care was “for or leading to gender reassignment surgery.”

The payer generally covers similar care and medical interventions for cisgender patients, according to the lawsuit. But the claim denials led CP’s family to pay out-of-pocket for the gender-affirming care, resulting in unnecessary financial stress.

BCBSIL motioned for summary judgment on the claims, while the plaintiffs cross-motioned for summary judgment on their claims and the class claims. The court has denied the payer’s motion for summary judgment and granted the plaintiffs’ cross-motion.

The court determined that BCBSIL is a “health program or activity” that receives federal funds and thus cannot discriminate based on race, national origin, sex, age, or disability in its role in administering ERISA health plans.

This includes the CHI health plan provided by St. Michael Medical Center in Bremerton, Washington, which is part of CommonSpirit Health, formerly the Catholic Health Initiatives Franciscan Health System.

“The court’s decision not only establishes that categorical exclusions for coverage of gender-affirming care are unlawful discrimination, but it also concludes that health insurers who receive federal funds and act as third-party administrators have an independent duty to not administer discriminatory ERISA health plans,” Omar Gonzalez-Pagan, counsel and health Care strategist for Lambda Legal, said in the press release.

“This is a victory not only for CP and his parents, but also for the hundreds of transgender people who were, are, or were likely to be denied medically necessary gender-affirming care because of BCBSIL’s administration of approximately 400 ERISA health plans with these unlawful exclusions. The court’s decision sends a clear message that third-party administrators that accept federal funds cannot discriminate when administering employer-sponsored health plans.”

Recently, a nonprofit organization sued the state of Georgia for denying coverage of transgender-related healthcare for members of the Georgia State Health Benefit Plan (SHBP). The lawsuit followed an earlier win in June 2022 in which a Georgia federal district court ruled that an employer cannot exclude or deny coverage for transition-related medical treatments from its employee health insurance plan.

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The Medicare drug price negotiations are slated to save the federal program around $6 billion across 10 selected medications.

The variation in trauma activation charges cannot be fully explained by clinical need, but by trauma center ownership and type.

Healthcare law experts discuss how telehealth providers can stay compliant and vigilant as the Department of Justice accelerates ...

Telehealth use surged among dementia patients during the COVID-19 pandemic, with various social determinants influencing ...

Massachusetts public health officials detail the implementation of a telehealth-based hypertension management program that ...

Women's health in the U.S. trails similarly developed nations in terms of outcomes, care access and healthcare affordability.

VA patients enrolled in the SDOH pilot rideshare program had fewer transportation barriers to care, more access and fewer ...

Most community health centers are bogged down by provider and staff shortages, but they're still able to offer next-day and ...

Key considerations for selecting an EHR vendor include assessing practice needs, conducting a thorough market scan and evaluating...

The proposed rule, which is available for public comment until October 8, 2024, would require HHS contractors to use certified ...

The Traverse Exchange interoperability network supports nationwide health information exchange (HIE) for MEDITECH customers, ...