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Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief (2023)

Chapter: Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief

Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
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images Proceedings of a Workshop—in Brief

Supporting the Health and Well-Being of Transgender and Gender Diverse Youth

Proceedings of a Workshop—in Brief


To explore existing evidence-based guidance and best practices on supporting the well-being of transgender and gender diverse youth, the National Academies of Sciences, Engineering, and Medicine (the National Academies) Forum for Children’s Well-Being (the Forum) held a workshop on April 25, 2023. The workshop included presentations from experts as well as perspectives from youth and parents. This Proceedings of a Workshop—in Brief provides a high-level summary of the topics addressed in the workshop. Additional details, including a workshop recording, can be found on the National Academies’ workshop webpage.1

INTRODUCTION2

Carlos Santos (he/him/his), Forum member, UCLA Luskin School of Public Affairs, introduced the workshop by noting that this was the first National Academies workshop to focus solely on gender diverse youth. He explained that workshop participants intended to approach the topic through an intersectional lens, recognizing that many gender diverse youth also face racism, heterosexism, ableism, classism, and nativism. Brenda Blasingame (she/her/hers), Forum member, Vav Amani Consulting, LLC, added that the workshop would highlight the best available science, including peer-reviewed research, clinical expertise, and policy analysis, and evidence from sources such as the lived experiences of gender diverse youth and their parents and of community leaders who work directly with gender diverse youth. The goal of this workshop, she said, was to inform decision makers who have the power to impact the health and well-being of gender diverse youth.

THE HISTORY OF GENDER DIVERSE YOUTH

To set the stage for the workshop, stef shuster (they/them/theirs), Michigan State University, provided a historical overview of gender-affirming care. However, they noted, the medical establishment has a history of making harmful assumptions about transgender people. To highlight this, shuster shared examples of correspondence between medical providers in the mid-1900s that argued that transgender people were incapable of having agency over their own health or their bodies. These assumptions, shuster said, caused providers to aim their care toward achieving gender normativity, rather than affirming diverse gender identities.

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1https://www.nationalacademies.org/event/04-25-2023/supporting-the-health-and-well-being-of-gender-diverse-youth-a-workshop

2 In welcoming the audience to the workshop, Forum Co-Chair Leslie Walker-Harding, Seattle Children’s Hospital, explained that throughout the workshop a variety of terms may have been used, including gender diverse youth, nonbinary youth, trans youth, or gender fluid youth. The workshop intended to address the health and well-being of all youth included in these groups.

Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
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While some of these assumptions have been challenged in the medical establishment over time, shuster called attention to three common, but false, assumptions that continue to impact the well-being of gender diverse youth. First, there is an assumption that transgender people and gender-affirming care are new; however, they pointed out that gender-affirming medical interventions have been offered since at least the early 1900s, and gender identity clinics were prevalent from the 1960s through the early 1980s. Second, there is the assumption that transgender people lack the maturity or mental stability to make decisions about their own health. This assumption has contributed to state actors and medical providers claiming the authority to determine the gender of transgender people for them. shuster added that this assumption is now used to support arguments that youth who are transgender are incapable of self-determination. Lastly, they pointed out that attacks on providers of gender-affirming care and on transgender people have persisted over time. Today, shuster said, this manifests as legislation limiting access to gender-affirming care, including the criminalization of healthcare providers and of parents seeking gender-affirming care for their children.

LIVED EXPERIENCE OF GENDER DIVERSE YOUTH AND PARENTS OF GENDER DIVERSE YOUTH

The first panel conversation brought together gender diverse youth and their parents to share their own experiences. Panelists comprised Stephen Chukumba (he/him/his), a self-described proud father of a transgender son, Nadeen Herring (she/her/hers), a self-described proud mother of a transgender son, as well as Libby Gonzales (she/her/hers) and Wyatt Williams (he/him/his), two adolescents who identify as gender diverse. The panel was moderated by Kabir Amari (they/them/theirs), planning committee member, National Prism Alliances at Teach for America. Insights from these panel participants are presented throughout this proceedings in brief.

