Geographic Distribution of Clinical Care for Transgender and Gender-Diverse Youth

There are no national databases with standardized and validated information about health care services for TGD youth. We selected databases that included the most comprehensive information. We aggregated data from the Human Rights Campaign for pediatric gender clinics for gender-expansive youth, Psychology Today for MH providers for TGD youth by state, Movement Advancement Project (MAP) for state-by-state assessment of gender identity laws and policies, and the 2020 US Census for estimates of youth ≤18 years.^37,46–48 

We used the Human Rights Campaign’s “Interactive Map: Clinical Care Programs for Gender-Expansive Children and Adolescents” on June 15, 2022.⁴⁶  Providers self-submit their sites to be included on this map. Information is reviewed and included only if the Human Rights Campaign considers programs “comprehensive multidisciplinary programs” that include MH and medical services for TGD youth. It is possible that other pediatric gender clinics and smaller practices are not included in this map provide care to TGD youth.

Data pertaining to MH providers for TGD youth was ascertained via the Psychology Today’s “Therapist Finder” feature by state.⁴⁷  Therapists pay to list themselves in the database and self-report their services and qualifications. In each search for therapists, “issues” selected was “transgender,” and “age” selected were “children (6 to 10)” AND “preteens/tweens (11 to 13)” AND “adolescents/teenagers (14 to 19).” “Toddlers/preschoolers (0 to 6)” were not included because their inclusion significantly lowered the number of MH providers for TGD youth available per state and represent a small percentage of children referred for TGD services. Some parents of TGD youth younger than age 6 years seek MH services for their child, and thus, the lack of clinicians serving this age group is a disparity in resources.^49,50  With no existing universal directory of MH providers, Psychology Today is the best available proxy for determining these data; however, there are likely providers who are not listed in this resource, as well as providers who may not provide developmentally sensitive or gender-affirming services. All data for TGD youth therapists via Psychology Today was collected in 2021. The World Professional Association for Transgender Health (WPATH) also has a searchable provider list.⁵¹  We decided to use Psychology Today as the provider list reference because it generated more results. Providers and families may find additional providers on WPATH.

We used the MAP’s “Snapshot: LGBTQ Equality by State” under the “Gender Identity” column of the “State Data Table,” updated June 2022 to ascertain gender identity equality scores for laws.³⁷  Laws are considered pertaining to gender identity if they explicitly mention gender identity and/or expression. The laws assessed and the gender identity equality scores pertain to both adults and youth. A state’s “policy tally” for gender identity is derived by counting the number of laws and policies that affect equality for gender identity. Examples of relevant law categories included within the policy tally for gender identity equality scores are: “Bans on transgender youth sports participation,” “Safe schools: school nondiscrimination,” “Safe schools: anti-bullying,” “Bans on medical care for transgender youth,” “Bans on insurance exclusions of transgender-related care,” “Hate crime laws,” “Gay/trans panic defense bans,” “Restrictions on name changes,” “Name change process,” “Changing gender marker on driver’s licenses,” “Changing gender marker on birth certificates,” and “Gender neutral markers.” MAP assigns a point value for each policy. These points are added to yield a “policy tally” for each state. If a policy is harmful or discriminatory, the policy earns negative points. If a policy is gender-inclusive or protective, the policy earns points. Fractions of a point are given when a state has enacted a portion of a law, or when local laws provide protection but do not apply to the entire state. Gender identity equality scores range from ≤0 to 22. A score ≤0 means the state has many harmful laws and policies pertaining to gender identity. A score between 0 and 5.25 means the state has low protection for gender identity, achieving 0% to 24.9% of the possible points. A score between 5.5 and 10.75 means the state has fair protection for gender identity, achieving 25% to 49.9% of the possible points. A score between 11 and 16.25 means the state has medium protection for gender identity, achieving 50% to 74.9% of the possible points. And a score of 16.5 and 22 means the state has high protection for gender identity achieving 75% to 100% of the possible points. The MAP Web site (https://www.lgbtmap.org/equality-maps) provides more information about MAP gender identity policy scores.

We used the US 2020 census to determine the population of people <18 years by state.⁴⁸ 

Prevalence rates for TGD youth was ascertained using both a recent conservative estimate for transgender youth prevalence rate (ie, 1.8%) and a recent liberal estimate for TGD youth prevalence rate (ie, 9.2%).^2,3 

The 50 states of the United States and the District of Columbia, with an estimated 2020 population of 73 106 000 younger than age 18 years, results in an estimated range of 1 315 908 to 6 725 752 TGD youth in the country. The United States has 65 TGD youth clinics, and 11 191 MH providers who self-identity as serving TGD youth. Table 1 contains the data for the per capita results for each region and for the United States. The United States has an average of a “fair” protection of 7.98 equality score in gender identity laws and policies. There are at best 20 245 TGD youth per clinic in the United States and at worst 103 473 TGD youth per clinic (Table 2). At best, there are 118 TGD youth per TGD youth MH provider available and at worst 601 TGD youth per TGD youth MH provider available.

