Gender-affirming care for youth
Gender-affirming care for youth refers to the array of supports provided by a healthcare team to young people who are trans, non-binary, and gender expansive, i.e., whose gender identity differs from the sex they were assigned at birth1, 2. This care begins with a supportive, gender-affirming environment, where patients and their families can explore questions, concerns, and emotions, and have frank discussions with providers who present information to aid in medical decision making around developmentally appropriate care options, determining which (if any) interventions are appropriate and when, and connecting them to other supportive resources1, 2, 3.
The standard of care is described in the guidance and protocols of authoritative bodies, such as the World Professional Association for Transgender Health (WPATH) and the Endocrine Society, as care and ongoing assessment by an integrated team of physicians, mental health providers and social services professionals1, 2, 4, 5. Care should be individualized and provided along a continuum, from counseling to legal interventions, and can include support for social transition (such as changing a person’s name, pronouns, wardrobe, and hairstyle to align with their gender identity6), non-medical resources to change appearance, speech therapy, and medical resources such as medications like puberty blockers and gender-affirming hormones1, 2, 4, 5. The decision on when and if to initiate treatment is personal, involving exploring the potential risks and benefits based on each patient’s unique needs2. An individual’s gender identity may be on the binary (i.e., male or female) or non-binary. Non-binary individuals may identify as neither male nor female, a combination of both, or neither; individuals may also identify as genderqueer, genderfluid, or gender non-conforming7.
Analysis of insurance data suggests that most youth diagnosed with gender dysphoria (the clinical diagnosis used for patients experiencing distress related to the incongruence between their gender identity and their sex assigned at birth) do not receive medical interventions8, 9, 10. For youth who do receive care, most gender-affirming medical care is provided during or after puberty; for those under 18 years old, parental consent is required1, and surgery is rarely provided to trans youth under 18 years old1, 9. Many patients who come into care spend time with therapists and mental health professionals engaged in understanding these feelings of gender incongruence or dysphoria and assessing whether different gender affirming supports or medical treatments would be helpful1. Puberty blocker medications (gonadotropin-releasing hormone analogues) can be used during this time, especially early in puberty, to suppress the release of gender incongruent sex hormones and delay or prevent development of gender incongruent permanent sex characteristics such as facial and body hair, or breast development, giving trans and non-binary patients time to explore their gender identity and how much they wish to transition1, 2. The effects of puberty blockers are reversible11, and these drugs have been used to treat patients with precocious puberty since the 1980s2, with a temporary pause on bone density accrual that resumes once puberty blockers are discontinued and hormone therapy begins11, 12. If patients, their parents or guardians, and their care providers determine it is appropriate, hormone therapy (the use of estrogen, testosterone, or other analogues) can be used later in adolescence (or adulthood) to induce the development of sex characteristics more aligned with patients’ gender identity1, 4, 5. This development occurs slowly and some changes are partially reversible if hormones are stopped1, 4, 5.
Not all transgender or gender diverse individuals experience gender dysphoria or distress13, 14, and not all seek medical care13, 15. While not all gender-affirming care is medically-focused, the available evidence is largely related to medical interventions and their impacts on trans and non-binary individuals who are able to access such care and choose to interact with the medical system.
Randomized controlled trials (RCTs) are often considered the gold standard of scientific evidence. However, they are inappropriate in evaluating the effectiveness of gender-affirming care for youth, due to the inability to blind participants and providers to interventions over the long term, and the likelihood of study drop-out or non-adherence once patients discover they are in a control group16. Observational studies are often used to study mental health outcomes, and observational evidence is regularly used for clinical decision making where RCTs are not available, including off-label drug use in pediatric practice16. Just over 10% of all clinical guidelines from the American Academy of Pediatrics are based on well-designed and -conducted RCTs and metanalyses, while almost half are based on RCTs with minor limitations or observational studies with consistent findings17. Complementary, well-designed observational studies reduce the risks of drop out and non-adherence for highly desired interventions and can be more generalizable to real-world patient populations, and these types of studies, particularly longitudinal studies, are what this summary and analysis is based on.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Improved mental health
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Reduced suicidal ideation
Improved well-being
What does the research say about effectiveness?