EVIDENCE ON THE PHYSICAL AND MENTAL HEALTH OF GENDER DIVERSE YOUTH

Following the lived experience panel, Russ Toomey (he/him/his), University of Arizona, moderated a panel focused on research on the physical and mental health of gender diverse youth. Myeshia Price (she/her/they/them), The Trevor Project, began by sharing data from the 2022 National Survey on LGBTQ Youth Mental Health—a survey of nearly 34,000 youth ages 13–24 in the United States. This survey found that more than half of transgender and nonbinary youth reported seriously considering suicide in the past year, and nearly one in five attempted suicide (Figure 1). Transgender and nonbinary youth also experience higher rates of anxiety and depression than cisgender youth (Figure 2). Price noted that while transgender and nonbinary youth have higher rates of adverse mental health outcomes, they “are not inherently prone to suicide risk because of their gender identity but rather are at higher risk because of how they are mistreated and stigmatized in society.” Echoing this during the parent and youth perspectives panel, Gonzales commented, “Trans kids have a higher likelihood of mental health issues, but wouldn’t you [too] if the government was constantly asking if you had a right to exist or have health care or go to the bathroom or just play soccer with your friends?”

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FIGURE 1 Rates of suicidality in youth, 2022.
SOURCE: Myeshia Price presentation, taken from The Trevor Project 2022 National Survey on LGBTQ Mental Health https://www.thetrevorproject.org/survey-2022/assets/static/trevor01_2022survey_final.pdf
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FIGURE 2 Rates of anxiety and depression in youth, 2022.
SOURCE: Myeshia Price presentation, taken from The Trevor Project 2022 National Survey on LGBTQ Mental Health https://www.thetrevorproject.org/survey-2022/assets/static/trevor01_2022survey_final.pdf
Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
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Price added that several factors may serve to protect the mental health of transgender and nonbinary youth. For example, access to affirming spaces at home or school is associated with a decreased risk for suicide. This was echoed in the youth and parent perspectives panel by Gonzales who emphasized the impact of affirming spaces, including those that display pride flags or safe space stickers. Respecting pronouns, Price noted, is also associated with decreased risk for attempting suicide. W. Williams shared a similar perspective, noting that using affirming pronouns is an easy way for gender diverse youth to feel respected in their classrooms.

Further, Price shared that transgender and non-binary youth reported various sources of joy, some of which are currently being threatened by legislation. These include learning about LGBTQ history, participating in athletics and exercise, and having access to gender-affirming health care. Curricula was also a topic of conversation during the youth and parent perspectives panel, where W. Williams commented that not being able to learn about LGBTQ history in school is isolating, and Gonzales added that learning about LGBTQ history would help her to better understand herself and her community.

Next, Kate Kuvalanka (she/her/hers), Miami University, discussed the role of affirmation within families. She explained that family can be a source of rejection for many transgender and gender diverse youth, noting that families may be hostile or reject youth. Based on a 2018 report from the Human Rights Campaign (HRC), she added, 57 percent of all transgender and gender diverse youth have been mocked or taunted by their families because of their identities.3 Experiences of gender-based rejection from families, Kuvalanka said, are associated with higher rates of negative health outcomes. Conversely, she added, family acceptance and affirmation are associated with improved psychological outcomes for transgender and gender diverse youth.

Barriers to family acceptance, Kuvalanka explained, may include bias, fear, or a lack of understanding and systemic barriers such as a lack of resources or unsupportive communities or laws. Conversely, family acceptance can be supported through caregiver access to evidence-based resources, access to professionals with training in supporting gender diverse youth, and community connections to advocacy organizations. During the youth and parent perspectives panel, Chukumba commented that the HRC Parents for Transgender Equality Council played an essential role in helping him to realize that his child could be safe and have a normal childhood. Herring added that her local children’s hospital, the Children’s Hospital of Philadelphia (CHOP), gave her the language to explain what her son was experiencing, and introduced her to family support groups. CHOP, she said, helped her appreciate the “joy of knowing and learning from a transgender child.”

Family acceptance, Kuvalanka noted, isn’t all or nothing—families can range from low levels of acceptance to high levels of acceptance; individual family members can also be both accepting and rejecting. For example, she said, a parent may support the social transition of their child but may not support their child’s use of gender-affirming hormones. However, family acceptance does tend to increase over time from when a child discloses their gender diverse identity, Kuvalanka said.

Herring said she provides family support by not making assumptions about her child’s experiences. Chukumba added that providing family support also includes having situational awareness and being prepared to protect his child at every moment. He also said that his family sets ground rules for anyone who interacts with his child, including other family members, to ensure his son feels affirmed and accepted.

