gender reassignment surgery america

Putting numbers on the rise in children seeking gender care

By ROBIN RESPAUT and CHAD TERHUNE

Filed Oct. 6, 2022, 11 a.m. GMT

Thousands of children in the United States now openly identify as a gender different from the one they were assigned at birth, their numbers surging amid growing recognition of transgender identity and rights even as they face persistent prejudice and discrimination.

As the number of transgender children has grown, so has their access to gender-affirming care, much of it provided at scores of clinics at major hospitals.

Reliable counts of adolescents receiving gender-affirming treatment have long been guesswork – until now. Reuters worked with health technology company Komodo Health Inc to identify how many youths have sought and received care. The data show that more and more families across the country are grappling with profound questions about what type of care to pursue for their children, placing them at the center of a vitriolic national political debate over what it means to protect youth who identify as transgender.

Diagnoses of youths with gender dysphoria surge

In 2021, about 42,000 children and teens across the United States received a diagnosis of gender dysphoria, nearly triple the number in 2017, according to data Komodo compiled for Reuters. Gender dysphoria is defined as the distress caused by a discrepancy between a person’s gender identity and the one assigned to them at birth.

Overall, the analysis found that at least 121,882 children ages 6 to 17 were diagnosed with gender dysphoria from 2017 through 2021. Reuters found similar trends when it requested state-level data on diagnoses among children covered by Medicaid, the public insurance program for lower-income families.

Gender-affirming care for youths takes several forms, from social recognition of a preferred name and pronouns to medical interventions such as hormone therapy and, sometimes, surgery. A small but increasing number of U.S. children diagnosed with gender dysphoria are choosing medical interventions to express their identity and help alleviate their distress.

These medical treatments don’t begin until the onset of puberty, typically around age 10 or 11.

For children at this age and stage of development, puberty-blocking medications are an option. These drugs, known as GnRH agonists, suppress the release of the sex hormones testosterone and estrogen. The U.S. Food and Drug Administration has approved the drugs to treat prostate cancer, endometriosis and central precocious puberty, but not gender dysphoria. Their off-label use in gender-affirming care, while legal, lacks the support of clinical trials to establish their safety for such treatment.

Over the last five years, there were at least 4,780 adolescents who started on puberty blockers and had a prior gender dysphoria diagnosis.

This tally and others in the Komodo analysis are likely an undercount because they didn’t include treatment that wasn’t covered by insurance and were limited to pediatric patients with a gender dysphoria diagnosis. Practitioners may not log this diagnosis when prescribing treatment.

By suppressing sex hormones, puberty-blocking medications stop the onset of secondary sex characteristics, such as breast development and menstruation in adolescents assigned female at birth. For those assigned male at birth, the drugs inhibit development of a deeper voice and an Adam’s apple and growth of facial and body hair. They also limit growth of genitalia.

Without puberty blockers, such physical changes can cause severe distress in many transgender children. If an adolescent stops the medication, puberty resumes.

The medications are administered as injections, typically every few months, or through an implant under the skin of the upper arm.

After suppressing puberty, a child may pursue hormone treatments to initiate a puberty that aligns with their gender identity. Those for whom the opportunity to block puberty has already passed or who declined the option may also pursue hormone therapy.

At least 14,726 minors started hormone treatment with a prior gender dysphoria diagnosis from 2017 through 2021, according to the Komodo analysis.

Hormones – testosterone for adolescents assigned female at birth and estrogen for those assigned male – promote development of secondary sex characteristics. Adolescents assigned female at birth who take testosterone may notice that fat is redistributed from the hips and thighs to the abdomen. Arms and legs may appear more muscular. The brow and jawline may become more pronounced. Body hair may coarsen and thicken. Teens assigned male at birth who take estrogen may notice the hair on their body softens and thins. Fat may be redistributed from the abdomen to the buttocks and thighs. Their testicles may shrink and sex drive diminish. Some changes from hormone treatment are permanent.

Hormones are taken in a variety of ways: injections, pills, patches and gels. Some minors will continue to take hormones for many years well into adulthood, or they may stop if they achieve the physical traits they want.

Hormone treatment may leave an adolescent infertile, especially if the child also took puberty blockers at an early age. That and other potential side effects are not well-studied, experts say.

The ultimate step in gender-affirming medical treatment is surgery, which is uncommon in patients under age 18. Some children’s hospitals and gender clinics don’t offer surgery to minors, requiring that they be adults before deciding on procedures that are irreversible and carry a heightened risk of complications.

The Komodo analysis of insurance claims found 56 genital surgeries among patients ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021. Among teens, “top surgery” to remove breasts is more common. In the three years ending in 2021, at least 776 mastectomies were performed in the United States on patients ages 13 to 17 with a gender dysphoria diagnosis, according to Komodo’s data analysis of insurance claims. This tally does not include procedures that were paid for out of pocket.

A note on the data

Komodo’s analysis draws on full or partial health insurance claims for about 330 million U.S. patients over the five years from 2017 to 2021, including patients covered by private health plans and public insurance like Medicaid. The data include roughly 40 million patients annually, ages 6 through 17, and comprise health insurance claims that document diagnoses and procedures administered by U.S. clinicians and facilities.

To determine the number of new patients who initiated puberty blockers or hormones, or who received an initial dysphoria diagnosis, Komodo looked back at least one year prior in each patient’s record. For the surgery data, Komodo counted multiple procedures on a single day as one procedure.

For the analysis of pediatric patients initiating puberty blockers or hormones, Komodo searched for patients with a prior gender dysphoria diagnosis. Patients with a diagnosis of central precocious puberty were removed. A total of 17,683 patients, ages 6 through 17, with a prior gender dysphoria diagnosis initiated either puberty blockers or hormones or both during the five-year period. Of these, 4,780 patients had initiated puberty blockers and 14,726 patients had initiated hormone treatment.

Youth in Transition

By Robin Respaut and Chad Terhune

Photo editing: Corrine Perkins

Art direction: John Emerson

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Gender Confirmation Surgery (GCS)

What is Gender Confirmation Surgery?

• Transfeminine Tr

Transmasculine Transition

• Traveling Abroad

Choosing a Surgeon

Gender confirmation surgery (GCS), known clinically as genitoplasty, are procedures that surgically confirm a person's gender by altering the genitalia and other physical features to align with their desired physical characteristics. Gender confirmation surgeries are also called gender affirmation procedures. These are both respectful terms.

Gender dysphoria , an experience of misalignment between gender and sex, is becoming more widely diagnosed.  People diagnosed with gender dysphoria are often referred to as "transgender," though one does not necessarily need to experience gender dysphoria to be a member of the transgender community. It is important to note there is controversy around the gender dysphoria diagnosis. Many disapprove of it, noting that the diagnosis suggests that being transgender is an illness.

Ellen Lindner / Verywell

Transfeminine Transition

Transfeminine is a term inclusive of trans women and non-binary trans people assigned male at birth.

Gender confirmation procedures that a transfeminine person may undergo include:

• Penectomy is the surgical removal of external male genitalia.
• Orchiectomy is the surgical removal of the testes.
• Vaginoplasty is the surgical creation of a vagina.
• Feminizing genitoplasty creates internal female genitalia.
• Breast implants create breasts.
• Gluteoplasty increases buttock volume.
• Chondrolaryngoplasty is a procedure on the throat that can minimize the appearance of Adam's apple .

Feminizing hormones are commonly used for at least 12 months prior to breast augmentation to maximize breast growth and achieve a better surgical outcome. They are also often used for approximately 12 months prior to feminizing genital surgeries.

Facial feminization surgery (FFS) is often done to soften the lines of the face. FFS can include softening the brow line, rhinoplasty (nose job), smoothing the jaw and forehead, and altering the cheekbones. Each person is unique and the procedures that are done are based on the individual's need and budget,

Transmasculine is a term inclusive of trans men and non-binary trans people assigned female at birth.

Gender confirmation procedures that a transmasculine person may undergo include:

• Masculinizing genitoplasty is the surgical creation of external genitalia. This procedure uses the tissue of the labia to create a penis.
• Phalloplasty is the surgical construction of a penis using a skin graft from the forearm, thigh, or upper back.
• Metoidioplasty is the creation of a penis from the hormonally enlarged clitoris.
• Scrotoplasty is the creation of a scrotum.

Procedures that change the genitalia are performed with other procedures, which may be extensive.

The change to a masculine appearance may also include hormone therapy with testosterone, a mastectomy (surgical removal of the breasts), hysterectomy (surgical removal of the uterus), and perhaps additional cosmetic procedures intended to masculinize the appearance.

Paying For Gender Confirmation Surgery

Medicare and some health insurance providers in the United States may cover a portion of the cost of gender confirmation surgery.

It is unlawful to discriminate or withhold healthcare based on sex or gender. However, many plans do have exclusions.

For most transgender individuals, the burden of financing the procedure(s) is the main difficulty in obtaining treatment. The cost of transitioning can often exceed $100,000 in the United States, depending upon the procedures needed.

A typical genitoplasty alone averages about $18,000. Rhinoplasty, or a nose job, averaged $5,409 in 2019.  

Traveling Abroad for GCS

Some patients seek gender confirmation surgery overseas, as the procedures can be less expensive in some other countries. It is important to remember that traveling to a foreign country for surgery, also known as surgery tourism, can be very risky.

Regardless of where the surgery will be performed, it is essential that your surgeon is skilled in the procedure being performed and that your surgery will be performed in a reputable facility that offers high-quality care.

When choosing a surgeon , it is important to do your research, whether the surgery is performed in the U.S. or elsewhere. Talk to people who have already had the procedure and ask about their experience and their surgeon.

Before and after photos don't tell the whole story, and can easily be altered, so consider asking for a patient reference with whom you can speak.

It is important to remember that surgeons have specialties and to stick with your surgeon's specialty. For example, you may choose to have one surgeon perform a genitoplasty, but another to perform facial surgeries. This may result in more expenses, but it can result in a better outcome.

A Word From Verywell

Gender confirmation surgery is very complex, and the procedures that one person needs to achieve their desired result can be very different from what another person wants.

Each individual's goals for their appearance will be different. For example, one individual may feel strongly that breast implants are essential to having a desirable and feminine appearance, while a different person may not feel that breast size is a concern. A personalized approach is essential to satisfaction because personal appearance is so highly individualized.

Davy Z, Toze M. What is gender dysphoria? A critical systematic narrative review . Transgend Health . 2018;3(1):159-169. doi:10.1089/trgh.2018.0014

Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization: Systematic Review of the Literature . Plast Reconstr Surg. 2016;137(6):1759-70. doi:10.1097/PRS.0000000000002171

Hadj-moussa M, Agarwal S, Ohl DA, Kuzon WM. Masculinizing Genital Gender Confirmation Surgery . Sex Med Rev . 2019;7(1):141-155. doi:10.1016/j.sxmr.2018.06.004

Dowshen NL, Christensen J, Gruschow SM. Health Insurance Coverage of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information . Transgend Health . 2019;4(1):131-135. doi:10.1089/trgh.2018.0055

American Society of Plastic Surgeons. Rhinoplasty nose surgery .

