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History. In the US in 1917, Alan L. Hart, an American tuberculosis specialist, became one of the first trans men to undergo hysterectomy and gonadectomy as treatment of what is now called gender dysphoria. In Berlin in 1931, Dora Richter became the first known transgender woman to undergo vaginoplasty.

Gender-affirming surgery gives transgender people a body that aligns with their gender. It may involve procedures on the face, chest or genitalia. Common transgender surgery options include:

Facial reconstructive surgery to make facial features more masculine or feminine.
Chest or “Top” surgery to remove breast tissue for a more masculine appearance or enhance breast size and shape for a more feminine appearance.
Genital or “Bottom” surgery to transform and reconstruct the genitalia.

Is gender affirmation surgery the only treatment for gender dysphoria?

No. Surgery is just one option. Not everyone who is transgender or nonbinary chooses to have surgery. Depending on your age and preferences, you may choose:

Hormone therapy to increase masculine or feminine characteristics, such as your amount of body hair or vocal tone.
Puberty blockers to prevent you from going through puberty.
Voice therapy to adjust your voice or tone or help with communication skills, such as introducing yourself with your pronouns.

People may also socially transition to their true gender with or without surgery. As part of social transitioning, you might:

Adopt a new name.
Choose different pronouns.
Present as your gender identity by wearing different clothing or changing your hairstyle.

How common is gender affirmation surgery?

Surveys report that around 1 in 4 transgender and nonbinary people choose gender affirmation surgery.

What happens before gender affirmation surgery?

Before surgery, you should work with a trusted healthcare provider. A healthcare provider can help you understand the risks and benefits of all surgery options.

Many insurance companies require you to submit specific documentation before they will cover a gender-affirming surgery. This documentation includes:

Health records that show consistent gender dysphoria.
Letter of support from a mental health provider, such as a social worker or psychiatrist.

What happens during transgender surgery?

What happens during surgery varies depending on the procedure. You may choose facial surgery, top surgery, bottom surgery or a combination of these operations.

Facial surgery may change your:

Cheekbones: Many transgender women have injections to enhance the cheekbones.
Chin: You may opt to soften or more prominently define your chin’s angles.
Jaw: A surgeon may shave down your jawbone or use fillers to enhance your jaw.
Nose: You may have a rhinoplasty, surgery to reshape the nose.

If you are a transgender woman (assigned male at birth or AMAB), other surgeries may include:

Adam’s apple reduction.
Placement of breast implants (breast augmentation).
Removal of the penis and scrotum (penectomy and orchiectomy).
Construction of a vagina and labia (feminizing genitoplasty).

If you are a transgender man (assigned female at birth or AFAB), you may have surgeries that involve:

Breast reduction or mastectomy.
Removal of the ovaries and uterus (oophorectomy and hysterectomy).
Construction of a penis and scrotum (metoidioplasty, phalloplasty and scrotoplasty).

What happens after gender affirmation surgery?

Recovery times vary based on what procedures or combination of procedures you have:

Cheek and nose surgery: Swelling lasts for around two to four weeks.
Chin and jaw surgery: Most swelling fades within two weeks. It may take up to four months for swelling to disappear.
Chest surgery: Swelling and soreness last for one to two weeks. You will need to avoid vigorous activity for at least one month.
Bottom surgery: Most people don’t resume usual activities until at least six weeks after surgery. You will need weekly follow-up with your healthcare provider for a few months. These visits ensure you are healing well.

It’s important to understand that, for most people, surgery is only one part of the transitioning process. After surgery, you should continue to work with a therapist or counselor. This professional can support you with social transitioning and your mental health.

RISKS / BENEFITS

What are the benefits of gender affirmation surgery?

Research has shown that transgender individuals who choose gender-affirming surgery experience long-term mental health benefits. In one study, a person’s odds of needing mental health treatment declined by 8% each year after the gender-affirming procedure.

What are the risks or complications of gender affirmation surgery?

Different procedures carry different risks. For example, individuals who have bottom surgery may have changes to their sexual sensation, or trouble with bladder emptying. In general, significant complications are rare, as long as an experienced surgeon is performing the procedure.

With any surgery, there is a small risk of complications, including:

Bleeding.
Infection.
Side effects of anesthesia.

RECOVERY AND OUTLOOK

What is the outlook for people who have gender affirmation surgery?

Most people who choose these surgeries experience an improvement in their quality of life. Depending on the procedure, 94% to 100% of people report being satisfied with their surgery results. In general, people who work with a mental health provider before surgery tend to experience more satisfaction with their treatment results.

WHEN TO CALL THE DOCTOR

When should I see my healthcare provider?

After surgery, you should see your healthcare provider if you experience:

Bleeding for more than a few days after surgery.
Pain that doesn’t go away after several weeks.
Signs of infection, such as a wound that changes color or doesn’t heal.

A note from Cleveland Clinic

Gender affirmation procedures help people transition to their self-identified gender. Gender affirmation surgery may involve operations to change the face, chest or genitalia. You may choose to have one type of surgery or a combination of procedures. Before and after surgery, it’s important to work with a mental health provider. Research shows that having a trusted therapist makes you more likely to be satisfied with your surgery results.

Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence

There is an unknown percentage of transgender and gender non-confirming individuals who undergo gender-affirmation surgeries (GAS) that experiences regret. Regret could lead to physical and mental morbidity and questions the appropriateness of these procedures in selected patients. The aim of this study was to evaluate the prevalence of regret in transgender individuals who underwent GAS and evaluate associated factors.

Discordance or misalignment between gender identity and sex assigned at birth can translate into disproportionate discomfort, configuring the definition of gender dysphoria. This population has increased risk of psychiatric conditions, including depression, substance abuse disorders, self-injury, and suicide, compared with cis-gender individuals. Approximately 0.6% of adults in the United States identify themselves as transgenders. Despite advocacy to promote and increase awareness of the human rights of transgender and gender non-binary (TGNB) individuals, discrimination continue to afflict the daily life of these individuals.

Gender-affirmation care plays an important role in tackling gender dysphoria. Gender-affirmation surgeries (GAS) aim to align the patients’ appearance with their gender identity and help achieve personal comfort with one-self, which will help decrease psychological distress. These interventions should be addressed by a multidisciplinary team, including psychiatrists, psychologists, endocrinologists, physical therapists, and surgeons. The number of GAS has consistently increased during the last years. In the United States, from 2017 to 2018, the number of GAS increased to 15.3%.

Significant improvement in the quality of life, body image/satisfaction, and overall psychiatric functioning in patients who underwent GAS has been well documented. However, despite this, there is a minor population that experiences regret, occasionally leading to de-transition surgeries. Both regret and de-transition may add an important burden of physical, social, and mental distress, which raises concerns about the appropriateness and effectiveness of these procedures in selected patients. Special attention should be paid in identifying and recognizing the prevalence and factors associated with regret. In the present study, we hypothesized that the prevalence of regret is less than the last estimation by Pfafflin in 1993, due to improvements in standard of care, patient selection, surgical techniques, and gender confirmation care. Therefore, the aim of this study was to evaluate the prevalence of regret and assess associated factors in TGNB patients 13-years-old or older who underwent GAS.

Methods:

A systematic review of several databases was conducted. Random-effects meta-analysis, meta-regression, and subgroup and sensitivity analyses were performed.

Results:

A total of 27 studies, pooling 7928 transgender patients who underwent any type of GAS, were included. The pooled prevalence of regret after GAS was 1% (95% CI <1%–2%). Overall, 33% underwent transmasculine procedures and 67% transfemenine procedures. The prevalence of regret among patients undergoing transmasculine and transfemenine surgeries was <1% (IC <1%–<1%) and 1% (CI <1%–2%), respectively. A total of 77 patients regretted having had GAS. Twenty-eight had minor and 34 had major regret based on Pfäfflin’s regret classification. The majority had clear regret based on Kuiper and Cohen-Kettenis classification.

Conclusions:

Based on this review, there is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made in regard to selection criteria for GAS. However, there is high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population.

I Underwent Gender Transition Surgery: Here’s What The Media Doesn’t Tell You

I awoke confused. Where was I? What happened, and why was I lying on the bathroom floor soaked in urine mixed with blood?

As I wiped the urine from the inside of my legs, I reached for something to help me to my feet, still unaware of where I was. Too weak to stand alone, I leaned forward onto the countertop for stability and looked into the mirror. Who was this middle-aged man staring back at me? Where was Kellie? Where did I go? What had I become? I felt Kellie on the inside, but within a matter of months, who I was was gone.

Shaking my head to alleviate the pain and disorientation I was experiencing, it all flashed back. I turned to the toilet. I was there. I had passed out again from the pain of having six inches of bacteria infected hair on the inside of my urethra. This time, the infection was so severe that I had a silicon tube placed in my arm to deliver IV antibiotics. Every morning I awoke to the pain. It took everything I had to get dressed for work, hobble to my car, enter the hospital, and receive my IV antibiotics. Survival itself became a struggle.

Just 15 months prior, I had undergone a phalloplasty, a female-to-male bottom surgery in which doctors created a phallo using skin harvested from the arms and legs. This marked the sixth surgery I’d undergone within two years. It was the most traumatic of them all, and I’d begun to endure the crippling pain associated with the side effects of a surgery I was told would be routine.

Yet, despite the dangers of such serious medical procedures, surgeons who enter the field of transgender surgery need little to no specialized training. Doctors looking to expand their horizons can essentially make a trip to the local OfficeMax and have a sign made saying, “Transgender Surgeon,” hang it on the door, and – poof! – the transgender craze will supply them with a line of patients begging for surgery. Instantly, they have insurance companies approving $50,000 procedures with profit margins mirroring brain surgery – no questions asked. These surgeons have the LGBTQ Force Shield to protect them from any criticism as well as an army of activists to rationalize any negative publicity as “transphobia.” These unqualified surgeons hide behind LGBTQ ideology to dodge medical malpractice cases because transgender surgery is considered experimental; and without a set baseline to compare results, lawsuits are almost impossible.

