MEDICAL TRANSITION GENERALLY FOLLOWS SOCIAL TRANSITION when the child’s or adolescent’s (transgender) identity has remained consistent over a period of time and the youth has demonstrated positive emotional and social adjustment in their affirmed gender. Medical interventions typically include hormone therapy and gender-affirming surgeries. The eligibility requirements, protocols, effects, benefits, and possible risks associated with each step are presented in this chapter.
For a transgender young person, the first steps in a medical transition may include the use of hormone/puberty blockers at the onset of puberty, followed at a later age by feminizing or masculinizing hormone therapy. Historically, hormone therapy was referred to as “cross-gender” hormone therapy. The newer nomenclature, “feminizing” or “masculinizing” hormone therapy, reflects the acknowledgment that hormone therapy is consistent with the young person’s affirmed gender identity and not “cross-gender.”
Surgical aspects of a medical transition may include chest reconstruction surgery for trans men or breast augmentation for trans women (“top” surgeries) and genital surgeries (lower or “bottom” surgery) for both trans men and women. (For trans men, the full nomenclature is “chest reconstruction surgery,” not “mastectomy” or “breast removal.”) Young adult trans women who medically transition after their initial puberty is completed may desire other feminizing procedures, such as a tracheal shave, hair removal, or facial feminization surgery (FFS).
Until recently, few transgender individuals were able to proceed with any medical aspects of their gender transition before reaching adulthood. The current version of the WPATH Standards of Care (SOC) suggests that eligibility decisions be assessed on an individual basis by medical and mental health providers in conjunction with the young people and their parents. Both the WPATH and U.S. Endocrine Society SOC specify that feminizing or masculinizing hormone therapy may begin at age 16 (Hembree, et al. 2009 WPATH, 2012). The more recent decision to allow adolescents to begin hormone therapy reflects research findings indicating decreased gender dysphoria and overall positive mental health and well-being among transgender adolescents when they are allowed to begin hormone therapy (Cohen-Kettenis, Delemarre–van de Waal, & Gooren, 2008).
Not all trans or gender-diverse individuals choose what some call a “full medical transition,” meaning all of the above steps: hormones and top and bottom surgeries. The choice to complete some but not all steps can be based on numerous factors, such as the degree of an individual trans young person’s gender dysphoria about their body, their socioeconomic status or access to health insurance and the financial cost of these procedures, or the presence of health conditions that might preclude medical interventions.
In addition, gender-fluid or nonbinary trans youth may not choose to pursue a medical transition or may choose only some medical steps—such as top surgery and no hormones, or hormones but no surgeries. It is critical to understand that these varying choices do not invalidate the young person’s affirmed gender identity, nor do they suggest that their transgender experience or status is any less legitimate.
WPATH Standards of Care (2012)
WPATH is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, advocacy, public policy, and respect in transsexual and transgender health (WPATH, 2012). This body of professionals works collaboratively to publish the WPATH Standards of Care (SOC). The SOC outline the best medical and mental health practices for promoting optimal care for trans and gender-nonconforming children and adolescents (as well as for adults). These guidelines are rooted in the best available research information as well as professional consensus. The first version was published in 1979, and the current (seventh) version was published in 2012 and is available on the WPATH website (www.wpath.org).
As described in the SOC, the document provides “clinical guidance for health professionals to assist transsexual, transgender, and gender-nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments” (WPATH, 2012, p. 1).
In this sense, the SOC provide guidelines for making decisions about when medical transition and the related hormone and surgical treatments are indicated for both adolescents and adults. The guidelines also describe the role of mental health services within the process of gender transition. While some health and mental healthcare providers interpret the SOC in a literal fashion, the document clearly indicates that the standards are meant to be flexible so that they can better “meet the diverse needs” of trans and gender-nonconforming youth (and adults). In this sense, they may be modified by individual health and mental health care providers and adapted within varying cultural contexts (WPATH, 2012, p. 2). While the SOC largely address the treatment of transgender adults, Chapter VI, “Assessment and Treatment of Children and Adolescents With Gender Dysphoria,” pertains specifically to medical and mental healthcare for transgender youth.
The material reviewed within this chapter will discuss eligibility criteria in detail and offer suggestions about more challenging decisions involving timing for proceeding with a specific medical intervention. From an overall perspective, mental health providers should always conduct a thorough assessment of the transgender adolescent’s mental, emotional, social, and familial functioning prior to any decisions about beginning hormone therapy or accessing surgical interventions. It is also essential to assess the trans adolescent’s current living environment, the level of caregiver/parental functioning, and the range and quality of supports available to young people as they begin their medical transition.
In keeping with the understanding of the SOC as flexible in an effort to better meet the varying needs of trans and gender-nonconforming youth, the length of time and/or number of assessment sessions should be determined by the needs of the individual adolescent and the complexity of their history and/or current situation. At the same time, transgender adolescents often experience profound gender dysphoria, as will be discussed in greater detail in Chapter 6. The intensity of their distress can lead to being at high risk for depression, self-harm, suicidal ideation, and other mental health concerns. This reality cautions mental health providers to refrain from delaying the onset of medical transition steps unnecessarily.
Hembree et al. (2009) suggest that it can be helpful to conceptualize medical interventions in terms of the three following categories when assessing adolescent readiness for each area of transition: fully reversible interventions, partially reversible interventions, and irreversible interventions. This framework offers a way for clinicians and families to explore the various types of medical interventions and the permanency of their consequences alongside the degree of consistency and certainty regarding the transgender teen’s affirmed gender identity.
FULLY REVERSIBLE INTERVENTIONS include the use of GnRH analogues (colloquially called puberty or hormone blockers) to suppress estrogen or testosterone production and consequently delay the development of secondary sex characteristics that emerge with the onset of puberty. In the treatment of young trans women, occasional alternative treatment options can include progestins or medications (such as spironolactone) that decrease the effects of androgens secreted by the testicles of adolescents who are not receiving GnRH analogues. Continuous oral contraceptives (or depot medroxyprogesterone) may be used to suppress menses among young transgender men. These interventions are fully reversible in that if GnRH analogues are discontinued, the development of adolescent’s birth-assigned secondary sex characteristics will quickly resume.
PARTIALLY REVERSIBLE INTERVENTIONS include masculinizing or feminizing hormone therapy that initiates the development of secondary sex characteristics to match the adolescent’s affirmed gender. While more detail follows, this means the administration of testosterone for young trans men and an anti-androgen and estrogen for young trans women. Some physical changes induced by these hormone treatments may be reversed through surgery (such as removal of breast tissue that developed while on estrogen). Other changes are not reversible (such as a trans man’s voice dropping after beginning treatment with testosterone).
IRREVERSIBLE INTERVENTIONS are surgical procedures (for example, once a trans man completes chest reconstruction surgery, there is no way to reverse the removal of breast tissue; while he could have implants, there is no way to restore breast tissue).
