Editor’s Note: On August 20, federal judge Sarah Geraghty granted a preliminary injunction on Senate Bill 140, blocking the section of the law that banned hormone therapy for minors. But due to a ruling from the 11th U.S. Circuit of Appeals that overturned a similar blocked law in Alabama, Geraghty reinstated the ban on September 5.
Georgia’s new law banning most gender-affirming healthcare for people younger than 18 has been sharply criticized by medical experts. “We are appalled to see politicians promote an agenda with such disregard for standards of medical care,” wrote dozens of Georgia physicians and medical providers in an open letter to lawmakers published in the Atlanta Journal-Constitution on March 16.
Senate Bill 140, which passed the Georgia General Assembly on a party-line vote, goes into effect on July 1 and bans hormone therapy and gender-affirming surgery for minors. The bill is part of a wider effort in Republican-led state legislatures to restrict gender transition in young people and in some cases adults. But such laws directly contradict the science: major American professional medical associations, including the American Academy of Pediatrics, the American Medical Association, the American Psychiatric Association, and the American Academy of Child Adolescents Psychology, among others, agree that gender-affirming healthcare is the best treatment for gender dysphoria.
This includes age-appropriate interventions for transgender minors. In their 2018 policy report, the American Academy of Pediatrics recommended that “youth who identity as TGD (transgender/gender-diverse) have access to comprehensive, gender-affirming, and developmentally appropriate healthcare.”
Section 1 of SB 140 contains seven “findings” lawmakers say justify the need for this law. But experts say these findings do not reflect the medical science of gender transition in minors. We spoke to several doctors and mental health providers to break down the facts—and myths—behind these findings to help you understand what’s actually happening.
Section 1(1): “There has been a massive unexplained rise in diagnoses of gender dysphoria among children over the past ten years, with most of those experiencing this phenomenon being girls.”
Fact: Gender dysphoria is not an unexplained “phenomenon;” it is a clinical diagnosis, backed by scientific evidence and methodical research, that occurs equally across sexes.
The reason that diagnosis of gender dysphoria is on the rise for people of all ages is far from unexplained. While transgender people have always existed, social stigma has only recently begun to decline, allowing more transgender and nonbinary people to express their identities. (This has been compared to the rising rates of left-handed people, a relatively common trait that was, until recently, artificially suppressed due to stigma.) Because medical research into transgender health and transition has improved dramatically in recent decades, providers are much better equipped to diagnose and treat these patients, as with other emergent medical issues like prolonged grief disorder or even new viruses like Covid-19.
A series of recent studies has debunked the “social contagion” hypothesis—the idea that adolescents, especially girls, are being influenced by their peers to spontaneously identify as transgender and seek gender-affirming care, hypothesized as “rapid onset gender dysphoria.” A 2022 study published in the Journal of the American Academy of Pediatrics found no difference in the birth sex of adolescents identifying as transgender, while another in the Journal of Pediatrics found no evidence to support the theory of rapid onset gender dysphoria.
Most importantly, medical experts stress that all adolescents who receive gender-affirming care first undergo thorough mental and physical health examinations before being diagnosed with gender dysphoria and approved for treatment. “This is not quick care,” said Dr. David Inwards-Breland, a pediatrician and former medical director of the Seattle Children’s Gender Clinic. “It’s methodical, bringing multiple disciplines together, in partnership with the parents and the patient for a good outcome.”
In treating transgender youth, medical providers rely on the standards of care established by the World Professional Association for Transgender Health (WPATH), which include specific best practices for treating children and adolescents. The first step before diagnosing gender dysphoria or beginning any medical interventions is a “comprehensive biopsychosocial assessment.”
“We want to get info from multiple sources about this young person and their needs,” explained Dr. Ren Massey, a psychologist and mental health chair of the WPATH Global Education Institute, which trains medical providers on evidence-based gender-affirming healthcare. “We talk to the youth patient, of course, but also to their parents or caregivers, sometimes other family members; we assess their academic function, social history, and their medical health.”
Section 1(2): “Gender dysphoria is often comorbid with other mental health and developmental conditions, including autism spectrum disorder.”
Fact: Dysphoria-linked depression and anxiety are largely abated by receiving gender-affirming care, and transgender people people with autism do not have that gender identity because they are autistic.
Transgender adolescents are more likely than their peers to have serious depression, anxiety, and suicidal ideation—until they begin gender-affirming care. A 2018 study found that when transgender youth first arrived at a clinic for care, they showed poorer psychological well-being than their cisgender (the term for people whose gender identity aligns with their sex at birth) peers, but after beginning treatment, their psychological well-being was similar to or better than those same peers. And a 2022 study in the Journal of the American Medical Association found that gender-affirming medical interventions for transgender and nonbinary youth were associated with 60 percent less risk of depression and 73 percent less risk of suicide.
