TRANSGENDER HEALTHCARE GUIDE
Transgender Healthcare 101:
Understanding Gender-Affirming Care in Montana
We are being flooded with well-financed and coordinated misinformation campaigns about the lives of transgender, nonbinary, and Two Spirit people. National anti-LGBTQ+ groups like the Alliance Defending Freedom are working overtime to spread inaccuracies, propaganda, and harmful stereotypes about trans people to sow division and fear. As they bullhorn their message to score political points, thoughtful people are absorbing those messages, and accurate information isn’t cutting through the noise.
The following report, compiled in partnership with Montana medical professionals provides a systemic review of evidence-based information for those seeking accurate information about transgender people’s lives and experiences. This is by no means a complete guide to every question people may have, but it addresses the major themes that keep appearing.
If you have questions about issues impacting trans, nonbinary, and Two Spirit people, please reach out to Shawn Reagor at [email protected] who can direct you to an appropriate expert.
Definitions
(shared from GLAAD)
Transgender
An adjective to describe people whose gender identity differs from the sex they were assigned at birth. People who are transgender may also use other terms, in addition to transgender, to describe their gender more specifically. Some of those terms are defined below. Use the term(s) the person uses to describe their gender. It is important to note that being transgender is not dependent upon physical appearance or medical procedures. A person can call themself transgender the moment they realize that their gender identity is different than the sex they were assigned at birth.
Nonbinary
An umbrella term used to describe someone whose gender identity falls outside of the traditional western binary; a gender identity that cannot be classified as exclusively male or female.
Two Spirit
A modern, pan-Native American term used by some Indigenous communities in the United States to describe queer and/or gender diverse people, replacing the inaccurate and often degrading phraseology imposed on gender-variant Indigenous peoples by white colonizers. Note that the term is not synonymous with western concepts like “transgender” or “queer”— it can mean many things depending on an individual’s culture or personal identity.
Facts about Transcare in Montana and the U.S.
1. Fact: Transgender people are confident about their gender identity and their decision to transition, and this decision is unwavering over time.
A study of 27,000 trans people published in 2021 in LGBT Health showed that almost 98% of trans people are happy with their transition. While 13% of trans people retransitioned at some point, only 2.4% of those people did so due to uncertainty about their gender identity. Of that 13% who retransitioned, 83% attributed their decision to factors like pressure from family, health care providers, bullying, or non-affirming environments. Concerns about vulnerability to violence and sexual assault were also cited as reasons for detransitioning. (Note: retransitioning involves affirming a cisgender identity after affirming a transgender identity.)
In July 2022, the medical journal Pediatrics published an article showing that most youth who identify as trans/non-binary do not change their identity. In 2018, an analysis assessed whether gender transition improves the mental well-being of transgender individuals. The analysis by the What We Know Project (WWKP), an initiative of Cornell University’s Center for the Study of Inequality, reviewed 56 studies regarding the impact on the menial wellbeing of transgender individuals. This analysis concluded that 93 percent of the studies found positive effects from gender transition, indicating “a robust international consensus in the peer-reviewed literature that gender transition, including medical treatments such as hormone therapy and surgeries, improves the overall well-being of transgender individuals.”
These findings clearly demonstrate that retransition and transition regret are not synonymous. Out of the small number of individuals who retransition, evidence suggests that retransition is largely forced upon them. These answers highlight the extreme barriers transgender people in the U.S. face. Overwhelmingly, trans folks have clarity in their gender identity and that gender identity is enduring over time.
Sources
Turban JL, Loo SS, Almazan AN, Keuroghlian AS. Factors Leading to “Detransition” Among Transgender and Gender Diverse People in the United States: A Mixed-Methods Analysis. LGBT Health. 2021 May-Jun;8(4):273-280. doi:10.1089/lgbt.2020.0437. Epub 2021 Mar 31. PMID: 33794108; PMCID: PMC8213007.
Kristina R. Olson, PhD; Lily Durwood, PhD; Rachel Horton, BS; Natalie M. Gallagher, PhD; Aaron Devor PhD. Gender Identity 5 Years After Social Transition.
