Social Issues

FAQ: What you need to know about transgender children

Transgender rights have once again emerged as a political flash point in America.

While President Biden signed an executive order expanding protections for LGBTQ people, Republican lawmakers have sought to roll back the rights of the transgender community — especially the rights of children. Across the country, conservative legislators have introduced and passed a wave of bills that would ban medical treatments for transgender children and restrict transgender students from playing in sports according to their gender identity.

Many of these political debates are laden with misinformation and misunderstandings about what it means to be a transgender teenager today, advocates and medical experts say.

Informed by medical guidelines, and interviews with doctors and experts, The Washington Post compiled answers to some of the most commonly asked questions about transgender young people.

Understanding the transgender community: The basics

What does it mean to be transgender?

Transgender is an umbrella term for anyone whose gender does not align with their sex assigned at birth. Cisgender is a term applied to people who are not transgender — people whose gender identity matches their assigned sex.

Gender identity is not the same thing as gender expression. For example, a cisgender woman might present in a more stereotypically “masculine” way but still identify as her female sex assigned at birth.

How do doctors diagnose gender dysphoria?

Gender dysphoria is defined as “psychological distress” that results from a mismatch between one’s sex assigned at birth and one’s gender identity, according to the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association (APA).

Not everyone who is transgender is diagnosed with gender dysphoria. Some transgender people do not feel discomfort or distress in their bodies. And not all people diagnosed with gender dysphoria will choose to undergo medical treatments or transition-related surgeries.

For adolescents to be diagnosed with gender dysphoria, they must have experienced “a marked incongruence” between their gender and their assigned sex at birth, lasting at least six months, according to the APA diagnostic manual. For young adolescents, this can be manifested as a strong desire to prevent the development of secondary sex characteristics, such as facial hair or breast growth.

Gender dysphoria can have serious health impacts. It can affect a person’s ability to function at school or work and can lead to intense anxiety, depression and suicide risk. Some adolescents or adults have experienced distress using the bathroom and developed gastrointestinal issues as a result, said Jack Turban, a doctor and fellow in child and adolescent psychiatry at Stanford University School of Medicine. Some transgender people who bind their chests have experienced skin infections and respiratory problems, Turban said.

A recent study from Turban and a team of other researchers found that exposure to gender identity conversion therapy — attempts by a professional to force a transgender person to be cisgender — was associated with increased odds of attempting suicide. Instead, major medical organizations such as the American Academy of Pediatrics have encouraged doctors and parents to take a gender-affirming approach to a transgender child’s care.

Jasper Swartz, 17, of Takoma Park, Md., identifies as nonbinary and uses they/them pronouns. Jasper is a member of Generation Z, a group of young Americans that is breaking from binary notions of gender and sexuality. (Bonnie Jo Mount/The Washington Post)

At what age do young people realize they are transgender?

This depends entirely on each individual case. With more information about the transgender community becoming available to young people and their parents, more children are coming out at earlier ages than in the past, and more transgender clinics are available to provide them with care.

Some people don’t realize they are transgender until they reach puberty, or later in adulthood. But some children show signs that they are transgender early on in childhood. “Not everybody puts their puzzle together in the same way or at the same time,” said Johanna Olson-Kennedy, medical director of the Center for Transyouth Health and Development at Children’s Hospital Los Angeles, one of the largest transgender clinics in the country.

Olson-Kennedy said the vast majority of transgender youth patients at the clinic first arrive when they have already reached puberty. The average age for presentation for services at the clinic is 15, she said. Despite the intense political focus on young transgender children, only 10 percent of the children arriving at her clinic are pre-pubertal.

How many young people identify as transgender?

The Williams Institute at the UCLA School of Law estimates that 0.7 percent of teens ages 13 to 17 identify as transgender. A recent Gallup poll found that 11 percent of LGBT adults identify as transgender. Re-basing this percentage to represent the share of the U.S. adult population, Gallup found that 0.6 percent of U.S. adults identify as transgender. But among Generation Z adults, about 2 percent identify as transgender, and researchers expect that number to continue to grow.

Does this mean there are more transgender people than before? Advocates say it’s merely a sign that more transgender people have the information and language available to understand and describe their identities. Transgender people have existed throughout history, including transgender children. But many clinics have been treating transgender children only in recent decades. Olson-Kennedy said her clinic has been taking care of trans young people since the 1990s.

“What’s happening now is not a massive surge in transgender people,” said transgender advocate Gillian Branstetter. “It’s an understanding that gender, much like sexuality, exists on a spectrum and is more fluid than people allow.”