Hormone Therapy
Historically, the first steps in a medical transition have involved masculinizing or feminizing hormone therapy. When transgender men begin testosterone, their bodies start developing male secondary sex characteristics, such as facial hair and a deeper voice. When transgender women begin taking an anti-androgen (testosterone receptor blocker) and estrogen, their bodies start developing female secondary sex characteristics, such as softer skin and breast development. The development of these male and female physical characteristics generally allows trans men and women to be more consistently viewed in their affirmed gender. The first medical transition steps for transgender youth may begin with GnRH analogues at the onset of puberty.
This section provides an overview of hormone/puberty blockers (GnRH analogues) for prepubertal trans youth, followed by an overview of masculinizing and feminizing hormone therapy for young trans men and trans women, respectively. It covers the types of hormones used, the mode of administration, reversible and irreversible physical effects/changes resulting from hormone therapy, and WPATH (2012) standards for beginning each intervention. Guidelines are outlined for conducting an assessment about whether and/or when hormone treatment is indicated, exploring potential medical, emotional, and social risks and/or benefits, and providing clinical support for parents and young people making these decisions.
Hormone/Puberty Blockers
Medical doctors have used gonadotropin-releasing hormone agonists (GnRH agonists) for about 30 years (Mul & Hughes, 2008). They were developed for use with children whose puberty began well in advance of the usual biological timeline (called “precocious puberty”). These children began developing secondary sex characteristics as early as age five or six when they were not emotionally, socially, or physically prepared for this experience. The medication did just what the name suggests: block puberty, essentially putting it on hold until the child was developmentally and physically prepared for the accompanying physical and emotional changes.
Given that these medications have been in use for 30 years, we have considerable research that documents few side effects. The use of GnRH agonists for suppressing puberty is completely reversible. When GnRH agonists are withdrawn, the child’s biological puberty simply resumes.
With transgender children, hormone blockers are typically prescribed for peripubescent youth, or youth in the initial stages of puberty (Tanner stage 2). Puberty is medically categorized into four stages that describe the progression of secondary sex characteristic development. Tanner stage 1 is the pubertal state of a child prior to any development of secondary sexual characteristics (i.e., no pubic hair, no breast development). Tanner stage 2 is the onset of puberty and is defined as the presence of breast budding in cisgender females, the growth of fine pubic hair in males and females, and the increase in testicular volume and thinning of the scrotal skin in cisgender males.
These medications are prescribed to prevent the development of secondary sex characteristics that match the child’s birth-assigned sex rather than their affirmed gender. Blockers are generally discontinued in mid to late adolescence. Assuming that the young person’s affirmed gender persists, masculinizing or feminizing hormones are begun when the GnRH agonists are withdrawn. This protocol means that the young person will experience a single puberty that matches their affirmed gender.
There are several advantages to using puberty blockers with prepubertal trans youth. First, by suspending the development of secondary sex characteristics that match a child’s birth-assigned sex and then moving directly to masculinizing or feminizing hormones, there is no need to attempt to later reverse, or undo, the effects of secondary sex characteristics that do not match the young adult’s affirmed gender.
For example, if a transgender young woman has already completed her birth-assigned puberty, her voice will have dropped (just as it does in cisgender males). Beginning feminizing hormone therapy after her voice has deepened will not reverse this effect and will not raise the pitch of her voice. As a result, she will go through life as a woman with a deep voice. This may provoke questions from those around her and raise her risk of being perceived as transgender, and trans women who are perceived as trans are at extremely high risk for street harassment or violence. Living with a deep, more male-like voice is also likely to exacerbate her gender dysphoria. Given the irreversible effects of testosterone, the use of puberty blockers at the onset of adolescence can greatly enhance her quality of life as well as her literal safety in the world.
Another benefit of preventing the development of birth-assigned secondary sex characteristics is typically a significant reduction in adolescent gender dysphoria. When faced with the emergence of secondary sex characteristics that are at odds with their affirmed gender, trans youth often experience profound distress. It increases the likelihood that their reflection in the mirror will not match their gendered sense of themselves. It can also feel as if their body is betraying them by becoming someone other than who they know themselves to be.
Many youth who come out in adolescence report not having had a strong sense of gender during preschool, kindergarten, or elementary school. Young children are physically fairly gender neutral. If a six-year-old wears girls’ clothes and grows long hair, she will be seen as a girl. If the same child cuts their hair and wears boys’ clothes, people will assume he is a boy. It is only with the emergence of secondary sex characteristics such as breasts, facial hair, and a deeper voice that our clothed bodies become more clearly male or female. As a result, gender may not have seemed particularly important for some trans children. It is the onset of puberty and the increased ways they are sexed/gendered in the world that typically precipitate the emergence of adolescent-onset gender dysphoria.
Not all young people come out early enough to begin hormone blockers and prevent the onset of puberty. With youth already in the midst of puberty, endocrinologists may use blockers to halt the progression of birth-assigned secondary sex characteristics. For some trans youth, this may alleviate aspects of their dysphoria, as illustrated by the following vignette.
One 15-year-old trans man had come out to his parents only a few months before calling me. Neither his parents nor I was ready to move forward with testosterone yet. We all felt we needed more time to explore his gender identity as well as some other mental health concerns. At the same time, this young man was experiencing profound gender dysphoria, and concomitantly significant depression and suicidal ideation. The concern about these risks led the parents, the young man, and a pediatric endocrinologist to begin hormone blockers as an interim measure that would relieve dysphoria and thus lower the young trans man’s risk factors.
The major benefit for this young man was that blocking his estrogen production shut down menses, a source of profound gender dysphoria for him and most trans male adolescents. Since the medication blocks only the production of estrogen, there are no irreversible effects, as mentioned previously. If the young man had discontinued the blockers, his body would have resumed estrogen production, meaning menses as well as other aspects of puberty. This can “buy time” for parents and professionals who want to further assess the solidity of the young person’s trans identity or their adjustment to their affirmed gender if they have socially transitioned. At the same time, some of the distress associated with their gender dysphoria (and thus risk of self-harming behaviors) may be alleviated. In this sense, hormone blockers can offer a first step when adolescents (or their parents) are not ready to begin feminizing or masculinizing hormones.
For young trans women already in the midst of their birth-assigned puberty, GnRH agonists will shut down their bodies’ production of testosterone, which generally relieves some of their dysphoria—for example, by decreasing sex drive and frequency of spontaneous erections. Decreasing gender dysphoria simultaneously reduces the risks for major depression, anxiety, and self-harming coping strategies.
For young trans women, like young trans men, the use of hormone blockers offers a longer period of time for gender exploration and ongoing assessment of their evolving gender identity development. Both parents and providers have more time to observe how the young woman experiences her social transition, as well as how she navigates moving through the world as a young woman, without the risk of irreversible effects of anti-androgens and estrogen.
The requirements for adolescents to begin puberty-suppressing medications such as leuprolide as outlined within the WPATH SOC (2012) include the following criteria.
