What is gender-affirming medical care for transgender children? Here’s what you need to know.

Editor's note: Updates to this story ceased in March 2022. For an updated guide to transition-related health care in Texas, please see this 2023 story.

Texas families with transgender children are facing new fears as state leaders continue targeting them and anti-trans policies crystalize as a top priority in the state Republicans' agenda.

The families have begun lawyering up after Gov. Greg Abbott directed the Texas Department of Family and Protective Services in February to investigate those who seek gender-affirming care for their children. The order came days after Attorney General Ken Paxton issued a nonbinding legal opinion classifying certain types of gender-affirming care as child abuse.

Civil rights groups sued to block Abbott's order as the first of these investigations came to light. A district judge granted a temporary restraining order, which was soon challenged by Paxton.

The legal fight comes months after Texas lawmakers failed to pass legislation that sought broader bans on transition-related medical care for transgender kids, including gender-affirming care that is widely accepted by leading health care groups.

Medical experts say Republican lawmakers’ rhetoric falsely claims that doctors and parents are allowing children to go through irreversible medical treatments.

Leading health care organizations in Texas — including the Texas Medical Association, Texas Counseling Association and Texas Pediatric Society — say gender-affirming care is the best way to provide care to transgender children. They’re not alone: the American Psychiatric Association, the American Academy of Pediatrics, the American Academy of Child & Adolescent Psychiatry and others agree — and have for years.

Here’s what you need to know about gender-affirming care, which lies at the heart of the brewing legal and political battles in Texas.

Areana Quiñones, executive director for the Texas nonprofit organization Doctors For Change, defined gender-affirming care as judgment-free, individualized care oriented toward understanding and appreciating a person’s gender. Providers often work with counselors and family members to ensure they have everything they need to navigate the health care system.

Under the gender-affirming model of care, more time is spent allowing kids to socially transition instead of focusing on medical treatment. A social transition consists of the steps a child takes to affirm their identity. An example could include allowing a child assigned male at birth to grow their hair or use a different name and wear clothing that better fits their identity.

This transition is done with their family and community’s support.

“The most important message is that trans kids are kids,” said Seth Kaplan, president of the Texas Pediatric Society. “And they deserve to have the same health care that all kids have, which is evidence-based health care that serves to promote their growth and development to help them become healthy, fully functioning adults.”

Sometimes, more medical support is needed for the child. Puberty or hormone blockers are used to give a transgender kid time before deciding what permanent transition-related treatment they want.

Puberty blockers are a type of medical treatment that delays puberty. They are completely reversible.

It is not uncommon for puberty blockers to also be a treatment for children who aren’t transgender. Since early onset puberty can cause health issues into adulthood, they have been an approved medical treatment for children for decades.

“Hormone blockers are used for a lot of different medical purposes, not just for transgender youth,” Quiñones said. “So I think that it's a slippery slope, when you're saying you're going to prohibit physicians from using this as a potential treatment for something.”

Some transgender children have more advanced medical procedures, like starting testosterone therapy. Those instances are rare, especially if they are allowed to go on puberty blockers, which give them more time to decide what medical procedures they want in the future when they are an adult.

Language in legislation targeting medical care for transgender children didn't reflect this reality, however. One bill filed during last year’s legislative sessions by state Rep. Matt Krause, R-Fort Worth, sought to ban “gender transitioning” and listed procedures that do not fall under gender-affirming care. The bill did not pass.

“The standards are to support pre-pubertal youth where they are,” said Celia Neavel, director of the Center for Adolescent Health at the People’s Community Clinic in Austin. “There’s nothing going on with hormones or surgery, there’s only living your life and being supportive of who you are.”

Medical experts say transgender children rarely if ever have surgeries like orchiectomies, hysterectomies and mastectomies before they're adults. Still, Abbott cited such procedures in an Aug. 6, 2021, letter directing the Texas Department of Family and Protective Services’ top official to determine whether such gender confirmation surgeries are child abuse under existing state law. Paxton also listed those procedures in his legal opinion, which is nonbinding, issued in Febrary.

Experts took issue with Abbott’s language in the letter, which repeatedly referred to gender confirmation surgery as “genital mutilation.”

“It's literally the harshest language possible, because he wants a reaction from his side,” said Andrea Segovia, Transgender Education Network of Texas’ field/policy coordinator. “And they can gain supporters in that of like, ‘Oh, that sounds awful. Yeah, we shouldn't be doing that to our minors.’”

