Here’s what to know about transition-related health care, which Texas has banned for children

For the second consecutive legislative session, some Republican Texas lawmakers in 2023 pushed bills that sought to limit the kind of health care treatments — like puberty blockers and hormone therapy — that leading medical associations support for trans children and young adults. In June 2023, Gov. Greg Abbott signed Senate Bill 14 and Texas joined 17 other states restricting transgender minors from accessing puberty blockers and hormone therapies.

Nearly 30,000 13- to 17-year-olds in Texas identified as trans in a federal survey published in 2022 — and this is likely an undercount.

[Texas lawmakers pursued dozens of bills affecting LGBTQ people in 2023. Here’s what passed and what failed.]

The stigma and discrimination trans people face often contribute to higher rates of stress and mental health problems compared to cisgender people, several studies have found. Experts say transition-related health care is often lifesaving and can be medically necessary for some people.

“Transition-related care” is an umbrella term referring to a range of social practices, hormone therapies, mental health treatments and medical procedures that support a person’s gender identity. Trans adults, under the care of doctors and mental health professionals, decide what types of medical care and practices, if any, make the most sense for them as individuals. Trans kids make those same medical decisions with permission from their parents and under the care of doctors and mental health care professionals.

Legislative debates centered on the age at which such care should be provided and what science and medical experts say about the treatments. Doctors and trans Texans said much of the political rhetoric surrounding the legislation misrepresented who was receiving such care and what treatments kids typically undergo.

Many trans Texans wondered why their access to care — which is often lifesaving — was up for debate in the first place.

“In my experience, trans people just want to live their lives,” said Marvin Bellows, a Texas counselor whose clients include trans and queer youth. “That’s even a common joke in trans communities: ‘We have an agenda — that’s to live.’”

A transgender person is someone whose gender identity does not completely align with the sex assigned to them at birth.

A cisgender person is someone whose gender identity aligns with the sex assigned to them at birth.

Gender dysphoria is the medical term for the distress someone experiences when their gender identity doesn’t match their body. Not all transgender people experience gender dysphoria. But trans people often use the term for the discomfort they feel when they are referenced by or treated as the wrong gender, or view themselves as not looking or feeling like the gender they are.

Gender euphoria, conversely, is a feeling of comfort and joy when gender identity and expression match.

Transition-related care is an umbrella term referring to a range of practices and therapies — from social behavior to health care treatments — that affirm a transgender person’s gender identity. It includes talking with a therapist or counselor, using the correct pronouns, taking medications that pause puberty or receiving hormone therapies.

This is often also called gender-affirming care.

Transgender adults make individual decisions about which combination of practices and treatments, if any, work for them. They consult with medical professionals about therapies and procedures. Before Senate Bill 14, parents, doctors and mental health care professionals were also involved in making decisions about the practices and treatments that make the most sense for transgender children.

Most transgender American adults say transitioning has made them more satisfied with their lives, according to a KFF/Washington Post survey released March 23.

Studies have found that transgender youth who take puberty blockers are significantly less likely to experience lifelong suicidal ideation than those who want the care and don’t get it. And studies show psychological trauma is reduced and life satisfaction increases when people who want transition-related hormone therapy get it.

Major medical associations support transition-related care. They include the American Academy of Pediatrics, the American Medical Association, the Endocrine Society, the World Medical Association and the World Professional Association for Transgender Health.

“The bottom line is, gender-affirming care is something that is evidence-based. There are multiple medical organizations that have reviewed the literature,” said Texas Pediatric Society president Louis Appel. “It’s not a one-size-fits-all approach. … These are complicated issues that really are best dealt with in the context of the physician-patient-family relationship.”

Providers overwhelmingly follow a care timeline set up by major national and global medical organizations. For example, the Endocrine Society, among other health organizations, recommends waiting until a teenager can give informed consent — usually around age 16 — to start hormone therapy. Major medical organizations including the American Academy of Pediatrics, the World Professional Association for Transgender Health and the Endocrine Society have published guidelines on age-appropriate timelines for care.

“Cisgender teenagers, together with their parents or guardians, are currently deemed competent to give consent to various medical treatments,” an Endocrine Society statement says. “Transgender teenagers should be afforded the same legal rights.”

Social transitioning happens when a transgender person starts presenting and introducing themself in a way that aligns with their gender identity. For a lot of people, this is what’s known as “coming out.” It can look like a new haircut or trying out a new name, said Landon Richie, a Texas college student who is a trans man and a policy associate for the Transgender Education Network of Texas. In addition to counseling, this is pretty much the only option for care available to young trans people before puberty.

“The experience of being around others who understand and accept me for who I am is lifesaving — not only for myself, but for so many other people,” Richie told reporters last month.

It can also include using certain pronouns and wearing clothes that express one’s gender identity. Recent studies show that young people who socially transition are overwhelmingly likely to keep identifying that way.