Rights Group: More U.S. Companies Covering Cost of Gender Reassignment Surgery. CNS News. http://cnsnews.com/news/article/rights-group-more-us-companies-covering-cost-gender-reassignment-surgery

The Sex Change Capital of the US. CBS News. http://www.cbsnews.com/2100-3445_162-4423154.html

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

• Introduction
• Conclusions
• Article Information

Error bars represent 95% CIs. GAS indicates gender-affirming surgery.

Percentages are based on the number of procedures divided by number of patients; thus, as some patients underwent multiple procedures the total may be greater than 100%. Error bars represent 95% CIs.

eTable.  ICD-10 and CPT Codes of Gender-Affirming Surgery

eFigure. Percentage of Patients With Codes for Gender Identity Disorder Who Underwent GAS

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Wright JD , Chen L , Suzuki Y , Matsuo K , Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348

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National Estimates of Gender-Affirming Surgery in the US

• 1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
• 2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

Question   What are the temporal trends in gender-affirming surgery (GAS) in the US?

Findings   In this cohort study of 48 019 patients, GAS increased significantly, nearly tripling from 2016 to 2019. Breast and chest surgery was the most common class of procedures performed overall; genital reconstructive procedures were more common among older individuals.

Meaning   These findings suggest that there will be a greater need for clinicians knowledgeable in the care of transgender individuals with the requisite expertise to perform gender-affirming procedures.

Importance   While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

Objective   To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants   This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures   Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

Results   A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance   Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Gender dysphoria is characterized as an incongruence between an individual’s experienced or expressed gender and the gender that was assigned at birth. 1 Transgender individuals may pursue multiple treatments, including behavioral therapy, hormonal therapy, and gender-affirming surgery (GAS). 2 GAS encompasses a variety of procedures that align an individual patient’s gender identity with their physical appearance. 2 - 4

While numerous surgical interventions can be considered GAS, the procedures have been broadly classified as breast and chest surgical procedures, facial and cosmetic interventions, and genital reconstructive surgery. 2 , 4 Prior studies 2 - 7 have shown that GAS is associated with improved quality of life, high rates of satisfaction, and a reduction in gender dysphoria. Furthermore, some studies have reported that GAS is associated with decreased depression and anxiety. 8 Lastly, the procedures appear to be associated with acceptable morbidity and reasonable rates of perioperative complications. 2 , 4

Given the benefits of GAS, the performance of GAS in the US has increased over time. 9 The increase in GAS is likely due in part to federal and state laws requiring coverage of transition-related care, although actual insurance coverage of specific procedures is variable. 10 , 11 While prior work has shown that the use of inpatient GAS has increased, national estimates of inpatient and outpatient GAS are lacking. 9 This is important as many GAS procedures occur in ambulatory settings. We performed a population-based analysis to examine trends in GAS in the US and explored the temporal trends in the types of GAS performed across age groups.

To capture both inpatient and outpatient surgical procedures, we used data from the Nationwide Ambulatory Surgery Sample (NASS) and the National Inpatient Sample (NIS). NASS is an ambulatory surgery database and captures major ambulatory surgical procedures at nearly 2800 hospital-owned facilities from up to 35 states, approximating a 63% to 67% stratified sample of hospital-owned facilities. NIS comprehensively captures approximately 20% of inpatient hospital encounters from all community hospitals across 48 states participating in the Healthcare Cost and Utilization Project (HCUP), covering more than 97% of the US population. Both NIS and NASS contain weights that can be used to produce US population estimates. 12 , 13 Informed consent was waived because data sources contain deidentified data, and the study was deemed exempt by the Columbia University institutional review board. This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We selected patients of all ages with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) diagnosis codes for gender identity disorder or transsexualism ( ICD-10 F64) or a personal history of sex reassignment ( ICD-10 Z87.890) from 2016 to 2020 (eTable in Supplement 1 ). We first examined all hospital (NIS) and ambulatory surgical (NASS) encounters for patients with these codes and then analyzed encounters for GAS within this cohort. GAS was identified using ICD-10 procedure codes and Common Procedural Terminology codes and classified as breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures. 2 , 4 Breast and chest surgical procedures encompassed breast reconstruction, mammoplasty and mastopexy, or nipple reconstruction. Genital reconstructive procedures included any surgical intervention of the male or female genital tract. Other facial and cosmetic procedures included cosmetic facial procedures and other cosmetic procedures including hair removal or transplantation, liposuction, and collagen injections (eTable in Supplement 1 ). Patients might have undergone procedures from multiple different surgical groups. We measured the total number of procedures and the distribution of procedures within each procedural group.

Within the data sets, sex was based on patient self-report. The sex of patients in NIS who underwent inpatient surgery was classified as either male, female, missing, or inconsistent. The inconsistent classification denoted patients who underwent a procedure that was not consistent with the sex recorded on their medical record. Similar to prior analyses, patients in NIS with a sex variable not compatible with the procedure performed were classified as having undergone genital reconstructive surgery (GAS not otherwise specified). 9

Clinical variables in the analysis included patient clinical and demographic factors and hospital characteristics. Demographic characteristics included age at the time of surgery (12 to 18 years, 19 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, 61 to 70 years, and older than 70 years), year of the procedure (2016-2020), and primary insurance coverage (private, Medicare, Medicaid, self-pay, and other). Race and ethnicity were only reported in NIS and were classified as White, Black, Hispanic and other. Race and ethnicity were considered in this study because prior studies have shown an association between race and GAS. The income status captured national quartiles of median household income based of a patient’s zip code and was recorded as less than 25% (low), 26% to 50% (medium-low), 51% to 75% (medium-high), and 76% or more (high). The Elixhauser Comorbidity Index was estimated for each patient based on the codes for common medical comorbidities and weighted for a final score. 14 Patients were classified as 0, 1, 2, or 3 or more. We separately reported coding for HIV and AIDS; substance abuse, including alcohol and drug abuse; and recorded mental health diagnoses, including depression and psychoses. Hospital characteristics included a composite of teaching status and location (rural, urban teaching, and urban nonteaching) and hospital region (Northeast, Midwest, South, and West). Hospital bed sizes were classified as small, medium, and large. The cutoffs were less than 100 (small), 100 to 299 (medium), and 300 or more (large) short-term acute care beds of the facilities from NASS and were varied based on region, urban-rural designation, and teaching status of the hospital from NIS. 8 Patients with missing data were classified as the unknown group and were included in the analysis.

National estimates of the number of GAS procedures among all hospital encounters for patients with gender identity disorder were derived using discharge or encounter weight provided by the databases. 15 The clinical and demographic characteristics of the patients undergoing GAS were reported descriptively. The number of encounters for gender identity disorder, the percentage of GAS procedures among those encounters, and the absolute number of each procedure performed over time were estimated. The difference by age group was examined and tested using Rao-Scott χ 2 test. All hypothesis tests were 2-sided, and P  < .05 was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc).

A total of 48 019 patients who underwent GAS were identified ( Table 1 ). Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged 12 to 18 years. Private insurance coverage was most common in 29 064 patients (60.5%), while 12 127 (25.3%) were Medicaid recipients. Depression was reported in 7192 patients (15.0%). Most patients (42 467 [88.4%]) were treated at urban, teaching hospitals, and there was a disproportionate number of patients in the West (22 037 [45.9%]) and Northeast (12 396 [25.8%]). Within the cohort, 31 668 patients (65.9%) underwent 1 procedure while 13 415 (27.9%) underwent 2 procedures, and the remainder underwent multiple procedures concurrently ( Table 1 ).

The overall number of health system encounters for gender identity disorder rose from 13 855 in 2016 to 38 470 in 2020. Among encounters with a billing code for gender identity disorder, there was a consistent rise in the percentage that were for GAS from 4552 (32.9%) in 2016 to 13 011 (37.1%) in 2019, followed by a decline to 12 818 (33.3%) in 2020 ( Figure 1 and eFigure in Supplement 1 ). Among patients undergoing ambulatory surgical procedures, 37 394 (80.3%) of the surgical procedures included gender-affirming surgical procedures. For those with hospital admissions with gender identity disorder, 10 625 (11.8%) of admissions were for GAS.

Breast and chest procedures were most common and were performed for 27 187 patients (56.6%). Genital reconstruction was performed for 16 872 patients (35.1%), and other facial and cosmetic procedures for 6669 patients (13.9%) ( Table 2 ). The most common individual procedure was breast reconstruction in 21 244 (44.2%), while the most common genital reconstructive procedure was hysterectomy (4489 [9.3%]), followed by orchiectomy (3425 [7.1%]), and vaginoplasty (3381 [7.0%]). Among patients who underwent other facial and cosmetic procedures, liposuction (2945 [6.1%]) was most common, followed by rhinoplasty (2446 [5.1%]) and facial feminizing surgery and chin augmentation (1874 [3.9%]).

The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020 ( Figure 1 ). Similar trends were noted for breast and chest surgical procedures as well as genital surgery, while the rate of other facial and cosmetic procedures increased consistently from 2016 to 2020. The distribution of the individual procedures performed in each class were largely similar across the years of analysis ( Table 3 ).

When stratified by age, patients 19 to 30 years had the greatest number of procedures, 25 099 ( Figure 2 ). There were 10 476 procedures performed in those aged 31 to 40 years and 4359 in those aged 41 to 50 years. Among patients younger than 19 years, 3678 GAS procedures were performed. GAS was less common in those cohorts older than 50 years. Overall, the greatest number of breast and chest surgical procedures, genital surgical procedures, and facial and other cosmetic surgical procedures were performed in patients aged 19 to 30 years.

When stratified by the type of procedure performed, breast and chest procedures made up the greatest percentage of the surgical interventions in younger patients while genital surgical procedures were greater in older patients ( Figure 2 ). Additionally, 3215 patients (87.4%) aged 12 to 18 years underwent GAS and had breast or chest procedures. This decreased to 16 067 patients (64.0%) in those aged 19 to 30 years, 4918 (46.9%) in those aged 31 to 40 years, and 1650 (37.9%) in patients aged 41 to 50 years ( P  < .001). In contrast, 405 patients (11.0%) aged 12 to 18 years underwent genital surgery. The percentage of patients who underwent genital surgery rose sequentially to 4423 (42.2%) in those aged 31 to 40 years, 1546 (52.3%) in those aged 51 to 60 years, and 742 (58.4%) in those aged 61 to 70 years ( P  < .001). The percentage of patients who underwent facial and other cosmetic surgical procedures rose with age from 9.5% in those aged 12 to 18 years to 20.6% in those aged 51 to 60 years, then gradually declined ( P  < .001). Figure 2 displays the absolute number of procedure classes performed by year stratified by age. The greatest magnitude of the decline in 2020 was in younger patients and for breast and chest procedures.