Many top-rated surgeons in the world refuse to conduct transgender bottom surgeries, not because of bigotry, but because they know the risks associated with an elective surgery marred by an incredibly high complication rate. However, for surgeons accustomed to making $300,000 a year for appendectomies and other less complicated procedures, the allure of increasing their salary instantly by performing ‘gender affirmation’ surgeries can often be impossible to resist. And as I experienced, many of the doctors taking part in these surgeries are content to ignore the complications associated with them as long as the money keeps coming in.

The complications associated with my surgery have re-written the date on my tombstone. I have shortened my life with this decision, and I think about my future grandchildren every day, knowing I may never meet them. I ache for them, and in my head I’m constantly saying, “I’m sorry my babies and future grandbabies. I’m so, so sorry.”

I remember the indoctrination and the unease as I began the surgery roller coasters, and when looking back, embarrassment falls upon me. How could I have been so stupid at 42 years old? As I deal with and try to recover from PTSD, I can still vividly recall the start of it all.

My eyes felt heavy, but the bright white walls of the surgery clinic kept me alert as the IV drugs started to take the edge off.

“You’ll be fine,” my fiance Lynette said, but something inside me told me differently. Something inside me screamed at me to leap off the gurney as the nurse began to unlock my hospital bed to wheel me into the operating room. Lynette could see I was anxious and squeezed my hand harder. The gesture comforted me, but deep down, I felt troubled that she was so eager to see me wheeled into the surgery room. I wished I had more time to talk to her, but instead it was all a whirlwind. I wanted to tell her my fears, but instead, I smiled at her, hoping that at any moment she would say, “Baby, I know you are doing this for me, and you don’t have to, because I will love you anyway, just the way you are.”

Minutes seemed like hours as the terror grew inside me. Until all at once it hit me, and I tried to lift my body to protest and say, “Stop, this is wrong!” But it was too late. Neither Lynette nor I said anything. By the time I came to my senses, the drugs had taken over.

The last thing I felt was the piercing cold of the metal operating table as the anesthesiologist said, “Count down from 100, sir.” I attempted to muster enough strength to say, “Wait, I’m not a sir. This is wrong.” But all I emitted was the inaudible flicker of my eyelids fighting to stay awake, as my mind raced. I wanted them to stop, then it all faded to black.

At the time of the surgery, it had been only two-and-a-half months since I started taking testosterone shots, but a transformation had already begun taking place. Almost instantly, my usual self-assurance — one of the critical components that made me an ultra-successful business sales executive — was slipping from me. I wondered why. My confidence and cocky air made people look up when I spoke at a sales presentation; I commanded attention. It was my sincerity, though, that made me different.

My decline in confidence started almost immediately after my first injection of testosterone, and it took several months to realize that I had stepped back in conversations. In sales meetings, I stopped raising my hand, inquiring about strategies, and fighting for accounts; I wanted to get in and out without too much noise. That was not who I was, and it confused me.

The reality was that, even though I had dreamed of having been born a male, thinking of how much easier my life would have been, I was not a male. Throughout my life, I dug deep, trying to develop a fondness for who I was, and it took a long time to begin the process of accepting myself. I dreamt of being the “ultra” boy my father wanted, the “King” in our family who would have had it all. I would have been the alpha male placed upon a pedestal decorated with footballs, motorcycles, money, attention, dirt, and everything else I loved.

Instead, who I really was became accepted, not celebrated, and I was painfully aware of that. I worked hard over the years, though, but despite finally starting to embrace my uniqueness, I was unable to resist the fantasy of what I was told medical transition could accomplish. The complications and hurdles were skimmed over, and my embrace of what I thought was self acceptance was not established enough to fight the dream I had played in my mind constantly as a child. The idea of fitting into a puzzle that I felt was always denied to me was something I couldn’t shake.

At 42, when the medical industry told me I could be born again, male, I believed them.

Within two-and-a-half months of testosterone treatment, pronouns were changing, people at work started to stare, and I was painfully aware. I began doubting myself and felt held back. I wanted to talk to Lynette, but she wrapped herself up in what my transition did for us as a couple, which supposedly fixed everything on paper. There was also nothing available to help me – on the internet, in books, or in Youtube videos – that detailed the emotional side of transitioning. Only joyful transgender people who’d been magically transformed could be found.

I was surprised at how quickly I was able to push the transition process along, considering the fact that I had only been on testosterone for a short period of time. It didn’t seem to matter to the medical professionals; they were all too eager to continue with the procedures and swipe the credit card.

The happy, lighthearted salesmanship of “medical transition” and its blunt reality don’t match up. Doctors and medical transition proponents don’t prepare you for transition-related post-traumatic stress disorders; they don’t mention post-traumatic stress disorder (PTSD) or any of the multiple hardships because it is considered transphobic.

I want to tell my story so that others can hear what the medical industry is too afraid to say out loud: That gender transition surgery is not the magical solution that doctors, the media, and culture describe.

