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What really is gender-affirming care?

Gender-affirming health care doesn't have to involve a transgender, non-binary, or gender-diverse patient at all.
What really is gender-affirming care?
Posted at 7:01 PM, May 04, 2023

The American Medical Association says "sex" refers to the biological differences between males and females. "Gender" is more of a construct, largely referring to society's established ideas of identity.

"Gender-affirming" is a large umbrella term. It can be a doctor's office keeping record of a patient's preferred name and pronouns like "they", "she", or "he", and calling them by it. 

It can be providing a transgender patient with routine medical care like a flu shot. Gender affirming health care doesn't have to involve a transgender, non-binary, or gender-diverse patient at all.

"That includes things like breast reconstruction for women who have had breast cancer. It provides care for men who have been injured in wars and have lost nerves in their pelvic region," Dr. John Steever, Pediatrician and Director of Special Programs, Mount Sinai Adolescent Health Center and associate professor of pediatrics and adolescent medicine at Icahn School of Medicine at Mount Sinai said. It's gender-affirming health care for transgender Americans — roughly 1% of the population — that's in focus now.

That care may include:

  • Mental health care
  • Treatments like puberty blockers or hormone therapy (injection/shots, oral medication, topical gels)
  • Surgery (in rare instances)

This greatly depends on age. Doctors Scripps News spoke with say providers will not consider gender-affirming medical treatment for kids who have not begun puberty. At most, they can offer family counseling or support.
They may use "gender-explorative approaches that don't sway a child in either direction. But there's no prescriptions, there's no surgeries. There's nothing going on," said Dr. Maddie Deutsch, Director of the UCSF Gender Affirming Health Program and President of the U.S. Professional Association for Transgender Health.

For a patient seeking medical care related to their gender identity not matching their sex, doctors follow a standard of care recommended by professional groups like The Endocrine Society or by the World Professional Association for Transgender Health, or WPATH. The latest WPATH guidance alone, called SOC8, revised in late 2022, is more than 250 pages long. The guidance is updated as more research comes out.

Dr. Deutsch helped write the WPATH guidance. She explains for adolescents who have started puberty,  puberty blockers or hormone therapy of estrogen or testosterone may be considered, but only after mental health and medical evaluations are completed. 

"They have to meet a diagnostic criteria for gender dysphoria or gender incongruence. And that diagnosis and assessment really need to be performed by a mental health clinician who has expertise in this area."

Dr. Angela Kade Geopferd, Medical Director of Children's Minnesota Gender Health Program explains evaluations take time.

"No one is walking into a visit and then walking out with the hormone prescription that same day. The other thing that takes time is actually getting into the clinic," they said. "Just to have a diagnosis of gender dysphoria, you have to have symptoms or be experiencing distress for six months or longer. So at a minimum, it's a months-long process. But I would say in many cases a years-long process."

Time plays a role for providers and patients when it comes to puberty or hormone blockers. Dr. Geopferd explains the role of puberty blockers is to allow patients more time to explore their gender.

"Gender expression and gender identity can evolve over time for a young person. So we intentionally give them lots of time and leave that flexible," Geopferd said. 

That WPATH guide of best practices suggests hormone therapy could begin in the 14 to 16-year-old range. But doctors Deutsch and Geopferd say providers mainly consider the stage of puberty before ultimately starting therapies.

For feminizing hormone therapy, or masculinizing hormone therapy, effects and risks vary by medication. Research, especially long term, is complicated and unclear for impacts like bone density, something WPATH doctors have responded to media coverage about recently.

Family planning and fertility impacts are considerations providers discuss with trans patients as well.

For follow-up monitoring, the Endocrine Society recommends doctors monitor an adolescent patient's clinical pubertal development every 3-6 months, and conduct exams and lab work every 6-12 months during sex hormone treatment. Hormonal blockers and therapies are generally reversible, but effects are determined by how long a patient has taken them.

The medications used in hormonal therapies are used in other areas of medicine too.

Leuprolide has been used for both precocious puberty and for prostate cancer. Spironolactone was initially created as a blood pressure medicine and can also be used to decrease acne because it works by lowering testosterone levels in the skin.

As for surgery, WPATH does not recommend gender-affirming surgery for anyone under 18. When it does happen, it's very rare.

"Another big misconception is that children are accessing surgery, so. There is no medical treatment, including surgical treatment for anyone who is before puberty. So the fact that there's some narrative around children accessing surgery is just completely false," Goepferd said.

A Reuters 2022 investigation of insurance claims data from Komodo Health found from 2019-2021, 832 surgeries occurred among patients ages 13 to 17 with a prior gender dysphoria diagnosis. That's fewer than 300 surgeries per year, across the entire country.

Dr. Deutsch says the surgical context for trans youth is typically one of two considerations. One: Transgender boys or trans masculine, non-binary people who are in late adolescence, 15-16 at least, who have large chests and are binding them daily.

"Maybe they're on testosterone and have already begun male puberty, but then they have visible breasts. There are a lot of harms associated with binding. In appropriate cases that have been thoroughly evaluated by a mental health clinician it is appropriate in some cases to perform chest surgery," Goepferd said. 

The second context Dr. Deutsch described as very rare: Carefully selected 17-year-old patients going for a genital procedure.

"These are 17-year-old kids who are eager to undergo a genital procedure typically before they go off to college. So they might be, you know, 17 and they want to go for vaginoplasty, in the summer before they go to college, when they're going to turn 18 in the fall. And these surgeries sometimes have a couple of months of time where you need to be somewhat cautious and you're doing a lot of self-care. And they don't want to have to miss school or take a semester off," Deutsch said. 

Deutsch adds these are cases with "very clear and consistent indications" after a mental health and medical evaluation from a mental health specialist or team of clinicians.

"We're not doing surgery on 13, 14-year-old kids. And all of these surgeries are very rare in cases where there's just no question. And that is what it should be like, and there should be a proper assessment in order to get to that place," Deutsch said. 

For any gender-affirming care in minors, patients can agree with treatment — called "assenting to care" — but a parent or guardian must consent. 

"The reality is that I can't even provide a vaccine for a child as a pediatrician without that parent's consent. So none of the care that we provide in gender-affirming care for young people is without parental consent, "Dr. Geopferd said.

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