What is and isn’t gender-affirming care?

Alarms are loud, attention-grabbing, dramatic, anxiety-inducing and action-provoking. Raising an alarm is an exceptionally effective tool for motivating people to do what you would like them to do. The challenge for those of us hearing alarms is to employ enough knowledge and critical-thinking skills to recognize false alarms.

On the social media platform X on May 17, the day Gov. Ron DeSantis signed Florida Senate Bill 254 into law, he wrote that: “With my signature, Florida permanently prohibits genital mutilating surgical procedures and experimental puberty blockers for minors. Minors given these procedures without their consent will now be able to recover damages for permanent injury or death caused by these medical experiments.”

Alarm! Genital mutilating surgical procedures for minors! Alarm!

Many LGBTQ+ activists and community leaders took to DeSantis’ post to discredit what he wrote and to point out his inaccuracies in it. One medical professional even took the time to post information for the governor on the many health care organizations that oppose his policy of restricting gender-affirming care for transgender youth. That list includes the American Medical Association, the American Psychiatric Association, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, just to name a few.

Given comments like those from the Florida governor and others in political power, Watermark has decided to look at some of the myths surrounding gender-affirming care by consulting with experts and medical providers to get a clear, clinical and factual answer to the question: What exactly is and isn’t gender-affirming care, and what services are and aren’t being offered to Florida’s youth?

First, let’s look at what exactly SB 254 says and what it does, as well as where the community stands as far as legal challenges to the law. On the website FLSenate.gov, readers can find the full bill text of the now law entitled “Treatments for Sex Reassignment.” The bill is largely concerned with “a child present in this state … subjected to or is threatened with being subjected to sex reassignment prescriptions or procedures.” A child, in the bill’s definition, is a person under 18 years of age. With defined exceptions, SB 254 prohibits gender-affirming care for children and requires additional steps for adults to receive gender-affirming care.

The ACLU of Florida’s position to oppose FL SB 254 summarizes potential consequences this way: “The bill criminalizes doctors for providing gender-affirming care to minors and allows a non-supportive parent to have the upper hand in child custody disputes in divorce proceedings if the other parent is supportive of their trans child’s health care. It imposes new onerous written consent procedures for gender-affirming care for adults, and requires that all care must be provided by an in-person physician.”

In May, when the bill was passed into law, Equality Florida, the state’s largest LGBTQ+ civil rights group, said in a statement: “The Gender Affirming Care Ban outlaws providing healthcare to transgender minors, including puberty blockers, hormone replacement therapy, and rare surgical interventions, stripping parents’ ability to seek medically-necessary health care for their children. While much of the bill proponents’ rhetoric focused on transgender youth, multiple bill provisions impact consenting transgender adults. The bill bans government entities from offering them gender affirming healthcare insurance, restricts their ability to access TeleHealth for care in the way nearly all other healthcare can be delivered, and denies their ability to receive care from highly trained nurses that provide a large portion of the gender affirming care in the state. It also allows courts–not other state agencies–to exercise jurisdiction in limited cases to modify an existing custody agreement when a parent may seek access to care for their minor child in another state.”

The law is being challenged in Florida’s courts with U.S. District Judge Robert Hinkle issuing a very narrow injunction in June that allows those transgender youth who were challenging the ban to access care while the lawsuit continues. In September, the same judge refused to issue a similar injunction for transgender adults in a class action lawsuit, asking “what irreparable harm” plaintiffs would suffer if he did not block the law in the run-up to a trial slated to begin Nov. 13.

What is Gender Affirmation?

Unlike sex assigned at birth, which is an assignment made to a child’s body based on a range of physical characteristics, gender identity is internal. Gender is how a person understands and experiences themselves. To affirm something is to publicly state it as a fact. So, gender-affirmation is publicly stating and reinforcing as true a person’s understanding of their gender. According to Drs. Kareen M. Matouk and Melina Wald with Columbia University’s Irving Medical Center/Gender Identity Program, “It is the community of people around them saying: you know yourself best and we trust you, we believe you, and we see you.”