Following Kuvalanka’s presentation, Jama Shelton (they/them/theirs), Silberman Center for Sexuality & Gender, Hunter College discussed housing instability and homelessness among transgender youth. They noted that while transgender youth make up about five percent of the total youth population, they account for 10 percent of youth experiencing homelessness. Further, 30 percent of transgender adults report experiencing homelessness at some point in their life. Shelton said there is no singular

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Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
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pathway to homelessness for transgender youth; while family dynamics may play a role for many youth, there are also systemic factors that contribute to a lack of safe, stable housing.

Transgender youth experiencing homelessness are at risk for being victims of violence and discrimination, Shelton said. They added that 26 percent of transgender people who experienced homelessness avoided shelters due to fear of mistreatment. Among transgender people who used shelters, 70 percent experienced some form of mistreatment, including harassment, sexual or physical assault, or expulsion because of their transgender identity.

However, Shelton said, despite the negative outcomes associated with homelessness, some transgender and gender diverse people who voluntarily left rejecting childhood homes still describe being better off. They shared a quote from one transgender person who said, “Honestly, if I never left home, I would probably be dead. Because I would’ve killed myself by now.” Shelton explained that while experiencing homelessness, many transgender people are also experiencing an opportunity to create homes in their genders, in their bodies, and with chosen families. They noted that these positive experiences do not mean homelessness among transgender people should be celebrated. Rather, Shelton suggested that the field does not fully understand the complexity of homelessness experiences among transgender youth. They concluded saying, “To support trans youth well-being, we need a radical cultural transformation” that includes not just addressing interpersonal and internalized factors, but also ideological and institutional levels of oppression.

To conclude this panel, Greta Bauer (she/her/hers), University of Minnesota Medical School, shared findings from the Trans Youth CAN! project, a clinical cohort of adolescents under age 16 referred to clinics in Canada for gender-affirming care. She noted that this project developed in response to an increase in pediatric patient referrals to specialist clinics for gender-affirming care. However, Bauer added, while referrals for gender-affirming care have increased, the absolute number of transgender adolescents remains incredibly small: less than 0.1 percent. She illustrated this with reference to data from the United Kingdom’s Tavistock clinic (Figure 3).

Before the Trans Youth CAN project began, participating adolescents reported high gender distress as well as high gender positivity, and Bauer noted that these are not binary experiences—youth may experience both positive and negative emotions about their gender simultaneously. She shared that among adolescents receiving gender-affirming medical care, after two years gender distress was lower and gender positivity was higher.

As part of this study, youth and parents were also asked about levels of regret around their pursuit of care. Overall, Bauer said, youth in her project reported that they did not regret their decision to receive gender-affirming care (Figure 4). Parents expressed worries about their child facing rejection, making irreversible decisions, about discussing their child’s gender with other family members, and about their child

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FIGURE 3 Referrals to the Tavistock clinic, which served the population of the U.K., as proportion of total adolescent population.
SOURCE: Greta Bauer presentation.
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FIGURE 4 Adolescent decision regret score items, Trans Youth CAN!
SOURCE: Greta Bauer presentation.
Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
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encountering violence. However, she said, parents also reported that the decision to seek gender-affirming care for their child strengthened their family, and only three out of 85 parents reported regret. Parents also reported pleasure in seeing their child become more confident and expressed a sense of hope for their child’s future. Bauer noted that, over two years, parents’ positive feelings remained stable while their worries decreased. When asked whether affirming their youth’s gender had weakened or strengthened their family, less than 10 percent of youth and parents said it had weakened the family, while about half said it had strengthened their family (the remainder reported no effect).

GUIDANCE AND BEST PRACTICES IN HEALTH CARE SETTINGS

Jason Rafferty (he/him/his), Hasbro Children’s Hospital, began the next panel discussion with an overview of the American Academy of Pediatrics’ (AAP) policy statement on gender-affirming care (Box 1). Citing research that shows children who identify as gender diverse know their gender as clearly and consistently as their developmentally matched peers. He said gender development is a normal process for all children; variation is also normal, just as it is in other areas of development. The AAP recommendations for practitioners who provide gender-affirming care are based on four core assumptions: (a) transgender identities and diverse gender expressions do not constitute a mental disorder; (b) variations in gender identity and expression are normal aspects of human diversity, and binary definitions of gender do not always reflect emerging gender identities; (c) gender identity evolves as an interplay of biology, development, socialization, and culture; and (d) if a mental health issue exists for a gender diverse child, it most often stems from stigma and negative experiences, rather than being intrinsic to the child’s gender identity.4

