Trans Healthcare: FAQ and Myth Dispelling for Healthcare Providers

Written by Noelle Martin

The purpose of this article is to answer questions and dispel common misconceptions that healthcare providers might have about treating and interacting with transgender patients. This article was written in alignment with Stand with Trans’ vision statement: to erase the stigma surrounding transgender identities. The phrase transgender/nonbinary (TNB) is used throughout this article as an umbrella term to refer to the many diverse gender identities that differ from one’s sex assigned as birth, but I recognize that it fails to fully account for all identities. For a list and definitions of other terms you might encounter in this document please refer to the glossary included in the supplemental materials. This article can be read straight through, or each section can be read independently for answers to specific questions.

Frequently Asked Questions

How do I provide gender affirming care?

Some providers might be familiar with the terms gender-informed care, gender-responsive care, gender-aware care, and gender-sensitive care that have been used in healthcare and related fields to refer to aspects of respecting or acknowledging gender identities and differences. However, the term gender affirming care is the most widely used to describe the standards of care for TNB people. Gender affirming care encompasses many actions within the medical field such as respecting a patient’s chosen name and pronouns, respectful and inclusive language, and prioritizing care over curiosity. These general practices, along with specific services such as psychotherapy and gender affirmative medical and surgical care, are lifesaving practices for TNB patients. The World Professional Association for Transgender Health (WPATH) recommends gender affirming practices as the best quality of care for TNB people seeking healthcare (Tordoff et al. 2022). Since the organization’s creation in 1979, they have sought to promote quality care and respect for TNB health. WPATH released version 8 of their full guide of recommended standards of care based on the most up to date evidence-based research findings as of 2022, that will be referenced throughout this article (Coleman et al., 2022).

Some people have suggested using a “wait and see” approach with TNB youth, denying them of gender affirming care until they prove their TNB identity has persisted long enough. This method of care is seen as harmful and deprives young TNB people of the support that they need (Rafferty et al., 2018). Refusing to provide time sensitive medical interventions to young TNB people can exacerbate their experiences of gender dysphoria and open them up to further stigmatization based on their physical appearance by allowing them to undergo their endogenous puberty which produces irreversible physical changes. These experiences are strongly associated with mental health outcomes throughout adolescence (Coleman et al., 2012).

Why do I need to know this?

Beyond their gender identity, TNB individuals are first and foremost people, who require affirming doctors in all their interactions with the medical system. Knowing how to interact with TNB patients empowers healthcare professionals to provide better quality care. The 2015 US Transgender Survey collected responses from 27,715 TNB participants, and 33% endorsed having a negative experience related to their gender from a healthcare provider in the past year. Additionally, 23% responded that fear of mistreatment prevented them from seeing a provider (James et al., 2016). Early insights from the 2022 US Transgender Survey with responses from 92,329 TNB people report that 48% of those who saw a healthcare provider (79% of the sample) in the past year had a negative experience because they were TNB (James et al., 2024). In other words, over 35,000 TNB people experienced healthcare denial, misgendering, abusive language, or rough/abusive treatment when going to see a healthcare provider. These experiences within the healthcare system contribute to the health disparities faced by this population.

A common misconception is that only medical professionals who provide hormones or perform gender affirming surgeries need to know anything about TNB patients, but TNB people have general health needs just like any other person. A plethora of international and national health organizations across the board support gender affirming practices by all medical professionals such as the American Psychological Association, the Endocrine Society, the American Medical Association, World Health Organization, and the World Medical Association (AMA, 2021; APA, 2024; Hembree et al., 2017; WHO, n.d.; WMA, 2015)

Why are there more TNB people now?

Increasing acceptance, visibility, and information about TNB identities has allowed more people to express themselves fully. Changing societal stigma and access to the internet have contributed greatly to these changes. Additionally, when looking at data from the past, there were no reporting options for those who were TNB. Surveys did not ask about these experiences, often conflating sex and gender and only including binary options (Hart et al., 2019). Therefore, TNB people were underrepresented, and thus invisible in any population data. There are still issues of data collection forms not being inclusive of TNB identities especially in the healthcare system (Stokes & Lecuyer, 2023). TNB people go through various milestones of identity development: feeling their gender was different, identifying as TNB, telling others they are TNB, and affirming their gender in some way. In a generational study with TNB participants, researchers found that younger TNB people had shorter gaps in time between each of these milestones (Puckett, et al. 2022). This indicates that younger generations have an easier time identifying their feelings of difference as being TNB, an easier time telling others, and an easier time living in their affirmed gender.

There is a misconception that being TNB is a social contagion spread amongst youth. The study that popularized this idea of social contagion and rapid onset gender dysphoria was published in 2018 and has since been retracted. The study utilized flawed and biased methodology, recruiting a sample of parents from an anti-trans website to report on what they thought their children experienced (Littman, 2019). Even though there are now shorter gaps between TNB identity milestones than in prior generations, TNB identity realization still occurs significantly before a TNB person comes out to their parents (Turban et al., 2023). This means that parents are not always reliable reporters on the gender identity of their children, and we encourage providers to keep this in mind when interacting with adolescent patients and their families.