For youth who are born transgender, meaning their gender identity does not align with their sex assigned at birth, gender affirmation can be live saving.

MYTH: Gender-affirming care is only medical

Gender-affirming transitions can happen to various degrees in multiple facets of life, including social, legal and medical. Social gender-affirmation might include name changes, adoption of gender-affirming pronouns and changes to clothing and hairstyles. Legal gender-affirmation might include changes to birth certificates, driver’s licenses and passports. Medical gender-affirming care is the target of SB 254 and the portion of this discussion that tends to have the most misconceptions. We will look into medical gender-affirming care below.

MYTH: Primary care and gender-affirming care are entirely different

According to the office of Population Affairs of the U.S. Department of Health and Human Services, “Gender-affirming care is a supportive form of healthcare. It consists of an array of services that may include medical, surgical, mental health, and non-medical services for transgender and nonbinary people.”

Interacting with any medical provider that will affirm a youth’s gender identity, even just by using their correct pronouns, regardless of the reason for the medical visit is gender-affirming medical care. Among Metro Inclusive Health in Tampa Bay’s listing of services for transgender healthcare and support services, clients will find “Inclusive Primary Care.” Both transgender and cisgender youth — transgender being a person whose gender identity does not correspond with the sex assigned to them at birth and cisgender being a person whose gender identity does correspond with the sex assigned to them at birth — need medical services for wellbeing not related to gender. A sprained ankle. A skin rash. A slow thyroid. Health and Human Services reports, “for transgender and nonbinary children and adolescents, early gender-affirming care is crucial to overall health and well-being.”

On its website, Central Florida’s Hope & Help has a tagline in the “About Us” section that reads “Hope & Help is the warm hug of health care you need to get tested and treated in a safe, friendly environment.”

MYTH: Gender-affirming medical care for youth is surgical

According to Brian Martinez, senior operations director of Hope & Health, “surgical care on minors is basically non-existent.” Martinez speaks not only from his experience working for an Orlando-based provider of gender-affirming care but also from the research he did for his doctoral dissertation about gender-affirming care for minors.

Often, gender-affirming medical care is discussed along a potential progression that emphasizes individual needs which may or may not begin with puberty blockers, may or may not initiate cross-sex hormones and may or may not include gender-affirming surgeries.

Puberty blockers are medicines used to postpone puberty in children, with the most commonly used puberty blockers being gonadotropin-releasing hormone agonists, which suppress the production of sex hormones. They are the only medical treatment recommended for minors and their effects are 100% reversible.

A common critique of this form of gender-affirming care is that children are not capable of making such medical decisions. While this critique is not often applied to cisgender children, who are assessed as being fully capable of knowing their gender and for who puberty blockers have been prescribed for various reasons since the 1990s, the reversible nature of puberty blockers weakens the validity of the critique, says Martinez.

On its website, Cedars-Sinai offers assurances to parents of cisgender children regarding the use of puberty blockers to treat what is called “precocious puberty — marked by breast development before age eight or testes growth before age nine — with hormonal suppressants, also called puberty blockers. With supervision, these reversible drugs safely and effectively delay a child’s development until they’re ready.”

Usually at age 16, with parental/guardian and physician approval, medical care for transgender youth can include gender-affirming hormones. Those medications typically come as estrogen patches and pills or weekly testosterone injections.

Speaking with The Associated Press in 2022, Dr. Stephanie Roberts, a specialist at Boston Children’s Hospital’s Gender Management Service, said in girls transitioning to boys, testosterone generally leads to permanent voice-lowering, facial hair and protrusion of the Adam’s apple, and for boys transitioning to girls, estrogen-induced breast development is typically permanent.

A Google search for hormone replacement therapy is likely to bring up dozens of articles about its effectiveness in treating menopause in cisgender females. Cross-sex HRT can lessen symptoms for trans people just as same-sex hormone replacement therapy can lessen symptoms for cis people.

Under the guidance of their physicians, adults — those who are 18 years of age and older — may or may not decide to proceed with gender-affirming surgical procedures, which could include gender-affirming alteration to the face, voice, chest and/or genitals. According to the World Professional Association for Transgender Health, breast removal surgery is OK for those under 18 who have been on testosterone for at least a year. As stated above, hormone replacement therapy typically does not start in trans youth until age 16.

