Gender-Affirming Policies Support Transgender and Gender Diverse Youth’s Health

Transgender and gender diverse youth (TGD) (i.e., children and adolescents whose gender identity and/or expression differs from their sex assigned at birth) are more likely to experience poor health than their peers whose gender identity aligns with their assigned sex at birth (i.e., cisgender youth) due to stigma and marginalization. Fortunately, school policies that protect, include, and affirm TGD youth’s gender identity are associated with positive mental health and academic outcomes. TGD youth who have access to gender-affirming medical care experience improvements in mental health and often show mental health comparable to their cisgender peers. Some legislative efforts have attempted to block transgender youth’s access to gender-affirming medical care (e.g., puberty blockers) and school resources (e.g., sports teams that align with their gender identity). Policymakers, along with school personnel, must enact non-discrimination and anti-bullying policies that allow TGD youth equal access to school facilities and resources, and protect youth on the basis of their gender identity and expression. In this brief, we term policies and practices that recognize and support TGD youth’s identities and expression “gender-affirming care” and highlight opportunities to ensure the healthy development of all TGD youth. We highlight how medical and school contexts are critical for TGD youth’s development and health and offer evidence-informed policy and practice recommendations to guide efforts that support youth.

Transgender and gender diverse youth (TGD), which includes non-binary youth, are 2-3 times more likely than their cisgender peers to experience discrimination and a lack of safety in schools.^1-4 TGD youth are also 2-3 times more likely to report suicidality, depression, and anxiety than cisgender youth.^5-8 Studies document that 30-50% of TGD youth report attempting suicide.⁸ Conversely, transgender youth with supportive families and who have socially transitioned show normative rates of depression and only slightly more anxiety compared to their cisgender peers.^9-12 The more contexts (e.g., home, school, work) in which TGD youth experience gender-affirming support (i.e., chosen name use) the less they experience depressive symptoms and suicidal ideation and behavior.⁶ It is therefore necessary to ensure that TGD youth receive protection and support that affirm their gender identity and expression across multiple contexts. Notably, youth’s experiences with family, school, and medical care settings also vary by race/ ethnicity, geography, and socioeconomic status, which may exacerbate health disparities for TGD youth (e.g., youth without private health insurance may not have access to affirmative medical and mental health care).^13-15 Further, including questions about gender identity and expression in electronic medical records and state and national school-based surveys enables TGD youth to share their identity and experiences, and creates a better understanding of health disparities.¹⁶ Given the focus of recently proposed legislation, we highlight the importance of affirming policies and practices for youth in two contexts: medical care and school settings.

Access to Medical Services Promotes TGD Youth’s Health and Well-Being

Leading health associations deem gender-affirming health care to be appropriate and medically necessary for TGD youth who meet internationally recognized guidelines for care.¹⁷ Before puberty begins, no hormonal or surgical care is provided to TGD youth; rather, gender-affirming care focuses on youth’s social transition (i.e., change of name, pronouns, appearance, and use of spaces like restrooms that align with youth’s gender). When puberty begins the first hormonal intervention for which some TGD youth are eligible is puberty blocking (which temporarily delays puberty), the effects of which are reversible. These “blockers” are provided under the supervision of a licensed medical provider. Typically, a few years later, TGD youth might be prescribed hormones to begin puberty that aligns with the youth’s gender.¹⁸

Before puberty blocking, TGD youth often have high rates of depression, anxiety, and suicidality. On average, after puberty blockers and gender affirming hormones, levels of depression are no longer elevated,^19-22 anxiety is reduced,^19,20 body image improves,^19,23 and suicidality drops to levels typical for all youth.^21,22 The positive effects of gender-affirming health care have been found in adolescence during the initial medical transition,²⁰ and have been found to last for years into adulthood.^{19, 24-26} For example, TGD youth receiving puberty blockers showed similar mental health to their cisgender peers,^19,22 and better mental health than TGD youth not yet receiving treatment.^20,22 Studies find poorer mental health²⁰ and twice as many suicidal thoughts and attempts²² among youth not yet receiving gender-affirming care when compared to youth who are receiving care. Counseling and psychological support also contribute to improved mental health for TGD youth;¹⁹ however, they can not replace the benefit of medical care, when indicated, for TGD youth’s well-being.^20,21