These findings suggest that the number of GAS procedures performed in the US has increased dramatically, nearly tripling from 2016 to 2019. Breast and chest surgery is the most common class of procedure performed while patients are most likely to undergo surgery between the ages of 19 and 30 years. The number of genital surgical procedures performed increased with increasing age.

Consistent with prior studies, we identified a remarkable increase in the number of GAS procedures performed over time. 9 , 16 A prior study examining national estimates of inpatient GAS procedures noted that the absolute number of procedures performed nearly doubled between 2000 to 2005 and from 2006 to 2011. In our analysis, the number of GAS procedures nearly tripled from 2016 to 2020. 9 , 17 Not unexpectedly, a large number of the procedures we captured were performed in the ambulatory setting, highlighting the need to capture both inpatient and outpatient procedures when analyzing data on trends. Like many prior studies, we noted a decrease in the number of procedures performed in 2020, likely reflective of the COVID-19 pandemic. 18 However, the decline in the number of procedures performed between 2019 and 2020 was relatively modest, particularly as these procedures are largely elective.

Analysis of procedure-specific trends by age revealed a number of important findings. First, GAS procedures were most common in patients aged 19 to 30 years. This is in line with prior work that demonstrated that most patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age 7 years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. 19 Our findings were also notable that GAS procedures were relatively uncommon in patients aged 18 years or younger. In our cohort, fewer than 1200 patients in this age group underwent GAS, even in the highest volume years. GAS in adolescents has been the focus of intense debate and led to legislative initiatives to limit access to these procedures in adolescents in several states. 20 , 21

Second, there was a marked difference in the distribution of procedures in the different age groups. Breast and chest procedures were more common in younger patients, while genital surgery was more frequent in older individuals. In our cohort of individuals aged 19 to 30 years, breast and chest procedures were twice as common as genital procedures. Genital surgery gradually increased with advancing age, and these procedures became the most common in patients older than 40 years. A prior study of patients with commercial insurance who underwent GAS noted that the mean age for mastectomy was 28 years, significantly lower than for hysterectomy at age 31 years, vaginoplasty at age 40 years, and orchiectomy at age 37 years. 16 These trends likely reflect the increased complexity of genital surgery compared with breast and chest surgery as well as the definitive nature of removal of the reproductive organs.

This study has limitations. First, there may be under-capture of both transgender individuals and GAS procedures. In both data sets analyzed, gender is based on self-report. NIS specifically makes notation of procedures that are considered inconsistent with a patient’s reported gender (eg, a male patient who underwent oophorectomy). Similar to prior work, we assumed that patients with a code for gender identity disorder or transsexualism along with a surgical procedure classified as inconsistent underwent GAS. 9 Second, we captured procedures commonly reported as GAS procedures; however, it is possible that some of these procedures were performed for other underlying indications or diseases rather than solely for gender affirmation. Third, our trends showed a significant increase in procedures through 2019, with a decline in 2020. The decline in services in 2020 is likely related to COVID-19 service alterations. Additionally, while we comprehensively captured inpatient and ambulatory surgical procedures in large, nationwide data sets, undoubtedly, a small number of procedures were performed in other settings; thus, our estimates may underrepresent the actual number of procedures performed each year in the US.

These data have important implications in providing an understanding of the use of services that can help inform care for transgender populations. The rapid rise in the performance of GAS suggests that there will be a greater need for clinicians knowledgeable in the care of transgender individuals and with the requisite expertise to perform GAS procedures. However, numerous reports have described the political considerations and challenges in the delivery of transgender care. 22 Despite many medical societies recognizing the necessity of gender-affirming care, several states have enacted legislation or policies that restrict gender-affirming care and services, particularly in adolescence. 20 , 21 These regulations are barriers for patients who seek gender-affirming care and provide legal and ethical challenges for clinicians. As the use of GAS increases, delivering equitable gender-affirming care in this complex landscape will remain a public health challenge.

Accepted for Publication: July 15, 2023.

Published: August 23, 2023. doi:10.1001/jamanetworkopen.2023.30348

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Wright JD et al. JAMA Network Open .

Corresponding Author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 4th Floor, New York, NY 10032 ( [email protected] ).

Author Contributions: Dr Wright had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wright, Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wright.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Wright, Chen.

Administrative, technical, or material support: Wright, Suzuki.

Conflict of Interest Disclosures: Dr Wright reported receiving grants from Merck and personal fees from UpToDate outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

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Gender Confirmation Surgeries Rise 20% in First Ever Report Better access to care has increased transgender patients' ability to seek the help of plastic surgeons

• Monday, May 22, 2017

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ARLINGTON HEIGHTS, Ill. – For the first time, the American Society of Plastic Surgeons (ASPS) is reporting on the number of gender confirmation surgeries in the United States. ASPS—the world's largest plastic surgery organization—found that more than 3,200 transfeminine and transmasculine surgeries were performed in 2016. The procedures can include anything from facial and body contouring to gender reassignment surgeries.

"There is no one-size-fits-all approach to gender confirmation," said Loren Schechter, MD, a board-certified plastic surgeon based in Chicago. "There's a wide spectrum of surgeries that someone may choose to treat gender dysphoria, which is a disconnect between how an individual feels and what that person's anatomic characteristics are."

Access to gender confirmation procedures has improved in recent years. In just the first two years of collecting data, ASPS found the number of transgender-related surgeries rose nearly 20 percent from 2015 to 2016. "In the past several years, the number of transgender patients I've seen has grown exponentially," said Dr. Schechter. "Access to care has allowed more people to explore their options, and more doctors understand the needs of transgender patients."

Members of the American Society of Plastic Surgeons undergo intense training to help these patients address the incongruity between their bodies and the gender they know themselves to be.

"Surgical therapy is one component of the overall care of the individual," said Dr. Schechter. "It takes a team of experts across different disciplines working together to provide comprehensive care. I often partner with doctors who may prescribe treatments such as hormone therapy and mental health professionals who help patients through their transitions."

Choosing a team of experts can be a difficult path to navigate. ASPS President Debra Johnson, MD, a board-certified plastic surgeon in Sacramento, California, says it is crucial to choose a surgeon who is certified by the American Board of Plastic Surgery to ensure the highest safety and training standards.

"Board-certified plastic surgeons undergo rigorous training that is designed to not only provide the safest and best quality care, but also give patients a variety of options when it comes to gender affirming surgeries," said Dr. Johnson. "Our goal as plastic surgeons is to help get transgender patients to a place where they feel the most comfortable."

Gearah Goldstein worked with Dr. Schechter throughout her transition and says she had full confidence that she was in good hands. Goldstein knew from a very early age that that her gender did not align with her body. She now feels that she can live her life as the person she's always been.

"For transgender people, like myself, surgical options are a corrective treatment, not cosmetic," she said. "The types of surgeries someone has is very personal and private, and you wouldn't even know someone had surgery if you saw them walking down the street. It's not about how we're perceived by the public, but how we perceive ourselves."

Goldstein is now an advocate for transgender youth. She says everyone has a unique story, but that her experiences help her understand what someone with gender dysphoria is feeling and how it can become an unbearable burden. She says gender confirmation, whatever that means for the individual, can be truly life-changing.

"It has been a lifelong journey for me. Growing up, there wasn't even a word for transgender. There were no role models or anyone to tell me that I could do something about this feeling of being disconnected from the body I was born with," said Goldstein. "The reality that I lived through has allowed me to assure the next generation that there is nothing abnormal about what they're feeling."

The American Society of Plastic Surgeons (ASPS) is the largest organization of board-certified plastic surgeons in the world. Representing more than 11,000 physician members worldwide, the society is recognized as a leading authority and information source on cosmetic and reconstructive plastic surgery. ASPS comprises more than 92 percent of all board-certified plastic surgeons in the United States. Founded in 1931, the society represents physicians certified by the American Board of Plastic Surgery or the Royal College of Physicians and Surgeons of Canada.

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Age restriction lifted for gender-affirming surgery in new international guidelines

'Will result in the need for parental consent before doctors would likely perform surgeries'

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• Release Date: September 16, 2022

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• Expert can speak to transgender peoples’ right to bodily autonomy, how guidelines affect insurance coverage, how the U.S. gender regulations compare to other countries, more

CHICAGO --- The World Professional Association for Transgender Health (WPATH) today today announced  its updated Standards of Care and Ethical Guidelines for health professionals. Among the updates is a new suggestion to lift the age restriction for youth seeking gender-affirming surgical treatment, in comparison to previous suggestion of surgery at 17 or older. 

Alithia Zamantakis (she/her), a member of the Institute of Sexual & Gender Minority Health at Northwestern University Feinberg School of Medicine, is available to speak to media about the new guidelines. Contact Kristin Samuelson at [email protected] to schedule an interview.

“Lifting the age restriction will greatly increase access to care for transgender adolescents, but will also result in the need for parental consent for surgeries before doctors would likely perform them,” said Zamantakis, a postdoctoral fellow at Northwestern, who has researched trans youth and resilience. “Additionally, changes in age restriction are not likely to change much in practice in states like Alabama, Arkansas, Texas and Arizona, where gender-affirming care for youth is currently banned.”

Zamantakis also can speak about transgender peoples’ right to bodily autonomy, how guidelines affect insurance coverage and how U.S. gender regulations compare to other countries.

Guidelines are thorough but WPATH ‘still has work to do’

“The systematic reviews conducted as part of the development of the standards of care are fantastic syntheses of the literature on gender-affirming care that should inform doctors' work,” Zamantakis said. “They are used by numerous providers and insurance companies to determine who gets access to care and who does not.

“However, WPATH still has work to do to ensure its standards of care are representative of the needs and experiences of all non-cisgender people and that the standards of care are used to ensure that individuals receive adequate care rather than to gatekeep who gets access to care. WPATH largely has been run by white and/or cisgender individuals. It has only had three transgender presidents thus far, with Marci Bower soon to be the second trans woman president.

“Future iterations of the standards of care must include more stakeholders per committee, greater representation of transgender experts and stakeholders of color, and greater representation of experts and stakeholders outside the U.S.”

Transgender individuals’ right to bodily autonomy

“WPATH does not recommend prior hormone replacement therapy or ‘presenting’ as one's gender for a certain period of time for surgery for nonbinary people, yet it still does for transgender women and men,” Zamantakis said. “The reality is that neither should be requirements for accessing care for people of any gender.

“The recommendation of requiring documentation of persistent gender incongruence is meant to prevent regret. However, it's important to ask who ultimately has the authority to determine whether individuals have the right to make decisions about their bodily autonomy that they may or may not regret? Cisgender women undergo breast augmentation regularly, which is not an entirely reversible procedure, yet they are not required to have proof of documented incongruence. It is assumed that if they regret the surgery, they will learn to cope with the regret or will have an additional surgery. Transgender individuals also deserve the right to bodily autonomy and ultimately to regret the decisions they make if they later do not align with how they experience themselves.” 