1.A long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed) has been demonstrated.
2.Gender dysphoria has emerged or worsened with the onset of puberty.
3.Any coexisting psychological, medical, or social problems have been stabilized sufficiently so they will not likely interfere with treatment or compromise adherence.
4.Informed consent has been obtained from the adolescent (and legal guardian[s] if the youth is younger than the age of medical consent), and parents/guardians are willing to support the trans young person during treatment.
Some medical doctors require a written mental health assessment supporting this step prior to initiating puberty-suppressing medications; other doctors do not require this assessment, as the effects of the medication are reversible. This letter must be written by a licensed mental health clinician based on their completion of a gender assessment, including psychosocial and gender history, and a diagnosis of gender dysphoria. The Standards of Care (WPATH, 2012) outline what information should be included in these types of letters; sample letters are included in Appendix C.
Feminizing and Masculinizing Hormone Therapy
Assuming that their affirmed gender remains consistent, the SOC indicate that feminizing or masculinizing hormone therapy may begin during adolescence. In many jurisdictions, 16-year-olds are legal adults for medical decision-making and do not require parental consent. Given that there are irreversible physical changes associated with this intervention, it should be initiated when the trans young person is firmly grounded in their affirmed gender, both in the present and moving into adulthood. Ideally, the treatment decision is made among the adolescent, the family, and the medical provider.
Transgender Men and Testosterone
Masculinizing hormone treatment for transgender men involves taking testosterone. This is most frequently administered through an intramuscular injection in the buttock or thigh muscles. It can also be administered with a patch or gel. Masculinizing effects tend to occur more quickly with injections. Taking testosterone alone generally shuts down the production of estrogen, though some doctors may choose to use Lupron to shut down production of estrogen before beginning, or in addition to, testosterone.
Beginning treatment with testosterone essentially means entering a male puberty—even if the young person has already completed the puberty associated with their birth-assigned sex. Like a cisgender male adolescent who begins puberty, a young trans man will experience the development of male secondary sex characteristics over time as he begins taking testosterone. Some physical changes occur more quickly, and some only fully develop over the course of several years.
For older trans male youth who have already entered an estrogen-based (“female”) puberty, beginning testosterone generally causes menstruation to cease within three to six months. This effect is reversible. If the young man later discontinues testosterone, his body will resume the production of estrogen and menses will resume. As with a cisgender adolescent man, a young trans man’s voice will also drop or deepen with testosterone. This voice change often occurs within the first three to six months and is irreversible. If the young trans man stops taking testosterone at a later time, his voice will not return to its original pitch.
Taking testosterone creates additional facial and body hair, though the amount and location varies based on personal and cultural genetic variations and norms. For example, young Korean trans men may not experience significant facial hair growth, given that cisgender Korean men often have minimal facial hair. Other cultural genetic makeups may result in significant facial or body hair.
When cisgender boys begin puberty, it is not possible to predict how much facial or body hair will develop by the end of their adolescence. Even within cultural groups, some cisgender men are very hairy; some have lighter hair growth. Some cisgender men can grow a beard or full mustache; some cannot. The unpredictability of these variations holds true for trans men as well. Family members may make an “educated” guess based on norms within that family history, but individual genetics vary even within families.
The development of additional facial and body hair is irreversible. If the young trans man discontinues testosterone, the additional hair growth can be removed only through electrolysis or laser treatments. In the absence of testosterone and the resumption of estrogen production, the growth of facial and body hair will decline, but this will not cause existing hair to disappear without intervention.
As in cisgender men, other physical changes that occur with testosterone include skin texture becoming rougher due to pore enlargement. Trans men taking testosterone will gain additional muscle mass without working out—and will develop more muscle mass if they do work out (as do cisgender men). These initial changes—a deeper voice, more muscle mass, visible facial and body hair—form significant male gender markers in our world. Consequently, many young trans men begin to be more consistently read/seen as a man in the world as soon as three to six months after beginning testosterone.
Other effects of testosterone include body odor changes, the clitoris becoming larger, and, typically, an increase in sex drive. Over a longer period of time, body fat redistributes from the hips to the stomach area, and facial bone structure may shift, becoming more typically masculine in appearance. Depending on the trans man’s genetics, his hairline may recede over time and lead to male-pattern baldness.
Some trans male youth may think increasing their dose or frequency of testosterone will cause more rapid development of male secondary sex characteristics. This myth frequently circulates online. However, the reverse is actually true. High levels of testosterone can be converted to estrogen, thus defeating the aim of masculinizing hormone therapy.
Hormone Therapy for Transgender Women
Trans women take both estrogen and an anti-androgen. The latter is often called a “T blocker” because it blocks testosterone from attaching to receptors on the target cell and so functionally decreases testosterone activity. The anti-androgen is required because the dose of estrogen required to shut down production of testosterone is too high to be safe. In addition, without an anti-androgen blocking the production of testosterone, trans women would not experience the full effects of estrogen. These hormones are most frequently administered orally, though they can be injected and a skin patch is available.
Feminizing hormone therapy causes a trans woman’s face and skin to become softer as her pores become smaller. Over several years, her body fat redistributes itself from the stomach area to her hips, creating a more typical feminine body shape. As mentioned previously, the anti-androgen decreases, and can eliminate, spontaneous erections. Trans women may experience a decreased sex drive. These effects are reversible. If the young woman discontinues the anti-androgen and estrogen at a later date, the production of testosterone will resume, and each of these effects will return to their original state over time.
Estrogen does cause some breast tissue growth, though often only what would be an A or at best a small B cup size. Generally after two to three years, the full extent of breast development possible for a given young trans woman will be apparent. This breast development is irreversible. If the young woman discontinued hormone therapy, the breast growth she experienced would remain.
For trans women who begin feminizing hormone therapy after completing an initial testosterone-based/male puberty, taking estrogen and an anti-androgen does not change the size of an Adam’s apple, alter facial bone structure, or reduce height or bone structure/size. Taking estrogen will not raise the pitch of their voice (given that it would have dropped in the earlier “male” puberty). The anti-androgen and estrogen will slow the growth of additional facial and body hair but will not remove existing facial and body hair. This hair will need to be removed through electrolysis or laser methods.
The fact that “masculine” physical features, such as voice, height, facial bone structure, and size of hands and feet, cannot be reversed after an initial testosterone-based puberty increases the risk that trans woman may be “read” or seen as transgender in the world rather than simply being seen as a woman. In a culture marked by sexism, misogyny, and transphobia, this places trans women at increased risk of verbal harassment and physical violence as they navigate their day-to-day lives in the world. The existing lack of legal protection against discrimination also decreases employment opportunities, can place current employment at risk, and can jeopardize housing stability, contributing to increased homelessness.
