Transgender Medical Care: What You Should Know and How To Preserve Access to Care

Just 0.5 percent of the adult U.S. population—1.3 million people—identifies as transgender.¹ Yet, attacks on the community dominate much of the political sphere.² In just the past few years, states have proposed hundreds of bills³ that seek to ban transgender medical care. In addition to causing direct harm, these bills aid in proliferating misinformation about transgender health care—such as false claims that children undergo surgeries at school without parental consent.⁴ Proponents of bans on transgender medical care also promote harmful rhetoric that this care, especially when provided to young people, is experimental and wholly irreversible,⁵ but nothing could be farther from the truth.⁶

Although a small share of the population, transgender people—or those who identify with a gender different than the one they were assigned at birth⁷—are a vital part of their communities. They are nurses, scientists,⁸ actors, teachers, and even veterans⁹ and elected representatives,¹⁰ and they contribute to their local economies,¹¹ volunteer regularly, and are consistent civic participants.¹²

Everyone deserves access to the medical care that they need. Transgender medical care includes a full spectrum of evidence-based, lifesaving care.¹³ Still, what that care entails can vary. This report lays out the basics of transgender medical care for youth and adults and offers recommendations to preserve and expand access to this care.

Transgender medical care,¹⁴ also referred to as gender-affirming care, comprises a suite of medical care options¹⁵ to treat gender dysphoria—the medical diagnosis¹⁶ used to describe the psychological distress that results from an incongruence¹⁷ between an individual’s sex assigned at birth and their gender.

According to the World Health Organization, gender-affirming care can consist of one or more “social, phycological, behavioral, or medical interventions.”¹⁸ It can range from hormone replacement therapy (HRT) to surgery.¹⁹ Like other medical care, treatment for gender dysphoria is not one-size-fits-all; rather, it is tailored to meet each patient’s medical needs through individualized determinations made with a patient’s team of health care providers in accordance with accepted, evidence-based standards of care.

For many people, both transgender youth and adults, access to gender-affirming or transgender medical care is lifesaving.²⁴ It increases physical and mental wellness; facilitates increased participation in school, work, and community spaces; and is strongly correlated²⁵ with decreased depression and suicidality. According to the “2022 U.S. Transgender Survey,” 94 percent²⁶ of respondents were more satisfied with their life after transitioning, including 97 percent²⁷ of respondents who had at least one surgery. The regret rates of transition are also extremely low for both youth²⁸ and adult trans people.²⁹ A systematic review of surgical studies found that the regret rate after gender-affirming surgery was 1 percent,³⁰ compared with 14 percent for a range of nongender-affirming surgeries.³¹

One form of transgender medical care is medical transition, which includes interventions³² such as puberty blockers, HRT, and surgery. Many of these interventions are fully reversible.

Puberty blockers and hormone replacement therapy

Puberty blockers, or gonadotropin-releasing hormone analogs, are medications that pause puberty.³³ Young people may go on these medications at the onset of puberty. Puberty blockers are safely used to treat many conditions in addition to gender dysphoria, such as central precocious puberty³⁴ and several types of cancer.³⁵

Puberty blockers are recommended by both the Endocrine Society³⁶ and the World Professional Association for Transgender Health³⁷ to pause puberty³⁸ until such a time that the patient’s health care team determines whether and if it is appropriate to prescribe hormone replacement therapy. This medication pauses “breast growth, voice deepening, facial structure changes, Adams’ apple development, and facial hair”³⁹ and can reduce the need for future surgical interventions by avoiding these changes.⁴⁰ Puberty blockers are safe, and their effects are fully reversible.

For older teens and adults, HRT is the provision⁴¹ of estrogen or testosterone to induce physiological changes that align with the patient’s gender identity. Effects of testosterone⁴² can include thickened vocal cords, which lower the voice. In contrast, the effects of estrogen include a decrease in muscle mass and strength.⁴³ Both testosterone and estrogen will cause fat redistribution throughout the body and face, changes to scalp and body hair, and changes to skin texture.