I learned from this experience that human beings can be convinced of anything if rendered at the right time, the right way, and by the right people, and I am no exception. Now, I want to protect others from the same lies that I fell for. Because the truth is worth it.

Scott Newgent is an author, activist and founder of TReVoices, which advocates for the end of childhood gender transitioning.

Jazz Jennings’s Doctors Revealed Her Gender Confirmation Complications Were ‘Severe’

“I think in hindsight we would have never sent you home from the hospital.”

Jazz Jennings has had a tougher transition than her doctors expected. In the last two years, the teen reality star and LGBTQ+ activist has undergone multiple gender confirmation surgeries, and her doctors are now revealing more details about what went wrong in the new season of TLC’s I Am Jazz, People reported.

In the episode clip, Jazz’s doctors, Marci Bowers, MD, and Jess Ting, MD, speak to Jazz and her family about the previous surgeries. Bowers admits Jazz “has had a very difficult surgical course,” in the show. “She had a very incredible first surgery—it went seemingly very well, but there were problems. And that prompted a second surgery, which I was not a part of, unfortunately.”

“Taking Jazz on as a patient for surgery, we knew it was going to be a one-of-a-kind surgery,” Ting explained in the clip. “We don’t have the experience of having said we’ve done 50 of these. I was just not expecting her to have a complication as severe as what she did have.”

“This has been a real journey, hasn’t it? We knew it would be tough—it turned out tougher than any of us imagined,” Bowers tells Jazz’s family. “I think in hindsight we would have never sent you home from the hospital. You know, easy to say now. When I wasn’t here when you had problems and had to go back, I can’t tell you how stressful that was.”

It hasn’t been easy for Jazz, either. She shared a bit of what she’s gone through on Instagram. Jazz opened up in the caption: “As portrayed in this teaser, the past year has been extremely challenging. I have experienced some of my highest highs and lowest lows… Although it continues to be difficult to cope with the hurdles life throws my way, I have been actively working every day to get better and improve my mental health.”

Jazz went through her initial gender confirmation surgery in June 2018. Doctors had to use a new technique because she started using hormones at such a young age. Since she hadn’t developed enough tissue to construct a vagina, Jazz’s doctors used tissue from her stomach lining.

Jazz experienced complications and had to return for a follow-up procedure. “There was just an unfortunate event and setback where things did come apart, and there was a complication,” she told the outlet. “I had to come back in for another procedure, but it was just all part of the journey. The good thing though is that it was only cosmetic and external so it wasn’t too dramatic.”

Jazz came out as transgender at age 5 and has been sharing her transition in the TLC series I Am Jazz and on her Youtube channel. FYI: Gender confirmation surgery gives “transgender individuals the physical appearance and functional abilities of the gender they know themselves to be,” according to the American Society of Plastic Surgeons (ASPS).

Conclusion

I want to say that if you are at least 18 years of age and you want to change your sex, go for it. I frankly don’t care. However, I don’t believe that you should receive any special breaksd or benefits once you make the decision. You are also still male or female, no matter what you do to your body. You will always have either XX or XY chromosmes, so you will always be either a genetic male or female. Sorry guys. SHould you be allowed to participate in your new sexes sports? The answer is no. You still are genectically either a male or female and you still have the benefits inherent to that sex. Which means that you havve an unfair advantage. We make blood doping and other performance enhancers illegal, so why should we allow the greatest enhancement, sex to be a factor? It just doesn’t make any sense.

We took away all of Lance Armstrongs Tour de France wins, because he blood doped. This probably only gave him a 1 to 10 percent advantage over his fellow competitors, while Lia Thomas’ sex gave him a much greater advantage. He shattered records witout hardly even trying. If we are going to allow this to take place, then stop barring atheletes that use performace enhancing drugs and practices. It is only fair. By the way, I watched a Netflix speacial on blood doping, and the individual doping didn’t really do much better when compared to his previous race times. He did however, recover more quickly.

I also do not believe that tax payer dollars used be used to pay for grender reasignments or abortions, end of story. You want it, you pay for it.

Finally, leave our children alone, childhood, puberty and so on are difficult enough without a lot of adults with their own hidden agenda’s trying to screw with them. You have plenty of time to screw up your life once you become an adult.

Transgender people only make up a very small percentage of the population, so just deal with it. The rest of use are tired of you trying to hyjack everything, because you aren’t happy with either your penis or your vagina. Boo fucking Hoo!

Resources

dailywire.com, “I Underwent Gender Transition Surgery: Here’s What The Media Doesn’t Tell You.” By Scott Newgent; my.clevelandclinic.org, “Gender Affirmation (Confirmation) or Sex Reassignment Surgery.”; ncbi.nlm.nih.gov, “Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence.” By Valeria P. Bustos, MD, Samyd S. Bustos, MD, Andres Mascaro, MD, Gabriel Del Corral, MD, FACS, Antonio J. Forte, MD, PhD, MS, Pedro Ciudad, MD, PhD, Esther A. Kim, MD, Howard N. Langstein, MD, and Oscar J. Manrique, MD, FACS; womenhealthmag.com, “Jazz Jennings’s Doctors Revealed Her Gender Confirmation Complications Were ‘Severe’: ‘I think in hindsight we would have never sent you home from the hospital’.” By Jennifer Nied; washingtonpost.com, “FAQ: What you need to know about transgender children.” By Samantha Schmidt;

Addendum

FAQ: What you need to know about transgender children

Transgender rights have once again emerged as a political flash point in America.