Trans women from lower socioeconomic brackets who are unable to financially afford hormone therapy sometimes access hormones on the street or online. In both cases, the purity of the hormone is not assured. Accessing hormone therapy in this manner means it is not medically supervised, thus increasing potential health risks. Trans women purchasing hormones this way may inject together, using shared needles, creating additional health risks.
Some trans women inject silicone for breast and/or hip development. In addition to being illegal, this poses tremendous health risks. As with other substances obtained from a nonmedical source, the purity is unknown. Silicone injections can cause disfigurement and death, generally due to pulmonary complications resulting from immune system reactions. Additionally, silicone does not necessarily remain where injected and may migrate to other sites, causing significant health risks and physical damage. Typically, a more experienced trans woman obtains the silicone and other trans women meet to inject at gatherings often called “silicone parties.”
While choices to obtain hormones outside medical supervision or inject silicone oneself may appear self-destructive, it is essential to remember the high risks of discrimination, harassment, and violence that exist for trans women perceived as trans in the world. More than one in four trans persons have been the victims of bias-driven assault. These numbers are significantly higher among trans women and in particular, among trans women of color. In data collected by the National Coalition of Anti-Violence Program (NCAVP) (2015), over half (55%) of anti-LGBTQ homicide victims were trans women and half (50%) were trans women of colwor, despite the fact that transgender people represented only 19% of the total homicide reports (National Coalition for Anti-Violence Programs (NCAVP), 2015). A “normative” feminine figure with visible breasts and hips can enable trans women to be more consistently read as women (rather than as trans women) and thus significantly contribute to their safety when in public.
Given the irreversible effects of testosterone during puberty, the value of hormone blockers for young, prepubescent trans women is unequivocal. Beginning hormone blockers at the onset of puberty or shortly thereafter means that these trans women will not develop male secondary sex characteristics, like a deeper voice or facial hair. They may not grow as tall as they would during a male puberty and their bone structure will typically be smaller and more delicate.
Assuming their affirmed gender identity remains consistent, these adolescent trans women would begin anti-androgens and estrogen in mid to late adolescence. Without the emergence of male secondary sex characteristics, such an individual will likely be more consistently viewed as a woman (as opposed to a trans woman) as she moves into adulthood, greatly enhancing both her mental and emotional well-being and her physical safety.
Feminizing or masculinizing hormone therapy generally continues throughout a transgender person’s lifetime. There will never be a time when a trans man’s body naturally produces testosterone nor a time when a trans woman’s body produces estrogen. Some trans men choose to discontinue testosterone after achieving the desired masculinization, though if they are younger than menopausal age, menses resumes. For both trans men and women, the dosage can be reduced after a hysterectomy, orchiectomy/castration, or gender-confirming surgery. The dose can also often be lowered as trans people age (when hormones levels are naturally decreasing in cisgender men and women).
Additional Thoughts About Hormone Therapy and Trans Adolescents
As mentioned above, the Standards of Care (SOC) indicate that adolescents may begin feminizing and/or masculinizing hormone therapy at age 16, citing the fact that in many countries 16-year-olds are considered legal adults for making their own medical decisions and parental consent is no longer needed (WPATH, 2012, p. 20). At the same time, the SOC do state that the ideal is for this decision to be made in conjunction with the transgender young person, their family, and their medical and mental health providers. Within the United States, laws specifying the age at which a young person can make their own medical decisions without parental consent vary by state. Many states have additional provisions for youth who are homeless or unaccompanied or have been emancipated.
Some medical doctors categorically will not prescribe feminizing and/or masculinizing hormone therapy for trans youth younger than 18 years. At the same time, there are a growing number of medical providers and children’s gender centers that may initiate feminizing and/or masculinizing hormone therapy at 14 to 18 years of age. Beginning this treatment at a younger age generally occurs only when the young person’s affirmed gender identity has been consistent and they have already been living in their gender identity for a period of time. The specific length of time varies based on the needs of the young person, family input, and recommendations from medical and mental health providers.
As with other medical interventions for transgender youth, medical doctors require a written letter of support from a licensed mental health clinician indicating that the young person meets the criteria for a diagnosis of gender dysphoria and is mentally, emotionally, and socially prepared for this next step. This letter includes a psychosocial and gender history, a diagnosis of gender dysphoria, and a recommendation to proceed with hormone therapy as specified in the Standards of Care (WPATH, 2012); sample letters are included in Appendix C.
With the immense physical changes and development occurring during adolescence, it is generally best to refer transgender youth to pediatric endocrinologists, who hold a greater body of knowledge and expertise around adolescents and their hormonal well-being. The exception may be a reputable adolescent health center or practice where nonspecialty pediatricians are knowledgeable about the medical treatment of transgender youth, including puberty-suppressing and feminizing and/or masculinizing hormone protocols. For trans young adults, a general medical doctor such as an internist or family practitioner can prescribe and monitor hormones if they are familiar with the protocols. However, when additional health concerns or conditions (such as diabetes or a heart condition) are present, referral to an endocrinologist is always advised.
Some medical and mental health providers may be reluctant to prescribe puberty suppressants and/or feminizing or masculinizing hormones to adolescents. This is generally due to concerns about potential health risks or worry that irreversible changes precipitated by the latter could pose a problem if the young person later “changed their mind” and decided they were not transgender.
While these concerns hold some merit, they must consistently be balanced against the risks of delaying medical transition among transgender adolescents. Delay or denial of hormone therapy ensures that the young person’s gender dysphoria will continue, and over time the degree of dysphoria will likely intensify. In addition, trans youth who physically appear different from similar-aged peers (e.g., a 17-year-old trans boy whose voice has not yet dropped) may be at higher risk for verbal harassment and/or physical abuse and bullying.
Recent research indicates that the level of gender-related abuse experienced by trans adolescents is strongly associated with the degree of internal psychiatric distress the young people are experiencing (Nuttbrock et al., 2010). In light of this, the SOC emphasize that “withholding puberty suppression and subsequent feminizing or masculinizing hormone therapy is not a neutral option” for adolescents (p. 21). The following vignette illustrates some of the complexities of these decisions about readiness.
Assessment of Readiness for Hormone Therapy
EVAN
Evan was a 17-year old-transgender young man (natal female) with a history of gender dysphoria dating back to early childhood. His parents reported that he had resisted wearing girls’ clothes by age six and that most of his early playmates were boys. During the fall of his freshman year in high school, Evan came out to his parents as gay. The following March, he told them he was not really gay but instead transgender and identified as a boy. During late April, his parents brought him to see me for gender evaluation and support.
The parents (mother/father) had been divorced for five years and shared custody of Evan and his brother (three years younger). While their primary residence was with their mother, the two apartments were only blocks apart so that the boys could go back and forth easily. The divorce had been difficult for the family. It had been precipitated in part by the father’s addiction. He (the father) was now sober three years and the relationships between all of them had improved. As the oldest child (and perceived daughter), Evan had sometimes been his mother’s confidant after the parents separated, and their relationship remained close.