Rafferty noted that the AAP chose to use the term “affirmation” rather than “transition,” explaining that affirmation implies a person is allowed to be their true self and it is society that transitions or changes to accept and value them. The goal of gender-affirming care, he said, is not a particular treatment, but ensuring that youth feel validated and cared for. Consequently, gender-affirming care can take several forms based on each patient’s experience, development, family, and values. Affirmation, Rafferty said, can happen at a psychosocial level through emotional, social, or legal affirmation (e.g., name change). Affirming care for preadolescent youth focuses on these psychosocial supports. He added that affirmation can also happen at a medical level through care such as puberty blockers and gender-affirming hormone therapy (for youth who have reached the onset of puberty). Lastly, Rafferty said, for those over the age of 18, affirmation can happen at a surgical level through gender-affirming surgeries. In closing, he echoed previous comments, saying family acceptance is the most crucial component of acceptance—even a little less rejection can improve a child’s self-esteem and life satisfaction.

Following these opening remarks, a panel of providers from across the country shared their perspectives on providing gender-affirming care. Providers represented clinics serving different regions of the country and providing a range of services to support gender-affirming care. Several of the panelists noted that in addition to the guidelines set forth by the AAP, there are evidence-based guidelines from the American Society for Reproductive Medicine, The Endocrine Society, and the World Professional Association for Transgender Health (WPATH).

In discussing misconceptions about gender-affirming care (Box 2), Tandy Aye (she/her/hers), Stanford University School of Medicine, said while puberty blockers are not indicated before the onset of puberty, there is a common misconception that providers are treating 3- and 4-year-olds with these treatments. Further, she noted, puberty blockers serve to pause—rather than prevent—puberty for adolescents experiencing dysphoria or distress related to their gender to give them more time to explore their gender identity. In some youth who have been on blockers, gender-affirming hormones may be indicated to allow that youth to experience a puberty more aligned with their gender

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4 Hidalgo, M. A., Ehrensaft, D., Tishelman, A. C., Clark, L. F., Garofalo, R., Rosenthal, S. M., Spack, N. P., & Olson, J. (2013). The Gender Affirmative Model: What we know and what we aim to learn. Human Development, 56(5), 285–290.

Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
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identity. Others may want to go through the puberty that is driven by their internal hormones. Regardless of the use of blockers, all youth must go through puberty for healthy development.

Christy Olezeski (she/her/hers), Yale Pediatric Gender Program, added that some people believe gender-affirming care is not evidence-based, despite it being grounded in the guidelines set forth by organizations

Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
×
Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
×

such as the AAP and WPATH. Aye suggested that education of patients and their families is important; often their information is limited to a brief news clip or social media posts that may be based in misconceptions.

Gwendolyn Quinn (she/her/hers), New York University School of Medicine, highlighted needs around reproductive health care for transgender and gender diverse youth. Specifically, she noted, providers sometimes fail to ask about goals for parenthood in the future, and there is a need for more research on how hormone treatment might affect fertility. Additionally, Quinn said, there is a misconception that gender-affirming hormones act as birth control. She emphasized that this is not true and can lead to unexpected pregnancies, adding that there is a need for more attention to reproductive health—including intimacy and pleasure—for gender diverse youth.

In addition to these misconceptions, there are other challenges associated with providing gender-affirming care. Gina Sequeira (she/her/hers), Seattle Children’s Gender Clinic, said the biggest such challenge at her program is capacity. Despite doubling their team over the past two years, they still have a waitlist of over 100 patients. Olezeski agreed, adding that medical school education typically includes just five hours of training in LGBTQ health care which can make it difficult for primary care providers to address capacity needs. Rafferty added that insurance coverage for affirming care has been a challenge in his work and has become less available over time as state bans give insurance providers leverage to push back on covering gender-affirming care. He estimated that at least 95 percent of his patients need insurance coverage to be able to access appropriate care, but many lack adequate coverage.

Next, the panelists discussed the link between mental and physical health in gender-affirming care. Olezeski noted that body dysphoria is prevalent among gender diverse youth and is unlikely to be resolved through mental health care alone; instead, she said, gender-affirming medical care can be beneficial in addressing physical aspects of one’s discomfort in their body. However, there is still a need for emotional and psychological support as the youth explores their identity in a biopsychosocial multidisciplinary care model.

