In recent years, transgender people — and particularly, transgender kids — have become pawns in a broader political struggle.
Florida officials in June proposed a rule preventing the state’s Medicaid program from reimbursing providers for a series of therapies meant to treat gender dysphoria. Florida joined other red states that have moved to restrict access to those medical treatments.
Gender dysphoria is defined as strong, persistent feelings of identification with another gender coupled with significant discomfort and distress with one’s own assigned gender and sex.
Florida’s efforts follow years of litigation and lawmaking driven by conservatives about whether transgender girls can compete in women’s sports, how the existence of transgender people is explained in schools and which bathroom is appropriate for them to use.
Essentially, those in favor of treating the condition with hormonal therapy care and those against the practice are accusing each other of the same thing: distorting the scientific evidence in order to politicize the well-being of children.
Let’s delve into some of the most important questions on the subject.
1. How many kids in Florida have gender dysphoria?
An estimated 16,200 Florida teenagers — roughly 1.32% of children aged 13 through 17 — identify as transgender, according to a June report by The Williams Institute, a think tank at UCLA’s School of Law. The report uses data from Florida’s 2019 Youth Risk Behavior Survey. Across the U.S., as many as 300,000 teens identify as transgender, the report found.
That does not mean they meet the psychological criteria to be diagnosed with gender dysphoria. Based on the number of people who seek treatment, up to 0.014% of those assigned male at birth and 0.003% of those assigned female at birth are later diagnosed with gender dysphoria, according to the American Psychiatric Association.
To be diagnosed, the condition must persist for six months, and children must be able to verbalize their discomfort, according to the definition of gender dysphoria offered by the American Psychiatric Association.
2. What causes gender dysphoria in kids?
It’s not clear. However, the number of children needing services to treat gender dysphoria or related mental health issues is on the rise in some western countries such as the United Kingdom. Some attribute this to decreasing social stigma to being transgender, or the increased availability of services. Others, including conservative policymakers, have hypothesized the condition is socially influenced.
3. Why do some transgender people seek treatment?
For Nikole Parker, gender identity was a matter of life and death.
“I would not be alive if I did not transition,” said Parker, who’s now the director of transgender equality at the LGBTQ advocacy group Equality Florida.
Many transgender people experience gender dysphoria so acutely it has negative consequences for their mental health. Parker says when she began her transition journey at 19, she wanted to align her body with her gender identity so much that she acquired hormones off the black market.
At least one in four kids diagnosed with gender dysphoria report having attempted suicide, according to three studies cited by a peer-reviewed case report.
4. How are kids treated for gender dysphoria?
The medical therapies, which experts say should be administered gradually along with extensive consultation from mental health professionals, fall under three categories.
First, if a child has not already gone through adolescence, they can be put on puberty blockers. This can alleviate distress from body changes that don’t align with identity. Puberty blockers can also buy children time to figure out how — or whether — they want to proceed with their transition.
Next, they can be prescribed hormones: typically estrogen for transgender girls and testosterone for transgender boys. Like puberty blockers, these hormones treat a number of other medical conditions. The Endocrine Society, which advises doctors on hormone science, notes that for most kids, 16 is the youngest age that they can consent to treatment.
Finally, people can pursue gender confirmation surgeries that involve reconstructing reproductive organs. However, medical societies do not generally recommend these irreversible surgeries for children.
In a recent report, Florida’s Agency for Health Care Administration explored whether insurance should cover these therapies and whether they fall under the state’s professional medical standards, or whether they were “experimental or investigational.”
The state decided the scientific community had not demonstrated enough evidence to show whether the treatments were safe or effective in easing the mental health burden associated with gender dysphoria. More traditional mental health counseling is appropriate for transgender kids, but not hormonal therapies, Florida officials have said.
Major medical societies such as the Endocrine Society and American Academy of Pediatrics and the World Professional Association for Transgender Health disagree with the state’s assessment. They recommend the treatments be available for kids and adults.
