Transgender and gender-diverse (TGD) youth experience barriers to accessing health care and are at risk for poorer overall health compared with cisgender peers. In the last year, dozens of US legislative bills have been proposed to restrict the rights of TGD youth.1  A subset of these bills aims to restrict access to essential treatment of youth diagnosed with gender dysphoria, even when they meet rigorous criteria, as determined by a multidisciplinary evaluation (Table 1).1,2  Other proposed legislation would criminalize clinicians who provide gender-affirmative medical care (GAC) for TGD adolescents, with one bill currently under consideration in Oklahoma classifying providing GAC as a felony punishable by 3 years to life in prison.1  Clinicians and parents fear that legislation eliminating access to GAC will lead to worsening mental health and increased suicidality for their TGD children.3 

TABLE 1

Bills Proposed During the 2021 US State Legislative Session to Date

StateMedical Bans
Alabama SB 10: Explicitly bans all forms of medical care, specifying gender-affirming hormones and surgery and mandates parents are informed of a child’s gender identity if a patient discloses they are transgender to a clinician. 
Arizona SB 1511: Classifies GAC as child abuse. 
Georgia HB 401: Classifies providing GAC to youth aged <18 y as a felony punishable by up to 10 y in prison. 
Indiana SB 224: Classifies GAC as child abuse and stipulates criminal penalties for medical clinicians. 
Iowa HF 193: Stipulates a penalty of license revocation for medical clinicians providing GAC. 
Kansas HB 2210: Criminalizes providing GAC to minors. 
Kentucky HB 336: Bans medical clinicians from providing GAC for minors. 
Mississippi SB 2171: Bans GAC for people aged <21 y. 
Missouri SB 442: Classifies GAC for youth aged <18 y as felony child abuse and introduces criminal penalties for medical clinicians. 
Montana HB 113: Bans medical clinicians from providing GAC to patients aged <18 y. 
New Hampshire HB 68: Classifies GAC as child abuse. 
Oklahoma SB 676: Bans GAC for youth <21 y; includes a penalty for health care clinicians of imprisonment with a minimum of 3 y to life. 
Texas HB 68: Classifies GAC as child abuse. 
Utah HB 92: “Prohibits a physician or surgeon from performing a transgender procedure on a minor.” 
StateMedical Bans
Alabama SB 10: Explicitly bans all forms of medical care, specifying gender-affirming hormones and surgery and mandates parents are informed of a child’s gender identity if a patient discloses they are transgender to a clinician. 
Arizona SB 1511: Classifies GAC as child abuse. 
Georgia HB 401: Classifies providing GAC to youth aged <18 y as a felony punishable by up to 10 y in prison. 
Indiana SB 224: Classifies GAC as child abuse and stipulates criminal penalties for medical clinicians. 
Iowa HF 193: Stipulates a penalty of license revocation for medical clinicians providing GAC. 
Kansas HB 2210: Criminalizes providing GAC to minors. 
Kentucky HB 336: Bans medical clinicians from providing GAC for minors. 
Mississippi SB 2171: Bans GAC for people aged <21 y. 
Missouri SB 442: Classifies GAC for youth aged <18 y as felony child abuse and introduces criminal penalties for medical clinicians. 
Montana HB 113: Bans medical clinicians from providing GAC to patients aged <18 y. 
New Hampshire HB 68: Classifies GAC as child abuse. 
Oklahoma SB 676: Bans GAC for youth <21 y; includes a penalty for health care clinicians of imprisonment with a minimum of 3 y to life. 
Texas HB 68: Classifies GAC as child abuse. 
Utah HB 92: “Prohibits a physician or surgeon from performing a transgender procedure on a minor.” 

Since this article was submitted, several of these bills may have transitioned or been passed, resulting in a name change. Additionally, some of these bills may have been defeated after the date of publication; however each of these bills was proposed during the first legislative session of 2021, and other states will likely propose similar legislation. Adapted from American Civil Liberties Union. Legislation affecting LGBT rights across the country. Available at: www.aclu.org/legislation-affecting-lgbt-rights-across-country. Adapted from Freedom for All Americans. Legislative tracker: Anti-transgender legislation. Available at: https://freedomforallamericans.org/legislative-tracker/anti-transgender-legislation/. Accessed February 11, 2021. HB, house bill; HF, house file; SB, senate bill.

Despite these objections, in December 2020, the Bell versus Tavistock ruling in the United Kingdom mandated that court approval be obtained before initiating medical treatment of TGD youth <16 years old.4  Troublingly, this decision stated that TGD youth are unable to consent to treatment with medications that suppress pubertal progression, including patients who were already approved to start these medications.4  This ruling, along with proposed legislation banning GAC in the United States, promotes dangerous misconceptions about the care of TGD youth. Specifically, these legislative actions are not concordant with the following: (1) current evidence-based guidelines endorsed by multiple professional societies, (2) ethical models of pediatric care that support patients’ ability to participate in shared medical decision-making, and (3) parents’ or guardians’ ability to provide consent on behalf of a child.2,5  We will focus on “blockers,” an essential gender-affirming medical treatment targeted by recent legislation, to address the ways in which these bills threaten the health and well-being of TGD youth.

