Gender-affirming care, especially for minors, has sadly become a political battleground over the past few years. You might have read, or heard, terms like “gender ideology”, “rapid onset gender dysphoria”, or “social contagion”, especially when discussing young people. If you’re feeling somewhat confused, it’s understandable. There is so much misinformation out there that it has become increasingly challenging for people outside of the field to even understand what gender-affirming care is, and why it matters. Fortunately, all major, reputable professional associations now have some information available to their members, as well as the public, to counter such misinformation. I was privileged to be part of the task force that worked on AAMFT’s Gender-Affirming Care Position Statement, as well as being one of the editors, and contributors, working on the draft AAMFT Gender-Affirming Care Guidelines. Many other organizations also have position statements and/or guidelines for their members, and I have included a few at the bottom of this blog post. For now, let’s take a moment to clarify what gender-affirming care is and why it matters now, maybe more than ever.
Defining gender-affirming care
In its simplest definition, gender-affirming care (from hereon referred to as GAC) is any type of medical care, whether psychological or physiological, that supports and affirms someone’s gender identity and/or expression. Interventions in GAC can be social, psychological, legal, and medical. Usually GAC involves a multidisciplinary team of providers, including Marriage and Family Therapists (MFTs), and most of the public attention has been focused on medical interventions, especially surgical ones. Even though GAC has mostly been discussed in reference to transgender people, people of any gender might access GAC. In fact, according to a study of medical data published in the Journal of American Medical Association, cisgender boys received 97% of the breast reduction operations performed on minors in the United States. Other results from the study highlighted that, in 2019, the rates of receiving a gender-affirming surgical procedure with a gender dysphoria diagnosis were “5.3 per 100 000 total adults compared with 2.1 per 100 000 minors aged 15 to 17 years, 0.1 per 100 000 minors aged 13 to 14 years, and 0 procedures among minors aged 12 years or younger”. The majority of the procedures were chest-related ones, at a rate of 59.7% for adults and 96.4% for minors. Out of the total of 636 breast reductions procedures carried out on adults, 80% were performed on cisgender men, while out of the 151 breast reduction procedures 97% were carried out on cisgender boys, as stated earlier. No procedures were carried out among minors aged 12 years old or younger, and most of the procedures conducted on minors were on young people aged between 15 and 17 years old. Given that, despite these facts, the attention remains on the care of trans people, especially youth, let’s turn our attention to why GAC is needed and it’s, in fact, considered a form of life-saving care by both trans people and gender specialists.
The need for culturally-attuned gender-affirming care for trans, nonbinary and/or gender expansive people.
GAC is often referred to as “life-saving care” by many trans, nonbinary and/or gender expansive (TNBGE) people. With the rates of suicidality being ten times as high for TNBGE people when compared to cisgender people, it seems to make sense that care that enables people to live more at peace with themselves (and also be more accepted and acceptable to mainstream society) would be considered essential. Let me break some numbers down to make sure we understand just how essential this type of care is. In 2023, a new study by the Williams Institute at UCLA School of Law found that 81% of transgender adults had thought about suicide, with 42% having attempted and 56% having engaged in non-suicidal self-injury. Just like we see in other marginalized and oppressed populations, the study also found higher rates of problematic alcohol and substance use and of psychological distress, such as depression and anxiety. The numbers for TNBGE youth are equally concerning, with the Trevor’s Project 2023 U.S. National Survey on the Mental Health of LGBTQ Young People indicating that about half of TNBGE youth surveyed had seriously contemplated attempting suicide, with 1 in 5 having actually attempted. Rates for Black, Brown, Latinx and Indigenous TNBGE youth were higher than for their white counterparts. Around three quarters of TNBGE respondents experienced depression and anxiety.
If this is starting to sound discouraging, it’s because it is. Sadly these numbers seem to be on the rise given the current political climate with the Trevor’s Project finding “an overall volume increase of nearly 700% [for calls to their helpline] on Nov 6, compared to the weeks prior” and NPR reporting that suicide attempts amongst TNBGE youth had increased up to 72% in states that had passed anti-trans laws. It’s important to state that those numbers are not due to people’s gender identity, but rather to the stigma, rejection, bullying, harassment and violence that TNBGE youth and adults experience in our cisgenderist world, including in family therapy. In fact, multiple studies have shown that there are protective factors, especially for youth, with family acceptance, correct pronoun use and various forms of GAC reducing, or even downright eliminating, those health disparities between TNBGE and cisgender youth. In addition to these protective factors, regret rates for GAC medical interventions are lower than for most surgical interventions, ranging from around 1% to 13% depending on which study is considered. We also need to remember that rates of surgical interventions in minors are so low as to be negligible, as shown in the study mentioned earlier in this article, making the issue of potential regret somewhat moot.
When we take all the facts from reputable sources into consideration, it seems pretty straightforward to state that GAC saves lives, and that it’s our ethical duty, as both MFTs and healthcare providers, to not only provide it, but also to do so in a way that is culturally attuned and effective. In fact, given the role that family acceptance plays as a protective factor for those who are most vulnerable, that is young people, and especially young people of the global majority, MFTs have a key role as part of the multidisciplinary teams involved in the care of youth and their families. At a time when bold rhetoric with little substance, if any, behind it, is loud and ubiquitous, it’s important to remember what our priorities as healthcare providers are. I hope that you will agree with me that those priorities are to do the least harm possible, and to provide forms of care that have been proven, over and over, to have more benefits than downsides, as it’s the case for gender-affirming care.