5. How irreversible are these therapies?
A team of Yale researchers wrote a policy paper in April criticizing conservative-run states for restricting access to puberty-blocking drugs, arguing that the therapies are “safe, effective, and fully reversible.”
The drugs have been prescribed by doctors since the 1980s to treat kids suffering from a phenomenon called “precocious puberty,” in which some children begin the process of puberty at an inappropriately early age. Once a child is of the proper age to go through puberty, they are taken off the drugs.
Some other academics, including many cited by Florida officials, argue the effects of puberty blockers aren’t fully reversible. They say there’s not enough evidence to demonstrate whether puberty blockers alleviate the mental health symptoms of gender dysphoria — nor is there enough evidence on the long-term effects of the drugs prescribed to kids to treat gender dysphoria.
Hormonal therapies present more significant long-term effects for children, some of which can be irreversible, such as a reduction in fertility.
Michael Haller, the chief of pediatric endocrinology at the University of Florida, works at a clinic in Florida that treats children with gender dysphoria. He says his patients benefit from hormonal therapies, and that the families know the potential downsides.
“The majority of the bodies that have looked at the available data and who take care of these patients have argued in favor of these treatments,” Haller said.
Some who have undergone hormonal therapies say they regret the process. Experts on both sides of the debate around hormonal therapies agree more study is needed. Haller said in his experience, the number of children who regret transitioning is “exceedingly low.”
6. Who to believe on hormone therapy?
State officials are questioning the authority of three medical societies: the Endocrine Society, the American Academy of Pediatrics and the World Professional Association for Transgender Health.
Those three groups have endorsed hormonal therapies care based on studies that rely on survey results; doctors shouldn’t heed their advice, Florida officials say.
“Physicians who recommend sex reassignment treatment are not adhering to an evidence-based medicine approach and are following an eminence-based model,” the June report from the state reads. Florida officials argued the guidance recommending puberty blockers to treat childhood gender dysphoria is based on studies that involved “small sample sizes and subjective methods.”
In response, the World Professional Association for Transgender Health, a nonprofit dedicated to advancing the health of transgender people, called the state’s report “misleading and dangerous.” The Endocrine Society stands by its guidance, which was primarily crafted by nine experts according to the group’s standards for evidence-based guidelines. The American Academy of Pediatrics also backs its guidance, which was created with the help of more than a dozen expert members.
Paul Hruz, an associate professor of pediatrics at the Washington University School of Medicine in St. Louis, was one researcher cited in the Florida report. He said Florida officials did a good job highlighting what he describes as gaps in the science that call into question the efficacy of hormonal treatments for kids.
“I think it would be erroneous to say we know the answer and that we’re going to limit our investigation,” Hruz said.
Haller said the bulk of the scientific evidence, along with the clinical benefits he’s seen, justify prescribing hormonal therapies.
”The benefits far outweigh the risk,” Haller said.
Another researcher cited by the Florida Agency for Health Care Administration, James Cantor, testified in favor of a law that blocks the use of puberty blockers and hormone therapies for children during a recent federal court case in Alabama.
The judge wrote that he gave Cantor’s testimony “very little weight” as it emerged in cross-examination that Cantor had never treated a transgender child under the age of 16 or diagnosed a child with gender dysphoria.
7. What action is the state proposing?
The Florida Department of Health issued guidance in April recommending against gender-affirming care for kids. It also recommended against “social transitioning,” in which a child takes on a different outward presentation. That can include assuming a new name or wearing new clothes.
Critics of the state’s guidance, including DeSantis’ former surgeon general, signed a letter in April noting that Florida’s stance on social transitioning is not in line with the countries cited by the state that are skeptical of hormonal therapies.
Surgeon General Joseph Ladapo, who leads the state health department, asked a few weeks later that the Florida Board of Medicine create rules that could restrict access to certain gender dysphoria treatments.
The Agency for Health Care Administration has now proposed a rule that would block Medicaid from covering “procedures that alter primary or secondary sexual characteristics.”