Quinn added that many transgender and gender diverse youth face other systemic stressors in their lives such as racism and commented that providers of gender-affirming care should consider using an intersectional lens in their work, recognizing that each young person will face a unique combination of systems of disadvantage. Building on this idea, Sequeira pointed out that most gender-affirming care for adolescents is in large urban areas, limiting access for youth in rural communities.

Concluding their panel discussion, the panelists commented on what keeps them motivated in their work. Olezeski said she is motivated by wanting to see kids be kids, and to see them feel affirmed in who they are. Rafferty commented that gender-affirming care is a field driven by a true understanding of your patients’ needs through building trust and listening. Aye added that it is a privilege to learn the stories of the young people and to be able to help them. Quinn concluded that while it will not happen in her lifetime, she is motivated by the idea that future generations will be less concerned about gender identity, and they will be able to just be who they are without societal perceptions of what they should look like.

Following their remarks, panelists responded to audience questions. One audience member asked the panelists how providers can promote positive social change. Rafferty said that he has had some success in being proactive about talking to media outlets from a physician perspective to provide information about where the science stands. Aye noted that 22 professional medical societies joined an amicus brief supporting access to gender-affirming care.5 She also said that sharing positive stories about gender diverse youth can help change the narrative.

Next, an audience member asked for advice on how to talk to decisionmakers about the importance of

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5Loe v. Texas, W.D. Tex. D-1-GN-23-003616 (2023). https://downloads.aap.org/DOFA/AmicusBriefARtransgenderlaw.pdf

Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
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gender-affirming care, noting that sometimes a health care team might recognize its importance but find themselves at odds with their institution’s leadership. Olezeski commented that using terms such as “evidence-based” and “lifesaving” can be persuasive for executive leadership. Sequeira added that she’s found it helpful to frame and recognize that gender-affirming care is in line with the mission and values of most health care providers and organizations, especially related to provision of equitable care.

Lastly, David Willis (he/him/his), Forum co-chair, Center for the Study of Social Policy, asked each of the panelists to identify the greatest knowledge gaps that they would like to see addressed in future research. In response, Sequeira called for more attention to intersectionality in gender-affirming care, noting that young people have multiple aspects to their identities that may result in differences in their needs or in the best approach to providing them care. In the youth and parent perspective panel, this call was echoed by parent participant Chukumba, who said there is a need for greater diversity in the stories being told. Quinn said the field of reproductive health has multiple gaps, including a lack of tools specific to adolescents to measure quality of life and sexual health. Aye added that large, longitudinal prospective studies of youth will set the stage for better preventative care in the future. Olezeski noted that this research needs to include people who are typically underrepresented, including youth who identify as nonbinary. Rafferty concluded that there is a need for more research on how stigma affects transgender youth across their life course.

BEST PRACTICES FOR WELL-BEING AND FEDERAL AND STATE POLICY

The next panel focused on the extent to which policies draw on evidence to promote the health and well-being of gender diverse youth. To begin this panel, Christy Mallory (she/her/hers), Williams Institute at the University of California, Los Angeles School of Law, gave a brief overview of current state laws that restrict access to gender-affirming care. She began by noting that 19 states currently have laws that ban or limit access to gender-affirming care for youth, most of which include provisions that allow a state licensing board to revoke a license to practice medicine from a physician who provides gender-affirming care to a minor. Some laws, Mallory added, go even further in making it a felony for physicians to provide gender-affirming care. Further, several laws created a right of private action, allowing private parties to sue physicians for provision of gender-affirming care.

During the youth and parent perspective panel, Herring commented that restrictive policies are “truly a matter of life and death,” adding that her “child deserves to be protected, to be celebrated.” Chukumba commented that “no one would let this happen to cisgender kids,” and called on all parents to advocate for the protection of transgender youth.

Following Mallory’s remarks, Kellan Baker (he/him/his), Whitman-Walker Institute, briefly explained insurance policies related to gender-affirming care. Medicare—which often sets the standard for private insurers—began covering gender-affirming care in 2014, he explained. Baker continued, insurance programs that receive federal funding, including Medicaid, are required to cover gender-affirming care; however, 10 states still have a statutory or regulatory exclusion for gender-affirming care due to the difficulty of enforcing nondiscrimination protections. Several recent court cases, he added, have resulted in the reversal of bans on coverage of gender-affirming care by Medicaid.