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 functioning18, 19, 20, 21 , 22, 23, 24, reducing depression19, 24, 25, 26, 27, 28, 29 and suicidal ideation22, 25, 26, 28, 30, 31. 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 needed32 and underway. In the U.S., transgender populations face discrimination, harassment, and violence based on their gender identity30, and this kind of minority stress, as well as worsening political hostility towards trans populations, negatively impacts the mental health of trans youth14, 33, 34. Harms from stigmatization cannot be undone by gender-affirming care alone35, 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 youth26. A smaller longitudinal study showed similar effects in transgender youth, particularly in patients who are transfeminine (assigned male at birth) receiving puberty suppression28. 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 patients21, 23, 24, 36. U.S.-based studies, which are largely longitudinal, suggest gender-affirming hormones can improve patient mental health and well-being18, 20, 22, decreasing depression20, 25, 27, 29, anxiety20, 27, 29, and suicidality and suicidal ideation22, 25. Gender-affirming hormones can increase body satisfaction19, 20, 29 and appearance congruence18, 20, 29, which may positively impact other mental health concerns18, 19, 27. 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 dissatisfaction12, 37, 38.
Few youth who receive puberty blocks or gender affirming hormones stop receiving all gender-affirming medical care37, 38. For example, rates of discontinuing puberty suppression and not advancing to hormone therapy appear to be 3.5% or lower across a variety of studies12 and in a 2-year study of adolescents receiving gender-affirming hormones, 2.9% stopped treatment20. Overall, discontinuation rates of gender-affirming hormones are low, with most studies showing discontinuation rates under 10%39. 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 insurance38, 39. 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 treatment40.
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 care30, 31. Evidence from Brazil suggests that having multiple sources of gender affirmation, including social, medical, and legal recognition can decrease depression and anxiety41. 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 surgery42. For these patients, their gender dysphoria was eliminated, psychosocial functioning improved, and their well-being matched or was better than non-trans adults42. However, some experts suggest that widespread social support (from medical care, society, family, and peers) accounts for the positive outcomes of Dutch trans adolescents43.
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 communities44. 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 adulthood6, 45. Having unsupportive families is associated with increased likelihood of suicide attempts45, while having supportive and accepting parents is associated with decreased odds of depression46. 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 life47. 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 suicidality46. 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 support19.
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 youth34. For example, support from aunts and “other mothers” may help LGBTQ youth, including trans youth, by educating other family members and providing support and safety48. 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 groups49.
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 exclusion50. Legal and interpersonal stigma and discrimination have negative impacts on the mental health of trans and gender nonconforming youth33, 34. 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 age51. 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 distress34.
There is little evidence available for non-binary populations7, 52, who have diverse needs not centered in the gender binary53 which are likely different than the needs of those who are binary transgender54, 55, 56. It is unclear what the impact of the “Dutch Protocol” may be for them57. The experiences of trans individuals who don’t interact with health professionals are also largely absent from the available literature52. There is a need to focus beyond medical transition52 and to center trans and non-binary experience that includes individualized care accounting for gender-related marginalization and resilience13.
Barriers and Facilitators
Youth face barriers in accessing gender-affirming care, including systemic bias58 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 times59. Youth also face additional restrictions on access to care due to their age and the need for parental consent58 and barriers due to lack of support from family59. Youth may not know what is available to them58, 59, such as being unaware that puberty suppression is a possibility58, or how to acquire it59. 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 gender59.
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 providers60. Other health system and community-level barriers include limited clinical decision support for providers, and negative biases61. 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 difficult62. Telehealth video appointments may be one solution to reaching patients residing outside of urban areas62, and there is interest in receiving gender-affirming care in more accessible settings, such as remotely through telemedicine63, 64 or in primary care63, 64, 65.
Recent legislative bans further decrease access to gender-affirming care for trans and non-binary youth54. 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 bans66. 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 care3. 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 communities3, 67.
How could this strategy advance health equity? This strategy is rated potential to decrease disparities: supported by some evidence.
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 outcomes20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 78. 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 schools79, and experience family rejection than their cisgender peers14.
Mental Health Disparities and Suicidality
Trans and non-binary youth face disparities in mental health, including depression, anxiety, and suicidality, compared to their cisgender peers33, 80, including their cisgender sexual minority peers14, and are more likely to be bullied and harassed33. 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 suicide81. 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 suicide82. 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 hormones83.
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 care63. 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 care63. 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 avoidance55.
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 white33, 67. One Minnesota-based study showed that transmasculine youth were more likely to be bullied than transfeminine youth82. 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 counterparts84. Trans youth also experience marginalization and instability in employment, housing, and healthcare access33, 67.
LGBTQ+ populations as a whole face significant health inequities15, 85. Trans and gender-diverse populations of all ages face many barriers to receiving gender-affirming care14, including discrimination in the health care system85, 86, underinsurance, and poverty86. Trans youth face the same marginalization and discrimination that trans adults face33. 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 care54.