What do gender affirmation and gender dysphoria really look like in someone’s life?

Gender affirmation journeys are all different, and not everyone chooses to medically or surgically affirm their gender, especially for those who fall outside of the gender binary. Gender affirmation is a spectrum across the dimensions of social, legal, medical, and surgical affirmation (Shah et al., 2023). Social affirmation involves name and pronoun changes, wearing different clothing and hairstyles, and/or using a different bathroom. Legal affirmation involves changing name and gender marker on official records. Medical affirmation involves gender affirming hormones or puberty blockers. Surgical affirmation will be covered more in another section, but it involves surgical changes made to the body such as facial, chest, or genital adaptations (Shah et al., 2023). Gender dysphoria refers to the distress experienced by a TNB person resulting from the incongruence between their experienced gender and their sex assigned at birth. Not all TNB people experience gender dysphoria, and this may impact their decision to medically or surgically affirm their gender (Coleman et al., 2012). Some TNB people may experience gender incongruence without the distress associated with gender dysphoria. Treatment for gender dysphoria/incongruence has become increasingly individualized: each person taking various combinations of affirming steps across the four dimensions mentioned previously (Coleman et al., 2012).

There is a misconception that being TNB is inherently a mental illness. The DSM V was changed in 2013 to include the term gender dysphoria rather than the more pathologizing and stigmatizing “gender identity disorder.” Growing understanding of TNB people characterizes these identities as natural human variation across the gender spectrum rather than an illness (Davy & Toze, 2018). Diagnostic caveats and signifiers allow for medical, surgical, and therapeutic treatments for those who experience incongruence without distress and for continued treatments for those whose dysphoria has been alleviated by some previous treatment (Davy & Toze, 2018). However, it is important to note that a diagnosis is not always required to receive treatment.

When should puberty blockers and hormones be prescribed?

Gonadotropin releasing hormone (GnRH) analogs, known colloquially as Puberty Blockers, suppress gonadotrophin releasee, thereby suppressing LH and FSH, pausing pubertal changes such as development of secondary sex characteristics and menstruation for children assigned female at birth (Kumar et al. 2014). GnRH analogues are typically administered at or after Tanner stage 2 of puberty and are often used in pediatric populations of cisgender children experiencing precious puberty. GnRH analogues are considered completely reversible, such that if a child were to stop taking the medication they would go through their endogenous puberty (Hodax et al., 2020). Puberty blockers as a form of gender affirming care are typically administered to children who recognize their TNB identity before or during puberty. Blockers give children time to grow up and explore their gender more without the increases in gender dysphoria associated with experiencing the endogenous puberty that feels wrong to them or the development of irreversible phenotypes of secondary sex characteristics. It is for these reasons that GnRH analogues have been shown to significantly improve the well-being of TNB youth (De Vries et al., 2011; De Vries et al., 2014). There are some concerns about a potential decrease in bone density with prolonged use of GnRH analogues, but more research is needed in this area (Rafferty et al., 2018; Vlot et al., 2017). Therefore, the recommendations for duration of GnRH analogue use are currently evolving, and providers for whom it is relevant should stay up to date with the most recent guidelines.

Gender Affirming Hormones (GAH) induce physiological changes that affirm a TNB person’s identity. The peak effects are expected within one to two years. Typically, GAH consist of estradiol and an anti-androgen, such as spironolactone, for transfeminine individuals and testosterone for transmasculine individuals. The dosages and timeline for administration are tailored to each person and decided upon with oversight by an endocrinologist (Coleman et al, 2022). A lot of early research on TNB youth, looked at GAH administration starting at 16 years of age, but current standards of care suggest earlier start times more similar to endogenous puberty are acceptable, allowing the child to experience pubertal changes with their peer group (Hodax et a., 2020). There is some evidence to support the administration of GnRHs after tanner stage 5 (adult hormone levels) to repress endogenous hormones when first starting GAH (Rafferty et al., 2018). GAH interventions are considered to be partially reversible, since the development of some secondary sex characteristics such as voice deepening cannot be reversed while others can be reversed with reconstructive surgery (Coleman et al., 2012).

Some misconceptions of these treatments are that they are dangerous or radical. However, GnRH analogues treatments were developed for use with cisgender populations. GnRH analogues are frequently used to treat premenstrual syndrome, endometriosis, uterine leiomyomas, and other conditions in cisgender women and precious puberty in cisgender boys and girls (Kumar et al., 2014). Additionally, GAHs mirror the endogenous pubertal hormones that adolescents’ bodies produce. Administration of normal hormone levels is not harmful to the body (Hodax et al., 2020; Rafferty et al., 2018; Coleman et al., 2022).

Who receives gender affirming surgery?

Gender affirming surgery is just one of the many types of gender affirming care that TNB people receive. Surgical affirmation may involve any of these surgeries: vaginoplasty, phalloplasty, orchiectomy, oophorectomy, facial feminization, breast augmentation, chest reconstruction, or others (Shah et al., 2023). Many of the treatments to the reproductive system are considered irreversible, and often require extensive consultation with psychiatrists and medical practitioners prior to the scheduling of procedures. TNB youth rarely get surgery and if they do, it is older youth getting chest masculinization surgery. Chest dysphoria in transmasculine youth is not typically alleviated by GAH. Therefore, Chest masculinization surgeries are considered for some transmasculine minors who experience high levels of psychological distress (Olson-Kennedy et al., 2018; Coleman et al., 2022). These chest masculinization surgeries for transmasculine youth have high satisfaction rates and good surgical results (Marinkovic & Newfield, 2017; Olson-Kennedy et al., 2018). There is less data on breast augmentation surgeries for youth, possibly due to less need for these surgeries since estrogen administration can result in the development of breast tissue for transfeminine individuals (Coleman et al., 2022). Guidelines suggest that surgical decisions should be made on a case-by-case basis (Hodax et al., 2020; Coleman et al., 2022). Most insurance policies do not cover gender affirming surgeries for minors and many do not even cover these procedures for adults, so cost is usually a barrier to these procedures (Rafferty et al., 2018; Shan et al., 2023).

A common misconception about gender affirming surgery is that medical professions are expected to perform major surgeries on TNB youth frequently. As previously discussed, chest reconstruction surgeries are performed for transmasculine youth on a case-by-case basis, but other gender affirming surgeries are usually not provided until the TNB individual is able to perform their own informed consent at age 18 (Shan et al., 2023; Coleman et al., 2022).

Do people regret “transitioning”?

People stop and start gender affirmation steps based on what feels best for them, but regret is not typically associated with these changes. TNB people explore their gender identity and do what is best for them at the time. Many times, TNB people see all different stages of their lives and their various gender identities and expressions as important and vital parts of their lives that helped them grow and learn who they are (Turban & Keuroghlian, 2018). There has been a shift away from the terms transition and detransition due to the implication within these terms that gender identity is reliant upon physical or medical transition steps and occurs in one linear path. The term gender affirmation allows for the inclusion of more non-linear, non-binary, non-medical, or non-surgical experiences. However much of the research on this topic uses the term detransition, so that term is used here to describe the choice to discontinue gender affirmation treatment and/or have surgery to reaffirm their gender assigned at birth (Turban et al., 2021).

A common misconception is that many TNB people regret their gender affirmation steps and return to living as their gender assigned at birth because they realized they were wrong about their gender identity. In discussion of this topic, it is vital to point out that regret is not synonymous with detransition. When talking about surgery specifically, regret is the wrong concern. With no other surgical procedure besides gender affirmation surgeries are regret rates something that people consider when evaluating the surgery. Healthcare providers measure quality of care and improvement of long-term outcomes. Decisions for surgery are based on an assessment of pros and cons: are the potential benefits of the surgery better than any potential negatives? Early insights from the 2022 US Transgender Survey show that 97% of TNB respondents who experienced surgical affirmation reported they were a lot more satisfied (88%) or a little more satisfied (9%) with their lives afterwards (James et al., 2024). With gender affirming surgery, the potential benefits are very high.

People detransition or stop gender affirming treatments for a variety of reasons besides regret, such as because they achieve their desired results, because they lose access to insurance or experience other financial barriers, because they are pressured from family or employers, or because they do not feel safe living in their affirmed gender (Turban et al., 2021). Analysis of data from the 2015 US Transgender Survey, showed that the majority of people who had a history of detransition reported external factors, such as harassment or family rejection, as contributors to their detransition (Turban et al., 2021). In a large cohort study of TNB people who experienced surgical gender affirmation 0.6% of transwomen and 0.3% of transmen experienced regret. However, many of those who regretted the surgery stated that this regret was due to the social stigma they faced because of their surgical affirmation, not because of the physical effects of surgery (Wiepjes et al., 2018). A meta-analysis of studies done on regret after gender affirmation surgery showed extremely low prevalence, but they note there is a huge problem of lack of standardized and validated questionnaires for this population (Bustos et al., 2021). Overall, the rates of regret and detransition are very low, but it is important not to erase the experience of those who do regret the steps they took towards gender affirmation away from their gender assigned at birth. These individuals should also be supported in their gender journey. However, these experiences of detransition are often weaponized as anti-trans talking points, so it is challenging to do research on this topic without the results being taken out of context to harm the TNB community.

Conclusion

This article presents the current facts about quality healthcare for TNB individuals and dispelled some common misconceptions. Not every healthcare provider needs to know the details about gender affirming hormones or surgery, but every healthcare provider should know how to best care for TNB patients. Gender affirming care is a holistic approach and requires support from healthcare providers across the board. Knowing more about TNB topics makes healthcare providers better at their jobs and produces better long-term outcomes for TNB people seeking care. If you still have questions or are curious about more steps you can take to support TNB people, please explore the Stand with Trans website or the supplemental readings provided at the end of this document.