More U.S. Hospitals Offering Gender-Affirming Surgeries

A boon is underway at medical institutions from coast to coast, aimed at helping transgender Americans who suffer gender dysphoria because of the mismatch between their bodies and their gender identity.

Gender-transition services and surgeries are becoming more widely available across the nation, and more insurance companies are adding coverage to help the more than one million Americans who identify as transgender.

“Access to these treatments is lifesaving for many transgender people,” said Kate Kendell, executive director at the National Center for Lesbian Rights, one of the nation’s strongest legal advocates for LGBTQ Americans. “The recent sea change among insurers and state Medicaid programs is long overdue, and we must be vigilant about protecting and expanding these protections.”

“Half of the respondents to the 2011 National Transgender Discrimination Survey said they had to educate their health care providers on how to treat them appropriately,” Mara Keisling, executive director of the National Center for Transgender Equality (NCTE), told NBC OUT. “Too few providers are sufficiently trained in how to treat transgender patients, and even fewer have the expertise to offer critical transition-related services. It is heartening that an increasing number of medical institutions and providers are learning about the importance of competency around transgender issues and transition-related procedures.”

The Cleveland Clinic, Boston Medical Center, Oregon Health and Science University in Portland and Mount Sinai Hospital in New York City are among the latest medical centers to provide gender-affirming procedures.

“At Mount Sinai, we are offering the full array of services for transgender people regardless of whether they have already accomplished their transition,” Zil Goldstein, a nurse practitioner and program director at Mount Sinai’s Center for Transgender Medicine and Surgery , told NBC OUT. “We want people to know that these treatments are available, and also that our staff are prepared to serve and care for the transgender community with sensitivity.”

This month an institution with a controversial history regarding transgender health care added its name to the list: Johns Hopkins Medicine. Johns Hopkins made history in 1965 as the first academic institution to offer gender-affirming surgeries, but it stopped in 1979 and never resumed. However, in a letter posted earlier this month , it reaffirmed its "commitment to the LGBT community” and announced it will resume gender-reassignment surgeries in 2017.

“We have committed to and will soon begin providing gender-affirming surgery as another important element of our overall care program, reflecting careful consideration over the past year of best practices and the appropriate provision of care for transgender individuals," the letter stated.

Even though not every transgender individual seeks or qualifies for surgery -- because of personal reasons, their health or insurance coverage -- demand is high. The increase in services has ramped-up since 2014, when the U.S. government’s Centers for Medicare and Medicaid Services started covering transgender-related procedures, which have been indelicately called “sex change operations.” A more common name is sex reassignment surgery, or SRS, and a more popular name within the trans community is gender confirmation surgery, or GCS.

"Despite the recent improvements in institutions offering these lifesaving transgender health services, there is still an unmet need for compassionate and comprehensive care,” Goldstein told NBC News.

“This is life-affirming and, in many cases, lifesaving treatment that is recognized as medically necessary by the medical profession,” Jillian Weiss, executive director of the Transgender Legal Defense and Education Fund , said. “It is crucial that we have a cadre of medical professionals across the county and around the world who have the training and experience to provide health care to the millions of transgender people who require it."

Right now, 12 states and the District of Columbia offer Medicaid programs covering transition-related care, according to the NCTE. But that leaves 38 states with none.

“No one should be denied medically necessary care because of who they are, and yet, that has been the reality for most transgender people for decades,” Kendell of NCLR told NBC OUT. “These positive changes are long overdue, and they are already under attack by anti-LGBT groups. We must be vigilant about defending and protecting them.”

Dawn Ennis is an award-winning journalist who was the first to transition in a network TV newsroom. She is now a freelance writer, producer and editor, as well as a widow, a single parent of three children, and the subject of an award-winning documentary, Before Dawn/After Don . Ennis is also on YouTube , on Twitter and blogging at lifeafterdawn.com

Follow NBC OUT on Twitter , Facebook and Instagram .

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Trans kids’ treatment can start younger, new guidelines say

This photo provided by Laura Short shows Eli Bundy on April 15, 2022 at Deception Pass in Washington. In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy hopes to get breast removal surgery next year before college. Bundy, 18, who identifies as nonbinary, supports updated guidance from an international transgender health group that recommends lower ages for some treatments. (Laura Short via AP)

FILE - Dr. David Klein, right, an Air Force Major and chief of adolescent medicine at Fort Belvoir Community Hospital, listens as Amanda Brewer, left, speaks with her daughter, Jenn Brewer, 13, as the teenager has blood drawn during a monthly appointment for monitoring her treatment at the hospital in Fort Belvoir, Va., on Sept. 7, 2016. Brewer is transitioning from male to female. (AP Photo/Jacquelyn Martin, File)

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A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Association for Transgender Health said hormones could be started at age 14, two years earlier than the group’s previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association provided The Associated Press with an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn’t match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group’s standards of care and director of the University of Minnesota Medical School’s human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents’ consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

“Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision,” he said. “That is why we recommend a careful multidisciplinary assessment.”

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment , along with new efforts to prevent or restrict the treatment.

Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of the World Professional Association for Transgender Health last year after voicing concerns about “sloppy” treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn’t always happen.

“They tell me horror stories. They tell me, ‘Our child had 20 minutes with the doctor’” before being offered hormones, she said. “The parents leave with their hair on fire.’’

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association’s new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8% in kids.

Anderson said she’s heard recent estimates suggesting the rate in kids is as high as 1 in 5 — which she strongly disputes. That number likely reflects gender-questioning kids who aren’t good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

“That’s just absolutely cruel,’’ she said.

Dr. Marci Bowers, the transgender health group’s president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been “forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis.’’

Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, North Carolina, resident struggled miserably with gender discomfort before his treatment.

Poulos said he’s glad he was able to get treatment at a young age.

“Transitioning under the roof with your parents so they can go through it with you, that’s really beneficial,’’ he said. “I’m so much happier now.’’

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

“Those decisions are best made by patients and patient families and medical professionals,’’ they said. “It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together.’’

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn’t strong evidence in favor of transgender medical treatment for kids.

“In medicine ... the treatment has to be proven safe and effective before we can start recommending it,’’ Mason said.

Experts say the most rigorous research — studies comparing treated kids with outcomes in untreated kids — would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That’s no change from the group’s previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

—Sex hormones — estrogen or testosterone — starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.

—Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum ag wasn’t listed.

—Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Association support allowing kids to seek transgender medical treatment, but they don’t offer age-specific guidance.

Dr. Joel Frader, a Northwestern University a pediatrician and medical ethicist who advises a gender treatment program at Chicago’s Lurie Children’s Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they’re prone to risk-taking and they take into account long-term consequences of their actions only when they’re much older.

Coleen Williams, a psychologist at Boston Children’s Hospital’s Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

“Medical intervention in any realm is not a one-size-fits-all option,” Williams said.

Follow AP Medical Writer Lindsey Tanner at @LindseyTanner.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

More people are getting gender-affirming care, under attack in many states. Few are kids

The number of people seeking gender-affirming surgeries such as breast and chest operations or genital reconstruction nearly tripled during the three years before the coronavirus pandemic, a new study shows.

The study tracked more than 48,000 patients who had operations in hospitals and same-day surgery centers from 2016 through 2020, the most recent data available. The number of patients getting these operations nearly tripled from 4,552 in 2016 to 13,011 in 2019, before decreasing slightly in 2020 amid the coronavirus restrictions that postponed or halted many types of non-emergency operations, according to the study published Wednesday in JAMA Network Open .

Gender-affirming surgeries were most popular with young adults; more than 25,000 people ages 19 to 30 received these procedures. Fewer than 8% of patients − a total of 3,678 − were 12- to 18-year-olds, a group scrutinized by lawmakers pursuing restrictions mainly in conservative states .

Banned: Gender-affirming care for minors no longer allowed in North Carolina

Insurance coverage, awareness, satisfaction drive gender operations

Dr. Jason D. Wright, the study's lead author and an associate professor of gynecologic oncology at Columbia University, said the purpose of the study was to get an accurate count on such operations at hospitals and outpatient surgery centers.

The researchers sifted through databases to find people diagnosed with gender identity disorder , transsexualism or a personal history of sex reassignment. From there, researchers tracked whether those patients sought a range of gender-affirming surgeries.

More than half of the people in the study had breast and chest procedures, making it the most common type of gender-affirming operation. More than 1 in 3 people received genital reconstruction − a category that included any surgical intervention of the male or female genital tract. Others sought facial and cosmetic procedures such as hair removal, hair transplants, liposuction and collagen injections.

Gender-affirming surgeries are becoming more common as insurers offer more robust coverage. About 3 in 5 patients were covered by a private insurance plan, and 1 in 4 had Medicaid, the government health insurance plan for low-income and disabled residents.

People are also more aware these surgeries are available, Wright said.

"More patients have had access to these procedures," Wright said. "Not only are most of these procedures very safe from a complication standpoint, but they're also associated with favorable outcomes with relatively high rates of patient satisfaction."

Proud purple to angry red: These Florida residents feel unwelcome in 'new' Florida

22 states restrict gender-affirming care for minors

Last week, North Carolina Republican state lawmakers overrode Democratic Gov. Roy Cooper’s veto and passed legislation barring surgical gender-transition procedures to anyone under 18, with some exceptions. The legislation, which takes effect immediately, also prohibits medical professionals from providing hormone therapy puberty-blocking drugs.

Minors who had begun treatment before Aug. 1 may continue receiving that care if their doctors deem it medically necessary and their parents consent.

Louisiana, Texas, Missouri, Florida and Nebraska are among states that passed legislation restricting gender-reassignment operations among minors or limiting other gender-affirming care. In all, 22 states have restrictions on gender-affirming operations or related care for transgender minors.

"These are happening in conservative, Republican-led states. The language being used to promote the policies is around protection," said Lindsey Dawson, associate director of HIV policy and director of LGBTQ+ health policy for KFF, a nonpartisan health foundation. "But really, the policies target gender-diverse young people and aim to restrict providers from delivering what is widely considered best-practice medical care."

Wright said the study provides data on how frequently gender-affirming surgeries are performed and requested − important information for doctors to consider when discussing care with patients.

"More patients are asking for information about these services," Wright said. "As these procedures become more common, we need to have the expertise to care for transgender populations who are interested in surgery."

Contributing: The Associated Press

What to Know About the Gender-Affirming-Care Bans Spreading Across the Country

O nly six states in the U.S. have not introduced a bill restricting LGBTQ rights during this legislative session, including Delaware and Illinois. Bathroom bills, measures that would limit the ability to update identity and gender information on records and IDs, sports bans, and bans on gender-affirming care are all up for consideration in states across America.

That last category of bills is growing. On Thursday, Iowa prohibited gender-reassignment procedures and prescriptions, and two of Florida’s State Senate committees passed Senate Bill 254, which would add onto the existing gender-affirming-care restrictions by prohibiting entities from using state funds to cover gender-affirming care, among other things.