Overall, there is no completion point or required set of procedures for a trans person. Each of these decisions is personal and individual, and a person’s experience of themselves as transgender is equally valid irrespective of their medical decisions.

MYTH: Genital surgical procedures on minors is a new phenomenon

Since the 1960s, surgical alterations of the genitalia and reproductive organs have regularly been encouraged and performed by the medical establishment on very young intersex children. A joint report published by the Human Rights Campaign and InterACT explains that based on, “unproven recommendations of a single prominent psychologist some surgeons in the US continue to perform medically unnecessary ‘normalizing’ surgeries on children, often before they are one year of age. These operations include clitoral reduction surgeries — procedures that reduce the size of the clitoris for cosmetic reasons. … Other operations include gonadectomies, or the removal of gonads, which result in the child being sterile and forced onto lifelong hormone replacement therapy.”

SB 254 makes an exception for the alarm DeSantis raised about the “genital mutilation of children” if a physician assesses the “external biological sex characteristics” of a child as “unresolvably ambiguous.” The takeaway of the recent Florida legislation being that surgical procedures on intersex children are acceptable to reinforce the gender binary but unacceptable if perceived to be challenging the gender binary.

MYTH: Gender-affirming care is only for transgender people

The medical need for HRT as well as the social desire to more deeply connect to one’s sense of gender is a shared experience between cisgender people and transgender people. In his June 6 injunction on SB 254 regarding transgender minors, Hinkle wrote that, “Testosterone and estrogen are routinely used to treat cisgender patients in appropriate circumstances. The medications are an effective treatment for conditions that should be treated … that is so for cisgender and transgender patients alike.”

Cisgender people often access non-medically necessary gender-affirming care such as hair transplants, breast augmentation, laser hair removal and steroids for body building. Elective care to feel better about oneself is frequently about enhancement of a characteristic traditionally associated with a gender, and within Florida’s law, and in similar laws and bills through the country, lawmakers never raised any red flags in regards to gender-affirming procedures for cisgender people.

MYTH: Gender-affirming care for youth can be delayed without consequence

The Columbia School of Psychiatry states that “higher rates of anxiety, depression and suicidal ideation” are found in transgender and nonbinary youth, especially when their gender identity is ignored or rejected by family and friends.
“It is well documented that TGNB [Transgender, Non-Binary] adolescents and young adults experience anxiety and depression, as well as suicidal ideation, at a much higher rate than their cisgender peers,” Matouk and Wald wrote. “In contrast, numerous research studies have found that gender-affirming care leads to improved mental health among TGNB youth.”

According to The Trevor Project’s 2020 National Survey on LGBTQ Youth Mental Health, 54% of young people who identified as transgender or nonbinary reported having seriously considered suicide in the last year, and 29% have made an attempt to end their lives.

The World Professional Association for Transgender Health has created Standards of Care guidelines for providers working with trans and nonbinary individuals.

Matouk and Wald write that “Providers following these ethical guidelines are obliged to facilitate and encourage family support and involvement. All medical interventions for any child under the age of 18 require parental consent, as well as the child’s assent. It is recommended that adolescents and their parents be involved in psychological care to help them best understand the benefits, risks, and permanent effects of gender-affirming interventions. Youth undergoing medical interventions are also carefully monitored by a specialized endocrinologist to ensure for their safety and well-being. Moreover, when possible, adolescents are provided with options for fertility preservation.”
Activists and advocates have long exclaimed that gender-affirming care is not something that needs to be determined in Congress and in statehouses across the country. Medical professionals, who work with those seeking health care, and the acceptance of parents/legal guardians of LGBTQ+ youth is what should be guiding that care.

For more information and/or transgender services in your area, contact Hope & Help in Central Florida at 407-645-2577 and visit HopeAndHelp.org. In Tampa Bay, you can contact Metro Inclusive Health at 727-321-3854 and visit MetroTampaBay.org.

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