Data are summarized by region (South, West, Northeast, and Midwest). There is variability within regions. Tables 3–6 contain the data by state within each region. All estimates of services are based on using 1.8% to 9.2% prevalence estimates for TGD youth.

The 16 states and the District of Columbia in the South region have the largest 2020 population (28 361 793 people <18 years of age) with an estimated range of 510 512 to 2 609 285 TGD youth. The South has the lowest number TGD youth clinics, with 14 clinics, and the lowest average equality score in gender identity laws and policies (1.96, a “low” protection score). The South has a total of 3602 MH providers for TGD youth. At best, there are 36 465 TGD youth per clinic and at worst 186 377 TGD youth per clinic. At best, there are 142 TGD youth per TGD youth MH provider available and at worst 724 TGD youth per TGD youth MH provider available.

The 13 states in the West region have the second largest 2020 population (17 560 440 people <18 years of age), with an estimated range of 316 087 to 1 615 560 TGD youth in the region. The West has the third lowest total number of TGD youth clinics, with 17 TGD youth clinics, the third lowest average equality score in gender identity laws and policies (11.38, a “medium” protection score), and a total of 2894 MH providers. In the West, at best there are 18 593 TGD youth per clinic and at worst 95 033 TGD youth per clinic. At best, there are 109 TGD youth per TGD youth MH provider available and at worst 558 TGD youth per TGD youth MH provider available.

The 12 states in the Midwest region have the third largest 2020 population (15 473 403 people <18 years of age), resulting in an estimated range of 278 521 to 1 423 553 TGD youth in the region. The Midwest has the second lowest total number of TGD youth clinics, with 15 clinics, the second lowest average equality score in gender identity laws and policies (5.54, a “fair” protection score), and a total of 2270 MH providers. At best, there are 18 568 TGD youth per clinic and at worst 94 904 TGD youth per clinic. At best, there are 123 TGD youth per TGD youth MH provider and at worst 627 TGD youth per TGD youth MH provider.

The 9 states in the Northeast regions have the smallest estimated 2020 population (11 710 364 people <18), with an estimated range of 210 787 to 1 077 353 TGD youth in the region. The Northeast has the highest total number of TGD youth clinics, with 19 clinics, the highest average equality score in laws and policies per state (17.75, a “high” protection score), and a total of 2425 MH providers. In the Northeast, at best there are 11,094 TGD youth per clinic available and at worst 56 702 TGD youth per clinic. At best, there are 87 TGD youth per TGD youth MH provider and at worst 444 TGD youth per TGD youth MH provider.

There were 19 states with no publicly listed TGD youth clinics: Alabama, Alaska, Georgia, Hawaii, Idaho, Kansas, Kentucky, Louisiana, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Dakota, South Dakota, Texas, and Wyoming. The state with the lowest equality score in gender identity laws and policies was Tennessee, with a “negative” score of −6.75. The state with the worst per capita TGD youth per MH providers was Mississippi, with a total of 22 providers in the state with a 2020 population of 683 680 people younger than age 18 years, making the estimated range of TGD youth in Mississippi 12 306 to 62 899, resulting in 559 to 2859 TGD youth per TGD youth MH provider.

The District of Columbia had the best per capita TGD youth per TGD youth clinics, with 1 clinic, resulting in 2059 to 10 523 TGD youth per clinic. The state with the highest equality score in gender identity laws and policies was California, with a “high” score of 21.75. The District of Columbia had the best per capita TGD youth per MH providers, with a total of 55 MH providers, resulting in an estimated range of 37 to 191 TGD youth per MH provider.

The data indicate a pervasive lack of medical and MH resources for TGD youth in the United States. Lack of these resources is particularly alarming given the higher prevalence of depression, anxiety, suicidality, and other MH concerns among TGD youth compared with their cisgender peers. Provision of gender-affirming medical care to TGD youth often requires a diagnosis of gender dysphoria and a letter of approval from an MH professional. Our findings highlight the need for better data and standards for classifying MH providers as competent to provide care for TGD youth. We could not find a database that included information about the competence and training of the MH providers who self-reported serving TGD youth. Of special concern is the possibility that some of these providers might engage in harmful interventions, such as conversion therapy.⁵² 

