What to know about transgender youth, health in Texas

AMARILLO, Texas (KAMR/KCIT) – In his most recent episode focused on the education, community, and health resources available to Texas children, Governor Greg Abbott issued a Tuesday letter directing the Texas Department of Family and Protective Services to criminally investigate parents in the state who help their transgender and gender-non-conforming children get affirming care.

In his letter, the governor directed that the department investigate any “reported instances of Texas children being subjected to abusive gender-transitioning procedures.” This came after Texas Attorney General Ken Paxton published a legal opinion arguing that Texas law may be interpreted to say that giving children gender-affirming care is child abuse.

The letter specifically argued, on the basis of Paxton’s published opinion, that gender-affirming therapies such as puberty blockers or doses of testosterone and estrogen are “abusive” and “already against the law” in the state, as well as a number of surgeries.

Although causing backlash from some, the ACLU said that the opinions of Abbott and Paxton did not have a legal impact upon state policy.

“Attorney general Paxton’s opinion and Governor Abbott’s letter have no legal effect, can’t change Texas law, and can’t override the constitutional rights of Texas families,” said the ACLU in the wake of Abbott’s letter, “No court anywhere in the country has ever found that gender-affirming care can be considered child abuse.”

However, even in recent months, Abbott’s letter and Paxton’s opinions were not the only instances of Texas legislators and officials attempting to frame gender-affirming healthcare in the state as abusive and prosecute those involved. During the most recent legislative session, Amarillo-area representatives John Smithee, Four Price, and Ken King sponsored a failed bill (House Bill 133) that would have banned physicians from giving gender-affirming healthcare under a penalty of possible license loss. HB 133 was paired with House Bill 68, which also failed, but would have legally altered the definition of child abuse to include gender-affirming physical and mental healthcare.

In 2021, Texas was one of the numerous states across the country that considered legislation banning transgender youth from receiving gender-affirming healthcare. Arkansas, notably, passed such legislation despite a veto from its governor.

These proposed pieces of legislation, as well as the opinions of officials such as Abbott and Paxton, do not reflect the most updated understanding of transgender and gender-non-conforming healthcare, nor are they supported by the official positions of healthcare leaders such as the American Psychiatric Association or the American Academy of Pediatrics. Instead, the American Psychiatric Association published guidelines on its website advising that providers should offer affirming care and spaces for patients, as well as healthcare resources in order to promote overall health. The Fenway Institute published a curriculum to be used by healthcare professionals regarding supportive care to patients in the LGBTQ+ community. The American Academy of Pediatrics published studies such as one from the University of Washington’s Department of Psychology, concluding that transgender and gender-non-conforming youth benefit from being allowed to socially transition and otherwise being given affirming care.

Part I || Gender-affirming healthcare and informed consent with children

Informed consent

Ethically and legally, the American Medical Association (AMA), the US Department of Health & Human Services (HHS), the American Hospital Association (AHA), and other healthcare authorities have created guidelines and directives regarding a patients’ rights when seeking and receiving treatment.

While the HHS referred to its informed consent guidelines in a manner focused on how to approach patients participating in medical trials and other research, the AMA and other health authorities expanded upon the guidelines of informed consent to discuss patients’ individual decisions about their health and caregivers and parents’ involvement in the health of their dependents.

Guidelines from the AMA about parents and children/caregivers and dependents and medical decisions included that physicians and healthcare providers should:

Provide compassionate, humane care to all pediatric patients.
Negotiate with parents/guardians a shared understanding of the patient’s medical and psychosocial needs and interests in the context of family relationships and resources.
Develop an individualized plan of care that will best serve the patient, basing treatment recommendations on the best available evidence and in general preferring alternatives that will not foreclose important future choices by the adolescent and adult the patient will become. Where there are questions about the efficacy or long-term impact of treatment alternatives, physicians should encourage ongoing collection of data to help clarify value to patients of different approaches to care.
Work with parents/guardians to simplify complex treatment regimens whenever possible and educate parents/guardians in ways to avoid behaviors that will put the child or others at risk.
Provide a supportive environment and encourage parents/guardians to discuss the child’s health status with the patient, offering to facilitate the parent-child conversation for reluctant parents. Physicians should offer education and support to minimize the psychosocial impact of socially or culturally sensitive care, including putting the patient and parents/guardians in contact with others who have dealt with similar decisions and have volunteered their support as peers.
When decisions involve life-sustaining treatment for a terminally ill child, ensure that patients have an opportunity to be involved in decision making in keeping with their ability to understand decisions and their desire to participate. Physicians should ensure that the patient and parents/guardians understand the prognosis (with and without treatment). They should discuss the option of initiating therapy with the intention of evaluating its clinical effectiveness for the patient after a specified time to determine whether it has led to improvement and confirm that if the intervention has not achieved agreed-on goals it may be discontinued.
When it is not clear whether a specific intervention promotes the patient’s interests, respect the decision of the patient (if the patient has capacity and is able to express a preference) and parents/guardians.
When there is ongoing disagreement about a patient’s best interest or treatment recommendations, seek consultation with an ethics committee or other institutional resource.

