Transgender youth

"Gender-affirming surgery often involves going through a number of hoops: waiting periods, hormone therapy and learning about the potential risks and benefits of the procedures. Although most surgeries are reserved for adults, the leading guidelines recommend that patients be at least 15 years old. This thorough process that trans people go through before receiving surgery may also explain the lower levels of regret."

"While the media seems all too happy to focus on trans children’s right to participate in activities alongside their peers (or, indeed, on trans children’s very existence), there is little coverage of one of the most pressing problems: the fact that they are significantly more likely to experience discrimination, harassment and violence at home or at school. Sometimes, horrific stories hit local news headlines, such as the trans teenage boy whose face was slashed by a gang of teenagers in Witham, Essex, or the eleven-year-old trans girl in Manchester who, after months of bullying, was shot with a BB gun at school. To date, though, the national media has more or less completely failed to explore the ways in which such egregious incidents form part of a wider pattern of abuse of trans children."

"Family rejection and estrangement have devastating long-term health implications. They also have a material impact. For some kids, the only option is leaving home. Others have no option at all: their parents kick them out. As a result, trans teenagers and young adults in Britain are much more likely to experience homelessness than their cisgender peers. [...] A minority within a minority, trans young people are disproportionately over-represented in the homeless population: one in four trans people have experienced homelessness."

"What is already known about this topic? Convenience samples indicate that transgender youths appear to be at higher risk for violence victimization, substance use, suicide risk, and sexual risk behaviors than are cisgender youth. What is added by this report? Population-based survey data from 10 state and nine urban school districts found that an average of 1.8% of high school students identify as transgender. Transgender students were more likely than were cisgender students to report violence victimization, substance use, and suicide risk, and, although generally more likely to report sexual risk behaviors, were also more likely to report having been tested for human immunodeficiency virus."

"Almost 2% of High School students identify as transgender"

"27% feel unsafe at or going to or from school"

"35% are bullied at school"

"35% attempt suicide"

"Nearly one in five people who identify as transgender are ages 13-17."

"Research shows transgender individuals are younger on average than the U.S. population. We find that youth ages 13 to 17 are significantly more likely to identify as transgender (1.4%) than adults ages 65 or older (0.3%)."

"At the state level, our estimates range from 3.0% of youth ages 13 to 17 identifying as transgender in New York to 0.6% in Wyoming."

"The majority of respondents who were out or perceived as transgender while in school (K–12) experienced some form of mistreatment, including being verbally harassed (54%), physically attacked (24%), and sexually assaulted (13%) because they were transgender. Further, 17% experienced such severe mistreatment that they left a school as a result."

"Gender-affirming treatment remains a topic of controversy, with many calling for greater access to gender affirming treatments to foster psychological well-being for transgender, nonbinary, and intersex individuals. There is accumulating literature that suggests transgender individuals suffer worse mental health outcomes than their cisgender peers; of particular concern is increased suicidality. The literature to date reveals concerning trends regarding suicidality in transgender individuals. A high prevalence of suicide attempts and thoughts of suicide occur in transgender youth compared to their cisgender peers. Transgender US military veterans have more than 20 times higher rates of suicide-related events than cisgender veterans. The prevalence of suicidal ideation and attempts varies by sample, with the prevalence of suicidal ideation sometimes as high as 50-75%. Rates of attempted suicide can reach peaks of 30% and above. One longitudinal study of over 6,000 transgender individuals in the US indicates that the highest risk of suicide is among those under 18 years of age."

"In the Netherlands, treatment with puberty suppression is available to transgender adolescents younger than age 18 years. When gender dysphoria persists testosterone or oestradiol can be added as gender-affirming hormones in young people who go on to transition. We investigated the proportion of people who continued gender-affirming hormone treatment at follow-up after having started puberty suppression and gender-affirming hormone treatment in adolescence."

"704 (98%) people who had started gender-affirming medical treatment in adolescence continued to use gender-affirming hormones at follow-up. Age at first visit, year of first visit, age and puberty stage at start of GnRHa treatment, age at start of gender-affirming hormone treatment, year of start of gender-affirming hormone treatment, and gonadectomy were not associated with discontinuing gender-affirming hormones."

"Most participants who started gender-affirming hormones in adolescence continued this treatment into adulthood. The continuation of treatment is reassuring considering the worries that people who started treatment in adolescence might discontinue gender-affirming treatment."