What is the relevant historical background?
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 20th century, with the work of Magnus Hirschfeld, who founded the Institute for Sexual Science in Berlin in 192232. After WWII, limited treatment was available for a small subset of adults who could be made to “fit” the gender binary87, including treatment through at least 9 U.S. academic medical institutions in the 1960s and 1970s32. Some transgender children received care as well88. 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 terminology32.
For most of the 20th century, treatment for trans and other gender non-conforming youth was focused on “correcting” behavior and psychology, not affirming it87. 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 benefits12. 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 reasons32.
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)70. 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 legislation32. 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 guardians57. 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 care89. Despite the justifications used by politicians in passing this legislation, this care meets conventional evidence standards for providing health care treatment35.
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 programs76, 77. 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 care76.
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 14th 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 14th amendment, the non-discrimination protections in the Affordable Care Act (Section 1557), or other claims90.
Equity Considerations
- 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?
Implementation Examples
The U.S. does not recognize sexual and reproductive health rights as human rights68.
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 care69. Additionally, 24 states impose professional or legal penalties for providing gender-affirming care to those under 1870; 6 states and 1 territory have made providing gender-affirming care to trans youth a felony69. 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 intersex71.
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 older72, 73. 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 banned72. Additionally, 8 states provide protection regardless of the patient’s location, enabling telehealth care provision72. Additionally, there are legal challenges in 17 states to the laws limiting or banning gender-affirming care70.
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 place74. 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 people75.
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 services76 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)77.
Implementation Resources
‡ Resources with a focus on equity.
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.
Seattle Children’s Gender Clinic-Education and resources - Seattle Children’s Hospital. (n.d.). Gender Clinic—Education and resources for healthcare professionals. Retrieved October 16, 2025.
NPAIHB-Leston 2020 - Leston, J., Haverkate, R., Wenger, H., Grimstad, F., Conniff, J., Wei, J., Gampa, V., Thomas, M., Jeffries, I., Jim, M., McCanta, L., & Ortega, S. (2020). Trans and gender-affirming care in IHS/tribal/urban facilities: 2020 strategic vision and action plan. Northwest Portland Area Indian Health Board.
LGBTQIA HEC-GA Pediatric Care Toolkit - LGBTQIA+ Health Education Center. (n.d.). Gender-affirming pediatric care toolkit. Retrieved October 16, 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.
A4TE-Trans health project‡ - Advocates for Trans Equality (A4TE). (n.d.). Trans Health Project. Retrieved June 25, 2025.
Yale Integrity Project - Yale Law School. (n.d.). The Integrity Project. Retrieved October 17, 2025.
Shuster 2024 - Shuster, S. M., & McNamara, M. (2024). Troubling trends in health misinformation related to gender‐affirming care. Hastings Center Report, 54(3), 53–55.
McNamara 2023 - McNamara, M., Abdul-Latif, H., Boulware, S. D., Kamody, R., Kuper, L. E., Olezeski, C. L., Szilagyi, N., & Alstott, A. (2023). Combating scientific disinformation on gender-affirming care. Pediatrics, 152(3), e2022060943.
HRC-Map of Attacks on GAC - Human Rights Campaign (HRC). (n.d.). Map: Attacks on gender affirming care by state. Retrieved June 25, 2025.
ACLU-LGBTQ rights map - American Civil Liberties Union (ACLU). (n.d.). Mapping attacks on LGBTQ rights in U.S. State Legislatures in 2025. Retrieved June 25, 2025.
Footnotes
* Journal subscription may be required for access.
1 AAMC-Boyle 2022 - Boyle, Patrick. (n.d.). What is gender-affirming care? Your questions answered. AAMC. Retrieved June 17, 2025.
2 AAP-Rafferty 2018 - Rafferty, J., American Academy of Pediatrics (AAP): Committee on Psychosocial Aspects of Child and Family Health, Committee on Adolescence, Section on Lesbian, G., Bisexual, and Transgender Health and Wellness. (2018). Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics, 142(4), e20182162.
3 Salvetti 2024 - Salvetti, B., Gallagher, M., Schapiro, N. A., & Daley, A. M. (2024). Prioritizing gender-affirming care for youth: The role of pediatric-focused clinicians. Journal of Pediatric Health Care, 38(2), 253–259.
4 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.
5 Hembree 2017 - Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., Rosenthal, S. M., Safer, J. D., Tangpricha, V., & T’Sjoen, G. G. (2017). Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society* clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 102(11), 3869–3903.