Just this year, five states—Mississippi, Utah, South Dakota, Iowa, and Tennessee—have passed bans on gender-affirming care for minors, and nearly 90 other bills targeting access to gender-affirming health care, including Florida’s, are being considered in the U.S.

Proponents of these measures often claim these laws will protect young Americans from what they portray as risky medical experimentation. “We need to let kids be kids, and our laws need to set appropriate boundaries that respect the rights and responsibilities of parents, while protecting children from the serious health, safety, and welfare consequences of social agendas that are totally inconsistent with how the overwhelming majority of parents want to raise their children,” says Florida State Sen. Yarborough, the sponsor of a gender-affirming-care ban in the state, in a press release.

But every major medical organization—including the American Medical Association, American Academy of Pediatrics, American Psychiatric Association, and more— agrees that gender-affirming care for transgender patients , which can range from social interventions, to hormonal treatments, to surgery, is both safe and medically appropriate. For transgender people, who face unemployment at twice the rate of the general population and have a suicide rate nearly nine times that of the broader U.S. population, the prospect of losing access to such care is harrowing.

“Many adolescents with gender dysphoria have severe negative psychological reactions to their bodies developing in ways that do not align with who they are, and [hormonal treatments] can temporarily put these changes on pause,” Dr. Jack Turban, Assistant Professor of Child & Adolescent Psychiatry at The University of California, San Francisco, tells TIME.

Here’s what to know about some of the gender-affirming-care bans being considered across the U.S.

Where have bans been passed already?

Eight states already have gender-affirming-care bans in place for people under the age of 18, and states like Tennessee and Iowa, which both passed legislation this year, are part of the rise in anti-trans legislation being considered more broadly.

They join states like Arkansas, which passed similar legislation two years ago. (Ongoing lawsuits in Arkansas have delayed the program from rolling out, though legislators passed a measure that would criminalize medical practitioners for providing gender- affirming care for minors in March 2023.) Arizona and Alabama also passed gender-care bans in 2022, though the latter’s law is temporarily blocked by legal challenges.

Most laws in this category, like that of Tennessee, would ban puberty blockers and hormone treatment from being used to treat gender dysphoria. Patients would also be unable to undergo surgery.

Healthcare providers who violate the Tennessee law can be sued in civil court within 30 years of the violation. They could also face a fine of up to $25,000 and have their license restricted.

The Tennessee law, which could face lawsuits, is set to go into effect in the summer, though minors who are currently undergoing treatment have until March 31, 2024 to stop treatment.

Where are gender-affirming-care bans being considered?

While the many restrictions on gender-affirming care being considered in state houses across the country do share some similarities, state lawmakers are trying a range of tactics to control access to such medical treatment.

In Oklahoma, for example, state senators are advancing Senate Bill 613 , which would revoke doctors’, nurse practitioners’, or advanced practice nurses’ licenses if they offer gender-transition services to people under the age of 18. (Legislators did add a measure that says the bill would not prevent mental health counseling, depression and anxiety medication or “medications prescribed, dispensed, or administered specifically for the purpose of treating precocious puberty or delayed puberty in that patient.”)

Another bill being considered in the state, Senate Bill 129, adds onto the restrictions by banning transgender medical care at hospitals that indirectly receive public funding. This includes hospitals that are on land that is owned by a state or local government, according to the Oklahoman . House Bill 2177, meanwhile, would prohibit insurance from covering some gender-affirming care, including puberty blockers for minors, is also being considered.

“[People said] we need to protect sports…and then [legislators] didn’t and we knew it wasn’t going to stop there,” Eddie Hefner, a 22-year-old trans, nonbinary Oklahoma resident says. “That’s not what this is about. This is trans-affirming care across the board. And trans health care is essential for saving [lives] because, [for] a lot of the people that I know, to them it is just normal health care.”

Hefner, who plans on getting one gender-affirming surgery in the future, fears that legislators will make age restrictions increasingly strict—and, they say, 18 is already too late for some care. Under previous medical guidelines, UC San Francisco’s Turban tells TIME, most doctors did not allow patients to use gender-affirming hormones until age 16. (Doctors and mental health providers now work with parents to assess the best time frame for a patient to start estrogen or testosterone, which in some cases may be before 16.) But puberty blockers, which stop processes like voice changes or breast growth, are often used in the earlier stages of puberty.“Forcing [patients] to undergo a puberty that doesn’t align with who they are,” he says, “can be horrifying and traumatic.”

In Florida, a ban took effect on March 16 after the Florida Board of Medicine voted in favor of banning gender-affirming care including puberty blockers, cross-sex hormones, and surgery for minors in November.

Doctors who violate the law could face fines and the potential to have their licenses revoked. Legislators are attempting to make that ban law through Senate Bill 254, which would also mean that any healthcare paid for by the state, like Medicaid or state-employee plans, would not cover gender-affirming care.

Devon Ojeda, the Senior National Organizer at the National Center for Transgender Equality, notes that despite the rhetoric used to attack this form of healthcare, cisgender people could also be affected by these types of bans. “Cancer survivors who get breast implants, regardless if they’re cisgender or not, [are getting surgeries that are] affirming their gender,” Ojeda says. “Gender affirming care is for everyone.”

The bill would also allow Florida courts “to enter, modify, or stay a child custody determination relating to a child present in this state to the extent necessary to protect the child from being subjected to sex-reassignment prescriptions or procedures in another state.”

Two Senate committees have passed the bill. It will now head to the Senate floor for a vote.

In Missouri, the State Senate voted to advance their gender-affirming ban after a series of back-door negotiations in which Republican lawmakers agreed they would not prohibit people who are already transitioning from doing so, according to the Associated Press . (Florida’s medical rule has a similar provision.) Missouri’s Attorney General Andrew Bailey also announced on Monday that he would pass an emergency rule that would limit gender-affirming care for minors.

Bailey’s plan would require minors endure 15 hour-long therapy sessions and get a full psychiatric evaluation over the course of 18 months before accessing gender-affirming care.

“I am dedicated to using every legal tool at my disposal to stand in the gap and protect children from being subject to inhumane science experiments,” Bailey tweeted .

Organizations like the ACLU, however, contend that these bills will not protect kids, but are instead “harmful and exploitative.”

“There’s nothing extraordinary about this care except that it saves lives,” Harper Seldin, Staff Attorney for the ACLU’s LGBTQ and HIV Project, tells TIME. “I think it’s important to realize that this is not just an attack on this small group of people but is in fact, part of an ongoing attack on the bodily autonomy of people in every state.”

Correction, April 3

The original version of this story misstated when patients may start gender-affirming hormones. Previous medical guidelines instructed doctors not to begin these treatments before patients turned 16, but those guidelines have been updated.

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States That Have Restricted Gender-Affirming Care for Trans Youth

As the issue of trans rights has become more political, states are increasingly banning gender-affirming care for trans minors.

States Restricting Gender-Affirming Care

Sue Ogrocki | AP

Trans-rights activists protest outside the House chamber at the Oklahoma state Capitol on Feb. 6, 2023, in Oklahoma City.

A large majority of transgender adults in the United States – 78% – say living with a gender different from the one assigned to them at birth has made them more satisfied with their lives, according to a survey from The Washington Post and Kaiser Family Foundation .

Among respondents, more than three-quarters had changed their type of clothing, hairstyle or grooming habits to align with their preferred gender, while 31% had used hormone treatments and 16% had undergone gender-affirming surgery or a related surgical treatment to alter their appearance.

But such options are becoming available on a more limited basis, as politicians in multiple states have attempted to restrict trans Americans’ ability to seek gender-affirming medical treatments.

What Is Gender-Affirming Care? 

The Human Rights Campaign, a LGBTQ+ advocacy group, defines gender-affirming care as “age-appropriate care that is medically necessary for the well-being of many transgender and non-binary people who experience symptoms of gender dysphoria, or distress that results from having one’s gender identity not match their sex assigned at birth.” The organization notes both the American Medical Association and the American Academy of Pediatrics support “age-appropriate, gender-affirming care for transgender and non-binary people.”

Conservatives often oppose the concept of gender-affirming care – which may or may not include surgery or other interventions – for various reasons, including religious beliefs and concerns about child abuse. “You don’t disfigure 10-, 12-, 13-year-old kids based on gender dysphoria,” Florida Gov. Ron DeSantis, a Republican, said at an August news conference.

Some have expressed concern about a lack of data on the possible long-term consequences of gender-affirming medical treatment for minors. A 2022 Reuters investigation , for example, found “no large-scale studies have tracked people who received gender-related medical care as children to determine how many remained satisfied with their treatment as they aged and how many eventually regretted transitioning.” Others, according to the article, have raised alarms about children who are not appropriately evaluated before receiving gender-affirming medical care.

These States Have Banned Gender-Affirming Care for Minors

Mississippi

North Carolina

North Dakota

South Dakota

West Virginia

Below are the states that have moved to restrict some form of gender-affirming care for minors in 2023 and so far in 2024, based largely on legislation tracking from the Equality Federation, an advocacy accelerator that works with a network of state-based LGBTQ+ organizations.

Some states, such as Arizona and Alabama , passed bans prior to 2023 and are not included on the list.

Dozens of bills are still being considered by lawmakers in other states, according to the federation. And officials elsewhere, including in Florida and Missouri, have bypassed state legislatures altogether.

Signed into law by new Republican Gov. Sarah Huckabee Sanders in March, Arkansas’ law will make health care providers liable for civil action for up to 15 years after a minor turns 18 if they performed a gender transition procedure on that minor – essentially making it easier to file malpractice lawsuits in these situations. On that note, experts say the law acts as a de facto ban on gender-affirming care for children because it makes it nearly impossible for providers to get malpractice insurance, according to the AP . In 2021, state lawmakers passed the nation’s first ban on gender-affirming care for minors. The move was temporarily blocked shortly after, but on June 20, 2023, a federal judge issued a permanent injunction against it, ruling the ban unconstitutional. It marked the first time such a state ban was overturned, but the more recent law signed by Sanders was still set to go into effect.

The state Department of Health’s Board of Medicine announced a new rule in March that prohibits several types of treatment and procedures – such as sex reassignment surgeries and puberty blockers – for treating gender dysphoria in minors. Then, on May 17, DeSantis signed into law a similar gender-affirming care ban from the state legislature , which, in addition to prohibiting procedures from being performed on minors, also grants Florida courts “temporary emergency jurisdiction” over a child if they have been subjected to or “threatened” with sex-reassignment prescriptions or procedures. The law also requires transgender adults to get written consent before undergoing such procedures by using a form adopted by the Board of Medicine and Board of Osteopathic Medicine, according to Reuters. But on June 6, a district court judge in Florida issued a preliminary injunction that temporarily blocked enforcement of some parts of the law on behalf of several young plaintiffs. Months later, the same judge ruled that the parts of the law that apply to transgender adults can still be enforced while it is challenged in court.

