Context and Importance of Gender-affirming Care

Gender-affirming care is an umbrella term for developmentally appropriate supports that have been shown to reduce anxiety, depression, and suicidal ideation in young transgender and gender-diverse people.

For young children, such care includes non-medical social processes such as changes in names and pronouns and the affirmation of gender expression-related choices like clothing and hairstyles. In older adolescents, gender-affirming care can also include medical interventions such as puberty blockers and supportive hormone therapies that may take place after careful consideration by families, professionals, and—most importantly—the youth themselves.

A growing body of research demonstrates that when transgender children and youth are supported in their identities, their mental health outcomes are similar to those of their cisgender peers. Transgender youth who are supported by their parents report greater life satisfaction and fewer depressive symptoms than those who report low levels of support. Additionally, supportive adults in school environments can increase transgender youth’s feelings of safety and reduce their school dropout rates.

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For many transgender youth, discrimination based on gender identity may exacerbate experiences of racism, sexism, and ableism.

Although exact numbers are difficult to obtain on the prevalence of additional identities within the transgender community, a recent report from the Williams Institute indicates that the transgender population within the United States is more racially and ethnically diverse than the overall population. Additionally, the 2015 National Transgender Survey, sponsored by the National Center for Transgender Equality, found that 39 percent of respondents indicated that they had a disability—more than twice the prevalence in the general population (15%). A growing body of research demonstrates the accumulation of stress—often due to increased experiences of victimization and discrimination that can come from having multiple marginalized identities— increases the risk of suicide. As a result, policies that are harmful to transgender youth are likely to disproportionately impact youth of color, youth with disabilities, and other youth with marginalized identities who happen to be transgender, too.

According to the 2015 National Transgender Survey, transgender individuals of color were more likely than those in the overall sample to report leaving school due to discrimination. Environments that discriminate against transgender students of color can have dangerous consequences for youth. For example, Black transgender women who experienced discriminating policies in schools faced greater involvement with the criminal justice system and a greater likelihood of eventual incarceration than their similarly identified peers who attended schools without discriminatory policies. Gender-affirming supports play a particularly important protective role for transgender and nonbinary youth who face the compounding effects of multiple forms of discrimination.

One in three transgender youth report having attempted suicide in the past 12 months, but research from the Trevor Project suggests that receiving gender-affirming supports may cut that risk in half.

Transgender youth also report higher rates of suicide attempts than their cisgender peers, at least in part due to experiences of discrimination and stigma. Data from the Youth Risk Behavioral Survey (YRBS) documented a nearly five-fold difference in the proportion of transgender youth reporting a suicide attempt in the past year compared to their cisgender peers.

Not all trans youth are harassed and discriminated against, but those who are face higher risks of suicide. Data from a large national survey of LGBTQ youth administered by the Trevor Project in 2021 point to the role of discrimination and stigma in increasing the risk of suicide for transgender youth. The study found that the rate of suicide attempts among transgender and nonbinary youth who reported experiences of discrimination based on their gender identity was double that of transgender youth who did not report these discriminatory experiences.

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Criminalizing Support for Transgender Youth Prevents Advocates from Protecting Youth Well-being

Policies that prevent access to critical supports for transgender children and youth not only limit essential health care but create environments that are known to intensify health disparities.

In 2021, more than 200 anti-LGBTQ+ bills were introduced across the United States in state legislatures. If implemented, these bills would create environments that prevent access to the services and care that trans youth need, such as gender-affirming health care, appropriately labeled identification forms (e.g., birth certificates and licenses), access to spaces such as bathrooms or locker rooms, and opportunities for participation in sports or school activities. These environments can increase transgender youth’s overall risk of experiencing violence. For example, a recent study found that transgender and nonbinary youth in schools with single-sex anti-trans bathroom restrictions faced increased rates of sexual assault. This study compared rates of sexual assault between schools with and without these policies. In schools with anti-trans policies, risk of sexual assault risk was 1.26 times higher for transgender boys, 1.42 times higher for nonbinary youth assigned female at birth, and 2.49 times higher for transgender girls.

Recent policies that characterize gender-affirming care as abuse put children at greater risk for family separation and poorer health outcomes.

For example, a recent policy in Texas deems many forms of gender-affirming care to be child abuse and requires that anyone supporting these practices be reported to Child Protective Services for investigation. As a result, adults who play helpful roles—the types that have documented positive relationships with the well-being of transgender children—face criminalization for their support. This policy, like other proposed policies that would criminalize the provision of gender-affirming care (such as those in Georgia, Idaho, and Kansas), may subject families and providers to investigations and surveillance and could funnel transgender youth into foster care, where they are more likely to experience negative outcomes.

Investigating families has negative impacts on families and youth, regardless of whether allegations of maltreatment are founded.

Child protection investigations can be a traumatic or distressing experience for families and children. Investigations present the possibility of family separation, which can cause fear, anxiety, and stress even if allegations are deemed unfounded. Children have described the investigation process as stressful and reported experiencing anxiety, shock, confusion, and fear of being removed from their families. In addition to the direct harm caused to children, directives to investigate families with children receiving gender-affirming care can lead to unnecessary surveillance of parents. This, in turn, results in apprehension and fear that thwart access to services and supports, an inability to access medically necessary health care for children, and adverse implications that result from the record-keeping of investigations, like parents losing their jobs or receiving negative flags on background checks. The benefits and importance of keeping families intact (when possible) and free of unnecessary child welfare surveillance are clear, and unnecessarily funneling more children and families into the child welfare system by broadening the definition of abuse and neglect contradicts years of research and best practices.

Foster care can lead to adverse outcomes, especially for LGBTQ+ youth.

Youth who are removed from their homes experience significant challenges at higher rates than their peers: They are less likely to receive a high school diploma, attend college, earn a living wage, and have stable housing. Research shows that these impacts may be exacerbated for LGBTQ+ youth. While in care, LGBTQ+ youth encounter an array of injustices, including discrimination, marginalization, lack of acceptance, placement instability, high rates of placement in congregate care, and a higher likelihood of running away. In turn, LGBTQ+ foster youth and former foster youth face disproportionate adverse mental health impacts in the form of elevated risk for anxiety and depression, post-traumatic stress disorder, substance use, self-harm, hospitalization, and suicidality. In addition to these injustices faced during their time in care, LGBTQ+ young people are further subjected to adverse outcomes like aging out of care without legal permanency, homelessness, and trafficking at higher rates than their peers.

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Policy Recommendations

The increase in policies that limit access to medically indicated, critically necessary gender-affirming care is creating an urgently dangerous environment for the well-being of transgender youth and their families across the nation. Without these vital supports, youth are at greater risk for anxiety, depression, and suicide. Furthermore, policies that initiate unwarranted contact with child protective services can damage entire families through unjustified separations and out-of-home placements that further increase a young person’s risk for poor mental health outcomes. However, some states are taking steps to ensure that transgender people can access the supports they need by creating affirming policies.

Policies that support transgender youth should do the following:

1. Ensure access to appropriate gender-affirming medical care.
2. Create supportive environments by allowing individuals to choose their gender markers on identification documents—for example, their names, genders, and pronouns.
3. Safeguard transgender youth’s access to the same types and quality of supports and activities as their peers.
4. Specifically support transgender children and their safety by using gender-affirming language and actively preventing bullying.

Policymakers everywhere must recognize that gender-affirming care—i.e., developmentally appropriate supports shown to reduce anxiety, depression, and suicidal ideation in young transgender and gender-diverse people—is a critical, medically indicated treatment that provides essential health support to youth, and that it is in families’ best interests to invest in systems that protect transgender youth.

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