While President Biden signed an executive order expanding protections for LGBTQ people, Republican lawmakers have sought to roll back the rights of the transgender community — especially the rights of children. Across the country, conservative legislators have introduced and passed a wave of bills that would ban medical treatments for transgender children and restrict transgender students from playing in sports according to their gender identity.

Many of these political debates are laden with misinformation and misunderstandings about what it means to be a transgender teenager today, advocates and medical experts say.

Informed by medical guidelines, and interviews with doctors and experts, The Washington Post compiled answers to some of the most commonly asked questions about transgender young people.

Understanding the transgender community: The basics

What does it mean to be transgender?

Transgender is an umbrella term for anyone whose gender does not align with their sex assigned at birth. Cisgender is a term applied to people who are not transgender — people whose gender identity matches their assigned sex.

Gender identity is not the same thing as gender expression. For example, a cisgender woman might present in a more stereotypically “masculine” way but still identify as her female sex assigned at birth.

How do doctors diagnose gender dysphoria?

Gender dysphoria is defined as “psychological distress” that results from a mismatch between one’s sex assigned at birth and one’s gender identity, according to the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association (APA).

Not everyone who is transgender is diagnosed with gender dysphoria. Some transgender people do not feel discomfort or distress in their bodies. And not all people diagnosed with gender dysphoria will choose to undergo medical treatments or transition-related surgeries.

For adolescents to be diagnosed with gender dysphoria, they must have experienced “a marked incongruence” between their gender and their assigned sex at birth, lasting at least six months, according to the APA diagnostic manual. For young adolescents, this can be manifested as a strong desire to prevent the development of secondary sex characteristics, such as facial hair or breast growth.

Gender dysphoria can have serious health impacts. It can affect a person’s ability to function at school or work and can lead to intense anxiety, depression and suicide risk. Some adolescents or adults have experienced distress using the bathroom and developed gastrointestinal issues as a result, said Jack Turban, a doctor and fellow in child and adolescent psychiatry at Stanford University School of Medicine. Some transgender people who bind their chests have experienced skin infections and respiratory problems, Turban said.

A recent study from Turban and a team of other researchers found that exposure to gender identity conversion therapy — attempts by a professional to force a transgender person to be cisgender — was associated with increased odds of attempting suicide. Instead, major medical organizations such as the American Academy of Pediatrics have encouraged doctors and parents to take a gender-affirming approach to a transgender child’s care.

Jasper Swartz, 17, of Takoma Park, Md., identifies as nonbinary and uses they/them pronouns. Jasper is a member of Generation Z, a group of young Americans that is breaking from binary notions of gender and sexuality. (Bonnie Jo Mount/The Washington Post)

At what age do young people realize they are transgender?

This depends entirely on each individual case. With more information about the transgender community becoming available to young people and their parents, more children are coming out at earlier ages than in the past, and more transgender clinics are available to provide them with care.

Some people don’t realize they are transgender until they reach puberty, or later in adulthood. But some children show signs that they are transgender early on in childhood. “Not everybody puts their puzzle together in the same way or at the same time,” said Johanna Olson-Kennedy, medical director of the Center for Transyouth Health and Development at Children’s Hospital Los Angeles, one of the largest transgender clinics in the country.

Olson-Kennedy said the vast majority of transgender youth patients at the clinic first arrive when they have already reached puberty. The average age for presentation for services at the clinic is 15, she said. Despite the intense political focus on young transgender children, only 10 percent of the children arriving at her clinic are pre-pubertal.

How many young people identify as transgender?

The Williams Institute at the UCLA School of Law estimates that 0.7 percent of teens ages 13 to 17 identify as transgender. A recent Gallup poll found that 11 percent of LGBT adults identify as transgender. Re-basing this percentage to represent the share of the U.S. adult population, Gallup found that 0.6 percent of U.S. adults identify as transgender. But among Generation Z adults, about 2 percent identify as transgender, and researchers expect that number to continue to grow.

[1 in 6 Gen Z adults are LGBT. And this number could continue to grow.]

Does this mean there are more transgender people than before? Advocates say it’s merely a sign that more transgender people have the information and language available to understand and describe their identities. Transgender people have existed throughout history, including transgender children. But many clinics have been treating transgender children only in recent decades. Olson-Kennedy said her clinic has been taking care of trans young people since the 1990s.

“What’s happening now is not a massive surge in transgender people,” said transgender advocate Gillian Branstetter. “It’s an understanding that gender, much like sexuality, exists on a spectrum and is more fluid than people allow.”