Evan was a bright, articulate, compassionate young man who formed friendships quickly with adults and peers and enjoyed socializing. He was passionate about math and science and wanted to become an engineer. Upon intake, Evan presented with some depression and anxiety. He had a history of cutting behavior (five to six times) prior to disclosing his transgender identification. He had a history of some drug and alcohol use. He had had some difficulty with school performance in the past, mostly in terms of not completing work in a timely manner, and took medication for ADHD. Overall, Evan presented as a relatively high-functioning high school student.
We met regularly beginning in April and into the summer. During this time, I met with his parents separately several times and with the three of them for periodic family sessions. Both parents were supportive of his affirmed gender.
Evan socially transitioned that fall at the onset of his sophomore year at the same small private school he had attended the previous year as a freshman. He successfully came out to his peers and navigated these relationships effectively throughout the academic year.
The following fall, in his junior year, Evan’s academic performance deteriorated. He was issued an academic warning at the end of his first quarter. When his grades did not improve during the second quarter, Evan was placed on academic probation. He was failing several classes. His attendance record showed numerous absences and instances of lateness in addition to periodically cutting classes.
Outside school, Evan began to be late and/or miss our appointments and often violated curfew at home. He appeared forgetful (or defiant?) and consistently had an excuse for why things were “not my fault.” He often lied about what had transpired when confronted with lateness, poor performance, etc. He appeared not to internalize the consequences of his behavior (e.g., behavior leading to school failure despite many admonitions and warnings during the first two marking periods).
During our sessions and family sessions, when Evan was confronted about his poor academic performance, he repeatedly insisted he was back on track and was up-to-date on all his homework and studying regularly. He consistently promised not to be late again.
In the following weeks, Evan alternated between feelings of failure and low self-worth and other moments of denial while still insisting that everything was fine. Evan had begun taking Lupron (hormone blocker) about four months before to decrease his gender dysphoria. The plan had been for Evan to begin testosterone that spring. When his school performance began to deteriorate, his parents and I talked with Evan about the need to get back on track at school in order to continue with this timeline. The frame for this was that if Evan was doing well in school and life, this was a sign that he was responsible enough and ready to begin masculinizing hormone therapy. If he was not able to be responsible at school, this might indicate that Evan was not mature enough to navigate responsible maintenance of hormone therapy.
Unfortunately, Evan continued to do poorly and was expelled from the school in February (of his junior year). At that point, it seemed unclear whether Evan should begin testosterone in the near future or wait until his behavior/performance improved and his academic situation stabilized. His parents were very angry about his poor academic performance and now expulsion as well as his repeated failure to take responsibility for his choices and actions. In our most recent session, Evan disclosed that he had had an episode of cutting during the past week and reported significant anger toward himself.
REFLECTION QUESTIONS FOR PARENTS OR PROFESSIONALS:
1.What thoughts do you have about what might be going on for Evan? Do you have any hunches about what may have contributed to his poor school performance and failure to take responsibility this year?
2.At this point, what position would you take in terms of the original plan for Evan to begin testosterone within the next one to two months? What factors would go into your decision? What do you see as the possible benefits or risks of Evan starting or delaying testosterone treatment?
3.How do you feel about permission to begin masculinizing hormone therapy being linked to Evan’s ability to “be responsible?”
4.Describe your intervention plan at this point. With Evan? With the parents? With the family as a whole? What do you think the next steps should be?
Deeper Exploration
This vignette illustrates the complexity of decisions surrounding the onset of hormone therapy with transgender adolescents. While the SOC provide guidelines, there is no single “measuring stick” to pinpoint exactly when a teenager is ready for this next step in their transition. Taking testosterone, or an anti-androgen and estrogen, does require some ability to be responsible—at minimum, adherence to the prescribed dosage and medical follow-up appointments. It can be challenging to weigh existing risk factors, such as the degree of the trans adolescent’s current gender dysphoria and how well they are managing this.
The SOC suggest that other aspects of a young person’s life should be relatively stable. Any mental health conditions should be resolved and stable enough so as to not interfere. However, this must often be balanced alongside the risks of delaying medical interventions. While we initially framed the onset of masculinizing hormone therapy as an affirmation of Evan’s ability to be responsible at home and school, this plan did have its risks. What if the fact that Evan was not doing well in school was linked to his gender dysphoria? Might Evan, in fact, do better in school after beginning hormone therapy? How do you, along with his parents, discern these factors? How do you sift through these concerns to arrive at an appropriate decision?
In this particular situation, the parents and I did come to the decision that Evan should begin taking testosterone as planned that spring. We agreed that it was not appropriate or effective to link beginning hormones to Evan’s behavior or performance. We identified that beginning testosterone was about Evan being more fully himself in his own body and within the world, and that it was not healthy to link this with his performance. We became clear that we did not want to send the message to Evan that “you can only be yourself if you do well”; we did not want to predicate his ability to be himself on what he did or did not do. If we believed Evan was a young man, then he should be able to be that young man to the fullest extent possible—regardless of whether he was currently being a responsible young man (as his parents or I might define this). As a result, we revised our initial plan and Evan did begin testosterone that spring. In addition to illustrating the complexities of these decisions, this vignette highlights the need to be willing to periodically reevaluate and revise the original plan.
Early Transition
Gender transition is an inherently public act. There is no way to transition in private. It is important for mental health providers to grasp the fact that as difficult as it is to manage the gender dysphoria prior to coming out as transgender, the visibility inherent in the early stages of medical transition can be equally challenging. Everyone in their day-to-day life is able to observe the physical changes as they occur—neighbors, grandparents, the bus driver, the guy at the corner deli, all of the parents’ friends.
Another challenge in the early stages of masculinizing or feminizing hormone therapy is being read half of the time as a woman and the other half of the time as a man—and not being able to predict how you are going to be read in any given situation. Most transgender adolescents arrive in my office ready to transition and begin hormone therapy a month ago. The degree to which their gender dysphoria has been intensifying is often what precipitates coming out to their parents. From their perspective, it feels like they have been living with this distress for so long (and they have) that they simply cannot tolerate it one minute longer—especially now that the news is out.
When they begin hormone therapy, they want to be consistently seen in their affirmed gender overnight. By this point, teenage transgender boys don’t ever again want to hear anyone say to their mother, “What a beautiful daughter you have.” Young transgender women don’t want to be “Sir’d” when they pay for hair products anymore. But given the fact that the physical changes happen over time, when transgender youth first begin hormone therapy, they are likely to be misgendered frequently (misgendering involves not using someone’s affirmed name or pronouns or describing trans men as women or trans women as men). Surviving this stage of the process, in which they still are not consistently being seen for who they are, is emotionally painful and draining as well as hard on their self-esteem.