"Being transgender is not a trend and transgender people have a history that spans centuries. Over the past few years, transgender visibility has increased dramatically, a sign that our society is becoming increasingly accepting of diverse gender identities. This is a positive sign, as more and more transgender people feel that they can live openly and receive support. Like the LGBTQ community has seen time and time again, increased visibility often leads to increased attacks by those who wish to shove us back in the closet. Lesbian, gay and bi+ young people should be free to declare their sexuality without others doubting them. The same should be true for young people who have a diverse gender identity."

"When a young child expresses that they are a gender other than their sex assigned at birth, their parents may support them in finding their own, unique identity. This can involve changing the child’s name, clothing or pronouns. Once a transgender youth reaches puberty, a doctor may prescribe them with reversible puberty blockers to safely delay the effects of puberty. Puberty blockers are not “experimental” treatments, but FDA-approved medications that have been used to treat precocious puberty in non-transgender children for several decades. Scientific studies demonstrate that access to puberty blockers reduces suicidal ideation and that parents’ affirmation of their child’s gender identity reduces rates of depression, anxiety and suicide to levels consistent with their cisgender peers. When kids are allowed the freedom to safely express themselves, they are happier, healthier and grow into thriving adults."

"Since 2013, HRC and other advocates have tracked over 200 cases of fatal violence against transgender and gender non-conforming people across 30 states and 113 cities nationwide. Beyond fatal violence, the transgender and non-binary community faces higher rates of harassment and physical assault — including transgender young people, with 43% of transgender youth reporting being bullied in school. Laws targeting transgender people — and the political rhetoric surrounding anti-transgender bills — send a message that transgender people are not worthy of equal treatment, contributing to dangerous stigma that drives this epidemic of violence. Bottom line: when transgender people aren’t valued — including by their own lawmakers — their lives are viewed by some as disposable, putting them at risk."

"Analysis of procedure-specific trends by age revealed a number of important findings. First, GAS procedures were most common in patients aged 19 to 30 years. This is in line with prior work that demonstrated that most patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age 7 years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. Our findings were also notable that GAS procedures were relatively uncommon in patients aged 18 years or younger. In our cohort, fewer than 1200 patients in this age group underwent GAS, even in the highest volume years. GAS in adolescents has been the focus of intense debate and led to legislative initiatives to limit access to these procedures in adolescents in several states."

"We are disappointed with this latest executive order. Policies that restrict or bana ccess to necessary medical care for transgender youth are harmful to patients and their families. Transgender youth need comprehensive, individualized, family-based care from multidisciplinary teams. Healthcare decisions should be made by patients, families, and their healthcare professionals, guided by evidence-based practices, clinical guidelines, and individual needs rather than government mandates."

"Transgender youths (those whose gender identity* does not align with their sex†) experience disparities in violence victimization, substance use, suicide risk, and sexual risk compared with their cisgender peers (those whose gender identity does align with their sex). Yet few large-scale assessments of these disparities among high school students exist."

"The reported prevalence of all experiences assessing violence victimization was higher among transgender students than among both cisgender males and cisgender females, including 23.8% reporting ever being forced to have sexual intercourse and 26.4% having experienced physical dating violence. A higher percentage of transgender students also reported lifetime use of all substances except marijuana than did cisgender male and cisgender female students; marijuana use was more prevalent among transgender students than among cisgender male students only. A higher proportion of transgender students reported all suicide risk outcomes than did cisgender students. Transgender students were more likely than cisgender students to report first sexual intercourse before age 13 years, sexual intercourse with four or more persons than were cisgender students, and no method to prevent pregnancy at last sexual intercourse. Transgender students were more likely than were cisgender females to have ever had sex (43.1% versus 33.2%) and to have drunk alcohol or used drugs before their last sexual intercourse (30.0% versus 17.9%). Transgender students were more likely than were cisgender males to report no condom use during their last sexual intercourse (63.8% versus 37.6%). Transgender students were less likely than cisgender males and cisgender females to have not ever been tested for HIV (70.0% versus 87.4% and 86.9%, respectively)."

"The results of this study validate findings from smaller clinical and web-based studies that, at a population level, transgender students are at disproportionately higher risk than are cisgender students for violence victimization, substance use, and suicide risk. The prevalence of reported substance use (e.g., 27.1%, 26.1%, 24.9%, and 35.9% reporting lifetime use of cocaine, heroin, methamphetamines, and prescription opioid misuse, respectively) and suicide risk (e.g., 34.6% attempting suicide in the last 12 months) are concerning. Given that violence victimization is a documented risk factor for substance use and suicide risk, implementation of interventions focused on reducing the victimization of transgender adolescents might be a key strategy for improving overall health."