Blasingame asked Mallory and Baker to discuss how recent policies focused on regulating gender-affirming care contradict the standards of care established by medical experts. Baker pointed to the evidence-based standards discussed by the previous panel and said that the medical standards of care are what many states are trying to ban. He commented that this is not in alignment with the federal government’s more recent shift towards evidence-based policy in general. Mallory added that while states are trying to ban this care, courts have demonstrated some support for evidence-based gender-affirming care. In Alabama, Arkansas, and Texas, for example, courts were asked to consider whether the bans were a violation of the equal protection clause based

Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
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on sex. Judges in these cases, she said, were able to rely on evidence-based standards of care to recognize the importance of gender-affirming care. Baker noted that often debates about gender-affirming care are not on equal scientific footing: gender-affirming care is based in evidence while prohibitions on gender-affirming care are based in opinion. He expressed how important it is for providers to continue to turn to the evidence, rather than be overwhelmed by the noise of opinions in the debate.

Blasingame next asked Mallory and Baker to speak about how cities and states can promote the well-being of gender diverse youth. Mallory responded that some states have passed laws that prohibit covered insurers from adopting exclusions for gender-affirming care and from discriminating based on gender identity. Expanding on this, Baker explained that well over two-thirds of Fortune 500 companies have inclusive insurance policies in place that provide coverage for gender-affirming care to their employees, though these companies typically employ people who already have access to more resources.

Additionally, several states have enacted what have become known as “trans refuge bills,” Mallory said. For example, California passed a law that prohibits the state from criminalizing parents, youth, or families who come to the state seeking gender-affirming care. Other states, she added, have enacted legislation that supports physicians in obtaining a license to practice, even after their license has been suspended by another state for providing gender-affirming care.

Baker added that the COVID-19 pandemic prompted the relaxation of telehealth regulations, which increased access to care for many young people and their families. Mallory noted that laws regarding telehealth have not caught up to physicians’ ability to provide care through telehealth, and navigating the laws can be incredibly complex.

Blasingame asked Mallory and Baker to consider how other policies dovetail with challenges in access to health care for gender-diverse youth. Baker commented that there has been a broader push to reduce the role of scientific evidence in decision making, going on to say that such decisions raise the question of who can and who should make private decisions about our bodies: individuals and their physicians or policymakers?

In response to Blasingame’s question, Mallory introduced the notion of the “chilling effect,” or the idea that people may feel prohibited from providing care that is legal because of fear or liability or an unstable policy landscape. A person’s ability to receive gender-affirming care, she said, depends on where they live, where their physician lives, where their physician practices and is licensed, where their prescribing pharmacy is located, where they are when they take the medication, and whether their insurance covers the type of care they want to access. Mallory commented that it is challenging for physicians and patients to navigate this, especially as it changes on a day-to-day basis.

Following their panel discussion, Mallory and Baker responded to several audience questions. One audience member asked how laws and policies affect gender diverse youth in schools. Mallory confirmed that increasingly legislation is being proposed and passed which forces children to be outed to educators and prevented transgender youth from using affirming pronouns. Baker added that a recent National Academies report emphasized that factors beyond health care are crucial to support gender-diverse youth, including social, political, and economic determinants.6 He noted that there is a need to address disinformation in science, and challenged funders to consider how they can support efforts to address the weaponizing of disinformation.

SUPPORTING GENDER DIVERSE YOUTH IN THEIR COMMUNITIES

The final panel of the day focused on the role community organizations can play in supporting gender-diverse youth. Luis Parra (he/him/his), University of Michigan, began with a presentation on his research related to hate, violence, community connection, and social support among gender-diverse youth of color. He noted that transgender youth of color experience particularly high rates of violence, which can impact their physical and

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6 National Academies of Sciences, Engineering, and Medicine. (2020). Understanding the well-being of LGBTQI+ populations. The National Academies Press. https://doi.org/10.17226/25877

Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
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mental health across their lifespan. Even vicariously experiencing trauma, he said, can have an impact. For example, following the Pulse nightclub massacre in 2016, Parra found adolescents and young adults living up to 1,000 miles away exhibited a higher cortisol level in the days following the attack. However, he said, research also shows that supportive relationships and community connections can also be protective for LGBTQ adolescents and young adults of color because feeling a sense of belonging and community connectedness can enhance mental health.