Senate Bill 140 was signed into law by Georgia Republican Gov. Brian Kemp in late March. The legislation , pushed forward by the Republican majority in the state’s General Assembly, prohibits “certain surgical procedures for the treatment of gender dysphoria in minors from being performed in hospitals and other licensed healthcare facilities.” There are exceptions, including treatments that are deemed “medically necessary” and situations covering continued treatment for minors undergoing “irreversible hormone replacement therapies” prior to July 1, 2023. A federal judge on Sept. 5 allowed Georgia to resume enforcing the portion of the law banning doctors from starting hormone therapy for transgender minors, weeks after blocking it with a preliminary injunction. The prohibition on surgical procedures was not covered by the legal challenges.

The state’s GOP Gov. Brad Little approved a bill that criminalizes providing gender-affirming care for youth. Signed on April 4, 2023, and set to go into effect in January 2024, the law was intended to make it a felony to provide hormones, puberty blockers or other gender-affirming medical care to minors. But in December 2023, a federal judge issued a temporary injunction blocking the law’s enforcement. Then the U.S. Supreme Court in April 2024 ruled that the state could enforce the ban against everyone except the plaintiffs who challenged it. Even before that ruling, Little in March signed a new law which will prevent transgender people in Idaho from using publicly funded programs to help cover the cost of gender-affirming care. The ban included in the legislation, which is scheduled to go into effect on July 1, 2024, extends to state employees on work health insurance and adults using Medicaid.

Republican Gov. Eric Holcomb signed into law on April 5 a bill banning all gender-affirming care for minors, after previously saying there was “some vagueness to it,” according to the AP. The governor said in a statement that “permanent gender-changing surgeries with lifelong impacts and medically prescribed preparation for such a transition should occur as an adult, not as a minor.” The parts of the law banning puberty blockers and hormone treatments for minors were blocked by a federal judge on June 16, 2023, following a request for a preliminary injunction by the American Civil Liberties Union of Indiana. But a federal appeals court ruling on Feb. 27, 2024, allowed those restrictions to go into effect.

Iowa’s ban , signed into law on March 22, prohibits health care professionals from “knowingly” performing certain medical practices on minors if they are “for the purpose of attempting to alter the appearance of, or affirm the minor’s perception of, the minor's gender or sex, if that appearance or perception is inconsistent with the minor's sex.” Practices covered by the law include hormone therapies and surgical procedures. As with other states’ laws, there are some exceptions, including a “medically verifiable disorder of sex development.”

The state on March 29 joined others in banning gender-affirming medical care for minors when the Republican-led Kentucky General Assembly voted to override Democratic Gov. Andy Beshear’s veto, becoming the first state led by a Democrat to approve such a ban in 2023. The law notes that any health provider who violates the prohibition can have their license or certificate revoked. A federal judge on June 28 temporarily blocked the portion of the law that would have banned transgender youth from accessing puberty blockers and hormone therapy, but that same judge lifted the injunction on July 14 – allowing the restrictions to go into effect. A federal appeals court panel on July 31 allowed the state to continue enforcing the law – and so did another in September.

With a successful override attempt of former Democratic Gov. John Bel Edwards’ veto by the state’s Republican supermajority legislature, Louisiana approved a ban on gender-affirming care for minors on July 18. The law , which went into effect on Jan. 1, 2024, covers procedures such as hormone therapies, puberty blockers and gender-reassignment surgeries. The ban’s ultimate approval came after a Republican lawmaker cast a tie-breaking vote to kill the legislation in May. But it was eventually resurrected and passed before Edwards’ veto. New Gov. Jeff Landry, a Republican, has supported the ban, saying in a post in X in May 2023, “Pediatric sex changes should have no place in our society.”

Mississippi’s law – among the first to be enacted in 2023 – bans any person from knowingly providing or engaging in conduct that aids and abets the performance of gender transition procedures on a minor in the state. The ban also prohibits the use of public funds or tax deductions for such procedures. Republican Gov. Tate Reeves said when he signed the bill into law that “radical activists” are telling children they are “just a surgery away from happiness,” according to the AP .

GOP Gov. Mike Parson on June 7 signed a bill that will restrict gender-affirming health care for minors and some adults in Missouri starting in late August. The law prevents the state’s Medicaid division from covering such treatment for people of any age, and prohibits providers from prescribing puberty-blockers or cross-sex hormones to minors until Aug. 28, 2027, unless they were being treated prior to the bill’s effective date. Missouri initially banned gender-affirming care in April through an emergency regulation from state Attorney General Andrew Bailey that limited treatments for both minors and adults, the latter of which was believed to be a first in the country . But Bailey terminated the rule – which had already been on pause due to a lawsuit – on May 16, citing the state legislature’s imminent ban. A circuit judge on Aug. 25 allowed the law to take effect.

Signed into law on April 28 by Republican Gov. Greg Gianforte, Montana’s ban on gender-affirming care for minors covers both surgical procedures and medications such as puberty blockers and testosterone. As with other state laws, the prohibition has exceptions including for someone “diagnosed with a disorder of sexual development.” Any physician who performs a banned procedure can be also sued in the 25 years following it if the after-effects result in any injury, “including physical, psychological, emotional or physiological harms.” Democratic state Rep. Zooey Zephyr, a transgender woman, was exiled from the Montana House floor after she said her fellow Republican lawmakers would have “blood on their hands” if they passed the bill. The law was set to take effect on Oct. 1, but a state judge issued a preliminary injunction on Sept. 27 that blocked its enforcement, according to the AP.

Republican Gov. Jim Pillen signed into law on May 22, 2023, a bill that limits gender-affirming medical care for minors, which covers people under the age of 19 in Nebraska. The law , which also bans abortions at 12 weeks of pregnancy, includes a ban on surgical procedures and limitations on “prescribed drugs related to gender alteration.” The regulations for hormone therapies – recommended by the state’s chief medical officer, a political appointee – were later approved by Pillen on March 12, 2024, and include a seven-day waiting period to start puberty-blocking medications or hormone treatments and a requirement for transgender patients under 19 to meet several therapy benchmarks. The gender-affirming care portion of the new law went into effect on Oct. 1, 2023.

Looking Back at 2023

The state’s Republican-dominated legislature on Aug. 16 voted to successfully override a veto from Democratic Gov. Roy Cooper and approve a ban on gender-affirming care for minors in North Carolina. The bill’s language covers both transition surgeries and puberty-blocking drugs or cross-sex hormones. The law goes into effect immediately, but as with other state bans that have been approved, there are some exceptions to the prohibition.

Republican Gov. Doug Burgum on April 19 signed a veto-proof bill into law that criminalizes providing gender-affirming medical care to minors. The law , which went into effect immediately as an “emergency measure,” makes performing sex reassignment surgery on a minor a felony, and makes providing gender-affirming medication such as puberty blockers to minors a misdemeanor. Burgum recommended in a statement that “thoughtful debate around these complex medical policies should demonstrate compassion and understanding for all North Dakota youth and their families,” according to the AP.

Republican Gov. Mike DeWine on Jan. 5, 2024, signed an executive order that prohibits young Ohioans from getting gender-affirming surgeries done before they turn 18. The order, which took effect immediately, came just a week after DeWine vetoed a bill from the state legislature that would have instituted a broader restriction on gender-affirming care for minors, including hormone therapies. But on Jan. 24, the state Senate successfully voted to override the governor’s veto, meaning the more wide-reaching ban – which also prohibits transgender girls and women from girls’ and women’s sports teams at both the K-12 and collegiate level – was expected to take effect in 90 days. That was until a judge on April 16 blocked the law by issuing a temporary restraining order.

GOP Gov. Kevin Stitt on May 1 signed into law a ban on gender-affirming care for minors in Oklahoma, saying he was “thrilled” to do so and “protect our kids.” The bill allows for any physician who knowingly provides gender transition procedures to be charged with a felony, but the prosecution must occur before the minor patient turns 45. The law went into effect immediately, but on May 18 the state agreed to not enforce it while opponents sought a temporary court order blocking it. A federal judge in October later declined to stop the law from taking effect.

Signed into law on Feb. 13, House Bill 1080 prohibits South Dakotan health care professionals from administering various types of gender-affirming procedures on minors. If a provider violates the law, the legislation requires a professional or occupational licensing board to revoke any license or certificate held by the provider. GOP Gov. Kristi Noem strongly supported the bill before signing it, according to the AP .

Tennessee’s legislation , which was signed by Gov. Bill Lee in March but was set to go into effect on July 1, bans health care providers from performing or offering to perform a medical procedure on a minor if its purpose is to enable that minor “to identify with, or live as, a purported identity inconsistent with the immutable characteristics of the reproductive system that define the minor as male or female.” It also prohibits such procedures if the purpose is to treat “purported discomfort or distress from a discordance between the minor's sex and asserted identity.” There are exceptions, and the law establishes penalties for providers who violate it. Just days before its July 1 effective date, a federal judge on June 28 temporarily blocked the portion of the law that would have banned transgender youth from accessing puberty blockers and hormone therapy. U.S. District Judge Eli Richardson, however, did not block the law’s ban on surgical procedures. A federal appeals court on July 8 temporarily reversed Richardson’s ruling, meaning the law can take effect at least until the court conducts a full review.

GOP Gov. Greg Abbott on June 2 signed a bill banning gender-affirming care for minors in Texas. The law contains exceptions similar to other states’ efforts at restricting transition care. The Texas Supreme Court on Aug. 31 allowed the law to go into effect on Sept. 1, overruling a state district judge who had issued a temporary injunction against the ban a week prior. The law’s passage was not Texas’ first attempt at limiting gender-affirming care: Abbott in 2022 ordered the investigation of families who were receiving such care, but the order was halted by a judge in the state.

Republican Gov. Spencer Cox signed into law on Jan. 28 the first gender-affirming care ban of the year. The Utah legislature’s Senate Bill 16 restricts health providers from performing “sex characteristic surgical procedures on a minor for the purpose of effectuating a sex change” or hormonal transgender treatment on minors who weren’t diagnosed with gender dysphoria before July 1, 2023. Cox said his approval of the law was an effort at least in part to pause “these permanent and life-altering treatments for new patients until more and better research can help determine the long-term consequences,” the AP reported .

A new law signed by GOP Gov. Jim Justice on March 29 prohibits minors from being prescribed hormone therapy and puberty blockers, or from receiving gender-affirming surgery. The law , which will take effect in January 2024, contains an exception geared toward youth for whom “treatment with pubertal modulating and hormonal therapy is medically necessary to treat the minor’s psychiatric symptoms and limit self-harm, or the possibility of self-harm.” In these cases, the minor must receive consent from their parents or guardians along with two medical providers.