While minor children are not officially considered to have the capacity to make healthcare decisions on their own, medical authorities have been clear that physicians have a responsibility to engage children in making decisions about their own care in keeping with the child’s ability to participate. While guidelines exist for physicians in dealing with minor patients who are aiming for confidential care outside of the influence of their parents or guardians, for the most part, it has been advised that physicians communicate fully with both the patient and their guardians throughout the treatment process.

These guidelines direct healthcare providers that have transgender youth as patients, who are pursuing medical care relating to their transition – often alongside legal and social transition – to make sure they do so with thorough communication between themselves, their guardians, and their physicians. This communication might include the different medical treatments available for minors, as well as their accompanying effects and research, according to notes from the AMA regarding healthcare for minors.

As noted in research regarding child development and gender identity, such as “The role of gender constancy in early gender development”, the University of California in San Francisco (UCSF) has noted that, “Awareness of one’s gender identity does not require cognitive capacity acquired in adolescence or early adulthood, nor does it require a fully myelinated frontal lobe. Gender studies in non-transgender participants have found that children are aware of their gender by the age of five or six, and often earlier.”

Puberty-blockers

Medical treatments for transgender and gender-non-conforming (GNC) youth vary depending on the individual’s physical, emotional, financial, and other circumstances. There is no one way to transition, which is one of the reasons medical authorities have been clear on the need for physicians to communicate with each patient individually and approach each situation with clarity and care.

However, medical treatments offered to transgender and GNC children are often among two categories – treatments commonly referred to as “puberty blockers”, and hormone-replacement-therapy (HRT). These are often available or not to youth depending on their stage of development, according to sources such as the UCSF, whether they are before or in the early stages of puberty, or whether they are well-along or in the final stages of puberty.

Youth with gender dysphoria (the feeling of discomfort or distress that might occur in people whose gender identity differs from their sex assigned at birth or sex-related physical characteristics) often experience trauma at the beginning of puberty – often somewhere between the ages of seven to 11, as noted by UCSF.

For children in the early stages of puberty who are experiencing gender dysphoria, physicians may prescribe gonadotropin-releasing hormone (GnRH) analogs, or “puberty blockers” that offer a reversible pause from unwanted or potentially traumatic puberty. This treatment plan was first developed by experts at the Gender Identity Clinic at the VU University Medical Center in Amsterdam.

It is important to note that these treatments are both safe and reversible according to healthcare authorities such as the European Federation of Endocrine Societies, and are meant to offer minors the opportunity to explore their gender identity while minimizing harm and other trauma. GnRH treatments are also used by physicians on minor patients that are not transgender or GNC for a range of circumstances. However, despite the small differences in circumstances, these treatments tend to undergo far more scrutiny and criticism publicly when made available to transgender and GNC children.

Puberty blockers are also meant to be temporary treatments, and healthcare leaders such as UCSF said that they are ideally paired with other supplements in order to avoid and otherwise minimize side effects such as possible diminished bone mineral density. However, as noted by medical authorities, such side effects are rare.

It is also important to note, as published by UCSF, that puberty blockers do not cause infertility. Instead, as explained by medical experts with UCSF, puberty blockers pause the development of mature sperm or eggs. Patients who decide that they do not want to proceed with their medical transition into hormone-replacement therapy because of later infertility risks can stop puberty blockers in order to go through puberty.

Hormone Replacement Therapy (HRT) and gender-affirming surgeries

Hormone-replacement Therapy, or HRT treatments, may be added to puberty blockers in order to encourage the development of feminizing or masculinizing features in transgender youth. As noted by UCSF, these are most often used for transgender and GNC adults and minors who have already completed or are farther along in puberty, in order to develop features that more closely match their gender identity and desired expression.

Gender-affirming hormones, or HRT treatments, are currently recommended by the Endocrine Society guidelines to begin at or after age 16. However, some specialty clinics and experts have recommended that the decision be individually determined by physicians, patients, and guardians depending on development instead of chronological age.