What does it mean to be nonbinary?

Nonbinary is a term used to describe people who do not identify exclusively as male or female. Some nonbinary people also identify as transgender, and some are also diagnosed with gender dysphoria, but others are not. Many — but not all — nonbinary people use they/them pronouns, instead of he/him or she/her. Some nonbinary people will use a combination of different pronouns.

What does it mean to be intersex?

Intersex is an umbrella term used to describe people with differences in sex traits or reproductive anatomy, which can include variations in genitalia, internal anatomy, hormones or chromosomes. Some people are born with these differences, while others develop them in childhood, according to the organization InterACT.

Transgender medical care for children

How does a young child transition?

For pre-pubertal transgender children diagnosed with gender dysphoria, doctors recommend avoiding gender-affirming medications, according to the Endocrine Society’s Clinical Practice Guideline, which sets standards of care for transgender people.

“If you have not yet started puberty, there’s nothing to block and nothing to add,” Olson-Kennedy said. “It’s about creating environments that are supportive.”

Rather than beginning a medical transition, pre-pubertal transgender children may begin a social transition, changing one’s name and pronouns, and wearing different clothing or hairstyles. This transition can in some cases involve legal changes to names and genders listed in identifying documents. Transgender children are not offered puberty blockers or hormone treatments until they reach puberty. Medical guidelines generally do not recommend genital gender-affirming surgeries before a child reaches age 18.

Chloe Clark, 15, who is a transgender girl, shops at an Urban Outfitters in Richmond Heights, Mo., on March 7, 2020. State legislators are considering a bill that would limit medical treatments for transgender minors. (Whitney Curtis for The Washington Post)

What are puberty blockers and when are they offered to transgender children?

Once a transgender child has met diagnostic criteria for gender dysphoria, and after the child first shows physical changes of puberty, clinicians may recommend puberty-suppressing treatments, also known as puberty blockers.

Puberty blockers are fully reversible. The medications pause puberty and prevent unwanted changes to teenagers’ bodies, such as periods in transgender boys or the deepening of the voice in transgender girls. The puberty blockers are intended to give young people more time to decide what to do next. At any point, a transgender teenager can stop taking puberty blockers and will continue to go through the puberty of their sex assigned at birth.

For decades, puberty suppression has been used by doctors to treat precocious puberty — abnormally early onset of puberty — in children, as well as endometriosis and prostate cancer in adults. But it was first used as gender-affirming treatment in the 1990s, at a transgender clinic in the Netherlands.

Politicians critical of puberty blockers have at times focused on federal approvals for the drugs. While puberty suppressants are approved by the Food and Drug Administration to treat children with precocious puberty, the medications have not been approved specifically for gender-affirming care. Olson-Kennedy argues that this lack of approval is because drug firms have declined to perform the studies necessary to get these approvals.

In general, because many drug companies avoid performing trials on children, it is common in pediatric medicine for doctors to prescribe drugs off-label.

What are hormone treatments and when are they offered to transgender youth?

Once a transgender teenager reaches later years in adolescence, some may request sex hormone treatment — estrogen for transgender girls and testosterone for transgender boys. These medications can help align a transgender person’s body to their gender identity, leading to facial hair growth and a deeper voice in transgender boys, for example, and breast growth in transgender girls.

Since these are partly irreversible treatments, the Endocrine Society recommends waiting to begin treatment until after a person has “sufficient mental capacity to give informed consent,” which the society said most adolescents have by age 16. In some cases, according to the 2017 guidelines, transgender youth may have this capacity by age 14. Each teenager’s ability to consent has to be determined individually, Olson-Kennedy said. “One person’s 14 is very different from another person’s 14.”

The Endocrine Society recommends starting treatment with a gradually increasing dose schedule carefully monitored by a multidisciplinary team of doctors.

In recent debates over transgender medical care, politicians have made claims that transgender children are undergoing genital surgeries at young ages. Current medical guidelines say children should not undergo gender-affirming genital surgery before they turn 18.

Chest surgeries can be performed on transgender teenagers before the age of majority in a given country (age 18 in the United States), according to standards of care from the World Professional Association for Transgender Health, “preferably after ample time of living in the desired gender role and after one year of testosterone treatment.”

Chloe Clark takes her prescription medicine, which includes hormone therapy drugs, before school on March 6, 2020, in St. Louis. (Whitney Curtis for The Washington Post)

What does scientific research tell us about these treatments and their impacts?