What does it mean to be nonbinary?

Nonbinary is a term used to describe people who do not identify exclusively as male or female. Some nonbinary people also identify as transgender, and some are also diagnosed with gender dysphoria, but others are not. Many — but not all — nonbinary people use they/them pronouns, instead of he/him or she/her. Some nonbinary people will use a combination of different pronouns.

What does it mean to be intersex?

Intersex is an umbrella term used to describe people with differences in sex traits or reproductive anatomy, which can include variations in genitalia, internal anatomy, hormones or chromosomes. Some people are born with these differences, while others develop them in childhood, according to the organization InterACT.

Transgender medical care for children

How does a young child transition?

For pre-pubertal transgender children diagnosed with gender dysphoria, doctors recommend avoiding gender-affirming medications, according to the Endocrine Society’s Clinical Practice Guideline, which sets standards of care for transgender people.

“If you have not yet started puberty, there’s nothing to block and nothing to add,” Olson-Kennedy said. “It’s about creating environments that are supportive.”

Rather than beginning a medical transition, pre-pubertal transgender children may begin a social transition, changing one’s name and pronouns, and wearing different clothing or hairstyles. This transition can in some cases involve legal changes to names and genders listed in identifying documents. Transgender children are not offered puberty blockers or hormone treatments until they reach puberty. Medical guidelines generally do not recommend genital gender-affirming surgeries before a child reaches age 18.

What are puberty blockers and when are they offered to transgender children?

Once a transgender child has met diagnostic criteria for gender dysphoria, and after the child first shows physical changes of puberty, clinicians may recommend puberty-suppressing treatments, also known as puberty blockers.

The medications pause puberty and prevent unwanted changes to teenagers’ bodies, such as periods in transgender boys or the deepening of the voice in transgender girls. The puberty blockers are intended to give young people more time to decide what to do next. At any point, a transgender teenager can stop taking puberty blockers and will continue to go through the puberty of their sex assigned at birth.

For decades, puberty suppression has been used by doctors to treat precocious puberty — abnormally early onset of puberty — in children, as well as endometriosis and prostate cancer in adults. But it was first used as gender-affirming treatment in the 1990s, at a transgender clinic in the Netherlands.

Politicians critical of puberty blockers have at times focused on federal approvals for the drugs. While puberty suppressants are approved by the Food and Drug Administration to treat children with precocious puberty, the medications have not been approved specifically for gender-affirming care. Olson-Kennedy argues that this lack of approval is because drug firms have declined to perform the studies necessary to get these approvals.

In general, because many drug companies avoid performing trials on children, it is common in pediatric medicine for doctors to prescribe drugs off-label.

What are hormone treatments and when are they offered to transgender youth?

Once a transgender teenager reaches later years in adolescence, some may request sex hormone treatment — estrogen for transgender girls and testosterone for transgender boys. These medications can help align a transgender person’s body to their gender identity, leading to facial hair growth and a deeper voice in transgender boys, for example, and breast growth in transgender girls.

Since these are partly irreversible treatments, the Endocrine Society recommends waiting to begin treatment until after a person has “sufficient mental capacity to give informed consent,” which the society said most adolescents have by age 16. In some cases, according to the 2017 guidelines, transgender youth may have this capacity by age 14. Each teenager’s ability to consent has to be determined individually, Olson-Kennedy said. “One person’s 14 is very different from another person’s 14.”

The Endocrine Society recommends starting treatment with a gradually increasing dose schedule carefully monitored by a multidisciplinary team of doctors.

In recent debates over transgender medical care, politicians have made claims that transgender children are undergoing genital surgeries at young ages. Current medical guidelines say children should not undergo gender-affirming genital surgery before they turn 18.

Chest surgeries can be performed on transgender teenagers before theage of majority in a given country (age 18 in the United States), according to standards of care from the World Professional Association for Transgender Health, “preferably after ample time of living in the desired gender role and after one year of testosterone treatment.”

What does scientific research tell us about these treatments and their impacts?

Research on these medications is still evolving, due in part to the nascent nature of the treatments, the challenges of performing studies on children and the small size of the transgender youth population. But several studies on puberty blockers have found that transgender young people who were treated with the medications showed lower rates of depression and anxiety, and demonstrated better global functioning.

A study conducted by Turban and colleagues, published in the journal Pediatrics in 2020, showed that young people who wanted a puberty suppressant and were able to access it had lower odds of considering suicide.

Critics of gender-affirming treatments often argue that children are too young to make these decisions and may regret them in adulthood. Skeptics will often cite statistics from studies suggesting that a majority of young transgender children will eventually grow out of their transgender identity later in life. But Turban and other experts have argued the methodology used in these studies is flawed because the researchers included a large cohort of children referred to transgender clinics, not children who actually met the criteria for gender dysphoria. He argued that many of these children were not transgender to begin with and may have simply been brought to the clinics by their parents because they were “tomboys” or gender-nonconforming children.