These struggles with how others perceive them occur alongside the trans adolescent’s own internal dysphoria and growing impatience to see their affirmed gender’s secondary sex characteristics in themselves. Here, too, there is the dynamic that the young person has lived with this distress for so long, lived with their current physical appearance not feeling right, that it feels impossible to tolerate it any longer. Given this, it’s not surprising that once beginning masculinizing or feminizing hormone therapy, many trans youth are out of bed every morning in front of the mirror to see if their body has changed any overnight.
Surgical Interventions
Top Surgery
Many transgender adolescents and young adults may want to pursue what is colloquially called “top surgery.” For trans men, “chest reconstruction surgery” (not “mastectomy” or “breast removal”) involves not only removal of breast tissue, but also the contouring of the chest to ensure a male appearance. Trans men with smaller breasts are often able to have a less invasive chest surgery called keyhole or drawstring. In these two procedures, the nipple generally remains attached to the body while breast tissue surrounding the nipple is removed. The fact that the nipple is not fully disconnected typically allows for greater nipple sensation post surgery.
Transgender men with larger breasts have a procedure called double incision. In this surgery, the nipple is detached while the breast tissue is removed and the areola is resized for a more masculine appearance. The nipple is then regrafted on. The need to completely detach the nipple (and its nerve endings) generally leads to minimal nipple sensation post surgery. More recently, the “button hole” technique (as opposed to the keyhole technique described above) has enabled larger-chested trans men to have breast tissue removed without fully detaching the nipples, thus preserving significant sensation post surgery. Top surgery for transgender men is generally performed on an outpatient basis unless there are other significant medical concerns that warrant closer post-surgical observation and a hospital stay.
Top surgery for transgender women includes breast augmentation using silicone or saline implants. While estrogen causes some breast growth (generally over a two- to three-year period), the growth is often relatively small, approximately an A or small B cup size. Like cisgender women, trans women vary in their preferences about the size of their breasts. Some women—trans and cis—may prefer smaller breasts; other women—trans and cis—may prefer larger breasts. The degree to which a transgender woman feels comfortable with the breast growth she experiences while taking estrogen plays a role in her desire for top surgery.
Breast augmentation surgery both increases breast size and enhances shape. Implants may be “round” or “teardrop” (anatomically shaped) and may be textured or smooth. Like top surgery for trans men, breast augmentation is generally performed on an outpatient basis.
On a personal level, top surgery decreases gender dysphoria in two ways. The first is that when a transgender woman looks in the mirror and sees that her chest is flat, it is extremely challenging for her to see herself as a woman—despite how strong her internal sense of herself may be. When she tries on clothes, she wants to be able to see her breasts—not just feel them in her mind. The same is true for a transgender man. When he has to wear a tie, he wants it to lie flat on his chest—not bulge out and then curve back in. When he’s wearing a T-shirt and catches a glimpse of himself walking by a shop window, he expects his chest to be flat. When it is not, he generally experiences gender dysphoria—sometimes profoundly so.
Second, all human beings share a basic human need to be seen for who we are by those around us and to have our identities validated by them. Transgender youth are no exception. After they have endured many years of being “misgendered,” typically, top surgery significantly contributes to their ability to have others in the world see and acknowledge them in their affirmed gender. In an early study examining the lives of transgender men, Devor (1997) highlighted the insight that “each of us has a deep need to be witnessed by others for whom we are, and each of us wants to see ourselves mirrored in others’ eyes as we see ourselves” (p. 46).
However, this ability to be recognized in one’s affirmed gender as one moves through the world goes beyond simply decreasing gender dysphoria. Top surgeries contribute to a young trans person’s emotional and physical safety in the world. When we see someone on the street whose attire or hairstyle or cut is androgynous, having a flat chest is a major way we determine whether they are “male.”
In the same way, visible breasts are a primary way people perceive someone as female. Consequently, top surgery (typically coupled with hormone therapy) greatly increases a trans woman’s or man’s ability to consistently be “read” or seen for who they are in the world—to be recognized in their affirmed gender. As discussed previously, being seen in your affirmed gender—and not “read” or “called out” as transgender—is perhaps the most critical factor that determines whether a young transgender man or woman is free from verbal harassment and physical and violence—even murder—in private and public settings.
The realities of sexism and misogyny place young trans women (and young trans women of color even more so) at particular risk of “street” harassment and violence. Trans women can be perceived as threatening to some straight cisgender men and their masculinity and/or heterosexuality. After assaulting or murdering a transgender woman, some men have claimed they could not be held responsible for their rage when they “discovered” she was transgender. Their justification was that they had been “deceived.” For these straight cisgender men, their attraction to a trans woman challenges their heterosexuality. In their minds, she is not really a woman, which then raises the untenable possibility (to them) that they were attracted to a man.
The pervasive impact of trans-prejudice, racism, and sexism on the lives of transgender youth, particularly poor trans youth, homeless transgender youth, and trans youth of color, underscores the reality of Judith Butler’s (2004) analysis that (human) lives are
supported and maintained differentially, that there are radically different ways in which human physical vulnerability is distributed across the globe. Certain lives will be highly protected, and the abrogation of their claims to sanctity will be sufficient to mobilize the forces of war. And other lives will not find such fast and furious support and will not even qualify as “grievable.” (p. 24)
Essentially Butler posits that not all lives count as human, or that some lives count as more fully human and worthwhile than do others. In this schema, trans lives and gender-nonnormative lives count less than cisgender, gender-normative lives do. The ways in which some lives are not even grievable particularly impacts trans women, trans people of color, and poor trans people, who are already marginalized in other aspects of their identities. Being a young transgender person compounds these risks and realities. From this understanding alone, top surgery should always be considered medically necessary for transgender individuals, including young trans people.
Despite these benefits, top surgeries are typically not performed before a young person reaches the age of majority. There are a limited number of surgeons in the United States who will perform top surgery at 16 to 17 years of age—generally when the young person has socially transitioned earlier and their affirmed gender has remained consistent. The SOC suggest that trans men younger than 18 years of age should ideally have lived in their affirmed gender for a period of time and have been taking testosterone for one year prior to obtaining chest surgery. Parental consent is required for all surgical procedures for minors.
Like hormone therapy, top surgery requires a letter from the young person’s doctor and/or licensed mental health practitioner or therapist (see sample mental health letters in Appendix C). There is no single universal timeline for top surgeries for transgender adolescents. Decisions about eligibility and timing must be flexible and individualized in accordance with the needs, risks, and benefits of each specific young person.
Some parents and/or medical and mental healthcare providers may be reluctant to permit top surgery for transgender adolescents younger than 18 years. However, it is important to note that from the trans youth’s perspective, obtaining this surgery prior to beginning college or entering the work world in a full-time manner may be very important. Again, the importance may be in terms of alleviating internal gender dysphoria and/or it may impact their ability to navigate college or employment without encountering harassment and discrimination.
