Youth and gender-affirming care: let’s start with ‘do no harm’

No decent person wants to hurt children. Yet as pediatricians and longtime public health practitioners, we’ve both seen how children can be harmed by adults’ poor decisions. Efforts to block gender-affirming care for trans children have been more about politics than about health, and kids are paying the price: More than 90% of LGBTQ+ youths say recent politics has harmed their mental health.

Tragically and predictably, they are experiencing higher rates of depression and suicide. In a 2021 study by The Trevor Project — a nonprofit suicide prevention group that supports LGBTQ+ youth — more than 50% of transgender and nonbinary youths reported that they had considered killing themselves, and 20% had actually tried to do so.

A political and cultural fight has become a mental health crisis for too many youths in America.

What might a “do no harm” approach look like when it comes to the issue of children and gender-affirming care? Here are a few principles to sideline the politics while prioritizing the health and well-being of the country’s children.

Listen intently, engage with humility. It’s not easy for a youth to figure out what to do when their body doesn’t match the person they are inside. Questions abound, emotions can run high, and the right course of action is not always clear.

During this time, it is essential for the adults in a trans child’s life to stop and listen. This can be challenging, as the emotions engendered by the situation can inhibit one’s ability to hear others. But listening without judging is essential to help bridge the gaps in understanding. Everyone needs — and deserves — to be heard: the pensive child, the questioning parent, and even the engaged health practitioner.

Relatively little is known about gender discordance, as this is an emerging field of medicine. Anyone dealing with gender discordance can benefit from listening to the experts, but also by asking them questions. Parents who might be in denial, or simply overwhelmed, need empathy. But most of all, children should be given guidance and support as they navigate these changes.

Gender-affirming care is proven to work. Youths questioning their gender are not hastily receiving irreversible procedures. No qualified health professional will begin a child’s treatment with medical interventions. Instead, the medical standard of care for these children begins with behavioral health and social supports designed to explore and affirm their identity. Providing the social, psychological, and behavioral supports these children need should be everyone’s first and highest priority.

Only after this kind of careful assessment is concluded can reflection about medically tested and approved therapies — which must include conversations with the patient and family — be initiated about treatments that might suit a particular young person. There is common ground in support of thoughtful gender-affirming care: More than 70% of people in the U.S. oppose legislation prohibiting such care for minors, a rare alignment of Republicans and Democrats.

Treatment for trans kids is a health issue. Gender-affirming care and social support are integral pieces of health care, and denying kids access to this care is as misguided as denying them antibiotics for an infection or stitches for a wound. Parents, skilled professionals, and the children themselves should determine what’s best, with the child’s mental and physical health being at the center of all efforts.

Politicizing this issue further deepens the cultural conflict around trans health care and is a disservice to everyone involved. It is in this climate that 3 out of 4 of LGBTQ+ kids say they have been discriminated against.

Conversion therapy harms children. Efforts to change a child’s sexual orientation or gender identity is known as conversion therapy. Thirteen percent of LGBTQ+ youth reported being subjected to it; 83% of those efforts occurred when the child was younger than age 18. A mismatch between the gender of one’s body and one’s sense of gender is not a mental disorder. Being trans or nonbinary is influenced by biology, development, socialization, and culture. Parents and politicians should no more forcibly try to alter a child’s gender or sexual orientation than they should try to force a left-handed child to become right-handed.

At a time when a child needs the support and love of the adults in their life more than ever, conversion therapy is likely to harm their physical and mental health and drive a wedge between parent and child.

Adhering to these principles won’t bridge America’s cultural divide or suddenly tone down the political rhetoric around gender-affirming care, but it will help children. And that should be enough. All children — including those who are questioning their gender — need affirmation, support, and love, not the stigma and negative experiences known to harm mental health and well-being.

No matter a person’s understanding of gender-affirming care and no matter their politics, doing no harm to children is the least we can do.

Julie Morita is a pediatrician, the executive vice president of the Robert Wood Johnson Foundation in Princeton, N.J., and the former medical director, chief medical officer, and then commissioner for the Chicago Department of Public Health. Donald Schwarz is a pediatrician, a senior vice president at the Robert Wood Johnson Foundation, and the former health commissioner for the City of Philadelphia.