Some factors that some researchers have argued support considering HRT before the age of 16 included:

Length of time on GnRH analogues – for those youth whose endogenous puberty is suppressed in the earliest stages of puberty, waiting until age 16 to add hormones means a potential 5-7 year gap, during which bone mineral density is only accruing at a pre-pubertal rate. This could potentially impact peak bone mineral density, and place youth at risk for relative osteopenia/osteoporosis.
Experiencing puberty in the last years of high school or early college years presents multiple potential challenges. The emotional upheaval that occurs for youth undergoing puberty happens normally at 11 or 12 years of age. For those youth who struggle with emotional lability at that age, they do so in a relatively protected environment, regulated by parents/caregivers, and without access to potential dangers such as motor vehicles, drugs, alcohol and adult (or almost adult) peers and sexual partners. Having the physical appearance of a sexually immature 11 year old in high school can present emotional and social challenges that are amplified by gender dysphoria.
Available data from the Netherlands indicates that those youth who reach adolescence with gender dysphoria are unlikely to revert to a gender identity that is congruent with their assigned sex at birth.

Before HRT treatments are begun for any patient, let alone patients who are minors, physicians and other healthcare providers were advised by UCSF and ethical guidelines from the AMA that they are obligated to review the expectations that patients have about the results of the treatments. According to medical leadership such as the AMA, providers are expected to help patients and their guardians understand what hormones can and cannot achieve, and create realistic expectations about gender-affirming hormones.

Both GnRH analog and gender-affirming hormone administration require parental/legal guardian consent if a patient is under the age of 18.

During the consent process for HRT treatments, released guidelines for providers and advice from UCSF noted that they are expected to include a conversation about fertility.

“While options are being explored to preserve future fertility for transgender youth, the current reality is that cryopreservation is very expensive, in many cases prohibitively so for those with ovaries,” noted the UCSF, “For youth whose pubertal process has been suspended in the earliest stages, followed by administration of gender-affirming hormones, development of mature sperm or eggs is unlikely at the present time, although it is noteworthy that there is active research developing gametes in vitro from the field of juvenile oncology.”

However, it was further noted by UCSF and other cited researchers that future infertility is often more problematic for parents and family members than it is for the patient. It is common for transmasculine youth, for example, to want to stop or prevent their menstrual cycles either through HRT or other contraceptive measures.

Surgical interventions and transgender youth

Since their origins in the 19th and 20th centuries according to a historical review of gender-affirming medicine in The Journal of Sexual Medicine, surgical interventions for transgender and GNC people that are pursuing physical transition have been considered an “integral” part of the process. Being dissatisfied with primary and secondary sex characteristics aligned with those present at one’s birth instead of one’s gender identity has been noted as a fundamental characteristic of gender dysphoria. Although not every transgender or GNC person will feel the need for or pursue these surgeries, they are common.

While there have been some cases of minor patients undergoing surgeries such as mastectomies (commonly pursued by trans-masculine people) or genital reconstruction, said UCSF, there are involved appeals processes for any such surgery. Especially regarding surgeries related to genitalia, the Endocrine Society Guidelines and World Professional Association of Transgender Health (WPATH) recommend that those surgeries are deferred until the patient in question is over 18 years of age.

According to notes from the UCSF and recommendations from WPATH, it is often unlikely that transgender and GNC children will be offered or be able to pursue surgeries before they are adults.

Regret and de-transitioning

As the access to gender-affirming treatments and surgeries has increased over the last few decades, concerns have been raised by some regarding how frequently people regret those treatments. Scientists and other researchers have undergone a number of studies to gauge the rate of satisfaction among people who pursue gender-affirming treatments and surgeries.

Both anecdotally and through scientific studies, such as those published by researchers from the Children’s Hospital of Los Angeles and the University of Southern California in Los Angeles, gender-affirming surgeries have been shown to positively impact both minors and young adults. The major study currently in circulation on the subject was conducted from 1972 through 2015 and focused on understanding the prevalence of gender dysphoria, how frequently gender-affirming treatments are performed, and the number of people experiencing regret.

As a result of the study, researchers reported that only 0.6% of transfeminine people and 0.3% of transmasculine people that underwent gender-affirming surgeries said they experienced regret.

Further, as once again noted by the UCSF, the reasons that transgender and GNC people experience regret after surgeries and transition, or “de-transition” back to a gender performance more aligned with how their sex was assigned to them at birth, vary. Often, people cite financial limitations, a lack of access to support and other resources, day-to-day violence and discrimination, and rejection from friends and family as major reasons for regret or de-transition. In essence, reasons not related to the person’s gender identity and desires.