Alex Iantaffi, PhD, SEP, CST, CST-S, LMFT.
AAMFT Approved Supervisor
Past President MAMFT
Former Chair QTAN
WPATH Certified Gender Specialist and Mentor (SoC8)
References and further reading
Ansara, Y. G., & Berger, I. (2016). Cisgenderism. The Wiley Blackwell encyclopedia of gender and sexuality studies, 1-3.
Blumer, M. L., Ansara, Y.G., & Watson, C. M. (2013). Cisgenderism in family therapy: How everyday clinical practices can delegitimize people's gender self-designations. Journal of Family Psychotherapy, 24(4), 267-285.
Coleman, E., Radix, A. E., Bouman, W. P., Brown, G. R., De Vries, A. L., Deutsch, M. B., ... & Arcelus, J. (2022). Standards of care for the health of transgender and gender diverse people, version 8. International journal of transgender health, 23(sup1), S1-S259. Can be accessed in various languages at https://wpath.org/publications/soc8/
Coolhart, D., & Shipman, D. L. (2017). Working Toward Family Attunement: Family Therapy with Transgender and Gender-Nonconforming Children and Adolescents. The psychiatric clinics of North America, 40(1), 113-125.
Cox, L. C., Benson, K. E., & Iantaffi, A. (2021). Therapists' Accountability and Engagement with Transgender and Nonbinary Couples. In Harvey, Rebecca, Megan J. Murphy, Jerry J. Bigner, and Joseph L. Wetchler, eds. Handbook of LGBTQ-affirmative couple and family therapy. (pp. 105-120). Routledge.
Dai, D., Charlton, B. M., Boskey, E. R., Hughes, L. D., Hughto, J. M., Orav, E. J., & Figueroa, J. F. (2024). Prevalence of gender-affirming surgical procedures among minors and adults in the US. JAMA Network Open, 7(6), e2418814-e2418814.
Edwards, L., Goodwin, A., & Neumann, M. (2019). An ecological framework for transgender inclusive family therapy. Contemporary Family Therapy, 41, 258-274.
Giammattei, S. V. (2015). Beyond the binary: Trans‐negotiations in couple and family therapy. Family process, 54(3), 418-434.
Iantaffi, A. (2015). Gender and sexual legitimacy. Current Sexual Health Reports, 7, 103-107.
Iantaffi, A. (2020). Gender trauma: Healing cultural, social, and historical gendered trauma. Jessica Kingsley Publishers.
Iantaffi, A. (2020). Increasing gender awareness to reduce harm in health care. Creative Nursing, 26(2), 83-87.
Keeley, S. (2022). Integrative Family Therapy with Transgender, Gender Diverse, and Non‐binary (TGDNB) Young People. Australian and New Zealand Journal of Family Therapy, 43(1), 151-162.
Kidd, J. D., Tettamanti, N. A., Kaczmarkiewicz, R., Corbeil, T. E., Dworkin, J. D., Jackman, K. B., ... & Meyer, I. H. (2023). Prevalence of substance use and mental health problems among transgender and cisgender US adults: Results from a national probability sample. Psychiatry research, 326, 115339.
McGeorge, C. R., Coburn, K. O., & Walsdorf, A. A. (2021). Deconstructing cissexism: The journey of becoming an affirmative family therapist for transgender and nonbinary clients. Journal of Marital and Family Therapy, 47(3), 785-802.
Nath, R., Matthews, D. D., DeChants, J. P., Hobaica, S., Clark, C. M., Taylor, A. B., & Muñoz, G. (2024). US national survey on the mental health of LGBTQ+ young people. West Hollywood, California: The Trevor Project.
Russell, S. T., Pollitt, A. M., Li, G., & Grossman, A. H. (2018). Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. Journal of adolescent Health, 63(4), 503-505.
Tordoff, D. M., Wanta, J. W., Collin, A., Stepney, C., Inwards-Breland, D. J., & Ahrens, K. (2022). Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA network open, 5(2), e220978-e220978.
Statements by other professional associations
APA Policy Statement on Affirming Evidence-Based Inclusive Care for Transgender, Gender Diverse, and Nonbinary Individuals, Addressing Misinformation, and the Role of Psychological Practice and Science
https://www.apa.org/about/policy/transgender-nonbinary-inclusive-care
American Academy of Child & Adolescent Psychiatry Policy Statement on Access to Gender-Affirming Healthcare
https://www.aacap.org/AACAP/Policy_Statements/2024/Access_Gender-Affirming_Healthcare.aspx
NASW Article on Gender-Affirming Care as Lifesaving
https://www.socialworkers.org/News/News-Releases/ID/2642/Gender-Affirming-Health-Care-Saves-Lives
AASECT Position Statement on the Dignity and Rights of Transgender and Gender-Expansive Individuals
Statement on ROGD by the Coalition for the Advancement &
Application of Psychological Science
https://www.caaps.co/rogd-statement
Endocrine Society Gender Dysphoria/Gender Incongruence Guideline Resources
https://www.endocrine.org/clinical-practice-guidelines/transgender-medicine-and-research
American Medical Association Clarification of Evidence-Based Gender-Affirming Care H-185.927
https://policysearch.ama-assn.org/policyfinder/detail/Gender?uri=%2FAMADoc%2FHOD-185.927.xml