Gender-affirming surgeries

Gender-affirming surgeries consist of a suite of procedures⁴⁴ transgender people may undergo to better align with their gender. A small number of these procedures are—very rarely⁴⁵—recommended for transgender people under the age of 18 on a case-by-case basis. Analysis of insurance claims data for surgeries from 2019 showed that out of 2,749 gender-affirming surgeries identified among more than 70 million insured individuals, only 85 surgeries were performed on transgender youth under 18.⁴⁶

The estimated population of trans youth in the United States is around 300,000, constituting just 1.4 percent of the 13–17-year-old population.⁴⁷ Guidelines for best practice gender-affirming care are dependent on the age of the patient.⁴⁸ Care for trans youth is designed to give young people and their families as much time as possible to understand their gender identity.⁴⁹ Like care for trans adults, youth care focuses on alleviating symptoms of gender dysphoria or gender incongruence and encompasses social, legal, and medical transition.⁵⁰ For those youth who need it, gender-affirming care can be lifesaving.⁵¹

Guidance from the World Professional Association of Transgender Health centers on proactive, patient-focused, gender-affirming care states that “[t]aken as a whole, the data show early medical intervention—as part of broader combined assessment and treatment approaches focused on gender dysphoria and general well-being—can be effective and helpful for many transgender adolescents seeking these treatments.”⁵²

How gender-affirming care differs for young patients

Transgender medical care for youth looks different than it does for adults. For patients who have yet to reach puberty, care may consist of mental health supports and social transitioning.⁵³ Once a young person reaches puberty, they may begin puberty blockers.⁵⁴ Young trans people do not begin HRT until adolescence, when later stages of puberty begin, often between the ages of 14 and 16.⁵⁵ It is important to note that patients, their families, and their providers can always choose to delay or forgo any of these medical interventions based on the needs of the young person.

While there is not a single process for how youth transition, current clinical practice requires the diagnosis of gender dysphoria or gender incongruence from a licensed mental health provider before a trans young person can receive clinical care.⁵⁶ Mental health providers (MHPs) who work with trans or gender-nonconforming patients do two things: First, they affirm the patient’s expressed gender identity. Second, they work with the patient over time to explore what gender alignment looks like for them.⁵⁷ Finally, the MHP will use their scientific knowledge of cognitive development to help patients and their families identify when it is developmentally appropriate for youth to make decisions about their medical transition.⁵⁸

The most common hormone intervention for trans youth is the prescription of puberty blockers.⁵⁹ Puberty blockers on their own are not permanent; they simply pause puberty.⁶⁰ If a patient stops using puberty blockers, then the endogenous puberty of their sex assigned at birth will resume.⁶¹ Side effects of puberty blockers⁶² are monitored by the patient’s health care team. Medical research shows that puberty blockers do not cause infertility if they are started after puberty begins.⁶³

The Endocrine Society’s clinical guidelines for youth⁶⁴ recommend that cross-sex HRT generally be provided to youth ages 16 or older. On a case-by-case basis, some providers may elect to prescribe HRT for younger patients when it is clinically indicated and when the patients and their families consent to this treatment. ⁶⁵ Many of the effects of HRT are not permanent if the patient ceases care.⁶⁶ The impact of cross-sex hormones on fertility differs from patient to patient,⁶⁷ and clinical guidelines encourage providers to counsel patients and families about the impact of treatments on fertility.⁶⁸

Surgeries are rarely performed on trans youth.⁶⁹ When they are, the surgeries are done with the consent of the patient, caregivers, and the full team of providers.⁷⁰ Despite rampant misinformation claiming young transgender people often undergo gender-affirming surgeries, this type of care is incredibly rare for those under 18. For example, a cross-sectional study of more than 20 million minors found that, when including cisgender males who undergo breast reduction surgeries, only 3 percent of breast reduction surgeries occurred on trans minors in 2019.

The importance of family and caregiver supports

Decisions about transgender medical care for youth are made in concert with a team of providers and their families.⁷¹ Like most pediatric and adolescent health care, it is important that providers support both their patient and the patient’s family.⁷² Stories from both physicians⁷³ and mental health providers⁷⁴ demonstrate the efforts made to align youth and caregivers during the transition process.

