Duke Sexual and Gender Minority Wellness Program
2023 POLICY BRIEF
Gender Affirming Care for Youth in North Carolina
Key Messages
- Around 8,500 youth between the ages of 13 and 17 in North Carolina identify as transgender, which means their gender identity is different from their sex assigned at birth
- For some transgender youth, the discrepancy between their gender identity and their sex assigned at birth causes severe clinical distress, known as gender dysphoria
- Gender dysphoria impairs quality of life and increases the risk of anxiety, depression, and suicide—last year, over half of transgender youth in North Carolina seriously considered suicide and 1 in 6 made a suicide attempt
- These health risks can be greatly reduced through gender affirming care, which involves a range of services that includes social support, consultation with families and schools, mental health care, and medical treatment
- To improve their health and wellbeing, transgender youth should have access to patient-centered, gender-affirming care from a multidisciplinary team of expert care providers—such care is tailored to the specific needs of individual patients based on their physical and cognitive development
Risks Facing Transgender Youth in North Carolina
Transgender people are those whose gender identity is different from the sex they were assigned at birth. From recent surveys conducted by the U.S. Centers for Disease Control and Prevention (CDC), researchers have been able to estimate the number of transgender youth in each state. Nationwide, there are about 300,000 youth between the ages of 13 and 17 who identify as transgender (1.4% of the US population), of whom around 8,500 live in North Carolina.[1]
Compared with cisgender youth—those whose gender identity matches the sex they were assigned at birth—transgender youth are at increased risk of many poor health outcomes, including substance misuse, anxiety, depression, impaired quality of life, psychological suffering, eating disorders, and suicide.[2],[3] The Trevor Project’s 2022 National Survey on LGBTQ Mental Health found that 53% of transgender youth in North Carolina seriously considered suicide last year and 16% made a suicide attempt.[4]
There are two main reasons why transgender youth face worse health outcomes than their cisgender peers. The first is that they suffer stigma, rejection, and discrimination, which can expose them to violence, bullying, harassment, and homelessness. Transgender youth make up 20-40% of all homeless youth.[5] The second is that around 40% of transgender youth experience gender dysphoria,[6] a term that refers to severe clinical distress or discomfort due to the discrepancy between their gender identity and their sex assigned at birth.
Treating Gender Dysphoria Through Gender-Affirming Care
For transgender youth who experience gender dysphoria, gender-affirming care provided by a multidisciplinary team of professional experts improves overall wellbeing and mental health.[7] There are at least 16 studies that have shown the benefits of gender-affirming care for transgender youth.[8]
Gender-affirming care encompasses a wide range of services tailored to the specific needs of individual patients based on their physical and cognitive development. The American Academy of Pediatrics defines such care as “developmentally appropriate, nonjudgmental, supportive care provided in a safe clinical space.”[9] The services include social support, consultation with families and schools, mental health care, and medical treatment.
▪ Social support
A key foundation of gender-affirming care is valuing children for who they are and supporting their gender identity as expressed in, for example, their clothing, hair, name, and pronouns. Research has shown that transgender youth who are provided this type of affirmative social support have similar rates of depression and anxiety as cisgender youth of the same age.[10]
▪ Consultation with families and schools
Gender-affirming care providers, especially social workers, often consult with families and schools, providing guidance, education, and support to promote the wellbeing and health of transgender youth. Around 130 schools in North Carolina have requested this kind of support from the Duke Child and Adolescent Gender Clinic. Schools often request support for understanding issues such as best practices for pronouns, names, and access to all-gender bathrooms.
▪ Mental health care
The care provided by a trained mental health professional with expertise in supporting transgender youth can help to ease gender dysphoria and its associated mental health consequences, such as anxiety and depression.
▪ Medical treatment
A very small proportion of transgender youth are given medical treatments from puberty onwards. Rigorous, comprehensive assessment of patients by a multi-disciplinary team is crucial before offering individualized medical treatments. Youth and their caregivers who seek medical treatment are not rushed into being put on medication.
Puberty Blockers
The first treatment that may be prescribed is puberty blockers for those who have strong, persistent gender dysphoria that gets worse at the onset of puberty. These are typically given at the age of around 10 or 11. Physicians have decades of experience prescribing puberty blockers to cisgender youth with precocious puberty (entering puberty too early, typically before the age of 10). The idea behind using these medicines for transgender youth is to “pause puberty,” giving them time to weigh their different options before they go through the physical changes of puberty. Puberty blockers are fully reversible. In prescribing puberty blockers, the aim is not to “lock in” a particular path forward, but to provide the youth, their families and health care providers more time more time.
