Gender-Affirming Care: What It Is and Why It's Necessary

“Transgender students need to be seen and acknowledged,” says Meem Fahlstrom, a middle-school teacher in Minnesota. For those who don’t have a supportive environment at home, “they need extra care,” in schools such as access to counseling and a student Genders & Sexualities Alliance (GSA) where they can connect with peers.

Of course, all young people need to be seen and acknowledged and given extra support if they don’t have it at home. But for LGBTQ+ students—and especially those who are transgender and nonbinary—these essentials are far too often missing. Moreover, these children inevitably must negotiate extremely hostile surroundings at the classroom, school or district level, in state politics and on social media. Educator support is often a lifeline under these conditions, so it is important for teachers and others to know how best to support their trans and nonbinary students. 

One significant dimension of this work is for educators to understand what gender-affirming care is—and what it isn’t.

Transgender youth have been the target of sustained fearmongering, disinformation and legislative discrimination for the last decade, and these unrelenting attacks have continued to increase. The first wave of this backlash was the so-called “bathroom bills” that banned trans students from using restroom facilities appropriate to their gender. Then came the barriers against transgender athletes participating in school sports. Most recently, anti-trans legislation has taken aim at gender-affirming care and restricting medical care for trans youth. Arkansas banned gender-affirming care in 2021, and in 2022, gender-affirming care for minors became illegal in Alabama and Arizona, and Texas issued a directive making the provision of such care a felony. Parents and caregivers face the risk of investigation for providing needed gender-affirming care for their children. There are at least 15 additional states considering more than two dozen similar bills. These bills are fueled by falsehoods—such as cable news host Tucker Carlson’s claim that gender-affirming care is “the sexual mutilation of children.” 

For educators to be effective allies to their trans and nonbinary students, they need to understand facts and recognize dangerous and politically motivated misinformation. 

Here are the basic facts about gender-affirming care for young people under age 18.

1. Trans and nonbinary children have agency: They know who they are.

Research shows that gender awareness is generally established by age 5 or 6, meaning that most people will have a sense of their gender by that age and that gender identity is usually stable—meaning that people don’t “grow out of it.”

Some children’s self-understanding is of being a different gender than the one they were assigned at birth; others’ is as nonbinary, including more specifically agender, gender-fluid or gender-nonconforming. As trans and nonbinary people have become more visible in our society, the possibilities of self-identification and self-expression have blossomed, and young people these days have a much broader range of gender identity and gender expression. This is something to celebrate.

2. Gender-affirming care is guided by what the individual child needs and varies from person to person. There is no one-size-fits-all.

Many, but not all, trans-identifying children experience gender dysphoria (clinically significant distress stemming from an incongruence the child recognizes between their sex assigned at birth and their gender identity), for example, which is one factor that can shape the appropriate care for an individual.

All medical gender-affirming care (see below for the difference between social and medical gender-affirming care) is done under the supervision of a team of health care providers, including, at a minimum, a doctor with expertise in adolescent care or endocrinology and a qualified mental health expert. No medical care happens without the involvement and consent of parents.

3. There is broad medical consensus on the necessity of gender-affirming care for trans and nonbinary minors as well as the appropriate medical options for such care.

The American Medical Association, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, the Endocrine Society, the American Psychological Association and the American Psychiatric Association all have “policy statements and guidelines on how to provide age-appropriate gender-affirming care,” reported Scientific American earlier this year. And they all “find such care to be evidence-based and medically necessary.”

Perhaps most importantly, medical experts confirm that withholding gender-affirming care from minors who need it causes grave harm. “When every single day you’ve been called the wrong name, you’ve been told to wear a certain kind of clothing, you’ve been given pronouns that do not match how you see yourself, it can take a toll on your mental health,” explains John Steever, M.D., from the Mt. Sinai Adolescent Health Center in New York City. Lack of gender-affirming care can lead to depression, self-harm such as cutting, suicide ideation and suicide attempts. Older children may also turn to substance use and risky behaviors.

The harm of withholding care has been documented in numerous studies that show not only that trans youth are at increased risk for these serious problems but also that receiving gender-affirming care significantly reduces those risks.

4. Social care is an important part of gender-affirming care, and before puberty, gender-affirming care is exclusively social.

Social affirmation includes allowing a child to dress in the clothes they choose and to keep the hair length and style they want. It also includes honoring a child’s self-identifying name and pronouns. For educators, supporting students in these self-expressions is critical, as is normalizing the practice of having students and adults identify their pronouns. And affirming a child’s gender identity through access to bathrooms, sports, activities and spaces in schools creates crucial supports for health and well-being.

For younger children, social affirmation is the entirety of gender-affirming care and is vital. Denying a child the ability to express their gender identity in these ways invalidates the child’s understanding of themselves and essentially erases them.

5. Gender-affirming medical care for minors includes several options. Genital surgery is not among them.

At the onset of puberty, the first possible gender-affirming medical treatment is the introduction of puberty blockers. These prevent the development of secondary sex characteristics, such as facial hair and a lower voice or the development of breasts. This is important because for many transgender children the emergence of these physical traits can be overwhelmingly distressing since they exacerbate the dichotomy between their lived gender and the sex assigned at their birth. (These medications are routinely used for cisgender children whose onset of puberty is unusually early.)

Puberty blockers “give kids some time,” says Steever. They can be safely taken for two to three years. (Taken indefinitely, they would affect bone density.) Working with a therapist at this stage, a child has sufficient time to decide whether or not to proceed with gender-affirming hormones.

Hormone treatment enables a transgender child to develop the secondary sex characteristics of their lived gender, helping create congruence between their physical appearance and their gender identity. 

Medical guidelines say that transgender minors should not get genital surgery. Transphobic fearmongering that claims such surgery is part of care for children is a deliberate falsehood. And it bears repeating that no medical gender-affirming care for minors happens without parental consent and a significant amount of counseling. Medical centers and experienced professionals have the expertise to work with youth and families to make decisions on gender-affirming care.

The laws and bills restricting or banning gender-affirming care are built on misinformation or deliberate disinformation and ignore the medical guidance of professionals about the necessity of care. The 2022 Texas directive, for example, goes as far as to define gender-affirming care as “child abuse.”

Steever counters that the real harm is denying a child’s agency, for example by “forcing kids into clothes they don’t want to wear or a name they don’t want.” This deprives them of not only their ability to express themselves, but their lived identity.

To best support transgender and nonbinary students, educators need to both affirm those students in their self-understanding and be ready to counter falsehoods about trans people and care whenever they encounter them. “We have to be proactive,” says Fahlstrom.

That proactivity starts with the willingness to learn more about trans people and the tremendous obstacles they face in society. (See further reading below.) It also includes acknowledging and affirming trans students and normalizing their existence through a consistent practice of pronoun introductions. It means making sure trans people are represented in the curriculum. “Safe space” stickers and signs can help signal a classroom or teacher who is supportive. At the school level, teachers, counselors, nurses, administrators, office staff and all adults can make a difference by being visible allies, by addressing bullying, and by advocating for inclusive policies.