Genital Surgeries
The historical definition of “sex reassignment” surgery by the medical establishment was genital surgery. It was this specific surgery (and not hormones or top surgery) that determined whether or not a person could legally be considered a man or woman in their affirmed gender. The gender marker on most legal documents could not be changed without documentation of genital surgery. This required a letter from the surgeon and, in some states, an actual copy of the operating room report as well to ensure the authenticity of the letter. The United States passport and social security agencies eliminated the genital surgery requirement several years ago.
Within the larger world as well, whether or not a person has had “the surgery” (genital surgery) is typically the benchmark of gender transition. Without lower surgery, trans men and women are often not classified as “real” men and women. For example, when one trans woman came out publicly, someone else tweeted that she would never consider the trans person a woman until “she has her pee-pee removed.”
This question about whether or not a transgender person has had genital surgery is a highly intrusive and personal question about their body. Before I came out as trans, I never had an acquaintance—let alone a stranger—ask me what my genitals looked like, but trans youth and adults, and I, get asked that question all the time. Beyond the intrusiveness, the question carries the implication that the questioner wants to know whether you are a “real” man or woman yet—clearly suggesting that the shape of our bodies is the sole determinant of what it means to be a man or a woman, as the above tweet reflects.
Given the cost of this surgery and the historical denial of health insurance coverage for trans-related surgeries, establishing the bar at genital surgery meant that many transgender people were unable to have the gender markers updated on their identification documents. This often “outed” them against their will in situations when identification was required, such as seeking employment, being stopped by the police, or traveling internationally. In addition to the emotional discomfort and dysphoria experienced in these situations, such disclosures risked the trans person’s safety in some settings. When you are traveling internationally and your gender presentation does not match the gender marker on your passport, you may be subject to suspicion, ridicule, invasive questions and searches, harassment, or even violence.
Among transgender youth and others in the larger trans community, more recent nomenclature for genital surgery includes “gender-affirming” or “gender-confirming” surgery. Both phrases dispute the belief that one’s sex is being changed or “reassigned.” In contrast, the transgender person’s gender is simply being confirmed or affirmed through these medical procedures. The terms “bottom” or “lower” surgery” are often used informally within trans communities.
As discussed earlier, transgender youth experience differing degrees and types of gender dysphoria regarding their body parts. As a result, they make varying decisions about the importance of particular surgical procedures. Still, for many trans youth and young adults, lower surgery can significantly decrease gender dysphoria and enable them to be more fully the gender they know themselves to be regardless of the genitalia present at birth.
Even though the Standards of Care (WPATH, 2012) indicate that genital surgeries should be performed only after the age of consent as an adult, it is important for mental health providers to be knowledgeable about these procedures when working with adolescents. Both youth and their families often want to know what is possible as the young person moves into adulthood.
Transgender Men
Genital surgery for trans men involves one of two procedures: metoidioplasty or phalloplasty. Metoidioplasty (sometimes called a “meta”) involves “releasing” the clitoris, which has become enlarged as a result of taking testosterone. This procedure creates a small phallus (about 4 to 6 cm) from the enlarged clitoris, which is then covered with adjacent skin. The metoidioplasty can be performed with or without urethral lengthening. Lengthening of the urethra allows trans men to void standing up. Penetration during sex is not generally possible with a metoidioplasty given the small size of the penis.
Phalloplasty creates a “standard-size” phallus using a skin graft, generally taken from the outside of the thigh, the back, or the radial forearm. Having a more “normative”-appearing penis can not only reduce dysphoria but also make being “outed” in settings like restrooms or locker rooms less likely. Urethral lengthening typically accompanies a phalloplasty, enabling urination while standing. Roughly 9 to 12 months after the phalloplasty is completed, penile implants can be inserted that allow for penetrative sex. These implants can be semi-rigid or inflatable. Both transgender men and surgeons typically have preferences for the type they recommend. Scrotoplasty, with the insertion of testicular implants, can accompany both metoidioplasty and phalloplasty. Both lower surgeries require a hysterectomy.
Some transgender men choose to have a hysterectomy even if they do not intend, or are unable, to have a metoidioplasty or a phalloplasty. While the internal organs are not visible body parts, the removal of what are typically considered female organs can relieve aspects of gender dysphoria for some trans men. There is also some research suggesting that having a hysterectomy after three to five years on testosterone may reduce certain cancer risks, although the evidence is not conclusive (Gorton, Buth, & Spade, 2005). A hysterectomy also stops the menstrual period and allows for time off testosterone shots without concern that menstruation will resume.
In the past, many trans men did not believe bottom surgery was worth pursuing. Without health insurance coverage, the cost was prohibitive for most trans men. Further, the penis created by early surgical techniques was rarely realistic enough to feel gender-congruent for trans men. The resulting penis at that time was minimally sensate, and penetrative sex post lower surgery was not as pleasurable as most trans men had anticipated or hoped. The lack of adequate resemblance to a cisgender man’s penis meant trans men often still did not feel safe or comfortable disrobing, or being in underwear or tight swim trunks, around cisgender people. Before more recent surgical advances, there was a high risk of postsurgical complications, with most resulting from the complexities of lengthening the urethra.
Phalloplasty techniques have greatly advanced in the past five to eight years across all indices—physical appearance, sexual satisfaction and pleasure, and reduction of postsurgical complications. Microsurgical advances have enabled surgeons to connect nerve endings within the erotic clitoral tissue to the nerve endings within the skin graft. This allows the formation of a penis that is more sensate and more capable of orgasm and sexual pleasure than was possible earlier. In addition, these surgical advances have resulted in significantly decreased complication rates.
Older pessimistic beliefs about lower surgery for trans men persist in many places. They can still be easily found on the Internet, where many trans men seek information today. In working with trans male adolescents, it is important to be able to correct these impressions and provide, or direct them to, more current and accurate information about these surgeries. For youth and their families as well as providers, one direct source of accurate information can be found at the growing number of transgender conferences emerging throughout the United States (see Appendix B). Many surgeons regularly present the surgeries they perform and the specific techniques and procedures utilized at these events. Additional invormation is also often located on their websites
Transgender Women
The standard genital surgery for transgender women is called vaginoplasty. The testicles are removed and the scrotal skin is used to create the labia majora (labiaplasty). The penile tissue is then inverted and used to construct the vagina, while the clitoris is constructed using erotically sensate tissue from the glans penis. The urethra is then shortened and positioned like that of a cisgender woman.
The fact that the vagina and clitoris are constructed from erotically sensate penile tissue as well as the consistent enhancement of techniques developed over time enables most transgender women to experience sexual satisfaction and pleasure post genital surgery. When surgery is performed by a knowledgeable and competent surgeon, the aesthetic appearance post surgery reflects no difference between transgender women and cisgender women. A transgender woman’s sexual partner would not become cognizant of her trans history simply based on the appearance or functionality of her genitals.
Largely due to the cost of vaginoplasty (and historical absence of insurance coverage), some transgender women choose to have an orchiectomy rather than vaginoplasty. This procedure involves removal of one or both testicles. The penis and scrotum are left intact. The removal of the testicle(s) reduces testosterone production and consequently can be helpful in alleviating gender dysphoria for some transgender women.