Bustos, Valeria P. MD; Bustos, Samyd S. MD; Mascaro, Andres MD; Del Corral, Gabriel MD, FACS; Forte, Antonio J. MD, PhD, MS; Ciudad, Pedro MD, PhD; Kim, Esther A. MD; Langstein, Howard N. MD; Manrique, Oscar J. MD, FACS. Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence
Cornell University’s Center for the Study of Inequality; What We Know Project. What does the scholarly research say about the effect of gender transition on transgender well-being?
2. Fact: Transgender youth know who they are and maintain their identity through the teen years into adulthood.
A recent study of transgender teenagers from the Netherlands showed that 98% of teens who chose to take puberty blockers to prevent the onset of the wrong puberty continued hormone treatment as adults. Puberty suppression allows a teen to experience life without developing irreversible characteristics like wide shoulders, a deep voice, hips, breasts, and other secondary sex characteristics.
Anti-trans operatives claim that “fickle” teens cannot be trusted to make permanent decisions about their gender identity. However, here is good evidence that being trans, like being gay, is an innate and enduring characteristic. The Endocrine Society, which tends to be quite conservative, is very clear on this subject. Gender identity is a matter of biology, not anatomy, and as such, it is enduring.
Gender identity was once considered malleable and subject to external influences. Today, we have a much better understanding of gender identity and this attitude is no longer considered valid. Understanding of gender identity has followed the evolution of our understanding of what it means to be gay. Medical professionals now understand that sexual orientation is innate, it is not chosen. There is considerable scientific evidence demonstrating a durable biological element underlying gender identity, such as a genetic basis, a basis in hormonal influences in the prenatal period and beyond, as well as a difference in brain structures. For instance, studies show:
The complete ineffectiveness of conversion therapy, which is actually shown to harm the mental and physical health of teens who are understanding their identity
Identical twins (who share the exact same genetic background) are more likely to both experience transgender identity as compared to fraternal (non-identical) twins
Female (XX) babies who were exposed to male hormones in utero are more likely to identify as transmale
Male (XY)-chromosome individuals with who have a medical condition that makes them insensitive to male hormone typically have female gender identity
Certain brain scan or staining patterns are associated with gender identity rather than external genitalia or chromosomes.
Sources
Maria Anna Theodora Catharina van der Loos, MD, Sabine Elisabeth Hannema, PhD, Daniel Tatting Klink, PhD, Prof Martin den Heijer, PhD, Chantal Maria Wiepjes, PhD. Continuation of gender-affirming hormones in transgender people starting puberty suppression in adolescence: a cohort study in the Netherlands. The Lancet. VOLUME 6, ISSUE 12, P869-875, December 01, 2022.
Saraswat A, Weinand JD, Safer JD. Evidence supporting the biologic nature of gender identity. Endocr Pract. Feb 2015;21(2):199-204. doi:10.4158/ep14351.ra
Rosenthal SM. Approach to the patient: transgender youth: endocrine considerations.J Clin Endocrinol Metab. Dec 2014;99(12):4379-89. doi:10.1210/jc.2014-1919
Heylens G, De Cuypere G, Zucker KJ, et al. Gender identity disorder in twins: a review of the case report literature. J Sex Med. Mar 2012;9(3):751-7. doi:10.1111/j.1743-6109.2011.02567.x
Dessens AB, Slijper FM, Drop SL. Gender dysphoria and gender change in chromosomal females with congenital adrenal hyperplasia. Arch Sex Behav Aug 2005;34(4):389-97. doi:10.1007/s10508-005-4338-5
3. Fact: In Montana, accessing health care is difficult, and accessing gender affirming care is even harder.
Throughout Montana, access to healthcare is a common problem. For those who are seeking gender affirming care, access is even more difficult. For example, in the Flathead Valley there are very few providers who offer trans healthcare. Difficulty accessing medical care of any kind is not unique to the Flathead or Montana, and trans care providers are scarce in nearly all non-urban centers around the country.