“This is not, I’m having a hard time adjusting to puberty. It’s, I can’t stand my body,” Massey explained. When these patients don’t get treatment, he said, “We see social decline, school dropout, hospitalization, suicide attempts.”
And while people diagnosed with gender dysphoria may be slightly more likely to have autism spectrum disorder, this is correlation, not causation: there is no evidence that being on the autism spectrum causes people to identify as transgender, and researchers say there’s no reason to deny people with autism or other neurodivergent diagnoses the same healthcare as neurotypical people.
“Just because these things can co-occur does not mean that one should be denied,” Varun Warrier, a researcher at University of Cambridge who published a 2020 study on the link between autism and gender diversity, told Spectrum News.
Section 1(3): “A significant portion of children with gender dysphoria do not persist in their gender dysphoric conditions past early adulthood.”
Fact: While detransition—where people who have undertaken some kind of gender transition stop the process—occurs, it is rare in both adolescents and adults.
In a longitudinal study of 317 American transgender youth published this year, 94 percent of subjects still identified as transgender and were still taking hormones five years after their initial social transition. Of the 6 percent who weren’t, 2.5 percent had gone back to being cisgender, while 3.5 percent had shifted to identifying as nonbinary.
A larger study of transgender adults found 13 percent of people who had stopped receiving some gender-affirming care had later detransitioned, but of those people, 82.5 percent said they chose to do so due to external pressure. “People may go back to [identifying as] cisgender because of family influence or community pressure to revert back,” said Inwards-Breland. “It’s not them deciding necessarily.”
While older studies found much higher incidence of “growing out” of transgender identity, experts say these studies relied on outdated diagnosis criteria that included many children who wouldn’t be diagnosed with gender dysphoria today, such as boys who grew up to be gay cisgender men but showed a childhood preference for girls’ clothes and toys. Moreover, not every child who expresses gender diversity will seek diagnosis or treatment for gender dysphoria, and those who do undergo thorough assessment by mental health and medical providers.
“The patient and family typically meet with a mental health professional for months [or] years prior to any medical intervention,” wrote Dr. Izzy Lowell, a family medicine physician and founder of Decatur’s QueerMed gender clinic, in an email. “Then there is a thorough evaluation, reviewing the patient’s gender history and general medical history.” Patients only move on to medical care “if the patient meets diagnostic criteria for gender dysphoria and their legal guardians and therapist all agree that medical treatment should be started.”
Section 1(4): “Certain medical treatments for gender dysphoria, including hormone replacement therapies and surgeries, have permanent and irreversible effects on children.”
Fact: Gender-affirming surgeries are extremely rare in people under 18, and hormone replacement therapy, some of which is reversible, is only introduced after lengthy evaluation and mental health care.
Hormone therapy allows transgender adolescents to go through the puberty that aligns with their gender identity and provides huge benefits that allow them to fit in with their peers, make it easier to “pass” or blend in as adults, and reduce the costs and pain of more medical interventions as a post-pubescent adult.
While hormone therapy for adolescents diagnosed with gender dysphoria is becoming more common, surgeries for minors are extremely rare. Many gender clinics—and insurance companies—don’t allow any surgeries on transgender patients younger than 18, and in the rare instances they happen, it is for adolescents in their later teens with a long history of gender dysphoria and years of prior hormone interventions. “Zero of my patients under 18 have had bottom surgery,” wrote Lowell. “A few (perhaps 5 out of over 500) under 18 have had chest surgery,” she wrote, but “only in cases where they had severe dysphoria about their breasts and had been on hormone therapy for at least 2-3 years.”
In a nationwide survey of gender-affirming healthcare for young people commissioned by Reuters, analysts found that in 2021, 4,231 patients younger than 18 began hormone therapy, but only 282 received chest surgeries. There were just 56 instances of genital surgeries on patients under 18 between 2019-2021.
While some effects of hormone therapy, like hair growth, voice change, and breast tissue, are permanent, many effects of both testosterone and estrogen treatment are reversible. “If the patient is done with puberty, a lot of the [effects] that occurred from the hormones will go away,” said Inwards-Breland.
Like all interventions to treat a medical diagnosis, there are risks and side effects of gender-affirming care. Medical providers say they discuss all possible risks, side effects, and outcomes of gender transition with patients and their families, just as they would with any medical treatment. “Patients don’t just show up on the doorstep of the clinic and get a prescription,” said Inwards-Breland. “We talk in detail about the risks and benefits that they need to think about as a family.”
Section 1(5): “No large-scale studies have tracked people who received gender-related medical care as children to determine how many remained satisfied with their treatment as they aged and how many eventually regretted transitioning.”
Fact: Like detransition, large-scale studies have found that regret over gender-affirming care is rare.
A 2021 survey of 27 studies, pooling nearly 8,000 transgender patients, found only 1 percent of subjects regretted their care.
“I have had one patient under age 18 stop hormone therapy treatment,” wrote Lowell of QueerMed. “In that case, they did not report any regret, they felt that their gender identity was ultimately more nonbinary than transgender.” She added that the patient was “glad to have had the treatment but did not want to continue after several years of taking hormone therapy.”
Inwards-Breland, who was the medical director of two large gender clinics, reported similarly low rates of young people who stopped their transition, and said the patients who did went on to identify as nonbinary rather than cisgender. “I’ve treated thousands of patients, and I’ve not personally had a patient who to my knowledge changed back to cisgender,” he said. “It does happen, I’m sure, but those numbers are extremely small.”
Section 1(6): “Under the principle of “do no harm,” taking a wait-and-see approach to minors with gender dysphoria, providing counseling, and allowing the child time to mature and develop his or her own identity is preferable to causing the child permanent physical damage.”
Fact: A wait-and-see approach can be harmful for mental health, and using puberty blockers until age 18 is not medically advisable.
Unlike other states’ bans on gender-affirming care for youth, Georgia’s law allows the use of puberty blockers, which stop the development of secondary sex characteristics as a “pause.”
“Blockers buy some time,” explained Massey, allowing a child and their family to explore social transition before deciding whether to move on to hormone replacement therapy. (A 2018 Dutch study found that 98 percent of adolescents who start on puberty blockers do continue on to hormone treatment.) From there, hormone treatment will induce puberty aligned with a patient’s gender identity, or, if blockers are stopped with no other treatment, puberty of the sex assigned at birth will occur.
But while puberty blockers can be a part of gender-affirming care, they are not meant to be a long-term solution. Medical experts say that staying on blockers until adulthood is a profound misunderstanding of the uses and risks of the treatment and does not account for the importance of undergoing puberty at a developmentally appropriate time alongside one’s peers.
Puberty is a critical time for mineral bone density development; delaying it too long can impact lifelong skeletal health. The hormone in puberty blockers can be linked to bone loss, but studies have found that the loss is restored or improved when followed by hormone treatment.
Just as damaging, Massey added, are the psychosocial impacts of delaying puberty until adulthood. “If you’re on puberty blockers for 6-8 years, you’re not going through puberty with your peers,” he said. “Imagine being that underdeveloped in high school—it puts a target on your back and limits your ability to develop relationships.”
Transgender teenagers want and need the same social experiences as their peers. Research shows that laws banning gender-affirming care for adolescents result in higher levels of depression, anxiety, and suicide ideation in transgender and gender-diverse youth, a decreased sense of safety, and lower engagement with the entire healthcare system.
Section 1(7): “The General Assembly has an obligation to protect children, whose brains and executive functioning are still developing, from undergoing unnecessary and irreversible medical treatment.”
Fact: Medical research is clear that denying gender-affirming care to transgender children can cause grievous harm.
After signing the bill into law, Governor Kemp tweeted, “It is our highest responsibility to safeguard the bright, promising future of our kids—and SB 140 takes an important step in fulfilling that mission.”
But medical experts who study gender dysphoria say the governor has it completely backwards. “My young patients tell me, I can’t imagine a future where I can’t transition,” said Massey. “Imagine myself at 24? I’m dead or an alcoholic.”
Gender dysphoria is not a passing phase or a generalized discomfort about growing up. The clinical diagnosis, developed over decades of careful research, is based on a broad matrix of data points about a person’s feelings about their body and sense of their own gender. While we are still learning about what causes gender dysphoria, we know from overwhelming evidence that gender-affirming healthcare treatments are the solution.
Denying young people access to those treatments will not keep them safer, experts say. “There will be vast downstream consequences to this law,” said Massey. “There will be more bullying, more dropping out of school, more suicide attempts, more suicide completions.”
During the hearings for SB 140, several young transgender Georgians testified about the anguish they experienced before receiving gender-affirming care. “These life-saving treatments are the reason I am able to speak to you today,” Leonardo Hinnant, an 18-year-old transgender man and Georgia State University student, told lawmakers.
“The reality of it is this: if this bill passes, transgender kids will die.”
Go deeper: LGBTQ advocates and medical providers worry that bills like Georgia’s SB 140 are only the beginning—a beachhead in a sustained assault on trans people in the U.S. Read our story from our June 2023 issue, “How young trans people—and their families and medical providers—are contending with a wave of animus.”