What is the state of gender-affirming care in America

03/03/2023

Illustration: Allie Carl/Axios

A growing number of states are authorizing restrictions on gender-affirming care, stoking public confusion about what it entails and where it's permitted.

State of play: Individual states have started enacting bans on gender-affirming care for trans youth in 2023, and more than 100 anti-trans health care bills have been introduced in state legislatures so far, according to data from the American Civil Liberties Union.

Most of these bills look to bar access to care — mainly surgery, hormone therapy and puberty blockers — for minors who seek to have their gender identity supported. However, some states are targeting people under 21.
Some pieces of legislation look to prohibit both state and private health plans from being required to cover these medical services.
While most of the measures focus on classifying gender-affirming care to minors as medical malpractice, some could make it a crime punishable by large fines and prison times.
Health experts say most anti-trans state bills are based on scientifically inaccurate information.

What gender-affirming care is

The World Health Organization defines gender-affirming care as a range of social, psychological, behavioral and medical interventions "designed to support and affirm an individual's gender identity" when it conflicts with the gender they were assigned at birth.

Major medical organizations, including the American Medical Association and the American Academy of Pediatrics, consider this type of care to be medically necessary and potentially lifesaving for transgender youth.
71% of LGBTQ youth — including 86% of trans and/or nonbinary youth — say the debate around state laws "restricting the rights of LGBTQ young people" has negatively impacted their mental health, according to a 2022 poll by The Trevor Project, which provides crisis intervention services.

How gender-affirming care typically works

1. The first step is usually social transition and counseling.

Trans kids who choose to undergo gender-affirming care usually start with social transition, meaning the young person presents in their preferred gender. They may also begin counseling.
Health providers encourage a minor's guardians and others around them to participate in social affirmation by referring to them with their preferred pronouns and name and supporting their gender expression.

2. Next, mostly reversible treatments might be considered.

In consultation with their family and health providers, as a patient gets older, they may then move on to treatments such as puberty blockers, which look to delay pubertal physical changes. A patient may also choose to undergo hormone therapy, some of the effects of which are reversible, depending on which stage of treatment.
Taking puberty blockers can allow a patient to take more time to decide whether they want to allow pubertal changes to take place or instead take cross-sex hormones, which work to develop sex characteristics associated with their preferred gender.
Medical guidelines generally state blockers and hormone therapy can be started once a youth starts to exhibit physical changes from puberty.

3. Irreversible surgical procedures may later be considered, typically for people over the age of 18.

Certain gender-affirming surgeries might be offered to teens, but this is on a case-by-case basis, evaluated by multiple health professionals.

Coverage and treatment for care

Most public and private health plans are prohibited from discriminating against a person because of their transgender identity, per the National Center for Transgender Equality. However, some health plans might exclude coverage for this type of care.

Often, a person must be diagnosed with gender dysphoria — defined as distress related to gender incongruence — to obtain coverage.
"A long-lasting and intense pattern of gender nonconformity or gender dysphoria" is a criterion for receiving hormone therapy, per the World Professional Association for Transgender Health, a medical nonprofit that lays out standards of care.
WPATH argues it's inappropriate to diagnose a patient as mentally ill. The group recommends that providers treat for gender incongruence instead of dysphoria, the former of which is regarded as a sexual health condition instead of mental health one.

What they're saying: There is no one-size-fits-all approach to gender-affirming care, as some patients may seek medical treatments while others may not, said Jerrica Kirkley, a physician specializing in family medicine and co-founder of Plume, a gender-affirming telehealth app.

"Gender-affirming care really is any care that is informed by the lived experience of trans people and delivered in a culturally competent and clinically competent way," Kirkley added.

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