Republican Gov. Mark Gordon on March 22 signed into law a measure that prohibits gender-affirming medical care for transgender minors. The ban , which is set to go into effect on July 1, 2024, covers treatment such as surgeries and puberty-blockers. While he did sign the bill, Gordon added that the legislation means the government is “straying into the personal affairs of families,” according to the AP.

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Tags: Arkansas , Florida , Georgia , Iowa , Mississippi , South Dakota , Tennessee , Utah , transgender people

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Young Children Do Not Receive Medical Gender Transition Treatment

By Kate Yandell

Posted on May 22, 2023

SciCheck Digest

Families seeking information from a health care provider about a young child’s gender identity may have their questions answered or receive counseling. Some posts share a misleading claim that toddlers are being “transitioned.” To be clear, prepubescent children are not offered transition surgery or drugs.

Some children  identify  with a gender that does not match their sex assigned at birth. These children are referred to as transgender, gender-diverse or gender-expansive. Doctors will listen to children and their family members, offer information, and in some cases connect them with mental health care, if needed.

But for children who have not yet started puberty, there are  no recommended  drugs, surgeries or other gender-transition treatments.

Recent social media  posts   shared  the misleading  claim  that medical institutions in North Carolina are “transitioning toddlers,” which they called an “experimental treatment.” The posts referenced a  blog post  published by the Education First Alliance, a conservative nonprofit in North Carolina that says  many schools are engaging in “ideological indoctrination” of children and need to be reformed.

The group has advocated the passage of a North Carolina bill  to restrict medical gender-transition treatment before age 18. There are now  18 states  that have taken action to restrict  medical transition treatments  for  minors .

A widely shared  article  from the Epoch Times citing the blog post bore the false headline: “‘Transgender’ Toddlers as Young as 2 Undergoing Mutilation/Sterilization by NC Medical System, Journalist Alleges.” The Epoch Times has a history of publishing misleading or false claims. The article on transgender toddlers then disappeared from the website, and the Epoch Times published a new  article  clarifying that young children are not receiving hormone blockers, cross-sex hormones or surgery. 

Representatives from all three North Carolina institutions referenced in the social media posts told us via emailed statements that they do not offer surgeries or other transition treatments to toddlers.

East Carolina University, May 5: ECU Health does not offer gender affirming surgery to minors nor does the health system offer gender affirming transition care to toddlers.

ECU Health elaborated that it does not offer puberty blockers and only offers hormone therapy after puberty “in limited cases,” as recommended in national guidelines and with parental or guardian consent. It also said that it offers interdisciplinary gender-affirming primary care for LGBTQ+ patients, including access to services such as mental health care, nutrition and social work.

“These primary care services are available to any LGBTQ+ patient who needs care. ECU Health does not provide gender-related care to patients 2 to 4 years old or any toddler period,” ECU said.

University of North Carolina, May 12: To be clear: UNC Health does not offer any gender-transitioning care for toddlers. We do not perform any gender care surgical procedures or medical interventions on toddlers. Also, we are not conducting any gender care research or clinical trials involving children. If a toddler’s parent(s) has concerns or questions about their child’s gender, a primary care provider would certainly listen to them, but would never recommend gender treatment for a toddler. Gender surgery can be performed on anyone 18 years old or older .

Duke Health, May 12: Duke Health has provided high-quality, compassionate, and evidence-based gender care to both adolescents and adults for many years. Care decisions are made by patients, families and their providers and are both age-appropriate and adherent to national and international guidelines. Under these professional guidelines and in accordance with accepted medical standards, hormone therapies are explicitly not provided to children prior to puberty and gender-affirming surgeries are, except in exceedingly rare circumstances, only performed after age 18.

Duke and UNC both called the claims that they offer gender-transition care to toddlers false, and ECU referred to the “intentional spreading of dangerous misinformation online.”

Nor do other medical institutions offer gender-affirming drug treatment or surgery to toddlers, clinical psychologist  Christy Olezeski , director of the Yale Pediatric Gender Program, told us, although some may offer support to families of young children or connect them with mental health care. 

The Education First Alliance post also states that a doctor “can see a 2-year-old girl play with a toy truck, and then begin treatment for gender dysphoria.” But simply playing with a certain toy would not meet the criteria for a diagnosis of gender dysphoria, according to the medical diagnostic manual used by health professionals.

“With all kids, we want them to feel comfortable and confident in who they are. We want them to feel comfortable and confident in how they like to express themselves. We want them to be safe,” Olezeski said. “So all of these tenets are taken into consideration when providing care for children. There is no medical care that happens prior to puberty.”

Medical Transition Starts During Adolescence or Later 

The Education First Alliance blog post does not clearly state what it means when it says North Carolina institutions are “transitioning toddlers.” It refers to treatment and hormone therapy without clarifying the age at which it is offered. 

Only in the final section of the piece does it include a quote from a doctor correctly stating that children are not offered surgery or drugs before puberty.

To spell out the reality of the situation: The North Carolina institutions are not providing surgeries or hormone therapy to prepubescent children, nor is this standard practice in any part of the country.

Programs and physicians will have different policies, but widely referenced guidance from the  World Professional Association for Transgender Health  and the  Endocrine Society  lays out recommended care at different ages. 

Drugs that suppress puberty are the first medical treatment that may be offered to a transgender minor, the guidelines say. Children may be offered drugs to suppress puberty beginning when breast buds appear or testicles increase to a certain volume, typically happening between ages 8 to 13 or 9 to 14, respectively.

Generally, someone may start gender-affirming hormone therapy in early adolescence or later, the American Academy for Pediatrics  explains . The Endocrine Society says that adolescents typically have the mental capacity to participate in making an informed decision about gender-affirming hormone therapy by age 16.

Older adolescents who want flat chests may sometimes be able to get surgery to remove their breasts, also known as top surgery, Olezeski said. They sometimes desire to do this before college. Guidelines  do not offer  a  specific age  during adolescence when this type of surgery may be appropriate. Instead, they explain how a care team can assess adolescents on a case-by-case basis.

A previous  version  of the WPATH guidelines did not recommend genital surgery until adulthood, but the most recent version, published in September 2022, is  less specific  about an age limit. Rather, it explains various criteria to determine whether someone who desires surgery should be offered it, including a person’s emotional and cognitive maturity level and whether they have been on hormone therapy for at least a year.

The Endocrine Society similarly offers criteria for when someone might be ready for genital surgery, but specifies that surgeries involving removing the testicles, ovaries or uterus should not happen before age 18.

“Typically any sort of genital-affirming surgeries still are happening at 18 or later,” Olezeski said.

There are no comprehensive statistics on the number of gender-affirming surgeries performed in the U.S., but according to an insurance claims  analysis  from Reuters and Komodo Health Inc., 776 minors with a diagnosis of gender dysphoria had breast removal surgeries and 56 had genital surgeries from 2019 to 2021.

Research Shows Benefits of Affirming Gender Identity

Young children do not get medical transition treatment, but they do have feelings about their gender and can benefit from support from those around them. “Children start to have a sense of their own gender identity between the ages of 2 1/2 to 3 years old,” Olezeski said.

Programs vary in what age groups they serve, she said, but some do support families of preschool-aged children by answering questions or providing mental health care.

Transgender children are at increased risk of some mental health problems, including anxiety and depression. According to the WPATH guidelines, affirming a child’s gender through day-to-day changes — also known as social transition — may have a positive impact on a child’s mental health. Social transition “may look different for every individual,” Olezeski said. Changes could include going by a different name or pronouns or altering one’s attire or hair style.

Two studies of socially transitioned children — including one with kids as young as 3 — have found minimal or no difference in anxiety and depression compared with non-transgender siblings or other children of similar ages.

“Research substantiates that children who are prepubertal and assert an identity of [transgender and gender diverse] know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender and benefit from the same level of social acceptance,” the AAP  guidelines  say, adding that differences in how children identify and express their gender are normal.

Social transitions largely take place outside of medical institutions, led by the child and supported by their family members and others around them. However, a family with questions about their child’s gender or social transition may be able to get information from their pediatrician or another medical provider, Olezeski said.

Although not available everywhere, specialized programs may be particularly prepared to offer care to a gender-diverse child and their family, she said. A child may get a referral to one of these programs from a pediatrician, another specialty physician, a mental health care professional or their school, or a parent may seek out one of these programs.

“We have created a space where parents can come with their youth when they’re young to ask questions about how to best support their child: what to do if they have questions, how to get support, what do we know about the best research in terms of how to allow kids space to explore their identity, to explore how they like to express themselves, and then if they do identify as trans or nonbinary, how to support the parents and the youth in that,” Olezeski said of specialized programs. Parents benefit from the support, and then the children also benefit from support from their parents. 

WPATH  says  that the child should be the one to initiate a social transition by expressing a “strong desire or need” for it after consistently articulating an identity that does not match their sex assigned at birth. A health care provider can then help the family explore benefits and risks. A child simply playing with certain toys, dressing a certain way or enjoying certain activities is not a sign they would benefit from a social transition, the guidelines state.

Previously, assertions children made about their gender were seen as “possibly true” and support was often withheld until an age when identity was believed to become fixed, the AAP guidelines explain. But “more robust and current research suggests that, rather than focusing on who a child will become, valuing them for who they are, even at a young age, fosters secure attachment and resilience, not only for the child but also for the whole family,” the guidelines say.

Mental Health Care Benefits

A gender-diverse child or their family members may benefit from a referral to a psychologist or other mental health professional. However, being transgender or gender-diverse is not in itself a mental health disorder, according to the  American Psychological Association ,  WPATH and other expert groups . These organizations also note that people who are transgender or gender-diverse do not all experience mental health problems or distress about their gender. 

Psychological therapy is not meant to change a child’s gender identity, the WPATH guidelines  say . 

The form of therapy a child or a family might receive will depend on their particular needs, Olezeski said. For instance, a young child might receive play-based therapy, since play is how children “work out different things in their life,” she said. A parent might work on strategies to better support their child.

One mental health diagnosis that some gender-diverse people may receive is  gender dysphoria . There is  disagreement  about how useful such a diagnosis is, and receiving such a diagnosis does not necessarily mean someone will decide to undergo a transition, whether social or medical.

UNC Health told us in an email that a gender dysphoria diagnosis “is rarely used” for children.

Very few gender-expansive kids have dysphoria, the spokesperson said. “ Gender expansion in childhood is not Gender Dysphoria ,” UNC added, attributing the explanation to psychiatric staff (emphasis is UNC’s). “The psychiatric team’s goal is to provide good mental health care and manage safety—this means trying to protect against abuse and bullying and to support families.”

Social media posts incorrectly claim that toddlers are being diagnosed with gender dysphoria based on what toys they play with. One post  said : “Three medical schools in North Carolina are diagnosing TODDLERS who play with stereotypically opposite gender toys as having GENDER DYSPHORIA and are beginning to transition them!!”