Due to a lack of data, it is difficult to know the exact proportion of transgender youth who are taking puberty blockers, but the proportion is very small—likely under 2%. For example, one analysis suggests that over the last 5 years, 4,780 out of the 300,000 transgender youth in the U.S. were prescribed puberty blockers, i.e., 1.6%.[11]
Puberty blockers are helpful for easing anguish. Transgender youth who receive puberty blockers have a 70% lower risk of considering suicide over the course of their life than transgender youth who wanted to start these medicines but never accessed this treatment.[12]
Gender-Affirming Hormones (GAH)
The second treatment is gender-affirming hormones (GAH)—testosterone or estrogen—to induce physical changes matching the person’s gender identity. This treatment is only partially reversible. In one study, 98% of youth who started GAH continued taking these hormones into adulthood.[13]
As with puberty blockers, it is difficult to know the exact proportion of transgender youth who are taking GAH, but the proportion is small. One analysis suggests that over the last 5 years, 14,726 out of the 300,000 transgender youth were prescribed GAH, i.e., around 5%.11
Those receiving GAH were less likely to ever consider suicide compared to those who wanted GAH but never accessed treatment.[14] Both puberty blockers and GAH can also reduce the risk of anxiety and depression and improve quality of life.[15]
Gender-Affirming Genital Surgery
Medical guidelines say that youth under the age of 18 should not receive gender-affirming genital surgery (which is irreversible).[16] In its standards of care guideline, the World Professional Association for Transgender Health says that chest surgery for female to male patients may be considered for older adolescents under 18 “preferably after ample time of living in the desired gender role and after one year of testosterone treatment.”[17] In one study, only 0.3% of transgender people expressed regret for having had gender-affirming surgery.[18]
Patients and Caregivers Show High Satisfaction Rates
Research in the Netherlands found no evidence that transgender people regretted taking puberty blockers or GAH in childhood, provided patients received comprehensive evaluation before starting these medicines.[19] Studies have also shown that parents and other caregivers report high satisfaction with gender-affirming care and see it as “lifesaving.”[20]
Medical Associations Support Gender-Affirming Care
Providing this holistic range of services to transgender youth is recommended by all major national professional associations—not just the American Academy of Pediatrics, but also the Society for Adolescent Health and Medicine and the Endocrine Society. The US Department of Health and Social Services states that “medical and psychosocial gender affirming healthcare practices have been demonstrated to yield lower rates of adverse mental health outcomes, build self-esteem, and improve overall quality of life for transgender and gender diverse youth.”[21]
Uncertainties About Medical Treatments
Despite the proven benefits of gender-affirming care, it is important to acknowledge that there has been very little research on the long-term effects of the medicines that may be used—puberty blockers and GAH—and that there is a potential risk of regret.
Some research suggests that puberty blockers may impair bone development[22] and that GAH can affect fertility.[23] The U.S. National Institutes of Health has funded a long-term study, the Transyouth Care Study, across four clinics that provide gender-affirming care to examine the long-term benefits and harms of puberty blockers and GAH.[24] The results of this study have not yet been published.
Patients and their parents need to be made aware of the limitations of the research on gender-affirming care.
DISCLAIMER: The information provided in this policy brief does not represent the institutional position of Duke University and is provided for educational and research purposes only.
[1] Herman JL, Flores AR, O’Neill KK. How many adults and youth identify as transgender in the United States? Williams Institute, UCLA School of Law, June 2022. https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/.
[2] Kimberly LL, Folkers KM, Friesen P, et al. Ethical issues in gender-affirming care for youth. Pediatrics. 2018;142(6):e20181537
[3] Connolly MD, Zervos MJ, Barone CJ, et al. The mental health of transgender youth: advances in understanding. Journal of Adolescent Health 2016;59:489-495
[4] The Trevor Project. 2022 National Survey on LGBTQ Mental Health: North Carolina. https://www.thetrevorproject.org/wp-content/uploads/2022/12/The-Trevor-Project-2022-National-Survey-on-LGBTQ-Youth-Mental-Health-by-State-North-Carolina.pdf
[5] https://transequality.org/issues/housing-homelessness
[6] https://www.reuters.com/investigates/special-report/usa-transyouth-care/
[7] Green AE, DeChants JP, Price MN, Davis CK. Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth. Journal of Adolescent Health 2022; 70:643-649
[8] https://www.psychologytoday.com/us/blog/political-minds/202201/the-evidence-trans-youth-gender-affirming-medical-care
[9] https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for
[10] Olson KR, Durwood L, DeMeules M, McLaughlin KA. Mental health of transgender children who are supported in their identities. Pediatrics. 2016;137:e20153223
[11] https://www.reuters.com/investigates/special-report/usa-transyouth-data/
[12] Turban JL, King D, Carswell JM, Keuroghlian AS. Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics. 2020 Feb;145:e20191725.
[13] https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(22)00254-1/fulltext#%20
[14] Turban JL, King D, Kobe J, Reisner SL,Keuroghlian AS. Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS ONE; 2022; 17: e0261039.
[15] Salas-Humara C, Sequeira GM, Rossi W, Dhar CP. Gender affirming medical care of transgender youth. Curr Probl Pediatr Adolesc Health Care 2019;49: 100683.
[16] https://www.washingtonpost.com/dc-md-va/2021/04/22/transgender-child-sports-treatments/
[17] https://www.wpath.org/publications/soc
[18] https://journals.lww.com/plasreconsurg/Abstract/9900/_Regret_after_Gender_Affirming_Surgery___A.1529.aspx
[19] https://abcnews.go.com/Health/wireStory/common-transgender-treatment-regret-detransitioning-97640151
[20] https://policylab.chop.edu/sites/default/files/pdf/publications/PolicyLab-Issue-Brief-Gender-Affirming-Care.pdf
[21] https://opa.hhs.gov/sites/default/files/2022-03/gender-affirming-care-young-people-march-2022.pdf
[22] https://pubmed.ncbi.nlm.nih.gov/25427144/