6 Turban 2021 - Turban, J. L., King, D., Li, J. J., & Keuroghlian, A. S. (2021). Timing of social transition for transgender and gender diverse youth, K-12 harassment, and adult mental health outcomes. Journal of Adolescent Health, 69(6), 991–998.
7 Kearns 2021 - Kearns, S., Kroll, T., O‘Shea, D., & Neff, K. (2021). Experiences of transgender and non-binary youth accessing gender-affirming care: A systematic review and meta-ethnography. PLOS ONE, 16(9), e0257194.
8 Hughes 2025 - Hughes, L. D., Charlton, B. M., Berzansky, I., & Corman, J. D. (2025). Gender-affirming medications among transgender adolescents in the US, 2018-2022. JAMA Pediatrics, 179(3), 342.
9 Dai 2024a - Dai, D., Charlton, B. M., Boskey, E. R., Hughes, L. D., Hughto, J. M. W., Orav, E. J., & Figueroa, J. F. (2024). Prevalence of gender-affirming surgical procedures among minors and adults in the US. JAMA Network Open, 7(6), e2418814.
10 Reuters-Respaut 2022 - Respaut, R., & Terhune, C. (2022). Putting numbers on the rise in children seeking gender care. Reuters Investigates. Retrieved on November 12, 2025.
11 van der Loos 2023 - Van Der Loos, M. A. T. C., Vlot, M. C., Klink, D. T., Hannema, S. E., Den Heijer, M., & Wiepjes, C. M. (2023). Bone mineral density in transgender adolescents treated with puberty suppression and subsequent gender-affirming hormones. JAMA Pediatrics, 177(12), 1332.
12 RAND-Dopp 2024 - Dopp, A. R. (2024). Interventions for gender dysphoria and related health problems in transgender and gender-expansive youth: A systematic review of benefits and risks to inform practice, policy, and research. RAND Corporation.
13 Huit 2024 - Huit, T. Z., Coyne, C., & Chen, D. (2024). State of the science: Gender-affirming care for transgender and gender diverse youth. Behavior Therapy, 55(6), 1335–1347.
14 Wittlin 2023 - Wittlin, N. M., Kuper, L. E., & Olson, K. R. (2023). Mental health of transgender and gender diverse youth. Annual Review of Clinical Psychology, 19(Volume 19, 2023), 207–232.
15 WHO-GAC - World Health Organization (WHO). (n.d.). Gender incongruence and transgender health in the ICD. Retrieved November 12, 2025.
16 Ashley 2023 - Ashley, F., Tordoff, D. M., Olson-Kennedy, J., & Restar, A. J. (2024). Randomized-controlled trials are methodologically inappropriate in adolescent transgender healthcare. International Journal of Transgender Health, 25(3), 407–418.
17 Matheny Antommaria 2025 - Matheny Antommaria, A. H., Kelleher, M., & Peterson, R. J. (2025). Quality of evidence and strength of recommendations in American Academy of Pediatrics’ Guidelines. Pediatrics, 155(4), e2024067836.
18 Olson-Kennedy 2025 - Olson-Kennedy, J., Wang, L., Wong, C. F., Chen, D., Ehrensaft, D., Hidalgo, M. A., Tishelman, A. C., Chan, Y.-M., Garofalo, R., Radix, A. E., & Rosenthal, S. M. (2025). Emotional health of transgender youth 24 months after initiating gender-affirming hormone therapy. Journal of Adolescent Health, 77(1), 41–50.
19 Chelliah 2024 - Chelliah, P., Lau, M., & Kuper, L. E. (2024). Changes in gender dysphoria, interpersonal minority stress, and mental health among transgender youth after one year of hormone therapy. Journal of Adolescent Health, 74(6), 1106–1111.
20 Chen 2023b - Chen, D., Berona, J., Chan, Y.-M., Ehrensaft, D., Garofalo, R., Hidalgo, M. A., Rosenthal, S. M., Tishelman, A. C., & Olson-Kennedy, J. (2023). Psychosocial functioning in transgender youth after 2 years of hormones. New England Journal of Medicine, 388(3), 240–250.
21 Van der Miesen 2020 - Van Der Miesen, A. I. R., Steensma, T. D., De Vries, A. L. C., Bos, H., & Popma, A. (2020). Psychological functioning in transgender adolescents before and after gender-affirmative care compared with cisgender general population peers. Journal of Adolescent Health, 66(6), 699–704.
22 Allen 2019 - Allen, L. R., Watson, L. B., Egan, A. M., & Moser, C. N. (2019). Well-being and suicidality among transgender youth after gender-affirming hormones. Clinical Practice in Pediatric Psychology, 7(3), 302–311.
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