Research on these medications is still evolving, due in part to the nascent nature of the treatments, the challenges of performing studies on children and the small size of the transgender youth population. But several studies on puberty blockers have found that transgender young people who were treated with the medications showed lower rates of depression and anxiety, and demonstrated better global functioning.

A study conducted by Turban and colleagues, published in the journal Pediatrics in 2020, showed that young people who wanted a puberty suppressant and were able to access it had lower odds of considering suicide.

Critics of gender-affirming treatments often argue that children are too young to make these decisions and may regret them in adulthood. Skeptics will often cite statistics from studies suggesting that a majority of young transgender children will eventually grow out of their transgender identity later in life. But Turban and other experts have argued the methodology used in these studies is flawed because the researchers included a large cohort of children referred to transgender clinics, not children who actually met the criteria for gender dysphoria. He argued that many of these children were not transgender to begin with and may have simply been brought to the clinics by their parents because they were “tomboys” or gender-nonconforming children.

A new study by Turban and other researchers from the Fenway Institute and Harvard Medical School found that 13.1 percent of currently identified transgender people have “detransitioned” at some point in their lives but that 82.5 percent of those people attributed their decision to external factors such as pressure from family, school environments and vulnerability to violence.

What are some of the risks of these medications?

Since puberty blockers are reversible, they do not impair fertility or lead to other permanent changes to a child’s body. Puberty suppressants do come with some risks, and the Endocrine Society’s 2017 guidelines mentioned the need for more research on the effects of the prolonged delay of puberty in adolescents.

Puberty suppression may include adverse effects on bone mineralization, according to the Endocrine Society, but the estimated calculated risk of bone fracture remains extremely low, Turban said, citing a recent paper in Pediatrics. For each patient, this likely low risk of fracture needs to be weighed against the risk of adverse outcomes from gender dysphoria itself, Turban said.

If a child has been on puberty blockers for years, “most endocrinologists will say by the time you get to 16, you make a decision. Either come off the blocker or start estrogen or testosterone to mineralize your bone,” Turban said.

For transgender teenagers who first take puberty blockers and then take estrogen and testosterone treatments, the Endocrine Society warns that the treatment may compromise fertility later in life. But Turban says more research is needed on the subject. The Endocrine Society recommends that clinicians counsel all transgender people seeking hormone treatments on their options for fertility preservation before they start taking estrogen or testosterone.

What legislation has advanced in the U.S. to restrict these medications?

As of April, at least 18 states have introduced bills to criminalize or ban access to puberty blockers, hormone treatments and transition-related surgeries for transgender minors. Legislators in Arkansas in early April voted to pass the nation’s first ban on gender-affirming medical treatments for transgender youth, overriding a veto from their governor. Gov. Asa Hutchinson (R) described the bill as a “vast government overreach” that would interfere with physicians and parents “as they deal with some of the most complex and sensitive matters involving young people.”

Major medical organizations including the American Psychiatric Association, American Academy of Pediatrics and the American College of Physicians have written in opposition to these bills. And according to the Williams Institute at UCLA School of Law, an estimated 45,100 transgender youth ages 13 and older in the United States are at risk of being denied gender-affirming medical treatments due to proposed and enacted state bans.

Transgender youth and sports

What are the current guidelines in the U.S. for the participation of transgender people in sports?

Policies on the participation of transgender students in high school sports vary from state to state. At least 16 states and the District of Columbia have policies that help facilitate the full inclusion of transgender, nonbinary and gender-nonconforming students in high school sports, according to TransAthlete.com and the American Civil Liberties Union. A patchwork of policies exists in other states, with at least 10 states requiring trans athletes to undergo some treatment, and 12 states effectively banning participation, including four that passed new laws and executive orders this year.

At the college level, NCAA guidelines require at least a full year of testosterone suppression before a transgender woman is allowed to compete with other women. That guidance, published in 2011 and citing medical experts, notes that transgender women “display a great deal of physical variation, just as there is a great deal of natural variation in physical size and ability among non-transgender women and men. … It is important not to overgeneralize.” The assumption that all people assigned male at birth are “taller, stronger, and more highly skilled in a sport” is not accurate, the handbook states.

At elite levels, policies also vary across national and international associations and federations. The International Olympic Committee issued guidance in 2015 for determining eligibility. According to the guidance, transgender men can compete in male categories without restriction, but transgender women must meet certain conditions, including demonstrating that their total testosterone level in serum has been below 10 nmol/L for at least 12 months before their first competition.

Andraya Yearwood, a transgender student-athlete, participates in the Connecticut Winter Indoor Track Championships in New Haven last year. (Stan Godlewski for The Washington Post)

What research is available about transgender athletes and whether they have an advantage over cisgender athletes?

