Editor’s Note: Ha Le (she/hers) is a resident physician in pediatrics at UCSF, whose passions include medical education, social justice, and narrative medicine. – Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics
Gender-affirming care reflects a range of interventions meant to support an individual when their gender identity conflicts with the one assigned to them at birth. Until the patient is 18 years of age, gender-affirming care generally refers to developmentally appropriate support as the child goes through a social transition (eg, changes in pronouns, names, hairstyles, and/or clothing), puberty blocking treatment, and/or hormone replacement therapy (HRT).
Gender-affirming care can positively impact the mental health of adolescents and young adults (AYA), reducing the risk of depression and suicidality. Yet it remains a controversial topic, with multiple states placing bans or restrictions on gender-affirming medical care to youth.
The continued misinformation and uncertainty regarding gender-affirming care and resulting consequences on policy underscore the necessity of more research. Dr. Rosemary Claire Roden and colleagues at Penn State University and Pace University have contributed to the growing body of literature on the topic in their Pediatrics article being early released this week entitled, "Treatment Goals of Adolescents and Young Adults for Gender Dysphoria" (10.1542/peds.2023-062202).
The retrospective study reviewed self-identified treatment goals, specifically regarding HRT and surgery, of 176 transgender and nonbinary (TNB) AYA, ages 11 to 23 years, seen at an adolescent medicine clinic in Pennsylvania for gender-affirming care from 2020 to 2022. Most of the participants were White (65.3%) and privately insured (73.3%). They were categorized, based on their experienced gender, as:
- Young men
- Young women
- Nonbinary: Nonbinary, agender, or gender-fluid individuals
- Eclectic: Those who did not have the language to describe their gender or declined to disclose their gender
The authors found that:
- Most participants, regardless of birth-assigned sex and gender group, were interested in HRT and surgery.
- A greater proportion of participants assigned female at birth (AFAB) were interested in surgery, specifically top (breast or chest) surgery, than those assigned male at birth (AMAB).
- More AMAB participants had a goal of bottom (genitourinary tract) surgery compared to AFAB participants.
- Fewer young women had a goal of top surgery than young men and nonbinary participants.
- There were no differences in interest with bottom surgery among experienced gender categories.
- Treatment goals for those in the eclectic group did not mirror that of other groups.
It should be noted that in the US, gender-affirming surgery is typically not performed until the individual has reached adulthood. Given that the participants in this study ranged in age from 11 to 23 years of age, surgery would be an option for some of them.
The findings reflect the nuances of gender-affirming care treatment goals among transgender and nonbinary youth. For instance, youth experiencing an eclectic gender had different preferences compared to those identifying as young women, young men, or nonbinary, suggesting the need to analyze the group separately in future research. Study findings are limited, however, by the homogeneity of the participants (mostly White and privately insured from a single geographic region), lack of longitudinal follow-up, subspecialty gender health clinical environment, and the ethno-cultural complexity with diagnosing gender dysphoria.
Nevertheless, the study is a critical addition to our understanding of gender-affirming care. As the authors write,
Children who experience gender dysphoria, the families they live in, and the condition itself are under scrutiny from media and lawmakers in the United States, usually centered on the ability, or perceived lack thereof, of a child to understand permanent changes in the body related to gender-affirming care...The authors hope that the results of this study might provide a counterpoint to this contemporaneous media narrative: TNB AYA are not a monolith, and they cannot be painted with a broad brush.
Gender, and our patients' relationships with their experienced gender, is a major component of their lives. As such, I highly encourage pediatric providers and anyone passionate about child and adolescent health to read this article in Pediatrics.
