According to data published by the Centers for Disease Control and Prevention, about 1.3 million adults and 300,000 youths in the United States identify as transgender, comprising only about 0.6% of the total population (Williams Institute, 2022). Despite this small number, transgender Americans, and youths in particular, have been pushed to the very forefront of partisan politics, leading to a sharp rise in public scrutiny and spawning an unprecedented number of new state laws that restrict access to evidence-based healthcare. Political rhetoric related to gender-affirming care is rife with misinformation on both sides of the aisle, and in the context of an extremely polarized and angry electorate, this rhetoric is dangerous to the health and well-being of an incredibly vulnerable population.
It perpetuates rampant social bias, discrimination, and stigma—all of which are factors known to contribute to the high rates of violence victimization, anxiety and depression, substance abuse, and suicidality among transgender youth and adults. But worse, widespread misinformation is galvanizing efforts in statehouses across the nation to ban access to healthcare that can quite literally be lifesaving, particularly for transgender youth. If nurses fail to intervene, we will have betrayed our commitment to evidence-based healthcare and violated our ethical duty to advocate for the health and wellbeing of our most vulnerable patients.
Health Disparities Among Transgender Youths
According to the Youth Risk Behavior Survey (YRBS) transgender youths in U.S. high schools experience significantly increased rates of physical and sexual violence victimization as compared to their cisgender peers (CDC, 2019). About 35% of trans youth reported school bullying, 24% reported being threatened or injured with a weapon at school, and 27% reported feeling unsafe while traveling to and from school. Almost 1 in 4 transgender youths reported forced sexual intercourse, a rate which is twice that of cisgender females and almost six times that of cisgender males of the same age. It’s important to note that the YRBS is administered in high schools, and thus it does not capture the experiences of transgender youths who were absent or those who dropped out of school entirely. According to the 2022 National Survey on LGBTQ Youth Mental Health, a survey conducted outside of schools, more than 50% of transgender youths reported that they were physically threatened or harmed due to their gender identity.
The 2022 National Survey on LGBTQ Youth Mental Health found that over 50% of transgender youth had considered suicide in the preceding year, with higher rates occurring in states considering legislation to ban access to gender-affirming care. A reported 12% of transgender females and 22% of transgender males actually attempted suicide in the preceding year, as did 19% of youths who identified as non-binary. Roughly 75% of transgender youths experienced symptoms of anxiety and 65% experienced symptoms of depression. Over 90% of all transgender and non-binary youth reported that they were worried about legislative efforts to ban gender-affirming care and/or restrict the use of public restrooms. Among youth surveyed in U.S. schools, reported lifetime substance abuse was significantly higher among transgender youth than their cisgender peers (CDC, 2019). It’s important to note that adverse childhood experiences, particularly violence victimization, are known risk factors for substance abuse and addiction among all youths, irrespective of gender identity (Meyer & Frost, 2013; He et al., 2022).
The 2022 National Survey on LGBTQ Youth Mental Health found that 38% of transgender females, 39% of transgender males, and 35% of non-binary youths had experienced housing instability and/or homelessness. LGBTQ+ youth and adults are disproportionately represented among people experiencing homelessness, and transgender youths are particularly at risk. These disparities can be attributed in large part to parental/family rejection, high rates of physical and sexual violence victimization, and the prevalence of mental health disorders such as depression and substance abuse (McCarthy & Parr, 2022).
“Nurses must always stress human rights protection with particular attention to preserving the human rights of vulnerable populations including transgender and gender-diverse youth.”The American Nurses Association
Gender-Affirming Care is Lifesaving
Gender-affirming care (GAC) encompasses a variety of social, psychological, medical, surgical, and legal interventions that support a person’s gender identity. Some socially oriented examples of GAC include using preferred pronouns and creating supportive home and educational environments. Examples of medically based GAC include treatment with puberty-blocking therapy, gender-affirming hormone therapy, and gender-affirming surgery. Legal examples of GAC include assisting transgender individuals in obtaining official documents that accurately reflect their gender identity and ensuring that medical records capture both the sex assigned at birth as well as gender identity.
Since 1975, more than 2,000 scientific studies have evaluated aspects of gender-affirming care, 260 of which are cited in the clinical practice guidelines of the Endocrine Society (ES, 2023). The totality of evidence clearly demonstrates the benefit of GAC, particularly for transgender youth and adolescents. Medical/surgical interventions are associated with significant improvements in psychological wellbeing, body image, and body satisfaction, as well as significant reductions in lifetime substance abuse, suicidality, and psychological distress; Furthermore, the greatest benefit is seen among those who receive treatment during adolescence. For this reason, access to gender-affirming care is supported by the American Medical Association, the American Academy of Pediatrics, the American Academy of Family Physicians, the American Psychological Association, the American Academy of Nursing, the American Nurses Association, the Pediatric Endocrine Society, the American College of Obstetricians and Gynecologists, and numerous other organizations in the United States and around the world.
Despite overwhelming consensus and support from experts in the fields of science and medicine, gender-affirming care (GAC) has been a major target for inflammatory political rhetoric. Unfortunately, the public is widely susceptible to misinformation shared by politicians due to a general lack of knowledge and understanding of the topic. Expert organizations, once highly revered by the American public, are now probably less capable of influencing popular opinion due to an erosion of public trust brought about by divisive political rhetoric during the COVID-19 pandemic. To complicate matters, pseudo-scientific organizations frequently publish inaccurate, biased information and methodologically flawed studies in an effort to sway public opinion. It can be very difficult for a layperson to discern the reliability of a source, and nearly impossible to accurately interpret technical jargon or evaluate the quality of evidence in totality. Even many nurses possess limited knowledge about transgender identity and gender-affirming care due to inadequate training and education provided by academic nursing programs, and they too can be misinformed by political rhetoric and junk science. It is vital that nurses develop a basic understanding of GAC so they can effectively care for transgender patients, educate lawmakers and the public, and advocate for evidence-based policies that support health equity.