Across the country, more than half of U.S. states have introduced bills in 2021 that would bar transgender participation in school sports according to their gender identity. Many of these bills argue that transgender women and girls have a biological advantage over cisgender girls when competing in sports. An Idaho bill, which was signed into law in 2020 but has been stalled in court proceedings, argues that transgender girls and women have “denser, stronger bones” and “larger hearts, greater lung volume per body mass” and other characteristics that lawmakers claimed would give transgender women an athletic edge.

But studies of the performance of transgender athletes so far are limited and based on small, narrow samples that some researchers say cannot necessarily be applied to high school sports.

One study published in the British Journal of Sports Medicine in 2020 suggested that transgender women in the U.S. Air Force retained certain athletic advantages over cisgender female peers for about two years into hormone therapy. The researchers assessed the medical records and fitness tests of 29 transgender men and 46 transgender women from 2013 and 2018, reviewing the number of push-ups and sit-ups they could perform in a minute and the time required to run 1½ miles.

The study’s authors found that when it comes to muscle strength, after two years of hormone therapy “you can’t distinguish the performance of the trans women with the average performance of cis women in the Air Force,” said the study’s lead author, Timothy Roberts, director of the adolescent medicine training program at Children’s Mercy Hospital in Kansas City, Mo. When it came to running times, the transgender women’s times did slow down but were still 12 percent faster on average than those of their cisgender female peers. But looking at the spread of run times among cisgender women, the transgender women were still slower than 9 percent of them.

“There’s natural variation in talent, there’s natural variation in testosterone levels,” Roberts said. “There’s never really been a level playing field.”

Roberts and the other authors of the study have cautioned against applying the study’s findings to high school athletics. The average age of the U.S. Air Force members in the study was 26. The athletic abilities of a trans person undergoing hormone therapy as an adult are going to be vastly different from those transitioning as teenagers. Roberts said. For transgender teenage girls who took puberty blockers followed by estrogen treatments, “they probably have absolutely no advantages over the other cisgender women.”

LGBTQ advocates and health experts say that assertions about the biological advantages of transgender athletes also fail to take into account social hurdles that may affect a transgender athlete’s ability to compete.

“Harassment and discrimination, years of internal turmoil and shame and a lack of validation … that inhibits the ability to thrive,” said Chase Strangio, an attorney and deputy director for transgender justice at the ACLU.

Olson-Kennedy said many of the trans girls she treats in her clinic avoid playing sports, in part because they don’t want to build muscle, but also because “in competitive sports … everything about it is dysphoria-producing,” she said. “What are people going to say? Are they going to accept me on the girls’ team? What’s the locker room situation going to be like?” These are the kinds of questions transgender girls ask before even considering playing sports, Olson-Kennedy said.

Some of the recent legislation has raised questions about how the restrictions would be enforced, and whether high school athletes would be subject to physical exams. LGBTQ advocates and transgender health experts say demanding certain hormone levels or requiring sex-verification exams to determine eligibility in sports can be harmful to both transgender and cisgender young people.

A proposed ban on transgender athletes participating in girls’ sports at public high schools in Utah would affect transgender girls like this 12-year-old swimmer seen at a pool in Utah on Feb. 22. (Rick Bowmer/AP)

How has the participation of transgender girls in sports impacted outcomes for cisgender high school athletes?

As lawmakers across the country introduced bills to restrict transgender participation in sports, the Associated Press contacted two dozen state lawmakers sponsoring such legislation. In almost every case, the AP reported, lawmakers could not cite “a single instance in their own state or region where such participation has caused problems.”

Many supporters of these bills point to a 2020 case in Connecticut. The families of three Connecticut high school track and field athletes filed a federal lawsuit objecting to a Connecticut Interscholastic Athletic Conference rule that allows high school athletes to compete in sports corresponding with their gender identity.

The lawsuit centered on transgender runners Andraya Yearwood and Terry Miller, who won a combined 15 state titles in different events. But two days after the Connecticut lawsuit was filed, one of the cisgender plaintiffs defeated one of the transgender girls in a state championship.

“We’ve had years and, in some cases, decades of inclusion … and just quite simply there are no examples of trans people taking over or winning in any sort of significant numbers,” Strangio said. “And there’s been zero examples of a trans girl in high school getting an athletic scholarship to compete in college.”

Typography animation by Sarah Hashemi and Audrey Valbuena. Editing by Annys Shin. Copy editing by Mike Cirelli. Design by J.C. Reed.

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