Blockers are the common term for a class of medications known as gonadotropin-releasing hormone analogues (GnRHas), which suppress undesired physical changes associated with puberty.2,6  Safety data for GnRHas are derived from their use in the treatment of central precocious puberty over the last 3 decades.7  In studies, researchers have described normal BMI, body composition, bone mineral density, gonadal function, and fertility in young adults who received GnRHas in childhood.7  Importantly, the effects of GnRHas on both luteinizing hormone pulsatility and clinical progression of puberty are reversible.2  In part because of a favorable safety profile, GnRHa use in TGD youth has increased in the United States in recent years.6 

TGD youth experience psychological and physical benefits from treatment with GnRHas.810  GnRHas prevent worsening distress from pubertal changes that are irreversible and incongruous with gender identity.2  GnRHas mitigate mental health comorbidities (eg, suicidality, depression, and substance use), which may stem from societal discrimination, minority stress, risk of rejection, and negative health implications associated with gender dysphoria.810  GnRHas may also eliminate the need for future gender-affirming surgeries, all of which entail medical risks and can be prohibitively expensive (eg, gender-affirming mastectomy or “top” surgery, facial feminization surgery).

The small number of TGD children (∼1.9%–3.6%) who discontinue GnRHa use reflects the strength of the multidisciplinary approach to GAC, which includes a psychosocial assessment and longitudinal follow-up.11  Low rates of retransition to the birth-assigned gender and high rates of progression to gender-affirming hormones likely reflect careful selection of candidates for GnRHa use by a multidisciplinary team. Consenting to GnRHa therapy does not compel TGD youth to pursue additional medical or surgical therapy but rather facilitates well-informed and carefully considered decisions about subsequent gender-affirming interventions without the stress of unwanted pubertal progression. GnRHas are thus an essential tool for promoting the overall mental health and well-being of TGD youth.810 

Bell versus Tavistock also raises concerns about fertility options for TGD youth.4  GnRHas alone do not impact future fertility. The physical effects of these medications are considered reversible, and therefore, youth have the option of pursuing fertility preservation options before initiating gender-affirming hormones, in some cases while using GnRHa. Additionally, TGD youth have been shown to be open to a variety of family-building options and may not desire to pursue fertility preservation.12  The psychological toll of experiencing undesired pubertal changes must thus be weighed against the variety of perspectives on fertility among TGD youth and evolving options for fertility preservation.

Pediatric care uses widely accepted models of parent or guardian consent for interventions that are considered in the best interest of the minor, accompanied by an assent process for minors when developmentally appropriate.5  The practice of allowing guardians to consent for a minor’s medical care with potential lifelong benefit and/or risk is standard of care in pediatrics (eg, vaccination, oncology treatment). As the use of GnRHa has clear benefits for TGD youth, it is appropriate for guardians, without the need for court approval, to consent to this treatment on behalf of their children.2,810 

Studies have revealed that by 12 years old, children have the capacity to make informed medical decisions. Under the “mature minor doctrine,” adolescents 14 to 17 years old who possess maturity and decisional capacity may provide consent for medical care. In some situations (eg, contraception or substance abuse), there is also legal precedent for obtaining consent for medical treatments directly from minors.5 

Proposed legislative bans on TGD medical care in the United States selectively undermine the use of well-established consent models as they are applied to the clinical care of TGD youth.4  Many TGD patients possess decisional capacity, and with guardian consent and the support of a multidisciplinary team, they are able to contribute to decisions in their own best interests about GnRHas and gender-affirming hormones. Furthermore, denying TGD youth access to GnRHas to prevent irreversible secondary sex characteristics incongruent with their gender has the potential to do significant harm by worsening gender dysphoria and psychological distress.

Efforts to restrict clinicians’ ability to provide GAC must be contextualized within the long-standing history of marginalization of TGD individuals, who still face inequitable access to medical care. By undermining access to GAC, Bell versus Tavistock and proposed anti-GAC legislation in the United States threaten to deepen pre-existing inequities, leading to increased morbidity and mortality among TGD youth and disproportionately harming TGD people of color and those living in poverty.

Underrepresentation of TGD people in medical and legislative leadership roles, and as clinicians, contributes to a dearth of valuable community knowledge in these settings. In medicine, TGD people are often excluded from the creation of clinical practice guidelines directly affecting the TGD community. All efforts must be made to include TGD voices in clinical care settings by hiring TGD health care workers and developing TGD clinical advisory boards. Finally, clinicians can have a powerful voice as advocates for TGD youth by reaching out to state and federal legislators to provide them with accurate information about the importance of GAC. Inclusive practices will ensure that clinical care is affirming and will allow pediatric providers to work more effectively in opposition to the damaging restrictions imposed by laws banning GAC in the United States and worldwide.1329 

We thank the TGD patients and their families who allow them the privilege of participating in their care. We also thank Ariel Botta, PhD, MSW, LICSW; Jennifer Gentile, PsyD; Peter Hunt, PhD; and Francie Mandel, MSW, LICSW.

Mr Barrera and Dr Williams provided consultation as transgender and gender-diverse members of the Gender Multispecialty Service Team, conceptualized and designed the content of the manuscript, drafted the initial manuscript, and reviewed and revised the manuscript; Drs Kremen and Harris, Dr McGregor, Drs Millington and Guss, Ms Pilcher, and Drs Baskaran, Carswell, and Roberts conceptualized and designed the content of the manuscript, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Tishelman conceptualized and designed the content of the manuscript, drafted the initial manuscript, and reviewed, edited, and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

     
  • GAC

    gender-affirmative medical care

  •  
  • GnRHa

    gonadotropin-releasing hormone analogue

  •  
  • TGD

    transgender and gender-diverse

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Carswell previously served as a consultant to Endo Pharmaceuticals in June 2018; the other authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.