Growing up has always brought challenges. For transgender or nonbinary adolescents, teens and young adults, growing up is especially fraught amid stigma that has recently been exacerbated by a wave of state laws that enable discrimination. For them, the Covid-19 pandemic has further complicated life due to losses of positive social interactions and connections.
Suicide has been ranked as the second-leading cause of death for people ages 10 to 14, and the third-leading cause for ages 15 to 24, according to data compiled by the Centers for Disease Control and Prevention (CDC). For transgender children, adolescents and young adults, evidence indicates that significantly higher rates of suicidal ideation are tied to complex school and family dynamics, increased bullying, and distressing effects of puberty and secondary sex characteristic development.
Transgender people face a disproportionately high burden of mental health conditions, including depression, anxiety, and suicidality, which can be tied to gender dysphoria, societal stigma and discrimination. Risks are heightened for transgender children, adolescents, and young adults. These factors drive rates of anxiety and depression that are as much as 10 times greater than those of their cisgender peers and result in alarmingly high rates of suicidal ideation and behaviors. Evidence shows that transgender or nonbinary youth who experience discrimination have higher rates of depressive mood, seriously considering suicide, a suicide attempt and multiple suicide attempts.
It is important to note that this higher suicide risk is not unavoidably associated with transgender or nonbinary status, but instead is the result of stigma, discrimination and mistreatment. A large body of medical literature demonstrates that with support at home, school and in the community–and with access to gender-affirming care–transgender youth do as well on mental health measures as their non-transgender peers.
Gender-affirming care under attack
Gender-affirming care seeks to minimize the distress trans individuals experience by providing a supportive, nonjudgmental environment that acknowledges the individual’s gender identity, or uncertainty about their gender identity. This type of care also offers interventions to reduce the incongruence between gender identity and the individual’s sex assigned at birth, and gives patients who struggle with their gender identity the time and support they need to resolve that struggle.
Despite widespread support from major medical associations for gender-affirming care as the accepted standard, state legislatures across the country are considering or have already banned physicians and other health care professionals from providing this care to minors. This includes denying access to medications that delay the onset of natal puberty and hormone therapy for older adolescents. Some of these measures also provide penalties—including criminal prosecution and disciplinary action by state medical boards—for physicians and other health professionals offering gender-affirming care to minors.
To date, two states–Alabama and Arkansas–have enacted laws prohibiting healthcare professionals from providing evidence-based gender-affirming care to minors. Both laws have been enjoined. In addition, Florida’s Medicaid program recently finalized rules banning coverage for gender-affirming treatments
Our AMA strongly opposes these types of discriminatory actions as dangerous government intrusions into the practice of medicine. Decisions about gender affirming care are properly made through shared decision-making between the patient, family, and physicians, without politicians inserting themselves into the medical exam room or second-guessing healthcare decisions. AMA policy specifies that clinical interventions for gender dysphoria should not be criminalized or otherwise restricted.
We must reject efforts by politicians and government to insert themselves into clinical decision-making, to force physicians to disregard clinical standards of care, or prevent us from fulfilling our ethical duty to act in the best interest of our patients. It is dangerous for any state to limit the range of options that physicians, patients, and families may consider when making decisions together for pediatric patients.
In addition to legislative advocacy, the AMA Litigation Center has stood up for transgender patients through amicus briefs supporting legal challenges to restrictive laws. We will continue to work diligently at the state and federal levels to expand access to medical services, reduce stigma in treating patients with unique care needs, and dismantle discriminatory barriers to care whenever and wherever they are found.
Importance of gender-affirming care
Every major medical association recognizes the vital role of gender-affirming care in improving the physical health and mental well-being of transgender individuals. Widely accepted standards of care and clinical guidelines recommend a staged process for transgender minors that enable young people to explore and live the gender that they choose while keeping options open. Studies have consistently demonstrated that providing gender-affirming care that is both age-appropriate and evidence-based leads to improved mental health outcomes. Conversely, denying such care is linked to a greater incidence of anxiety, depression and self-harm.
For these and other reasons, it is imperative that transgender minors be allowed to explore their gender identity under the safe and supportive care of a physician. Our AMA has partnered with the Fenway Institute, Howard Brown Health Center and other entities to create CME modules covering affirmative care for LGBTQ+ patients. You can find valuable educational resources on LGBTQ+ health care at the AMA Ed Hub™ Health Equity Education Center.
Also, the AMA Foundation is expanding its National LGBTQ+ Fellowship Program to include several of Harvard Medical School’s affiliated hospitals, as well as the Vanderbilt University Medical Center. This effort, launched in 2020, seeks to ensure that medical students and faculty, fellows and residents have the skills and expertise they need to render comprehensive and affirming care to LGBTQ+ patients.
Everyone deserves access to high-quality, evidence-based health care. Transgender children, like all children, have the best chance to thrive when they are supported and can obtain the health care they need. Our AMA will continue to work diligently at the state and federal levels to ensure that transgender or gender nonconforming individuals can receive compassionate care that meets their needs free from discrimination, unconscious bias or stigma. We will continue to fight to protect patient rights as well as physicians’ ability to render sound, evidence-based medical care.