"Some examples of elevated sexual risk emerged among transgender students. More transgender than cisgender students reported first sexual intercourse before age 13 years and having had four or more sex partners, and more transgender students than cisgender female students reported ever having had sexual intercourse and use of alcohol or drugs before last sexual intercourse. Transgender students were more likely than were cisgender students to forego pregnancy prevention at last sexual intercourse and were less likely than were cisgender males to use a condom at last sexual intercourse; however, without further information about the sex and gender identities of these youths and their partners, the risk implications of these results are uncertain and should be interpreted with caution. Transgender students were more likely to have ever received an HIV test, an important protective behavior, given the known higher HIV risk experienced by this population."

"Taking steps to create safe learning environments and provide access to culturally competent physical and mental health care might be important first steps to improving the health of transgender youths. Continued research into the health of transgender youths and development of effective intervention strategies are warranted."

"Use of puberty-blocking medications and cross-sex hormone treatments for children and adolescents who experience gender dysphoria is a complex modern medical controversy. Over the past decade, clinics have seen an explosion in the number of young people seeking such treatment. At the same time, there has been a complex debate over whether these medical interventions are safe, appropriate, and effective."

"Abigail Shrier is a journalist and author of a controversial 2020 book, Irreversible Damage: The Transgender Craze Seducing Our Daughters. She recently interviewed two doctors (both trans themselves) who provide treatment to trans youth. One, Marci Bowers, is the surgeon who treated reality TV star Jazz Jennings, whose life and transition are chronicled in the show I Am Jazz. Describing her treatment of Jennings, Bowers states,“If you’ve never had an orgasm pre-surgery, and then your puberty's blocked, it's very difficult to achieve that afterwards. I consider that a big problem, actually. It's kind of an overlooked problem that in our ‘informed consent’ of children undergoing puberty blockers, we’ve in some respects overlooked that a little bit .... if they’re not able to be responsive as a lover ... how does that affect their long-term happiness?” In her show, Jennings described that she had never had an orgasm. For a sexual clinician, the concept of orgasmic naiveté and the experience of sexual pleasure and health raise fascinating questions. Unfortunately, it turns out there is relatively little data or research to explore these issues in trans youth."

"It seems quite possible that the reduced physical genital development that results from puberty suppression could inhibit the phenomenological experience and behaviors associated with sexual climax. In other words, while youth who undergo trans-affirmative treatment may have less genital tissue with which to experience sexual stimulation, their bodies and brains are likely capable of sexual climax though they may feel the experience less intensely due to reduced genital tissue. It is possible that individuals assigned as male and female at birth may experience these effects differently, as seems evident in research with people who experience transition as adults. Finally, it seems likely that learning plays a role in this process, though contrary to Bowers, it seems unlikely that it is the only factor involved. However, it seems quite important that future research examine the sexual health experiences of individuals who initiate trans affirmative treatment prior to adulthood."

"Addendum/Update: In 2023, researchers published a study of 37 transwomen and orgasm functioning. 76% were able to achieve orgasm post affirmative surgery. There were no differences between those individuals who underwent puberty suppression or not. While these data do suggest there is a significant risk - 1 in 4 were unable to orgasm - the risk certainly doesn't appear to be as universal as has been suggested."

"Introduction: Concerns about future regret and treatment discontinuation have led to restricted access to gender-affirming medical treatment for transgender and gender-diverse (TGD) minors in some jurisdictions. However, these concerns are merely speculative because few studies have examined gender-affirming hormone continuation rates among TGD individuals."

"We noted a higher hormone continuation rate among TGD individuals who were younger than 18 years old at the time of first use of gender-affirming hormones compared with those who were aged 18 years and older when starting hormones. This has not been documented in previous studies. Parental support plays an important role in the mental health of TGD youth. A prior study of adults found that lack of family support for a TGD individual’s gender was associated with a history of discontinuing social or medical gender affirmation. Higher parental support may explain the higher continuation rate among patients who start gender-affirming hormones as minors compared with people who start as adults."

"We also found that individuals who start gender-affirming hormones before reaching the age of legal majority are less likely to subsequently discontinue use when compared with individuals who start hormones after becoming a legal adult. If replicated in future studies, the improved continuation rate among patients who are not legal adults at the time of treatment should provide some reassurance to those concerned about the ability of minors to provide informed assent to use of gender-affirming hormones. A higher continuation rate among minors could also be used to inform the actions of legislators and judges who wish to prohibit gender-affirming treatment for minors to protect them from the consequences of health care decisions they make with the assistance of their parents and health care providers."