For TGD youth, parents and providers collaborate and reference international standards to determine the best course of care.^16,26 Starting medical care before puberty is complete can often lead to a physical transition that better reflects TGD youth’s gender,²⁸ likely increasing social opportunities like friendships, dating, and employment in the future. In contrast, barriers to gender-affirming medical care due to lack of health insurance,¹⁴ limited family support, or health insurance exclusions^13-15 are associated with poorer mental health in adulthood.^{20, 21-24}

Schools Play an Important Role in TGD Children and Youth’s Positive Development and Mental Health

Transgender youth are 3.7 times more likely than cisgender youth to experience bullying and are 3.3 times more likely to miss school due to safety concerns.³ 58% of TGD youth also report having been prevented from using bathrooms that aligned with their gender identity.⁷ Many TGD youth are sent home or to detention for their gender expression (e.g., wearing make-up or nail polish or clothing that the school deems inappropriate for their gender).^29,30 When schools limit participation in sports and equal access to school facilities, TGD youth may miss out on important learning experiences (e.g., physical education classes),^1,31 be unable to use the bathroom for an entire day,^32-34 miss days of school,^3,32 and experience poorer mental health (e.g., depressive mood).⁷

By contrast, states and schools can implement policies that protect TGD youth from these harmful experiences.³ For example, anti-bullying and nondiscrimination policies that specifically name gender identity or expression as a protected status enable the monitoring of bias-based bullying and intervention, and are linked to lower rates of bullying and victimization.^35-37 Further, teacher training on gender identity and expression is associated with less school-based victimization.³⁸ School personnel can also support TGD students with their social transition by using the name and pronouns denoted by the student^6,39,40 and allowing them to use school facilities^32,33 and participate on sports teams that align with their gender identity.^1,2,31 When schools support TGD student’s social transition, they report better mental health.^6,32 One study found that transgender youth who could use their name in school were 56% less likely to report suicidal behavior.⁶ In addition, TGD adults who were able to have their name and gender marker on their passport or state ID, reported lower depression, anxiety, and suicidality,^39,40 and they were less likely to report feeling emotionally upset as a result of gender-based mistreatment.³⁹ Ultimately, transgender youth show more positive outcomes in school environments that implement and enforce policies and practices that affirm youth’s gender identity and protect them from discrimination.  

Policy and Practice Implications

Policymakers need to ensure TGD youth’s access to developmentally appropriate, gender-affirming health care and supportive school environments. More specifically, policymakers and school personnel can support TGD youth’s well-being by prohibiting discriminatory policies and implementing affirmative actions, such as:

Policies and Practices that Support TGD Youth in Medical Settings

1. Do not ban or penalize the use of developmentally appropriate, gender-affirming health care, including puberty suppression, gender-affirming hormones, surgical interventions, and mental health care for TGD youth.^{18-22, 26}

2. Require insurance coverage of developmentally appropriate, gender-affirming health care, including puberty suppression, gender-affirming hormones, surgical interventions, and mental health care for TGD youth.^{18-21, 26}

3. Standardize the collection and privacy of gender identity and expression data in medical records.^41-43

Policies and Practices that Support TGD Youth in Schools

4. Add gender identity and expression to state and federal anti-bullying and nondiscrimination policies in schools as protected statuses (e.g., the Equality Act would address this recommendation nationwide).^35-37

5. Allow students to change their name and gender on their legal documents and in their school files.^6,39,30

6. Allow students to engage in activities and sports that align with their affirmed gender.²

7. Protect the use of bathrooms and locker rooms that align with student’s affirmed gender, without having to disclose transgender status.^7,32,33

8. Implement training for school personnel on topics related to affirming gender identity and expression.^6,38

9. Mandate the collection of gender identity and expression data in state and national school-based surveys.^16,41

References

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