The earlier discussion of feminizing hormone therapy noted that estrogen does not reverse all the secondary sex characteristics accompanying a male puberty. Consequently, additional medical or surgical procedures may be sought by trans women who want to be more consistently viewed as women in the world. These can include a tracheal shave to reduce the size of an Adam’s apple, removal of facial or body hair through electrolysis or laser treatments, and/or facial feminization surgery (FFS) to achieve a more feminine facial appearance. There are some surgical approaches to voice feminization, but more typically trans women (or men) seek coaching around tone and pitch from a vocal therapist knowledgeable about the needs of transgender individuals.
The importance placed on gender-confirming surgeries varies among transgender women and men. In part, this is rooted in the different ways trans people may or may not feel comfortable with specific aspects of their bodies and body parts as well as their physical and sexual intimacy. For some trans men and women, these surgeries significantly reduce gender dysphoria and allow the trans man or woman to move more comfortably in their bodies and in the world. For these individuals, lower surgery is essential to their overall mental, emotional, social, and physical well-being.
Genital surgery may be less crucial for other trans men and women. It is critical to note that the varying importance of pursuing lower surgery is not indicative of whether a young trans woman or man is “truly” transgender. Instead, these different choices simply reflect the diverse ways human beings navigate their personal bodily comfort and pleasure.
As indicated earlier, the SOC indicate that genital surgery should not be performed until a transgender young person reaches the legal age of majority to give consent for medical procedures within their locale. The SOC also suggest that the youth live continuously in their affirmed gender for at least one year prior to obtaining lower surgery and are careful to note that turning 18 years old does not, in and of itself, suggest that lower surgery is recommended. Instead, the decision about eligibility and readiness should be determined based on numerous factors, including the young adult’s functioning, current familial and social support, and overall well-being.
Moving from one aspect of transition to the next should generally include time for adolescents and their parents to fully assimilate the effects of earlier interventions. Recommendations about the length of time lived in their affirmed gender, as well as the usual sequence of beginning with hormone therapy, followed by top surgery, and then potentially lower surgery, are not meant to be prescriptive for all transgender young people. The primary goal underlying these considerations within the SOC is to ensure that trans youth have the opportunity to experience living in their affirmed gender both internally and socially prior to making decisions involving irreversible physical changes. As with other steps within a medical transition, the SOC clearly state that the guidelines must be applied with an eye to the specific needs, goals, and context of each transgender young person.
Access to Transition-Related Medical Care
The Internet has significantly increased the amount of information available to trans youth and increased access to trans-knowledgeable and affirming medical and mental health providers. Trans youth today are likely to arrive in a therapist’s office having extensively researched how to transition. They have often watched videos and read blogs of young trans men and women recording their hormone treatment experiences, including their “progress” on a weekly or monthly basis. They may have communicated with trans youth across the United States and around the world. This increased access decreases isolation, contributes to trans youth coming out at younger ages, and provides greater knowledge of what is possible for trans youth today.
At the same time, not all information available on the Internet is accurate. It is important to evaluate what transgender young people have learned about the various aspects of medical transition to ensure that their beliefs reflect current medical information. Trans adolescents, family members, and others may have misinformation about various medical procedures, protocols, benefits and risks, and possible results.
Depending on laws for parental consent, age plays a significant role in regulating access to medical transition among adolescents. In families who are rejecting, trans youth may not be able to access medical care until they reach adulthood. Even after reaching the legal age for making medical decisions, many young adults remain dependent on their families for health insurance and financial support. Medical providers and/or parents who believe transgender identity is a psychiatric illness often impede transition among youth and may insist that the young person attend reparative therapy designed to “cure” their transgender identity.
Location can play a key role in determining who has access to trans-knowledgeable or affirming health care. Very few medical or nursing schools incorporate education about the needs of transgender youth. Consequently, in many locations there are few trans-knowledgeable or affirming healthcare providers. This goes beyond the provision of transition-related care, such as hormones and gender-confirming surgeries, to encompass general healthcare for transgender youth. For example, most healthcare providers think about gynecology in terms of women. Many are unaware that all people with vaginas need regular gynecological exams, including trans men if they have not had a hysterectomy.
In areas without trans-competent adult medical providers, doctors may lack knowledge about protocols for trans youth or simply be unwilling to provide hormone treatment for youth, including puberty blockers. The geographic distance and consequent isolation of many transgender youth and their families in rural communities can also form a barrier in locating and accessing medical care.
Socioeconomic status and lack of access to health insurance covering trans-related medical care often limits the ability to medically transition. Historically, health insurance has excluded any trans-related medical treatment. In particular, this has applied to hormone therapy and surgeries associated with medical transition. However, many health insurance plans have denied coverage for medical care that was completely unrelated to transition after they learned a member was transgender.
While the out-of-pocket cost for testosterone and estrogen is affordable for many working- and middle-class families with trans youth, hormone blockers are very expensive. Trans-related surgeries are generally not financially accessible without health insurance coverage. Top surgery typically costs $8,000 to $10,000 out of pocket. Genital surgery for trans women may cost $20,000 to $40,000, and it may cost as much as $80,000 to $100,000 for trans men. While some young adults or families may find the money to pay for top surgery, most simply cannot afford lower surgery without insurance coverage.
Lack of health insurance coverage for transgender individuals is rooted in stigma. Hormone treatment is regularly covered for cisgender people (e.g., menopausal cisgender women or older cisgender men with decreased testosterone levels). Transgender people are often denied surgical procedures routinely available to cisgender people. For example, most insurance policies cover chest surgery for cisgender men with gynecomastia, even though this procedure is largely about the man’s emotional sense of “gender congruence” and not a physical health risk.
In the past 5 to 10 years, more health insurance policies have begun to include trans-related medical care, generally in larger corporations and educational institutions who are able to write their own policies. A few states have mandated this coverage from both private and public insurers. However, the vast majority of trans youth across the U.S remained unable to access transition-related medical treatments that WPATH (2012) considers medically necessary for transgender people. Youth in child welfare and juvenile justice have routinely been denied trans-related medical care.
However, in May 2016, the U.S. Department of Health and Human Services (HHS) issued a document with final regulations clarifying many aspects of the 2010 Affordable Care Act (ACA). These guidelines are clear that discrimination against transgender people within healthcare is no longer legal. All health insurers receiving federal funds—most private insurers, state Medicaid, the Indian Health Service, and CHIP (Children’s Health Insurance Program) programs—must now provide transgender-related medical care in the same way they cover any other medical care. Insurers are no longer legally able to categorically deny a medical procedure simply because the member is transgender or because the procedure is related to a medical transition (National Center for Transgender Equality, 2016). While other factors continue to limit access to medical care for transgender youth, health insurance coverage is becoming less of a barrier in light of the HHS ruling.