A new study by Turban and other researchers from the Fenway Institute and Harvard Medical School found that 13.1 percent of currently identified transgender people have “detransitioned” at some point in their lives but that 82.5 percent of those people attributed their decision to external factors such as pressure from family, school environments and vulnerability to violence.

What are some of the risks of these medications?

Puberty suppressants do come with some risks, and the Endocrine Society’s 2017 guidelines mentioned the need for more research on the effects of the prolonged delay of puberty in adolescents.

Puberty suppression may include adverse effects on bone mineralization, according to the Endocrine Society, but the estimated calculated risk of bone fracture remains extremely low, Turban said, citing a recent paper in Pediatrics. For each patient, this likely low risk of fracture needs to be weighed against the risk of adverse outcomes from gender dysphoria itself, Turban said.

If a child has been on puberty blockers for years, “most endocrinologists will say by the time you get to 16, you make a decision. Either come off the blocker or start estrogen or testosterone to mineralize your bone,” Turban said.

For transgender teenagers who first take puberty blockers and then take estrogen and testosterone treatments, the Endocrine Society warns that the treatment may compromise fertility later in life. But Turban says more research is needed on the subject. The Endocrine Society recommends that clinicians counsel all transgender people seeking hormone treatments on their options for fertility preservation before they start taking estrogen or testosterone.

What legislation has advanced in the U.S. to restrict these medications?

As of Feb. 24, 2022, at least 22 states have introduced bills to criminalize or ban access to puberty blockers, hormone treatments and transition-related surgeries for transgender minors. In 2021,legislators in Arkansas voted to pass the nation’s first ban on gender-affirming medical treatments for transgender youth, overriding a veto from their governor. Gov. Asa Hutchinson (R) described the bill as a “vast government overreach” that would interfere with physicians and parents “as they deal with some of the most complex and sensitive matters involving young people.” Tennessee enacted a similar ban in 2021, and Alabama is considering one this year. The Alabama Senate passed Senate Bill 184 in late February, and the House will vote on it soon. Lawmakers in Indiana, Kentucky, Utah, Wisconsin and Missouri have introduced similar bills this year.

Major medical organizations including the American Psychiatric Association, American Academy of Pediatrics and the American College of Physicians have written in opposition to these bills. And according to the Williams Institute at UCLA School of Law, an estimated 45,100 transgender youth ages 13 and older in the United States are at risk of being denied gender-affirming medical treatments due to proposed and enacted state bans.

Transgender youth and sports

What are the current guidelines in the U.S. for the participation of transgender people in sports?

Policies on the participation of transgender students in high school sports vary from state to state. At least 16 states and the District of Columbia have policies that help facilitate the full inclusion of transgender, nonbinary and gender-nonconforming students in high school sports, according to TransAthlete.com and the American Civil Liberties Union.A patchwork of policies exists in other states, with at least 10 states requiring trans athletes to undergo some treatment, and11 states banning participation.

At the college level, NCAA guidelines require at least a full year of testosterone suppression before a transgender woman is allowed to compete with other women. That guidance, published in 2011 and citing medical experts, notes that transgender women “display a great deal of physical variation, just as there is a great deal of natural variation in physical size and ability among non-transgender women and men. … It is important not to overgeneralize.” The assumption that all people assigned male at birth are “taller, stronger, and more highly skilled in a sport” is not accurate, the handbook states. However, debate over the eligibility standard for transgender college athletes intensified recently in light of the record-smashing performance of University of Pennsylvania swimmer Lia Thomas. She joined the women’s team after competing for the men’s team for three seasons and undergoing more than two years of hormone replacement therapy as part of her transition. The NCAA issued a new policy earlier this year letting each sport determine the eligibility of transgender athletes.

At elite levels, policies also vary across national and international associations and federations. The International Olympic Committee issued guidance in 2015 for determining eligibility. According to the guidance, transgender men can compete in male categories without restriction, but transgender women must meet certain conditions, including demonstrating that their total testosterone level in serum has been below 10 nmol/L for at least 12 months before their first competition.

Andraya Yearwood, a transgender student-athlete, participates in the Connecticut Winter Indoor Track Championships in New Haven last year. (Stan Godlewski for The Washington Post)

What research is available about transgender athletes and whether they have an advantage over cisgender athletes?

Across the country, more than half of U.S. states have introduced bills in 2021 that would bar transgender participation in school sports according to their gender identity. Many of these bills argue that transgender women and girls have a biological advantage over cisgender girls when competing in sports. An Idaho bill, which was signed into law in 2020 but has been stalled in court proceedings, argues that transgender girls and women have “denser, stronger bones” and “larger hearts, greater lung volume per body mass” and other characteristics that lawmakers claimed would give transgender women an athletic edge.

But studies of the performance of transgender athletes so far are limited and based on small, narrow samples that some researchers say cannot necessarily be applied to high school sports.

One study published in the British Journal of Sports Medicine in 2020 suggested that transgender women in the U.S. Air Force retained certain athletic advantages over cisgender female peers for about two years into hormone therapy. The researchers assessed the medical records and fitness tests of 29 transgender men and 46 transgender women from 2013 and 2018, reviewing the number of push-ups and sit-ups they could perform in a minute and the time required to run 1½ miles.