This lack of providers is compounded by the myriad of barriers families face getting healthcare in general (cost, lack of insurance coverage, transportation, time off work for parents). Youth and their families also face tremendous social and emotional barriers when they come out come out as transgender.
From the medical standpoint, medical and mental health professionals follow national and international guidelines that lay out careful, methodical steps for identifying and caring for transgender and gender diverse people. They follow guidelines and standards of care from WPATH (World Professional Association of Transgender Health) and the Endocrine Society.
There are stringent standards of care, especially for youth.The standard of care for trans youth involves a multidisciplinary team that includes mental health professionals, primary care, and sometimes in the case of youth who have started puberty, pediatric endocrinologists. With transgender youth, no medication is used prior to puberty.
When medical treatment is considered, parents are always involved and parental consent is required. Mental health professionals and medical professionals provide careful assessments before initiating any treatment. Diagnoses are based on the systemic evaluation of signs of transgender or gender diverse identity that are persistent, consistent, and insistent, often starting in childhood, and often increasing as the trans adolescent approaches puberty.
Being a teenager is all about identity exploration. In today’s growing acceptance and visibility of trans people, and increased access to information, more youth have the language to understand what they are feeling, and they are coming forward as gender diverse. That does not mean that all of them will continue to think of themselves as trans or nonbinary over time. And it certainly does not mean that they all need hormone therapy.
This is where careful assessment by a team of mental health and medical health professionals is important. There is a difference between a teen that is thoughtfully questioning their identities and one that has had persistent and insistent transgender or gender diverse identity questions over sustained periods of time. Each child deserves to be listened to carefully and to have care tailored to their individual needs.
Sources
Nolan IT, Kuhner CJ, Dy GW. Demographic and temporal trends in transgender identities and gender confirming surgery. Transl Androl Urol. 2019 Jun;8(3):184-190. doi: 10.21037/tau.2019.04.09. PMID: 31380225; PMCID: PMC6626314.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). American Psychiatric Association. 2022
American Academy of Pediatrics policy statement, October 1, 2018. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents
Endocrine Society. Position Statement on Transgender Health 2022.
American Psychiatric Association 2022. A Guide to Working with Transgender and Gender Non Conforming Patients.
American Psychiatric Association. What is Gender Dysphoria?
4. When youth do not have access to healthcare that supports their gender identity, the outcomes are devastating.
Critics paint a very misleading picture of easy access to sympathetic health care providers and medication. The truth is that most trans youth face multiple barriers to basic checkups, let alone gender affirming care. What we know very clearly is that NOT providing gender-affirming care is dangerous. Due to the intense bullying and shaming that transgender adolescents and adults receive, they have much higher rates of depression, anxiety, eating disorders, self-harm, and suicide than cisgender youth.
Fear of rejection and feelings of not fitting in take a huge toll on mental health and wellbeing. Suicidal ideation is twice as high for transgender and gender diverse youth than cis gender kids, and suicide attempts are 3 times as high. Fortunately, research confirms that when children have access to competent care and affirmation, their risk of depression, anxiety and other negative mental health outcomes are on par with their cisgender peers.
In March of 2021, 7 million youth-serving professionals from more than 1000 child welfare organizations released an open letter calling for lawmakers in states across the country to oppose dozens of bills that targeted LGBTQ people, and transgender children in particular.
They called on legislators to oppose bills that:
Ban or limit access to medically-necessary, gender affirming care
Forbid students from using the restroom at school consistent with their gender identity, and
>Prevent transgender youth from playing sports alongside their peers, because those measures are known to harm transgender youth.
For many transgender youth and adults, gender affirming care is not only medically necessary, but can also be life-saving.
Sources
Human Rights Campaign, March 2021. Major Health, Education, and Child Welfare Organizations Oppose Anti-LGBTQ State-Based Legislation.
Olson, K. R., Durwood, L., DeMeules, M., & McLaughlin, K. A. (2016). Mental health of transgender children who are supported in their identities. Pediatrics, 137(3)
Turban, J. L., King, D., Carswell, J. M., & Keuroghlian, A. S. (2020). Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics, 145(2).