Following Parra’s presentation, a panel of community leaders discussed their own experiences working with gender diverse youth. Charity Jackson (she/her/hers), Teach for America Alabama Prism Board, explained that her organization provides opportunities for educators and teachers to learn how to support gender-diverse youth, especially considering restrictive laws in her state. a.t. furuya (they/them/theirs), Transform Together, is a community organizer in San Diego who works with both local and national nonprofits. Part of their work includes consulting with schools to help them be inclusive of LGBTQ students. Toni-Michelle Williams (she/her/hers) is the executive director of the Solutions Not Punishment Collaborative, a Black, transgender, queer-led organization dedicated to social justice in Atlanta.

Santos first asked each of the panelists to speak to the greatest challenges and opportunities in their work. T.-M. Williams responded that lack of resources is always a challenge, particularly when working with transgender people who are experiencing homelessness and joblessness. Community engagement, she said, can also be a challenge, especially as many Black and Brown communities lack the capacity and resources to participate in this work. Jackson echoed this challenge, noting that it can be particularly difficult to access resources and support in regions that are rural, under-resourced, or affected by discriminatory laws. furuya added the negative narratives about transgender youth that are so frequently shared in the media are detrimental to transgender youth mental health and well-being. Showing up for transgender youth, they said, is more than just hanging up a supportive poster; it is also taking them to the emergency room when they are in crisis, making sure they have appropriate clothing and housing, and calling legislators to advocate on their behalf. furuya noted that showing transgender youth there is hope for the future becomes more difficult when key supports—including gender-affirming care and inclusion of LGBTQ history in educational curriculums—are challenged.

Jackson noted that long-term engagement is critical, but difficult to maintain. While her organization is focused on sustainable, long-term support for LGBTQ students, they were initially limited to providing standalone professional learning sessions, which did not support sustained engagement or learning. Additionally, most sessions were in a single, large city in Alabama, which meant that teachers in the other parts of the state did not have access. Over time, Jackson said, they recognized that they needed to build lasting coalitions and partnerships across Alabama.

Santos next asked the panelists to speak about what it means to engage with youth as partners in community support work. Jackson said that first and foremost, youth need to have a seat at the table and to be treated as experts on their own experiences. For example, she said, school districts should have councils that invite students to speak for themselves about their needs. Jackson commented that when youth are part of the conversation, they also need to be protected; allies and community organizations should be careful not to exploit their stories and experiences. During the lived experience panel, Gonzales echoed this suggestion, noting that her mom always checks to make sure she is not speaking over or for Gonzales when sharing their family story. furuya added that inviting youth to the table means not ignoring them or getting defensive if they say something with which you disagree. Working with youth, they said, is such a privilege, and many adults learn more about themselves through their work with gender diverse youth. T.-M. Williams added that adults should not “be afraid to feel the uncomfortable feelings.”

Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
×

Following their panel discussion, the panelists responded to audience questions. The first asked what supports would promote additional research related to supporting gender diverse youth. T.-M. Williams responded there is a need for policies and research that address violence against the transgender community, including how to implement and support restorative justice practices. furuya added that White transgender and gender diverse youth who were assigned female at birth have been over-represented in the current research. There should be efforts to expand research recruitment to broader demographics to better reflect the true diversity of the transgender community, they said.

Blasingame asked the panelists to speak to how they have included the faith community in their work. Jackson responded that as someone who works in a region of the Southern U.S., where many tend to hold strong conservatively Christian religious views, partnerships with faith-based organizations have been important. For example, her organization has held sessions exploring how faith and sexuality intersect. However, Jackson noted, because many faith-based spaces are not supportive of the LGBTQ community, it can be difficult to build trust. T.-M. Williams added that Atlanta is home to many queer churches, queer pastors, and Black pastors who have been part of the movement. furuya commented that faith-based organizations outside of Christianity also have a history of supporting LGBTQ communities. For example, a local Muslim Student Association was a strong supporter in a campus movement to establish gender-neutral bathrooms. T.-M. Williams also noted that non-organized faith spaces can also provide spiritual support for gender-diverse youth.