Part II || Mental health for LGBTQ+ youth, safety, and discrimination

LGBTQ+ youth in Texas and the US

Estimated Transgender Youth Population in the United States, September 2020

Texas and California have been noted by researchers as the two states in the US with the highest amount of transgender and GNC youth. With over 10,000 reported transgender and GNC youth in each of those states, according to assembled reports from the University of California in Los Angeles (UCLA), their policies and resources stand to impact the majority of the demographic in the country.

As politicians and other community leaders across the country have increasingly begun to spread misinformation and sponsor restrictive policies targeting transgender and GNC youth, outreach organizations like the National Center for Transgender Equality have noted the difficulties those children face have only become more severe.

Homelessness, discrimination, and other struggles of transgender youth

Across the US, according to the National Center for Transgender Equality, one in five transgender people will experience homelessness at least once in their lifetime. According to a report from Chapin Hall at the University of Chicago, LGBTQ+ minors are 120% more likely to experience homelessness than their straight and cisgender counterparts. With around 7% of youth in the US reported as being LGBTQ+, the difference between the demographics is both obvious and severe.

In Texas, more than 30% of youth in foster care identify as LGBTQ+, compared to about 11% of the general population. The disparity, according to Texas CASA, is due in large part to the fact that children coming out to family members can lead to verbal and physical harassment, abuse, and full-on rejection. Texas CASA noted that those children face the same challenges and barriers as their peers such as dealing with trauma, placement changes, falling behind in school, mental health challenges, and more, but with the added layer of fear and further rejection, abuse, and harassment if they are open about their LGBTQ+ identity.

A lack of resources for healthcare, and a lack of information and communication between healthcare providers and the families and guardians of transgender and GNC youth, work to present further barriers for an already-struggling demographic. Transgender and GNC youth also face barriers in pursuing healthcare when in foster care or as wards of the state, with the need to seek court approval for seeking out puberty blockers and other gender-affirming treatments, according to UCSF.

LGBTQ+ mental health and suicide

Transgender and GNC children are more at risk for depression, anxiety, suicidal thoughts, and suicide attempts than their non-transgender peers, according to researchers included in the Journal of Adolescent Health. Healthcare leaders have noted that social transitioning or social gender affirmation is a way for children to express their identity. Further, recent studies have shown that the mental health of transgender and GNC youth who get social affirmations of their gender identity is very similar to their non-transgender peers.

“Gender is a crucial part of identity,” said Suzanne E. Kingery, M.D., a pediatric endocrinologist with Norton Children’s Endocrinology.

In a national survey of LGBTQ+ youth mental health for 2021, 42% of LGBTQ+ youth reported seriously considered attempting suicide in the past year – including more than half of transgender and nonbinary youth. Other key notes from the survey included:

94% of LGBTQ youth reported that recent politics negatively impacted their mental health.
More than 80% of LGBTQ+ youth said that COVID-19 made their living situation more stressful – and only one in three LGBTQ youth found their home to be affirming.
48% of LGBTQ+ youth reported they wanted counseling from a mental health professional but were not able to receive it in the last year.
30% of LGBTQ+ youth experienced food insecurity in the past month, including half of all Native/Indigenous LGBTQ+ youth.
75% of LGBTQ+ youth reported that they had experienced discrimination based on their sexual orientation or gender identity at elast once in their lfietime.
13% of LGBTQ+ youth reported being subjected to conversion therapy, with 83% reporting that it happened when they were under age 19.
Transgender and nonbinary youth who reported having pronouns respected by all of the people they lived with attempted suicide at half the rate of those who did not have their pronouns respected.
Transgender and nonbinary youth who were able to change their name and/or gender marker on legal documents, such as driver’s licenses and birth certificates, reported lower rates of attempting suicide.
LGBTQ+ youth who had access to spaces that affirmed their sexual orientation and gender identity reported lower rates of attempting suicide.

Overwhelmingly studies, medical leaders, healthcare organizations, and LGBTQ+ people themselves have shown that presenting transgender and GNC youth with affirmative support, mental and physical healthcare resources, and otherwise accepting environments is the most productive path to ensuring their health and safety.

Part III || What now? Resources and next steps

According to the above-mentioned studies, surveys, ethical guidelines, and testimony from healthcare leaders, gender-affirming care for transgender and GNC youth is not abusive or harmful as some politicians are increasingly beginning to claim. Rather, affirming and supportive care – socially, mentally, and medically – for transgender and GNC youth is necessary and, according to those sources and others such as the Trevor Project, life-saving.

Numerous organizations across Amarillo, the Texas Panhandle, the State of Texas, and the US have worked to offer education and resources to transgender and GNC individuals and their families. These include: