Gender-affirming care for youth

There is some evidence that gender-affirming care for youth, in the form of puberty suppression and/or gender-affirming hormone therapy, can improve or maintain mental well-being and psychosocial functioning (Olson-Kennedy 2025, Chelliah 2024, Chen 2023b, Van der Miesen 2020 , Allen 2019, Costa 2015a, de Vries 2011a), reducing depression (Chelliah 2024, Green 2022, Tordoff 2022, Grannis 2021a, Achille 2020, Kuper 2020, de Vries 2011a) and suicidal ideation (Green 2022, Tordoff 2022, Turban 2022, Achille 2020, Turban 2020, Allen 2019). Most studies follow patients for 1 to 2 years of treatment, though follow-ups range from 3 months to nearly 3 years. Longer term studies to optimize safety and care are needed (Carswell 2022) and underway. In the U.S., transgender populations face discrimination, harassment, and violence based on their gender identity (Turban 2022), and this kind of minority stress, as well as worsening political hostility towards trans populations, negatively impacts the mental health of trans youth (Garcia Gutierrez 2024, Tankersley 2021, Wittlin 2023). Harms from stigmatization cannot be undone by gender-affirming care alone (Shuster 2024), and additional evidence is needed to determine how minority stress and discrimination impact the effectiveness of gender-affirming interventions at improving mental health outcomes.

Medical Care

A U.S.-based prospective cohort study suggests gender-affirming care, including puberty suppression and gender-affirming hormones, may reduce odds of depression and suicidality in transgender and non-binary youth (Tordoff 2022). A smaller longitudinal study showed similar effects in transgender youth, particularly in patients who are transfeminine (assigned male at birth) receiving puberty suppression (Achille 2020). Studies in the United Kingdom and the Netherlands suggest puberty suppression with psychological support and therapy can stabilize or improve mental and behavioral well-being in early adolescent trans patients (Carmichael 2021, Van der Miesen 2020, Costa 2015a, de Vries 2011a). U.S.-based studies, which are largely longitudinal, suggest gender-affirming hormones can improve patient mental health and well-being (Olson-Kennedy 2025, Chen 2023b, Allen 2019), decreasing depression (Chen 2023b, Green 2022, Grannis 2021a, Kuper 2020), anxiety (Chen 2023b, Grannis 2021a, Kuper 2020), and suicidality and suicidal ideation (Green 2022, Allen 2019). Gender-affirming hormones can increase body satisfaction (Chelliah 2024, Chen 2023b, Kuper 2020) and appearance congruence (Olson-Kennedy 2025, Chen 2023b, Kuper 2020), which may positively impact other mental health concerns (Olson-Kennedy 2025, Chelliah 2024, Grannis 2021a). Studies from the U.S. and Canada suggest that, overall, youth who receive puberty blockers and gender-affirming hormones are satisfied with their experience; few experience regret or dissatisfaction (RAND-Dopp 2024, Olson 2024, Crabtree 2024).

Few youth who receive puberty blocks or gender affirming hormones stop receiving all gender-affirming medical care (Olson 2024, Crabtree 2024). For example, rates of discontinuing puberty suppression and not advancing to hormone therapy appear to be 3.5% or lower across a variety of studies (RAND-Dopp 2024) and in a 2-year study of adolescents receiving gender-affirming hormones, 2.9% stopped treatment (Chen 2023b). Overall, discontinuation rates of gender-affirming hormones are low, with most studies showing discontinuation rates under 10% (Gupta 2024). Patients may discontinue hormones for many reasons that do not involve a change in gender identity, including lack of social support, bullying, desire for fertility preservation, satisfaction with the physical changes that have occurred, or problems with adherence and other barriers to care such as lack of medical insurance (Crabtree 2024, Gupta 2024). A study of referrals to an Australian pediatric gender clinic suggests that re-identification with birth sex is rare, usually occurring before or during the assessment process, and prior to starting treatment (Cavve 2024).

Responses to the 2015 U.S. Transgender Survey of 27,715 transgender adults suggest that those who desired and were able to access puberty suppression or gender-affirming hormones during adolescence were less likely to experience suicidal ideation than those who wanted but did not receive this care (Turban 2022, Turban 2020). Evidence from Brazil suggests that having multiple sources of gender affirmation, including social, medical, and legal recognition can decrease depression and anxiety (Fontanari 2020). Foundational evidence from the Netherlands documented a group of young adults who had received care from a young age following the “Dutch Protocol” including psychological support, puberty suppression, gender-affirming hormones, and then, in adulthood, gender-affirming surgery (de Vries 2014). For these patients, their gender dysphoria was eliminated, psychosocial functioning improved, and their well-being matched or was better than non-trans adults (de Vries 2014). However, some experts suggest that widespread social support (from medical care, society, family, and peers) accounts for the positive outcomes of Dutch trans adolescents (de Vries 2023).

Supportive Environments and Quality of Life

Pre-adolescent transgender children who socially transition and are supported in their identities do not appear to suffer from the mental health issues reported by those who are unsupported by their families and communities (Olson 2016). Two studies looking at data from the 2015 Transgender Survey both concluded that negative experiences during K-12, such as bullying and harassment, appear to increase the risk of suicidality in adulthood (Miller 2024, Turban 2021). Having unsupportive families is associated with increased likelihood of suicide attempts (Miller 2024), while having supportive and accepting parents is associated with decreased odds of depression (Vance 2023). A study in 3 U.S. cities suggests that, for trans youth who have changed their name, there are lower odds of depression, suicidal ideation, and suicidal behavior when their chosen name is used in more areas of life (Russell 2018). In the Trans Youth Care United States Study, trans and non-binary youth were more likely to experience depression when not living in their affirmed gender identity, and more non-affirming experiences increased the likelihood of depression, anxiety, and suicidality (Vance 2023). Having higher levels of support from family and parents and experiencing less bullying before receiving treatment may be associated with better mental health outcomes after one year on gender-affirming hormones, compared to those with less support (Chelliah 2024).

Being able to use their chosen name, having positive relationships with parents and other sources of social support, and feeling safe and accepted at school appear to protect the mental health of trans youth (Tankersley 2021). For example, support from aunts and “other mothers” may help LGBTQ youth, including trans youth, by educating other family members and providing support and safety (Robinson 2023). Gender-affirming care can improve health-related quality of life scores for youth 10-17 years old but may not have the same impact on those receiving care who are 18-24. However, even with improvements, health-related quality of life remains lower than population standards for both groups (Gadomski 2024).

Further social and legal efforts are needed to sustain improvements to quality of life and to protect trans communities and individuals from marginalization, discrimination, and exclusion (Swan 2023). Legal and interpersonal stigma and discrimination have negative impacts on the mental health of trans and gender nonconforming youth (Garcia Gutierrez 2024, Tankersley 2021). The implementation of anti-transgender laws is associated with increased suicide attempts in trans and non-binary young people 13-24 years old by 7-72%, depending on the state, and with larger effects among those 13-17 years of age (Lee 2024). A systematic review reports that the most common risk factors for negative mental health for trans and gender non-conforming youth are having been abused (physically or verbally), discrimination, experiencing social isolation, having poor relationships with their peers, or low self-esteem, and notes that older children and adolescents are more likely to suffer from psychological distress (Tankersley 2021).

There is little evidence available for non-binary populations (Veale 2022, Kearns 2021), who have diverse needs not centered in the gender binary (Mellin 2024) which are likely different than the needs of those who are binary transgender (Sequeira 2025, Boyer 2022, Scandurra 2019). It is unclear what the impact of the “Dutch Protocol” may be for them (Preston 2024). The experiences of trans individuals who don't interact with health professionals are also largely absent from the available literature (Veale 2022). There is a need to focus beyond medical transition (Veale 2022) and to center trans and non-binary experience that includes individualized care accounting for gender-related marginalization and resilience (Huit 2024).

Barriers and Facilitators

Youth face barriers in accessing gender-affirming care, including systemic bias (Puckett 2017) and structural barriers such as cost, insurance coverage denials, difficult-to-navigate pathways to care, and the insufficient numbers of trained providers and related long wait times (Porsch-Ortega 2024). Youth also face additional restrictions on access to care due to their age and the need for parental consent (Puckett 2017) and barriers due to lack of support from family (Porsch-Ortega 2024). Youth may not know what is available to them (Porsch-Ortega 2024, Puckett 2017), such as being unaware that puberty suppression is a possibility (Puckett 2017), or how to acquire it (Porsch-Ortega 2024). In some cases, youth viewed long assessment processes prior to receipt of gender-affirming hormones as medical gatekeeping, or encountered issues with providers who did not understand non-binary identities and wanted youth to fit into a binary gender (Porsch-Ortega 2024).

Providers also face barriers, including lack of training and experience with trans youth, insurance issues, and insufficient community resources for referrals, such as mental health providers (Vance 2015). Other health system and community-level barriers include limited clinical decision support for providers, and negative biases (Sequeira 2023). Additionally, there are a limited number of gender-affirming care providers, and they are concentrated in urban areas with academic medical centers, making access for those living outside those areas even more difficult (Rodriguez 2025). Telehealth video appointments may be one solution to reaching patients residing outside of urban areas (Rodriguez 2025), and there is interest in receiving gender-affirming care in more accessible settings, such as remotely through telemedicine (Kahn 2024, Sequeira 2021) or in primary care (Kahn 2024, Sequeira 2023a, Sequeira 2021).

Recent legislative bans further decrease access to gender-affirming care for trans and non-binary youth (Sequeira 2025). Pediatric endocrinologists in states with legislation banning gender-affirming care for youth are concerned about legal action, face institutional pressure to their practice and career, and have greater concerns about their safety at work and at home than those working in states without bans (Gupta 2023). After passage of anti-transgender laws, some families with resources relocate to states without such laws, or to states with explicit shield laws, or travel there for care (Salvetti 2024). However, moving or accessing care in another state may not be an option for families with low incomes, those who rely on state programs such as Medicaid, and those from racialized backgrounds and other underserved communities (Azevedo 2023, Salvetti 2024).

Gender-affirming care has the potential to decrease disparities in mental health outcomes for trans youth, compared to the mental health of youth who are cisgender, by reducing negative mental health outcomes (Tordoff 2022, Costa 2015a, Green 2022, Turban 2022, Grannis 2021a, Van der Miesen 2020, Chen 2023b, Achille 2020, Kuper 2020, Allen 2019, de Vries 2011a, Tan 2024). Additional evidence is needed for its impact on non-binary youth. According to a 2023 nationwide survey, 3.3% of high school students are transgender, and an additional 2.2% are questioning; these students are more likely to have poor mental health and suffer from suicidality, experience violence, have unstable housing, feel less connected to their schools (MMWR-Suarez 2024), and experience family rejection than their cisgender peers (Wittlin 2023).

Mental Health Disparities and Suicidality

Trans and non-binary youth face disparities in mental health, including depression, anxiety, and suicidality, compared to their cisgender peers (Garcia Gutierrez 2024, Reisner 2015), including their cisgender sexual minority peers (Wittlin 2023), and are more likely to be bullied and harassed (Garcia Gutierrez 2024). In 2021, a survey of high school students across 18 states found that among students who identified as transgender, 71.5% reported poor mental health and 32.3% had attempted suicide (Suarez 2024). In an earlier Minnesota-based study, 20% of cisgender youth reported suicidal ideation compared to 60% of trans and gender nonconforming youth, with 31% of trans youth reporting attempting suicide (Eisenberg 2017a). A survey of transgender youth in Aotearoa/New Zealand showed that unmet need for gender-affirming care was associated with worse mental health, including double the risk of suicide attempts for those unable to receive hormones (Tan 2023).

Disparities Within the Disparities

Further disparities exist within the trans and non-binary populations. Trans youth who are Black and those who were assigned female sex at birth are the least likely to receive a gender dysphoria diagnosis and least likely to receive gender-affirming care (Kahn 2024). Trans youth with private insurance are more likely to receive gender-affirming care than those with public insurance or those using self-pay or charity care (Kahn 2024). Transmasculine (assigned female at birth) and non-binary patients report significantly more non-affirming health care experiences than patients who are transfeminine (assigned male at birth), and these non-affirming experiences are associated with health care avoidance (Boyer 2022).

Trans youth who are Black, Asian American and Pacific Islander, and Native and Indigenous report worse mental health outcomes, encounter more violence, feel less safe at school, and are more likely to encounter barriers to care than their trans counterparts who have been racialized as white (Garcia Gutierrez 2024, Azevedo 2023). One Minnesota-based study showed that transmasculine youth were more likely to be bullied than transfeminine youth (Eisenberg 2017a). In a Canada-based study, trans and non-binary youth who were Black, Indigenous, or from other racialized identities were more likely to be victims of violence, had higher odds of attempting suicide, and were more likely to forgo healthcare than their white counterparts (Chan 2023). Trans youth also experience marginalization and instability in employment, housing, and healthcare access (Garcia Gutierrez 2024, Azevedo 2023).

LGBTQ+ populations as a whole face significant health inequities (Medina-Martinez 2021, WHO-GAC). Trans and gender-diverse populations of all ages face many barriers to receiving gender-affirming care (Wittlin 2023), including discrimination in the health care system (Schall 2024, Medina-Martinez 2021), underinsurance, and poverty (Schall 2024). Trans youth face the same marginalization and discrimination that trans adults face (Garcia Gutierrez 2024). Even before recent legislative restrictions on gender-affirming care for youth were passed, trans and non-binary youth of color, those living in rural communities, and those in the Midwest and South had less access to gender-affirming care (Sequeira 2025).

Gender-diverse individuals have existed throughout human history. The ability to use surgery or medication to align an individual’s body with their gender identity began in the early 20^th century, with the work of Magnus Hirschfeld, who founded the Institute for Sexual Science in Berlin in 1922 (Carswell 2022). After WWII, limited treatment was available for a small subset of adults who could be made to “fit” the gender binary (Wuest 2024), including treatment through at least 9 U.S. academic medical institutions in the 1960s and 1970s (Carswell 2022). Some transgender children received care as well (Gill-Peterson 2018). After most of those programs closed near the end of the 1970s, the organization which would become the World Professional Association for Transgender Health (WPATH) was founded. Over time, the medical establishment has moved away from labeling and treating gender non-conformity as a mental illness that needed to be cured and towards a gender-affirming model; for example, the WHO’s ICD-10 (now ICD-11) adopted gender incongruence terminology (Carswell 2022).

For most of the 20^th century, treatment for trans and other gender non-conforming youth was focused on “correcting” behavior and psychology, not affirming it (Wuest 2024). These gender identity and expression change efforts, also called conversion therapy or reparative therapy, are not gender-affirming care, and appear to increase suicidal ideation and the likelihood and frequency of suicide attempts both in the short and long term, and have no benefits (RAND-Dopp 2024). Expanding gender-affirming care to youth began with work in the Netherlands to adapt adult treatment guidelines for adolescent needs. It was first offered in the U.S. at Boston Children’s Hospital in 2007, and treatment guidelines specific to adolescents were first published in 2009 by the Endocrine Society. By 2014, there were 32 adolescent programs in the U.S. and by 2022 there 60 pediatric and adolescent multidisciplinary gender programs; some have now been closed due to political reasons (Carswell 2022).

State legislatures have restricted or banned access to gender-affirming care for youth in 27 states (2 of these bans, in Arkansas and Montana, have been permanently enjoined by court order) (KFF-Dawson 2025a). Many large medical organizations, such as the American Academy of Pediatrics, the American Medical Association, and the American Association for Child and Adolescent Psychiatry, oppose such legislation (Carswell 2022). Recent efforts to ban gender-affirming care for youth stem from political and religious interests, not concerns within the medical field. Hospitals and providers have been threatened, and both providers and patients have moved to other states, which undermines evidence-based medicine and medical decision making for physicians, patients, and guardians (Preston 2024). The Cass Report, from the UK, is often used to support bans on adolescent gender affirming care, even though it does not recommend a ban and makes recommendations consistent with WPATH and Endocrine Society standards of care (Yale-McNamara 2024). Despite the justifications used by politicians in passing this legislation, this care meets conventional evidence standards for providing health care treatment (Shuster 2024).

A January 2025 executive order issued by President Trump attempts to restrict access to gender-affirming care through elimination of federal funding for healthcare institutions providing such care and eliminating coverage through federally supported insurance programs (Dowshen 2025, UCLA Law-Redfield 2025). The order also called for a report from the Department of Health and Human Services reviewing the current literature, though experts describe the resulting May 2025 report as violating scientific norms, misrepresenting the available evidence, and mischaracterizing both gender identity in youth and the current standards of care (Dowshen 2025).

In June 2025, the U.S. Supreme Court ruled in U.S. v Skrmetti that Tennessee’s gender-affirming care ban could stand, as it did not violate the Equal Protection Clause of the 14^th Amendment. Because the ruling was narrowly-based, other challenges to state laws banning gender-affirming care could be brought to the Supreme Court in the future based on the Due Process Clause of the 14^th amendment, the non-discrimination protections in the Affordable Care Act (Section 1557), or other claims (KFF-Dawson 2025b).

• What supports and care are available to transgender, non-binary, and questioning youth in your community or state?
• Who benefits from restricting access to gender-affirming care? Who is harmed?

The U.S. does not recognize sexual and reproductive health rights as human rights (Jorge 2021).

As of November 2025, 26 states and 1 territory, largely in the South and Midwest, ban the use of gender-affirming medication and surgery for trans youth (court rulings block enforcement of the bans in 2 of them); 1 additional state bans surgical care (MAP-Medical care bans). Additionally, 24 states impose professional or legal penalties for providing gender-affirming care to those under 18 (KFF-Dawson 2025a); 6 states and 1 territory have made providing gender-affirming care to trans youth a felony (MAP-Medical care bans). In November 2025, the American Civil Liberties Union was tracking 67 bills targeting gender-affirming care, which propose implementing additional bans for trans youth while exempting the same care for youth who are cis or intersex (ACLU-LGBTQ rights map).

In contrast, 18 states and Washington, D.C. have passed “shield” laws or have executive orders protecting access to gender-affirming healthcare for anyone 13 years or older (UCLA Law-Shield laws, MAP-Shield laws). The protections offered vary, but shield laws provide legal protections to trans patients, their families, and providers who receive treatment in that state, against civil, criminal, or professional consequences from states where gender-affirming care is banned (UCLA Law-Shield laws). Additionally, 8 states provide protection regardless of the patient’s location, enabling telehealth care provision (UCLA Law-Shield laws). Additionally, there are legal challenges in 17 states to the laws limiting or banning gender-affirming care (KFF-Dawson 2025a).

The rights of all people who are transgender are increasingly being threatened. In 2019, no states had laws pre-empting transgender rights at the local level, but by the end of 2023, 24 states had preemption laws in place (LawAtlas-State preemption). As of 2025, 28 states and 4 U.S. territories have low or negative equality scores related to gender identity or gender expression, based on the number of laws in place that target and harm transgender people (MAP-Equality).

In January 2025, President Trump issued an executive order to restrict access to gender-affirming care for those under the age of 19 by eliminating support at the federal level. This includes broader nationwide directives that agencies withdraw educational and research funds from health systems that provide such services (Dowshen 2025) and more direct actions, such as attempting to eliminate coverage of gender-affirming care for youth through federally supported insurance programs like Medicaid and TRICARE (health insurance for members of the military and their families) (UCLA Law-Redfield 2025).

‡ Resources with a focus on equity.

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HRC-Map of Attacks on GAC - Human Rights Campaign (HRC). (n.d.). Map: Attacks on gender affirming care by state. Retrieved June 25, 2025.

LGBTQIA HEC-Affirmative Services - LGBTQIA+ Health Education Center. (2020). Affirmative services for transgender and gender diverse people – Best practices for frontline health care staff. LGBTQIA+ Health Education Center. Retrieved October 16, 2025.

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WPATH-SOC 8 - Coleman, E., Radix, A. E., Bouman, W. P., Brown, G. R., De Vries, A. L. C., Deutsch, M. B., Ettner, R., Fraser, L., Goodman, M., Green, J., Hancock, A. B., Johnson, T. W., Karasic, D. H., Knudson, G. A., Leibowitz, S. F., Meyer-Bahlburg, H. F. L., Monstrey, S. J., Motmans, J., Nahata, L., … 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.

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* Journal subscription may be required for access.

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MMWR-Suarez 2024 - Suarez, N. A. (2024). Disparities in school connectedness, unstable housing, experiences of violence, mental health, and suicidal thoughts and behaviors among transgender and cisgender high school students—Youth Risk Behavior Survey, United States, 2023. MMWR Supplements, 73(4), 50–58.

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Olson 2024* - Olson, K. R., Raber, G. F., & Gallagher, N. M. (2024). Levels of satisfaction and regret with gender-affirming medical care in adolescence. JAMA Pediatrics, 178(12), 1354–1361.

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Rodriguez 2025* - Rodriguez, M., & O’Neil, J. (2025). The use of telemedicine by transgender and gender nonconforming youth. The Journal for Nurse Practitioners, 21(2).

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