EXPERIENCES OF TRANS JOY

Despite the many challenges that gender diverse youth face today, workshop participants also emphasized experiences of joy. For example, Olezeski shared a story about when her clinic brought in a hair stylist, a barber, makeup artists, and photographers to work with the gender diverse youth, with the goal of letting the adolescent patients “just be kids.” Herring noted that she had found joy in getting to know and learning from her transgender son.

During the lived experience panel, W. Williams noted that having his identity questioned can make it difficult to be “just a kid” sometimes. However, he said, he is a “multidimensional person” and finds joy in being a national award-winning poet and a ballet dancer. He also finds joy in the smaller moments of life, like “the sunset or seeing green grass after a long winter.”

Gonzales added that she finds joy in riding her bike around with her friends, walking to get ice cream, or going to concerts. She commented, “I wish that people understood we are full of joy.”

In response to these comments from W. Williams and Gonzales, Shelton commented that there is a tendency for research to be damage-centered, and instead, they expressed a desire to see trans joy emphasized more in future research. As part of their research, Shelton added, many youths have stated their own desire to talk about trans joy.

CONCLUSION

To conclude the workshop, Santos highlighted key points shared throughout the day. He recalled comments about the challenges that gender-diverse youth experience, but also emphasized the beauty of trans joy. Santos challenged the field to continue to move forward, through intersectional research, consideration of the larger sociocultural context, and improvement of practices in schools. Blasingame added that we must always remember that gender diverse youth are real people with real lives who are impacted by research and policy. She ended by sharing comments from her own children, who identify as transgender and gender diverse, about their experience when they came out as trans: “Now, I just am. I relate to people as individuals, and I relate to myself as an individual. I get to engage on my own terms, and even though I am still being monitored by society, I am no longer trying to live up to its expectations and limits. I am focused on being the best person I can be.”

Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
×

DISCLAIMER This Proceedings of a Workshop—in Brief was prepared by Erin G. Fox as a factual summary of what occurred at the workshop. The statements made are those of the rapporteur(s) or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

COMMITTEE Leslie R. Walker-Harding (Co-Chair, she/her/hers), University of Washington and Seattle Children’s Hospital; David W. Willis (Co-Chair, he/him/his), Center for the Study of Social Policy; Kabir Amari (they/them/theirs), Teach for America and Advocates for Youth; Brenda Blasingame (she/her/hers), Vav Amani Consulting, LLC; Sara Kinsman (she/her/hers), Health Resources and Services Administration; Caprice Knapp (she/her/hers), Health Management Associates; and Russell Blake Toomey (he/him/his), University of Arizona.

REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Jason Rafferty, Brown University. We also thank staff member David A. Butler for reading and providing helpful comments on this manuscript. Kirsten Sampson Snyder, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.

STAFF Amanda Grigg (she/her/hers), Program Officer; Briana Smith (she/her/hers), Senior Program Assistant; and Priyanka Nalamada (she/her/hers), Program Officer.

SPONSORS This workshop was supported by contracts between the National Academy of Sciences and the American Board of Pediatrics (unnumbered award) and the Health Resources and Services Administration of the U.S. Department of Health and Human Services (HHSH250201500001I/5R60219F34017). Additional support came from the Administration for Children and Families, American Academy of Pediatrics, Centers for Disease Control and Prevention, Chan Zuckerberg Initiative, Children’s Hospital Association, Family Voices, Global Alliance for Behavioral Health and Social Justice, Society for Child and Family Policy and Practice, Society of Clinical Child and Adolescent Psychology, Substance Abuse and Mental Health Services Administration, Well Being Trust, and ZERO TO THREE.

SUGGESTED CITATION National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press: https://doi.org/10.17226/27237.

Division of Behavioral and Social Sciences and Education

Copyright 2023 by the National Academy of Sciences. All rights reserved.

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Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
×
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Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
×
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Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
×
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Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
×
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Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
×
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Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
×
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Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
×
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Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
×
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Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
×
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Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
×
Page 10
Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
×
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Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
×
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Suggested Citation:"Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2023. Supporting the Health and Well-Being of Transgender and Gender Diverse Youth: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/27237.
×
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To explore existing evidence-based guidance and best practices on supporting the well-being of transgender and gender diverse youth, the National Academies of Sciences, Engineering, and Medicine Forum for Childrens Well-Being held a workshop on April 25, 2023. The workshop included presentations from experts as well as perspectives from youth and parents. This Proceedings of a Workshop-in Brief provides a high-level summary of the topics addressed in the workshop.

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