Lack of TGD clinics throughout the United States limits access to TGD-specific interventions. Current trends show an increase in referrals to TGD youth clinics, especially for starting hormone blockers or hormone replacement, gender-affirming surgery, and MH services.⁵³ 

Increases in laws and policies that discriminate against TGD youth and/or fail to protect them likely contributes to limit appropriate services and increases their MH concerns.^54–56  Some states specifically prohibit medical interventions for gender-affirming care. For example, Alabama passed a law classifying providing gender-affirming medical care to minors as a felony, and the Texas governor classified gender-affirming medical care as child abuse.^43,57  Additional states are considering enacting similar laws and policies.^58,59 

Even if a state has TGD youth clinics, MH providers, and favorable gender equity scores, geographic barriers remain. Clinics tend to be located in larger urban areas, whereas rural and less populated areas lack TGD clinics and/or MH providers.

State-by-state data on the MH of TGD youth is sparse, which prevents analysis of outcomes for TGD youth based on their available resources and laws. A recent study on TGD youth and adults found that protective state-level transgender-specific policies are associated with increased use of therapy and medical gender-affirmation services.⁵⁹  Recent findings suggest that policies may affect TGD individuals from various races and ethnicities differently. For example, TGD people of color reported using therapy and hormone treatment less often than non-Hispanic white participants. However, findings differed from state to state, with a few states having similar or more TGD people of color reporting using therapy compared with non-Hispanic white participants.⁵⁹  Quality data on the MH of TGD youth by state is needed to understand the impact of treatment, health care inequities, available resources, and laws. These data could inform advocacy efforts and advise research and development of clinical services.

Our findings support the need for pediatric health care providers to familiarize themselves with best practice treatments and resources for their TGD patients. Pediatric health care providers can educate parents about TGD youth. Many parents have difficulty and/or resistance to accepting that their child is TGD and contribute to the child feeling unsupported, which is associated with worse MH outcomes for TGD youth.⁶⁰  Pediatric health care providers can help parents find services by providing information on effective services and referring parents to WPATH standards of care and American Psychological Association guidelines for gender-affirming care.^5,6  In addition, providers in states without resources or with laws preventing intervention can provide parents with information about services in neighboring states and support groups (both in their states and online). Support groups for TGD youth and families (eg, PFLAG, lesbian, gay, bisexual, transgender, and queer centers, online support groups) can provide social support for TGD youth and their families and references to providers that provide gender-affirming care.⁶¹  School counseling services, when permitted, may also provide resources for TGD youth and their families.^62,63 

Lack of epidemiologic data on incidence of TGD youth, their MH problems, and information about service providers for TGD youth limited our findings and certainty in our data. Given that data for the TGD youth clinics were ascertained via self-submission by sites, there are likely TGD youth clinics missing from the “Clinical Care Programs for Gender-Expansive Children and Adolescents” interactive map (providers can submit their TGD youth clinics to this map at: https://hrc.wufoo.com/forms/clinical-care-program-submission- form/). Similarly, Psychology Today is unlikely to entirely reflect the available providers for 3 main reasons: (1) not all MH providers have profiles on Psychology Today, (2) selecting “transgender” as an issue does not mean providers are competent to treat TGD youth, and (3) listing does not guarantee accepting new patients. The same concerns apply to providers in WPATH. Nonetheless, with no other national database for services, families may use these databases to find a provider. Psychology Today has ecological validity because it is a commonly used resource for people seeking an MH provider.

Overall, the data for this study are limited because of a lack of comprehensive validated measures on TGD youth prevalence rates, TGD youth MH prevalence rates, gender clinics, and MH providers in the United States. Future investigations need to validate and expand these findings.

Data are needed on TGD youth and MH in relation to available services and policies. Data by state would allow for analysis of the relationship between geographic access to resources as well as the impact of laws. These data could inform advocacy efforts to provide more TGD resources and TGD-affirming laws. Findings that TGD youth are at a higher risk for suicide, depression, and anxiety than their cisgender peers speak to core values in health care to preserve life, promote equity, and improve/maintain a high quality of life for youth physically, socially, and psychologically.

A challenge to pediatric health care providers in developing and distributing information about resources for TGD youth is the potential unintended consequence of harassment of clinics and providers at their practices and via letters.⁶⁴  These concerns support the need for more public education and advocacy for city, state, and federal laws and policies to protect the interests of TGD youth.^65–67  Regressive policies that restrict access to care for TGD youth have been passed and/or are under consideration in legislatures throughout the United States.^54–59  In most cases, the voices of pediatric experts have either not been considered or have been ignored.

MAP

Movement Advancement Project

HRC

Human Rights Campaign

TGD

transgender and gender diverse

WPATH

World Professional Association for Transgender Health