Green, A. E., DeChants, J. P., Price, M. N., & Davis, C. K. (2022). Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth. Journal of Adolescent Health, 70(4), 643-649
5. Fact: Gender affirming care with hormones is slow and allows for pauses, adjustments, and reconsiderations as children mature emotionally.
Most physical changes that occur with gender-affirming hormones are reversible once hormones are stopped. While the vast majority of changes, especially those associated with delaying the onset of puberty such as “puberty blockers” are reversible, there are some changes associated with hormone therapy that may be permanent.
Medical care experts take gender affirming care very seriously and every stage of medical treatment is done with informed consent. A central tenent of transgender care is that patients and families have time and support over multiple checkups to thoroughly discuss the risks, benefits and alternatives to hormone therapy with their health care provider. Those seeking hormone therapy for themselves or their child are educated on which physical changes are permanent and which are reversible, should they stop hormone therapy.
Many transgender people do not seek medical intervention. For those who do, the process is long and cautious, allowing medical providers to evaluate incremental progress. Frequent checkups are required, and medical professionals ask questions at every stage in the process so they can adjust medication or treatment at any time.
Like any medical intervention, there is a cost benefit analysis to gender affirming care. That said, when an intervention (based on evidence) is known to be beneficial and withholding intervention (based on evidence) is known to be harmful, the practice is considered ethical and medically necessary. An analogy might be the use of insulin, which can be fatal, but is life saving for diabetics. Or antibiotics, which carry the risk of anaphylactic shock and death, but are routinely used to treat infection and save lives. Hormone treatment carries risks, but for those whom doctors and specialists determine it is an appropriate treatment, it is akin to any other medically necessary treatment.
It is important to remember that there are youth and adults who receive hormone therapy and puberty blockers for reasons other than gender-affirming care.
6. Fact: As a rule, gender-affirming surgery is only available for people 18 years old and older.
It is important to note that not every transgender person wants surgery. Every person’s transition path is unique, and for most, surgery is not part of the picture.
Except in very rare instances of top surgery, Montana’s youth are not getting reconstructive surgery. One of the requirements for surgery established by the WPATH standards of care is age of majority, which is 18 years old.
Among adults, research published in JAMA Surgery in 2021 finds gender-affirming surgery is associated with improved mental health outcomes among transgender people. However, most transgender adults do not get surgery of any kind due to barriers associated with costs and a lack of available care providers. Gender affirming surgery is expensive and there are very few surgeons who practice gender affirming care. In fact, there are no surgeons in Montana who perform bottom surgery. There are only a few surgeons in the entire U.S. who provide reconstructive bottom surgery. Even if more surgeons were available, surgery is often inaccessible to those who would choose it based on cost and lack of insurance coverage.
Based on National Institute of Health Data, about 25% of transmen and women get top surgery which is less expensive and offered by more surgeons than bottom surgery. Only 5-13% of trans women have bottom surgery and fewer than 5% of trans men have bottom surgery.
In Montana, chest masculinization surgery is available for adults 18 and older after consultation, but most people are not able to access that care due to cost and loss of income during the recovery time. In Montana, this surgery has been performed on older teens in rare circumstances when the youth’s parents and a team of healthcare and mental health professionals determine it is the best course of action.
Transgender people who want bottom surgery must travel out of state because there are no surgeons in Montana who offer it. As a result, banning surgery for transgender minors within Montana is unnecessary, because it is exceptionally rare and could end up delaying or restricting care for children who need surgery for reasons beyond gender care, such as reconstructive or other corrective surgery. Nuanced and complicated decisions regarding surgery are best left to families and trained medical professionals who are using scientific evidence to inform their recommendations.
Sources
World Professional Association for Transgender Health. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People [7th Version].
James, S., Herman, J., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. A. (2016). The Report of The 2015 US Transgender Survey. Accessed November 7, 2020.
Anthony N. Almazan, BA, Alex S. Keuroghlian, MD, MPH. Association Between Gender-Affirming Surgeries and Mental Health Outcomes. JAMA Surg. 2021;156(7):611-618. doi:10.1001/jamasurg.2021.0952.