Prohibition of Gender-Affirming Care as a Form of Child Maltreatment: Reframing the Discussion

Gender identity is one’s internal sense of self and can be binary, including transgender and cisgender identities, nonbinary and gender expansive, and not exclusively masculine or feminine.⁴  Gender dysphoria (GD) is the distress resulting from incongruence between one’s assigned sex at birth and gender identity; not all TGD individuals experience GD. Gender diversity is a normal part of child development.²  GAC entails a patient-centered approach that supports individuals in living their authentic gender identities, whether they exist on the binary or outside of it. Although some individuals make it seem that GAC is a new, experimental area of medicine, GAC is evidence-based. Furthermore, most TGD youth do not receive any medical interventions before puberty.²  When indicated, TGD youth may start gonadotropin-releasing hormone analogs, which have been used in pediatrics since the 1980s. They also may go on to receive gender-affirming hormones or surgical interventions, all of which are supported by a wealth of research on their safety and effectiveness. It’s for this reason that GAC has been reified in numerous reputable professional guidelines, including the American Medical Association, the Endocrine Society, the American Academy of Pediatrics, and the American Psychiatric Association.³ 

Child maltreatment is a serious problem, with estimates as high as 1 in 4 children experiencing some form of child abuse or neglect in their lifetime.⁵  The weaponization of child abuse in the discourse around GAC is fallacious and counterproductive, and it has led to numerous real threats to children’s safety and well-being.

There has been a recent deluge of legislation intended to limit access to GAC. Numerous states have introduced and passed bills that label supportive caregivers as abusive, and threaten them with child protective services investigations and child removal if they consent to GAC.^6,7  Multiple bills also outline various civil and criminal penalties medical providers face if they provide GAC. These penalties include loss of medical licenses, fines up to $500 000, and criminal charges.¹ 

Examination of the evidence and expert opinions highlight how these legislative efforts are, at minimum, the result of a lack of understanding, and in some cases fueled by malice and a desire to spread misinformation to propel forward an antitransgender agenda.⁸  Contrary to arguments put forth in anti-GAC legislative efforts,^6–8  GAC is not a form of child physical abuse, emotional abuse, or medical child abuse.

First, we will consider child physical abuse, acts that cause physical injury to children. There are wide-ranging health impacts of physical abuse that include diabetes, cardiovascular disease, anxiety, depression. Physical abuse can result in executive functioning challenges, altered brain anatomy, and functional changes, as well as epigenetic effects.⁹ 

GAC is not child physical abuse. Unlike child physical abuse, GAC does not cause harm to children. Instead, it decreases many negative health outcomes, including rates of depression, and improves well-being for children and adolescents.⁷  GAC has not been shown to lead to short- or long-term negative health effects, and in fact, the benefits of GAC have been shown to far outweigh the risks.²  GAC does not, therefore, constitute physical abuse.

Opponents have argued that GAC is a form of medical child abuse (MCA).^6–8  MCA refers to a child receiving unnecessary and harmful or potentially harmful medical care because of a caregiver’s overt actions including exaggeration of symptoms, lying about the history or simulating physical findings, or intentionally inducing illness in their child.¹⁰ 

GAC is not MCA. Although caregivers are vital supports in a child’s gender journey, the provision of gender-affirming medical and surgical care necessitates an alignment of the child’s goals with the evidence-based treatment plan determined most appropriate by the medical team. As a testament to GAC being patient driven, studies have found that the vast majority of youth who initiated medication intervention continue these treatments when followed in adulthood.¹¹ 

In summary, in contrast to MCA where a child receives harmful and unnecessary medical care because of the design of the caregiver, GAC reduces the well-documented negative health repercussions of untreated GD, and is patient driven, with interventions only pursued when they serve to achieve the patient’s goals.

Although there is no evidence to support the idea that providing GAC constitutes child maltreatment, there is evidence that denying such care results in significant harm to children and meets diagnostic criteria for medical neglect. Medical neglect refers to the failure to provide necessary medical care to a child, which in turn leads to or has the potential to lead to physical or psychological harm. Two of the guiding questions used in the diagnosis of medical neglect are:

1. is the anticipated benefit of treatment greater than its morbidity? and

2. is a child harmed because of a lack of medical care?

The benefits of GAC, most notably on mental health, self-esteem, and development, outweigh the risks in the majority of circumstances. GAC is, for many, lifesaving. Research highlights how transgender youth disproportionately experience negative mental health outcomes, including anxiety, depression, and suicidality.¹²  However, when children are supported in their gender identities and have access to GAC, they have better mental health outcomes.^12,13  Some studies demonstrate that appropriate GAC, in the context of caregiver support, entirely mitigates the increased risk of depression and suicidal ideation for TGD youth.¹² 

Children are harmed when their access to GAC is limited. It is potentially life-threatening for children to be denied GAC. Legislative restrictions mandate that caregivers and medical providers actively harm children and adolescents. Therefore, when state and federal entities limit access to GAC, their actions meet criteria for medical neglect.

Denying GAC not only represents medical neglect, but it is also state-sanctioned emotional abuse. In addition to the basic physical needs all people require for survival, humans have vital psychological needs. The degree to which these needs are met during childhood impact a child’s identity, capacities, and behaviors into adulthood.¹⁴  Emotional abuse involves actions, either as a repeated pattern or an extreme single incident, that thwart a child’s basic psychological needs.¹⁴  This form of abuse can be especially damaging because it undermines a child’s self-worth and psychological development.¹⁴  Policies that prohibit or limit a caregiver or physician’s ability to provide necessary GAC force caregivers and providers to perpetuate psychological distress.

In recent years, there has been extensive media coverage surrounding state and local bans that limit the rights of TGD individuals, including limitations on bathroom use, health care access, and participation in sports.¹⁵  Studies have shown there are direct negative health consequences for TGD individuals as a result of these bans and associated negative social media attention.^4,15–17  These policies and the media coverage of them have been shown to undermine TGD children’s sense of self-worth and psychological well-being,²  and are consistent with state-sanctioned emotional abuse.

That children may be separated from their caregivers in certain states, on the basis of legislative efforts to classify GAC as child abuse, is abhorrent, misguided, and harmful. GAC is not child abuse, and the rhetoric asserting that GAC is equivalent to child maltreatment is fallacious. On the basis of the definitions of emotional abuse and medical neglect, as well as the numerous studies that highlight the many benefits of GAC, withholding GAC from youth represents a form of child maltreatment. There is a growing number of policies targeting TGD youth. These policies jeopardize the well-being of children, and governments or individuals who restrict children from accessing this care should be held to account. We must advocate for the fair treatment and inclusion of TGD children in our society by ensuring they receive the medical care and support they need to thrive. Figure 1 outlines specific ways to advocate.

All children deserve love, acceptance, and care. Parents should be commended, not punished, for accepting their children for who they are. Physicians should similarly be supported, not penalized both professionally and mentally, for practicing evidence-based medicine. By supporting GAC, we can foster a society that promotes healthy parent–child relationships, supports evidence-based medicine, and values the well-being of all children.

GAC

gender-affirming care

GD

gender dysphoria

MCA

medical child abuse

TGD

transgender and gender diverse