When transgender youth are affirmed and supported by their families,⁷⁵ they are more likely to have better mental health and physical health outcomes.⁷⁶ According to the “2022 U.S. Transgender Survey,” 29 percent of the 16 and 17 year olds who completed the survey stated their immediate family was not supportive of their trans identity.⁷⁷ Amongst this same age group, 60 percent also reported experiences of mistreatment, harassment, and/or discrimination.⁷⁸ Accordingly, data show that all students, including trans youth, who attend schools with affirming policies are less likely to experience bullying by their peers.⁷⁹

Many trans people living in the United States struggle to access transgender health care.⁸⁰ More than two dozen states have banned or restricted provision of best practice gender-affirming care.⁸¹ In states where care is legal, high health care costs and lack of providers present their own challenges.⁸² In order to ensure that this lifesaving care is accessible to all who need it, multiple points of the health care infrastructure must be improved.

Improve provider education and training opportunities

In 2023, 82.4 percent⁸³ of health care providers said the lack of training and education on providing transgender health care was a barrier to providing this care. Interviews with trans youth and their caregivers also highlighted a need for improved training and awareness amongst providers and staff to decrease instances of discrimination and integrate transition care with primary health care visits.⁸⁴

A widespread shortage of medical providers is worsening, particularly in rural areas.⁸⁵ This shortage complicates the already significant barriers that exist in accessing transgender health care. For example, in 2015, 27 percent⁸⁶ of rural trans people had to travel 75 miles or more for transgender health care, and 35 percent⁸⁷ of rural trans people of color needed to travel 25 miles or more just to access routine health care.

In order to meet the urgent need for more providers trained to work with trans patients, state and federal funding should be used to support training and continuing education for medical providers and staff on working with transgender patients and on the provision of their care.

Expand state-level protections

Since 2021, 26 states⁸⁸ have passed bans or restrictions on best practice transgender medical care, causing some families to relocate across state lines in order to obtain needed care.⁸⁹ As of the publication of this report, litigation to stop or repeal these policies is active in 22 of those states. In cases such as United States v. Skrmetti,⁹⁰ the U.S. Department of Justice (DOJ) has intervened⁹¹ in support of protecting access to care for trans youth. These bans create a chilling effect on medical providers of transgender health care that makes it even more difficult for patients to get access.⁹²

In the coming months and years, it will be crucial for the DOJ and the White House to continue to support the families of trans youth as they defend access to the care they need. Furthermore, states must also affirm their constituents’ right to access the care they need—including transgender medical care. Some states, such as Minnesota⁹³ and Illinois,⁹⁴ have already passed legislation explicitly protecting access to such care.

Boost insurance coverage and affordability

In 2015, nearly 7 in 10 rural trans people reported that they were denied coverage for transition-related surgeries, and 1 in 4 were denied coverage for HRT by their insurance providers.⁹⁵ In 2023, 41.6 percent of providers said that the lack of insurance coverage for this health care prevented them from providing it.⁹⁶

Even where transgender medical care is legal, and even for those with insurance coverage, barriers to access may still be high.⁹⁷ Cost varies widely by state, insurance provider, and type of care. HRT, for example, can range⁹⁸ from less than $100 to more than $3,500 per year in out-of-pocket costs. And when health insurance is tied to employment, this puts access to affordable care at higher risk due to fear or experiences of discrimination. According to a 2024 Williams Institute report, 55 percent of transgender workers had experienced some form of discrimination in the workplace.⁹⁹

All insurance providers—including providers of Medicare, Medicaid, and Tricare—must equitably cover access to gender-affirming care. In order to minimize the impact of employment discrimination on access to affordable transgender health care, Congress must pass comprehensive nondiscrimination protections, such as those provided in the Equality Act.¹⁰⁰

Transgender medical care is a spectrum of evidence-based, best-practice care that can be lifesaving. The provision of all gender-affirming medical interventions are determined and prescribed in concert with patients, their providers, and—in the case of trans youth—their families.

In order to protect access to transgender medical care, providers need to be trained appropriately, bans on care must be overturned, and insurance must cover treatments. Everyone—including transgender people regardless of their age—deserves access to the medical care they need.