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Vote for gender affirmation: Life and death choice

Vote for gender affirmation: Life and death choice
© ROBYN BECK/AFP via Getty Images

Gender affirmation saves lives. 

And because anti-trans legislation is backed by the Trump administration and conservative GOP legislatures across the country, the November election can mean life or death for the estimated 150,000 to 385,000 trans and non-binary teens the U.S.

In 2020, over a dozen states introduced bills to restrict access to medical treatments for transgender minors. Some bills would even make it illegal for physicians to provide gender affirmative care at all. 

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Attempts to limit access to gender-affirming medical care is just one aspect of coordinated efforts to roll-back Obama-era rights for trans people. Sen. Kelly Loeffler (R-Ga.) recently introduced a bill that would prevent transgender girls from competing in girls’ sports. 

Gender affirmative medical treatments are recommended as standard-of-care by the World Professional Association for Transgender Health and the Endocrine Society. They are widely supported by reputable professional associations, including the American Academy of Pediatrics, American Academy of Family Medicine, the American Psychological Association, and the American Academy of Child and Adolescent Psychiatry. 

As a founding psychologist and behavioral health director for one of the largest multidisciplinary pediatric gender health clinics in the Midwest, I see that my patients and their families are scared — scared that health care they consider to be “life-saving” is being threatened. 

Research shows trans youth are at disproportionate mental health risk. Compared to cisgender (non-transgender) peers, trans adolescents are two to three times more likely to experience depression, anxiety, and suicidality. 

The 2017 Centers for Disease Control Youth Risk Behavior Survey shows that 35 percent of trans youth attempted suicide in the past year, compared to 7 percent of cisgender youth. 

There are more striking disparities when breaking down suicidality by gender identity. Just over 50 percent of transmasculine youth and 41.8 percent of non-binary/gender-queer youth report a past suicide attempt. 

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Nearly 30 percent of transfeminine youth and 27.9 percent of gender questioning youth reported a past suicide attempt. This compares to 17.6 percent of cisgender girls and 9.8 percent of cisgender boys reporting an attempted suicide. 

In the broadest sense, gender affirmation recognizes and appreciates gender diversity as normal variations on human diversity. Gender affirmation encourages people to follow their path to living authentically without privileging any outcome other than a sense of wholeness and emotional well-being. 

Parents often report a dramatic change in their children when they are supported to be who they know themselves to be—happier, more confident, and more engaged in their lives. A clear indication that gender affirmation is in their child’s best interest. 

Among children, gender affirmation could mean holding space for exploration, allowing a child to experiment with different clothing and hairstyles that make them feel good. For children who assert a gender different from their designated sex at birth, they can pursue a social transition, including a shift to using a different chosen name or pronouns.

The social transition may be phased, initially occurring only within the home or with trusted family members before expanding to public spheres. Or, as happens sometimes, children may proactively tell their friends and teachers exactly who they are and what names/pronouns they use without first consulting their parents. 

Trans youth finally have the opportunity to see themselves reflected in pop culture with the increasing visibility of trans actors and characters in film and on television. Among the most influential trans role models is Jazz Jennings, whose reality show I Am Jazz premiered on TLC in 2015. The show features Jazz and her family navigating typical teen angst in addition to common challenges faced by trans teens, including making decisions about gender-affirming medical care. 

A 2016 study shows that socially-transitioned trans children — children who are supported to live authentically — experience similar levels of depression and only marginally higher levels of anxiety than cisgender children. 

Social gender affirmation is also beneficial to the mental health of older trans adolescents ages 15-21. Indeed, research shows the use of a chosen name in more contexts (home, school, work, with friends) is associated with lower depression, suicidal ideation, and suicidal behavior. 

As youth enter puberty, affirmative medical interventions become available. Gonadotropin-releasing hormone agonists, or puberty blockers, may be prescribed to youth in the early stages of puberty who experience gender dysphoria or significant emotional distress stemming from a mismatch between gender and designated sex at birth. These medications temporarily put on pause a youth’s endogenous puberty and prevent the development of irreversible secondary sex characteristics that may be devasting to trans youth. 

A 2011 study of the first cohort of trans youth treated with pubertal suppression in the Netherlands showed that depression symptoms decreased, and general functioning improved significantly during pubertal suppression treatment. 

A recent study using data from the 2015 U.S. Transgender Survey found that trans adults that received pubertal suppression treatment had lower odds of lifetime suicidal ideation compared to those who wanted but did not receive puberty blockers. 

Older adolescents in the later stages of puberty are eligible for gender-affirming exogenous testosterone or estrogen. These medications induce the development of desired secondary sex characteristics that are aligned with an individual’s gender.

Two recent studies of U.S.-based youth show that hormones improve mental health. A 2019 study from Children’s Mercy Hospital reported significant increases in general well-being and decreased suicidality with hormone treatment. The other study, published in 2020 from Children’s Medical Center of Dallas, reported improvements in depression and anxiety after one year of hormone treatment. 

To be sure, access to gender affirmative medical treatment is not a panacea for trans youth. Indeed, data shows trans youth are significantly more likely than cisgender youth to be bullied at school (35 vs. 18 percent) and to be physically (24 percent vs. 5 percent) or sexually (24 vs. 7 percent) victimized. 

Yet there is no question that if access to gender affirmative treatments are further limited, trans youth will be harmed. Some may even lose their lives. 

Diane Chen, Ph.D., is a pediatric psychologist at Ann & Robert H. Lurie Children’s Hospital of Chicago, Associate Professor in the Departments of Psychiatry and Behavioral Sciences and Pediatrics at Northwestern University Feinberg School of Medicine, and a Public Voices Fellow through The OpEd Project. Follow her on Twitter @DrDianeChen.