Three aspects of gender-affirming care have taken center-stage in political discourse: puberty-blocking therapy (PBT), gender-affirming hormone therapy (GAHT), and gender-affirmation surgery (GAS). For context, each of these treatment modalities is briefly described below.
Puberty Blocking Therapy (PBT) utilizes GnRH analogues to suppress the progression of puberty, and the effects are fully reversible; If PBT is discontinued, biological puberty resumes. For decades, these medications have been safely used to treat conditions such as precocious puberty and endometriosis. When clinically appropriate, PBT can be initiated at the onset of puberty, typically between age 8 and 14. Hitting the “pause” button on puberty allows an adolescent more time to explore gender identity, and in consultation with their healthcare provider, consider future treatment options. During this time, many families benefit from counseling to help strengthen relationships and improve psychosocial support for the adolescent, efforts which help to improve long-term health outcomes among transgender youths. PBT is associated with a reduction in lifetime risk for suicidal ideation and a reduced need for gender-affirming surgical procedures later in life; When coupled with psychological support, PBT is associated with superior global functioning as compared to receiving psychological support alone (Turban et al., 2020). PBT does not increase the likelihood that a transgender adolescent will later choose to initiate gender-affirming hormone therapy (Guss & Gordon, 2022).
Gender-Affirming Hormone Therapy (GAHT) includes administration of hormones to enable the development of secondary sex characteristics that align with a person’s gender identity. GAHT induces changes in fat distribution, muscle mass, hair growth, breast and testicular volume, and voice characteristics, among other effects (Salas-Humara et al., 2021). The changes brought about by GAHT are considered partially reversible. According to consensus guidelines established by the World Professional Association of Transgender Health (WPATH, 2022), a patient may begin GHAT at age 14 if certain criteria are met and therapy is deemed clinically appropriate by their healthcare provider. GAHT is associated with improved body image and significantly decreased psychological distress and suicidal ideation, regardless of the age at which treatment begins; however, the greatest benefit is observed among adolescents. On average, adolescents who receive GAHT experience a greater reduction in psychological distress and suicidal ideation, and they engage in lower lifetime illicit drug use than those who begin GAHT in adulthood (Turban, 2022).
Gender-Affirming Surgery (GAS) includes several procedures ranging from simple to complex, which aim to align a person’s physical features with their gender identity. Examples include chest feminization or masculinization, vaginoplasty, phalloplasty, and tracheal shave, among many others. These procedures are generally considered to be irreversible, though partial surgical reversal may be possible in some cases. In a recent study conducted by researchers from Harvard T.H. Chan School of Public Health, gender-affirming surgeries were associated with a 42% reduction in psychological distress and a 44% reduction in suicidal ideation (Almazan & Keuroghlian, 2021). Additionally, a recent systematic review concluded that GAS is associated with significant improvements in quality of life, body image, body satisfaction, and overall psychiatric functioning (Wernick et al., 2019). WPATH Guidelines identify 15 as the minimum age for consideration of chest surgeries and 17 as the minimum age for genital surgeries, though it’s important to note that gender-affirming surgeries of any type are rare before age 18; Of the surgeries performed in this age group, the overwhelming majority are chest feminization/masculinization (Wright et al., 2023). Only about 1% of those who receive GAS go on to regret it, which is substantially lower than most elective and cosmetic surgeries (Bustos et al., 2021).
The Legal Landscape for Trans Youth
Over the past two years, the United States has seen an unprecedented surge in state laws that in some way ban gender-affirming care, with the largest impact to transgender youth. In the states bordering Virginia, the situation is particularly dire. West Virginia, Kentucky, Tennessee, and North Carolina have all passed laws that ban puberty blocking therapy, gender-affirming hormone therapy, and gender-affirming surgery for transgender youth. In these states, medications used for PBT and GAHT remain legal for cisgender youths who have other medical conditions, which demonstrates that these laws are intentionally targeting transgender youths, not the safety of gender-affirming medications. Several state bans have been temporarily blocked by federal judges, at least in part, as legal challenges are considered; however, the damage has been done, particularly in rural areas. Many clinics have closed due to the ever-changing legal landscape, and some states are now criminalizing the provision care. Given Virginia’s proximity to these states, we are likely to see a steady rise in transgender youths who travel here to receive lifesaving healthcare. Are you prepared to care for them? In 2024, Virginia may see legislative efforts to ban gender-affirming care for transgender youth, or even criminalize the provision of gender-affirming care by healthcare providers. If and when this happens, how will you respond?
Gender identity is intimately personal, and our perceptions related to gender expression are influenced by all sorts of social, cultural, religious, and even political factors. Irrespective of our personal beliefs, nurses have a professional obligation for advocacy.
Assistant professor Ashley Apple is the commissioner on government relations for the Virginia Nurses Association, and a family nurse practitioner. This essay was published in the November issue of Virginia Nurses Today, a publication of the Virginia Nurses Association that is sent to more than 100,000 Virginia RNs each quarter.