A growing bank of evidence also shows that social affirmation — using the right name and pronouns, receiving support and experiencing a sense of community — can decrease rates of depression and suicidal ideation, said Jason Rafferty, who authored the American Academy of Pediatrics’ 2018 policy statement on gender-affirming care.

“The real understanding that I think is coming from the data is that any support really helps build resiliency,” Rafferty said.

One of the first steps to accessing puberty blockers, hormone therapies and other transition-related care is talking with mental health care providers.

Industry standards guide behavioral health professionals to look at how long their clients have been experiencing gender dysphoria and whether it is likely to continue as they make recommendations for children, said Marvin Bellows, president of the Texas Society for Sexual, Affectional, Intersex and Gender Expansive Identities, a division of the Texas Counseling Association.

Providers are dissuaded from pushing young people to come out, socially transition or begin medical treatments.

“The exploration process is one of affirmation and acceptance, no matter what the conclusion is,” Bellows said. “That way, the client doesn’t feel pressure to identify in any particular way.”

Physicians and insurance will often request letters of support from a patient’s behavioral health providers before starting puberty blockers or hormone therapy, Bellows said. And some request a more ongoing relationship — for example, having a mental health care provider meet regularly with a patient to check on how they are doing and collaborate with a physician if any issues come up.

Providers also shouldn’t recommend transition-related care to kids if it’s not safe for them, whether that’s due to an unsupportive social environment or a number of other factors, Bellows said.

In some cases, physicians can prescribe puberty blockers to pause puberty and allow an adolescent more time to understand their gender identity, according to the Texas Medical Association.

“Puberty is not a neutral process,” said Jason Rafferty, who authored the American Academy of Pediatrics’ 2018 policy statement on gender-affirming care. “Your body produces hormones, whether it’s estrogen or testosterone, which will facilitate certain effects, which will dictate … from a gender perspective, how you’re seen and perceived.”

Physicians have been using puberty blockers with cisgender patients since the 1990s to pause early puberty. That is when puberty changes occur too soon in a child, such as those younger than 10. Puberty blockers are used off-label for transgender patients. Off-label use — when physicians prescribe FDA-approved drugs for an unapproved use — is both common and legal. The Agency for Healthcare Research and Quality reported 1 in 5 prescriptions were written for off-label use in 2015.

While a young transgender person is using puberty blockers, health care professionals monitor their physical and psychological health, according to the TMA. During that period of time, family members and the youth’s health care team discuss whether that person will stop using the blockers and continue puberty in their sex assigned at birth or begin using prescribed hormone therapy — for example, estrogen for trans girls or testosterone for trans boys.

The effects of puberty blockers are reversible after a person stops using them, major medical associations agree. Providers must advise adolescents on the risks of puberty blockers before beginning treatment, including potential effects on bone mineralization, according to the Endocrine Society.

Depending on the mental health of the patient, the benefits of treatment can heavily outweigh potential side effects, two doctors and a counselor told The Texas Tribune.

Hormone therapy enables transgender people to experience puberty in a way that more closely aligns with their gender identity. It can entail trans women taking estrogen and trans men taking testosterone.

It is best practice for providers to wait to recommend hormone therapy until a person is considered competent to consent to the treatment. That’s usually possible at 16 years old, according to the Endocrine Society. Physicians calculate potential risks and complications with a patient’s family and behavioral health team before starting any treatment. After starting, physicians meet regularly with patients to monitor hormone levels and run other tests.

Hormone therapy is partially reversible if a patient decides to stop treatment. Physicians must tell patients prior to beginning treatment that certain effects of hormone therapy, including breast growth or a deeper voice, are irreversible, according to the Texas Medical Association.

Some cisgender people also receive hormone therapy. Cisgender women use it to relieve symptoms associated with menopause and cisgender men use it when they experience low testosterone levels.

Minors can sometimes undergo surgeries on their breasts and chests — but only around ages 16 or 17, and only in specific circumstances after doctors weigh a patient’s situation with family support, said Jason Rafferty, who authored the American Academy of Pediatrics’ 2018 policy statement on gender-affirming care. Accessing puberty blockers at the start of puberty can help trans people avoid transition-related surgery later in life.

Cisgender people also get the same or similar surgery, like when they have breast augmentations and breast reductions.

Texas Pediatric Society president Louis Appel said he’s not aware of minors in Texas having bottom surgery, an umbrella term for surgery that involves genitals. Standards of care dictate that bottom surgery shouldn’t happen until a person is 18, Rafferty said.

Sometimes, people decide to stop gender-affirming care.

Not very many trans youth detransition. Research published in Pediatrics found that of the 300 young people who identified as trans at the start of a five-year study, 2.5% identified as cisgender by the end.

The most common reason for detransitioning is that transition efforts didn’t cause the social relief a person was looking for, said Marvin Bellows, a Texas counselor whose clients include trans and queer youth. That can happen as a result of anti-trans discrimination, unsupportive families or a number of other factors, Bellows said.