[Transgender rights emerge as a growing political flash point]

The study’s authors found that when it comes to muscle strength, after two years of hormone therapy “you can’t distinguish the performance of the trans women with the average performance of cis women in the Air Force,” said the study’s lead author, Timothy Roberts, director of the adolescent medicine training program at Children’s Mercy Hospital in Kansas City, Mo. When it came to running times, the transgender women’s times did slow down but were still 12 percent faster on average than those of their cisgender female peers. But looking at the spread of run times among cisgender women, the transgender women were still slower than 9 percent of them.

“There’s natural variation in talent, there’s natural variation in testosterone levels,” Roberts said. “There’s never really been a level playing field.”

Roberts and the other authors of the study have cautioned against applying the study’s findings to high school athletics. The average age of the U.S. Air Force members in the study was 26. The athletic abilities of a trans person undergoing hormone therapy as an adult are going to be vastly different from those transitioning as teenagers. Roberts said. For transgender teenage girls who took puberty blockers followed by estrogen treatments, “they probably have absolutely no advantages over the other cisgender women.”

LGBTQ advocates and health experts say that assertions about the biological advantages of transgender athletes also fail to take into account social hurdles that may affect a transgender athlete’s ability to compete.

“Harassment and discrimination, years of internal turmoil and shame and a lack of validation … that inhibits the ability to thrive,” said Chase Strangio, an attorney and deputy director for transgender justice at the ACLU.

[The fight for the future of transgender athletes]

Olson-Kennedy said many of the trans girls she treats in her clinic avoid playing sports, in part because they don’t want to build muscle, but also because “in competitive sports … everything about it is dysphoria-producing,” she said. “What are people going to say? Are they going to accept me on the girls’ team? What’s the locker room situation going to be like?” These are the kinds of questions transgender girls ask before even considering playing sports, Olson-Kennedy said.

Some of the recent legislation has raised questions about how the restrictions would be enforced, and whether high school athletes would be subject to physical exams. LGBTQ advocates and transgender health experts say demanding certain hormone levels or requiring sex-verification exams to determine eligibility in sports can be harmful to both transgender and cisgender young people.

A proposed ban on transgender athletes participating in girls’ sports at public high schools in Utah would affect transgender girls like this 12-year-old swimmer seen at a pool in Utah on Feb. 22. (Rick Bowmer/AP)

How has the participation of transgender girls in sports impacted outcomes for cisgender high school athletes?

As lawmakers across the country introduced bills to restrict transgender participation in sports, the Associated Press contacted two dozen state lawmakers sponsoring such legislation. In almost every case, the AP reported, lawmakers could not cite “a single instance in their own state or region where such participation has caused problems.”

Many supporters of these bills point to a 2020 case in Connecticut. The families of three Connecticut high school track and field athletes filed a federal lawsuit objecting to a Connecticut Interscholastic Athletic Conference rule that allows high school athletes to compete in sports corresponding with their gender identity.

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The lawsuit centered on transgender runners Andraya Yearwood and Terry Miller, who won a combined 15 state titles in different events. But two days after the Connecticut lawsuit was filed, one of the cisgender plaintiffs defeated one of the transgender girls in a state championship.

“We’ve had years and, in some cases, decades of inclusion … and just quite simply there are no examples of trans people taking over or winning in any sort of significant numbers,” Strangio said. “And there’s been zero examples of a trans girl in high school getting an athletic scholarship to compete in college.”

Typography animation by Sarah Hashemi and Audrey Valbuena. Editing by Annys Shin. Copy editing by Mike Cirelli. Design by J.C. Reed.

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Transgender youth and sports

What are the current guidelines in the U.S. for the participation of transgender people in sports?

What research is available about transgender athletes and whether they have an advantage over cisgender athletes?

But studies of the performance of transgender athletes so far are limited and based on small, narrow samples that some researchers say cannot necessarily be applied to high school sports.

“There’s natural variation in talent, there’s natural variation in testosterone levels,” Roberts said. “There’s never really been a level playing field.”

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RECOVERY AND OUTLOOK

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WHEN TO CALL THE DOCTOR

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Transgender medical care for children

How does a young child transition?

What are puberty blockers and when are they offered to transgender children?

What are hormone treatments and when are they offered to transgender youth?

What does scientific research tell us about these treatments and their impacts?

What are some of the risks of these medications?

What legislation has advanced in the U.S. to restrict these medications?

Transgender youth and sports

What are the current guidelines in the U.S. for the participation of transgender people in sports?

What research is available about transgender athletes and whether they have an advantage over cisgender athletes?

How has the participation of transgender girls in sports impacted outcomes for cisgender high school athletes?

Comments are not available on this story.

Transgender youth and sports

What are the current guidelines in the U.S. for the participation of transgender people in sports?

What research is available about transgender athletes and whether they have an advantage over cisgender athletes?

How has the participation of transgender girls in sports impacted outcomes for cisgender high school athletes?

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