What medical care for transgender minors is at stake in Supreme Court case?
The Supreme Court on Wednesday arguments will be heard in a case involving tennessee’s ban on gender-affirming care for transgender people under the age of 18.
At least 26 states have passed laws restricting or banning this care for minors, and most of those states are facing lawsuits.
The highest court of the land will decide whether that is the case Tennessee law violates the Equal Protection Clause of the 14th Amendment, which requires that people in similar circumstances be treated similarly under the law. Both parties in the case claim they are acting to protect minors from harm.
Gender-affirming care is supported by the American Medical Association, the American Academy of Pediatrics and other medical groups. Here’s what’s usually involved:
Youth who persistently identify as a gender different from their assigned sex at birth are often referred to clinics where teams from different medical specialties provide gender-affirming care.
Such care begins with an evaluation, which may include a pediatrician and a mental health specialist, who assess the extent to which, if any, the young person is distressed.
Those who meet certain criteria may be diagnosed with gender dysphoria if their suffering is persistent and significant.
Some youth and their families may decide to try a social transition that involves a new hairstyle, clothing, name, or pronouns. Experts agree that it’s helpful to let children express their gender in ways that match their identities.
Chazzie Grosshandler, 18, of Chicago, said she was 9 years old when she told her parents she was a girl and “not just a boy who likes girly things.” Two years later she received care.
“The very first step in gender-affirming care for me was when I told my parents that I was a girl and that I had felt that way for a long time and that they accepted me,” she said. “I think people get very confused when they hear the word ‘care’ that it has to be something medical. But the truth is, it’s more than just medical. It is love and acceptance.”
Additional interventions, such as puberty blockers, may be offered to some young people to alleviate distress and give them time to explore their gender identity.
The drugs, known as GnRH agonists, block the release of key hormones involved in sexual maturation. They have been used for decades to treat precocious puberty, a rare medical condition that causes puberty to start abnormally early.
The medication begins after a young person shows early signs of puberty: enlargement of breasts or testicles. This typically happens around ages 8 to 13 for those assigned female at birth, and a year or two later for those assigned male at birth.
The drugs can be given as injections every few months or as arm implants that can last a year or two. Many of the effects are reversible: puberty and sexual development resume once the drugs are stopped. Researchers are investigating the effects of puberty blockers on bone development, but no studies have shown an increased risk of bone fractures.
Young people can take puberty blockers for a number of years.
After puberty blockers, transadolescents go through puberty with or without hormone treatment.
Some may choose to take hormones to make their bodies better match their gender identity. They take manufactured versions of estrogen or testosterone – hormones that stimulate sexual development during puberty. Estrogen comes in skin patches and pills. Testosterone is available in injections, implants or gels.
Guidelines recommend starting this when teens are mature enough to make informed medical decisions. Many transgender people take the hormones for life.
If the medication is stopped, some physical changes remain. Testosterone generally leads to permanent lowering of the voice, facial hair and the development of the Adam’s apple. Estrogen can lead to permanent breast development.
Research on long-term hormone use in transgender adults has shown potential health risks, including a modest risk of blood clots with estrogen and negative cholesterol changes with testosterone.
Gender confirmation surgery in transgender teens is much less common than hormone treatment. When done among transgender youth, it almost always involves breast reduction in older transgender men.
Still, that kind of operation is extremely rare. It may be surprising that underage breast reduction surgery is most often performed on men who are not transgender. This is for a condition called gynecomastia, which means you have more breast tissue than normal.
A 2019 study of millions of insurance claims found that 151 breast reductions had been performed on U.S. minors. Almost all – 97% – were not transgender.
Research shows that transgender youth are susceptible to stress, depression and suicidal thoughts. Some research suggests that treating gender dysphoria can improve the well-being of young people, but some nuances remain unclear.
In one study, researchers tested and followed 315 transgender youth who received hormone therapy for two years. Depression and anxiety symptoms decreased and life satisfaction increased among those assigned as female at birth, but not among those assigned as male at birth. The researchers speculated that the youngster assigned male at birth might suffer more from stress because he was different from most of his peers.
In the same study, published last year in the New England Journal of Medicine, two participants died by suicide – one after six months and the other after a year.
Long-term studies of treatment outcomes are ongoing.
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