Major legislation targeting transgender Texans has been introduced in recent regular legislative and special sessions. In 2017, Abbott called a special session to, among other issues, pass a controversial bathroom bill that would have restricted which restrooms transgender Texans could use. The legislation ultimately failed in that special session after also failing in the preceding regular session.

Experts warn legislation like this demonizes transgender people, which can lead to them facing higher rates of violence and mental health issues.

“These kids already suffer from much higher rates of mental health concerns related to anxiety and the higher levels of suicidal ideation because of all the stress that they’re under,” said Kaplan, president of the Texas Pediatric Society. “And so these laws have the potential to just have a dramatic impact on these families.”

In 2019, Black transgender women like Muhlaysia Booker and Chynal Lindsey were killed in Dallas during a year that almost every transgender person murdered was a Black woman. Booker was found dead one month after being assaulted in a Dallas parking lot. When advocacy groups showed lawmakers pictures of Booker’s face, they stated every single lawmaker had a hard time looking at the photo.

“This was the first time legislators were faced with the reality of what was happening in a deeper way,” Emmett Schelling, Transgender Education Network of Texas’ executive director, said in a 2019 conversation about building trans political power. “In the midst of tragedy we were able to really make legislators understand the cost of the rhetoric and what our community was paying.”

Yet little more than a month after the conversation, Abbott and Paxton urged state agencies to investigate whether a mother supporting her 7-year-old child’s gender transition was committing “child abuse.” Jeffrey Younger, the child’s father, posted falsehoods on his blog about gender-affirming care, capturing outrage from Republican politicians like Abbott, Paxton and U.S. Sen. Ted Cruz. Younger is running as a Republican for Texas House District 63 in North Texas and is headed into a runoff with Ben Bumgarner in May.

Texas lawmakers promised to file legislation in response to the Younger case. Equality Texas CEO Ricardo Martinez said midway through the 2021 legislative session that Texas filed more anti-LGBTQ bills during that session than any other state legislature. That includes House Bill 25, which requires that student athletes play on sports teams that correspond to the sex listed on their birth certificate, and the certificate athletes present must have been issued near the time of birth. The law went into effect in January, making Texas the 10th state in the U.S. to enact similar legislation.

According to bill tracker Freedom For All Americans, only Tennessee matched the amount of anti-transgender legislation introduced in Texas. In July 2021, a federal court in Arkansas blocked a law criminalizing gender-affirming care from going into effect. Seventeen state attorneys general — including Paxton — had filed a brief in support of the law.

Krause and state Sen. Charles Perry, Republicans who championed some of the bills targeting transgender children in 2021, did not respond to the Tribune’s request for comment. Abbott also did not respond.

LGBTQ advocates say the political rhetoric surrounding anti-transgender legislation — and the possibility that the bills could become law — have dire consequences for trans kids’ mental health.

The Trevor Project's 2021 National Survey on LGBTQ Youth Mental Health found 52% of transgender and nonbinary youth seriously considered attempting suicide in the previous year. It also found that over 70% of transgender kids have experienced symptoms of generalized anxiety and major depressive disorder. Over that year, the organization, which offers crisis counseling for LGBTQ youth, has received over 9,400 crisis contacts from Texas.

“A majority of trans individuals have struggled with depression or anxiety, at a minimum, during their life and their process,” said Adrian Warren, president of the Texas Counseling Association. “And any time the government, or really any entity, has an anti-trans position, that does further harm. And so when it is something like the government, there’s a very large potential for harm.”

Medical providers are worried that any future legislation could impact their ability to provide treatment to Texas transgender kids.

“If you can’t even talk about it, and these kids can’t get the mental health services that they need and the counseling services that they need, then that has a huge detrimental impact on those kids,” said Kaplan, of the Texas Pediatric Society.

Some families with transgender children have proactively hired lawyers as a result of Abbott's directive. Transgender Texans are paying attention to further moves officials could make to stifle gender-affirming care.

During the 2021 legislative sessions, many transgender kids and their families spent hours testifying at the Capitol in support of gender-affirming care, along with doctor and counselors. At the time, some said they would consider leaving the state if any further action is taken.

Landon Richie and his family have considered such a move. Now 18, Richie began socially and medically transitioning as a teenager. He also got involved in transgender activism, and is now an intern with Transgender Education Network of Texas. A third-generation Texan, he has a younger nonbinary sibling, and his family has discussed moving if they have to.

“Trans people absolutely do belong in the state of Texas,” Richie said. “We make up an integral part of the fabric of this state. But every other year that’s the message that is sent, that trans people don’t belong. They’re second-class citizens. Texas doesn’t want us to exist in public life.”

Disclosure: Equality Texas and Texas Medical Association have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.