There are separate criteria for diagnosing gender dysphoria in adults and adolescents versus children, according to the Diagnostic and Statistical Manual of Mental Disorders. For children to receive this diagnosis, they must meet six of eight criteria for a six-month period and experience “clinically significant distress” or impairment in functioning, according to the diagnostic manual. 

A “strong preference for the toys, games or activities stereotypically used or engaged in by the other gender” is one criterion, but children must also meet other criteria, and expressing a strong desire to be another gender or insisting that they are another gender is required.

“People liking to play with different things or liking to wear a diverse set of clothes does not mean that somebody has gender dysphoria,” Olezeski said. “That just means that kids have a breadth of things that they can play with and ways that they can act and things that they can wear . ”

Editor’s note: SciCheck’s articles providing accurate health information and correcting health misinformation are made possible by a grant from the Robert Wood Johnson Foundation. The foundation has no control over FactCheck.org’s editorial decisions, and the views expressed in our articles do not necessarily reflect the views of the foundation.

Rafferty, Jason. “ Gender-Diverse & Transgender Children .” HealthyChildren.org. Updated 8 Jun 2022.

Coleman, E. et al. “ Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 .” International Journal of Transgender Health. 15 Sep 2022.

Rachmuth, Sloan. “ Transgender Toddlers Treated at Duke, UNC, and ECU .” Education First Alliance. 1 May 2023.

North Carolina General Assembly. “ Senate Bill 639, Youth Health Protection Act .” (as introduced 5 Apr 2023).

Putka, Sophie et al. “ These States Have Banned Youth Gender-Affirming Care .” Medpage Today. Updated 17 May 2023.

Davis, Elliott Jr. “ States That Have Restricted Gender-Affirming Care for Trans Youth in 2023 .” U.S. News & World Report. Updated 17 May 2023.

Montgomery, David and Goodman, J. David. “ Texas Legislature Bans Transgender Medical Care for Children .” New York Times. 17 May 2023.

Ji, Sayer. ‘ Transgender’ Toddlers as Young as 2 Undergoing Mutilation/Sterilization by NC Medical System, Journalist Alleges .” Epoch Times. Internet Archive, Wayback Machine. Archived 6 May 2023.

McDonald, Jessica. “ COVID-19 Vaccines Reduce, Not Increase, Risk of Stillbirth .” FactCheck.org. 9 Nov 2022.

Jaramillo, Catalina. “ Posts Distort Questionable Study on COVID-19 Vaccination and EMS Calls .” FactCheck.org. 15 June 2022.

Spencer, Saranac Hale. “ Social Media Posts Misrepresent FDA’s COVID-19 Vaccine Safety Research .” FactCheck.org. 23 Dec 2022.

Jaramillo, Catalina. “ WHO ‘Pandemic Treaty’ Draft Reaffirms Nations’ Sovereignty to Dictate Health Policy .” FactCheck.org. 2 Mar 2023.

McCormick Sanchez, Darlene. “ IN-DEPTH: North Carolina Medical Schools See Children as Young as Toddlers for Gender Dysphoria .” The Epoch Times. 8 May 2023.

ECU health spokesperson. Emails with FactCheck.org. 12 May 2023 and 19 May 2023.

UNC Health spokesperson. Emails with FactCheck.org. 12 May 2023 and 19 May 2023.

Duke Health spokesperson. Email with FactCheck.org. 12 May 2023.

Olezeski, Christy. Interview with FactCheck.org. 16 May 2023.

Hembree, Wylie C. et al. “ Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline .” The Journal of Clinical Endocrinology and Metabolism. 1 Nov 2017.

Emmanuel, Mickey and Bokor, Brooke R. “ Tanner Stages .” StatPearls. Updated 11 Dec 2022.

Rafferty, Jason et al. “ Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents .” Pediatrics. 17 Sep 2018.

Coleman, E. et al. “ Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7 .” International Journal of Transgenderism. 27 Aug 2012.

Durwood, Lily et al. “ Mental Health and Self-Worth in Socially Transitioned Transgender Youth .” Journal of the American Academy of Child and Adolescent Psychiatry. 27 Nov 2016.

Olson, Kristina R. et al. “ Mental Health of Transgender Children Who Are Supported in Their Identities .” Pediatrics. 26 Feb 2016.

“ Answers to Your Questions about Transgender People, Gender Identity, and Gender Expression .” American Psychological Association website. 9 Mar 2023.

“ What is Gender Dysphoria ?” American Psychiatric Association website. Updated Aug 2022.

Vanessa Marie | Truth Seeker (indivisible.mama). “ Three medical schools in North Carolina are diagnosing TODDLERS who play with stereotypically opposite gender toys as having GENDER DYSPHORIA and are beginning to transition them!! … ” Instagram. 7 May 2023.

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Catholic Healthcare Leader Warns of Transgender Mandate in Change to Obamacare Rule

This change means that any insurer or physician receiving federal financial assistance must cover or provide sex reassignment surgeries and therapies on the grounds that refusal to do so would constitute discrimination based on sex.

Chris Faddis, president of Solidarity HealthShare, is sounding the alarm over a new Biden administration change to the Affordable Care Act that he says denies religious freedom rights of Catholic and Christian health providers who object to sex change surgeries. 

The administration’s new rule amends the nondiscrimination clause in Section 1557 of the Affordable Care Act (also known as the ACA or Obamacare), by removing the word “sex” and replacing it with the phrase “sex (including discrimination on the basis of sex characteristics, including intersex traits; pregnancy or related conditions; sexual orientation; gender identity; and sex stereotypes).”

This reverses changes to ACA made under the Trump administration that excluded such procedures from mandated coverage. 

According to Faddis, who leads a Catholic health share group based out of Arizona, this means that “physicians and medical staff can no longer opt out of performing morally objectionable procedures, like transgender surgeries, without the risk of losing critical federal funding.”

In responding to fears that the rule will violate religious and conscience rights, the Biden Health and Human Services Department (HHS) claims that it has included a provision within the rule that “respects federal protections for religious freedom and conscience.” 

In the final rule, which is set to be filed in the Federal Register on May 6, HHS states that any part of the new guidance that violates “applicable” federal religious freedom and conscience protections “shall not be required.”   

However, Faddis told CNA that the rule’s wording is dangerously vague and would force hospitals and providers to “beg” for religious freedom exemptions that should be automatically afforded under the First Amendment. 

“We should not have to request something that the Bill of Rights says is a God-given right … we should not have to request our religious freedom,” he said. “Even [putting] the burden on an individual doctor or health system to come beg for clemency is a problem. This is not who this country is.” 

Faddis believes that it is “very uncertain” that religious providers’ requests would be granted. 

“How can we possibly trust that they're going to be favorable and friendly and not target or avoid answering these waiver requests?” he asked. 

To be clear, Solidarity HealthShare, which says on its website that it has served 55,000 patients since its founding in 2016, will not be impacted by the Biden administration’s change. This is because the rule specifically targets health insurers and providers. However, Faddis believes the new rule presents a broader danger to not just providers but also patients and the overall healthcare system. 

One such problem Faddis foresees is the possibility that a Catholic or religious provider may not be eligible to receive Medicaid or Medicare funding while their exemption requests are being considered. 

“If suddenly Catholic healthcare systems have to stop taking Medicare or Medicaid,” Faddis said, “not only would that drastically impact them and maybe even take them out of business, but it would also drastically impact the availability of care across the country, particularly in certain states [where] a large percentage of their care is provided by Catholic systems.” 

HHS did not immediately respond to CNA’s request for comment.

In a Friday statement HHS Secretary Xavier Becerra said that the new rule is a “giant step forward for this country toward a more equitable and inclusive health care system.”

According to Becerra, the rule “means that Americans across the country now have a clear way to act on their rights against discrimination when they go to the doctor, talk with their health plan, or engage with health programs run by HHS.”

HHS also clarifies in the rule that “nothing in section 1557 shall be construed to have any effect on Federal laws regarding conscience protection; willingness or refusal to provide abortion; and discrimination on the basis of the willingness or refusal to provide, pay for, cover, or refer for abortion or to provide or participate in training to provide abortion.”

The rule will go into effect on July 5, sixty days after being filed in the Federal Register.

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Advocates: Ban on reassignment surgery for minors would have broad impact on NH health care

Apr. 26—CONCORD — Alice Wade, a transgender woman from Dover in her 20s, said she had to go to Washington to have gender reassignment surgery last summer, and the follow-up services she received at a local hospital here were "laughable."

Wade and many transgender activists said that passing legislation to ban these procedures for anyone under 18 would harm the entire LGBTQ+ community.

"New Hampshire needs to improve when it comes to trans health care, and bills like this will make it harder," Wade testified during a hearing last week on the House-passed ban HB 619.

State Rep. Erica Layon, R-Derry, said the prohibition is appropriate because of the risks and experimental nature of the surgeries, especially on young people.

Layon noted state law does not allow a minor to use a tanning bed until they turn 18.

"I want people to be their authentic selves, but minors having this surgery is a disservice to parents and to minors," Layon said.

If the bill becomes law, New Hampshire would join 23 states that outlaw gender reassignment surgery for minors.

Transgender people like Wade have left the state to get the surgery where it was legal and available.

A coalition of health care organizations also spoke out against the legislation, which would contain the first provision in New Hampshire law to block physicians from making a medical referral, presumably in this case to an out-of-state provider who could perform the surgery.

Those organizations included the New Hampshire Hospital Association, National Alliance for Mental Illness, NAMI New Hampshire, the New Hampshire Medical Society and New Futures, a public health advocacy group.

Dr. Keith Loud, director of the Children's Hospital at Dartmouth-Hitchcock, said it's already hard to attract medical professionals to perform specialized procedures even without such proposed laws.

"Bills like this have a chilling effect on the ability to recruit and retain highly skilled individuals," Loud told the Senate Judiciary Committee.

Sen. Becky Whitley, D-Hopkinton, a candidate for Congress, said she found the ban on referrals the most troubling.

"Why in this one case are we legislating the practice of medicine?" Whitley asked Layon at one point.

Layon said the state has created guardrails for some medical practices, including a ban on conversion therapy for gay people.

Chris Erchull, a lawyer with GLBTQ Legal Advocates & Defenders (GLAD) said a report from the Journal of the American Medical Association found from 2016-2021 there were 101 gender reassignment surgeries for minors under 18 in the U.S., about 20 a year.

Often this was a vaginoplasty for a 17-year-old trans person so the surgery and recovery was complete before the minor headed off to college, Erchull said.

"This targets a class of people and denies them access to treatment," he said. "It is unconstitutional to single out a group of people for treatment under the law."

Under the bill, minors could still have surgeries if needed to correct a "malformation, malignancy, injury or physical disease." Surgery would also be permitted for sex development disorders or circumcision of males.

The House passed the bill last January, 199-175. The vote was not along party lines.

House Republicans backed it, 186-2.

Rep. Dan Hynes, a Bedford Republican who changed to independent before later resigning from the House, also voted against the bill.

House Democrats opposed it, 172-11.

[email protected]

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