I had already finished the first draft of this piece when I learned that the Supreme Court was hearing arguments on December 4 in US v. Skrmetti*, the big case on medical care for trans minors. The case challenges Tennessee's ban on gender-affirming medications for transgender youth—medications that are already legal for other medical purposes. The core arguments ask whether treating the same medications differently based on who receives them violates constitutional equal protection. I listened to the entire arguments and took notes; and while I admit that some of the personal stories were sad, particularly around youth with extreme distress about their bodies, it didn’t change my opinions or concerns, at least not at this juncture. It just confirmed for me how important it is for us all to stop, take a beat, and be open and honest with ourselves and each other as we grapple as a society with transgender issues. Youth medical transition is one of the most hotly debated issues of the day. While most dedicated conservatives are against any kind of intervention, there are some liberals who also hold more conservative views as well.
The current suggested sequence for youth gender transition established by WPATH* is known as the staged approach—starting with reversible to irreversible. It is reasonable, and I generally agree with it.
Social Transition: This is the safest and probably the best early identifier of the direction a child is headed. A social transition allows the child to try new names, pronouns, clothing, and hairstyles. The biggest risk, perhaps, is to a parent’s pocketbook while their teen is trying out new things.
Puberty Blockers: This is a temporary, supposedly reversible intervention starting from 10-12 years old. Blocking hormones gives a child more time to explore. I understand why pausing puberty is important, especially for trans girls (AMAB, assigned male at birth)—once puberty begins, it can be halted later, but not fully reversed.
As a transgender male (AFAB, assigned female at birth), I can surely empathize, but I waver on the appropriateness of this treatment. I worry that blocking hormones might be the cause of problems down the road. There is some evidence that points to issues around bone density, fertility, and natural brain development. There still isn’t enough research to be certain that most kids would be safe with this intervention. During the Skrmetti arguments, the Supreme Court pointed to European countries who have started to pull back on these treatments pending more research.
Hormone Therapy: Prescribing hormones starts around 14-16 years old and requires psychological evaluation and parental consent. This is the stage that brings irreversible changes and is where I depart even more from many of my fellow trans people. I’m fully on board with psychological evaluation, and more importantly, general adolescent therapy, which I’ll get to later. But the suggested age for beginning hormone therapy seems too young to me. Starting a kid on hormones in those critical years when they are at the pinnacle of teenage angst seems risky to their psychological well-being. Permanent changes from hormone treatment can interrupt the normal cognitive and emotional maturity meter.
When I was a young teen, transgender was not a term anyone knew yet. Hormones were used on children back then but for different reasons. As far as anyone was concerned, I was a tomboy who seemed to refuse to grow out of it. Do I wish gender hormone treatment would have been available to me back then? As an adult taking testosterone now, it would be easy for me to say, “I sure as hell would!” But I’d be answering that with my fully developed adult mind and reasoning ability. My wife has rightly pointed out that I’ve privately lamented not starting my transition much earlier. But when I fantasize about it, I imagine myself in my late 20s or early 30s. My late teens and early 20s were so troublesome I can’t really imagine such a scenario as gender-affirming care during that time. This is where it’s thorny for me, and for thousands of people who are now dealing with these questions, whether about themselves, a friend or family member. Where is the line, and how do we approach this fairly?
I am reminded of a childhood friend. Holly grew up in a nice brick home and her family appeared to be people of means. There was nothing about Holly that would suggest she was anything but a boy, and she made that known right up front. She could outplay any of the boys in sports. All her toys were what you’d expect to see in a boys room. She rode a boy’s bike and wore boys' clothes. None of the girls in my neighborhood were allowed to play with Holly. Her mother was exasperated and at a complete loss about what to do. I heard her talking with my mother about it. I heard other mothers in the neighborhood, as well as other girls, talking about Holly’s peculiarity too. Incidentally, after one sleepover, I was added to the list of girls who were not allowed to play her. We had “experimented,” like kids do, and my mother got it out of me!
When I ran into Holly years later, I was floored to see a gorgeous young woman, whom I learned was every boy's heart throb in high school. She was very popular and was living a big life in her senior year. When I saw her, my jaw dropped. “Holly? Are you Holly?” She looked at me somewhat embarrassed and a little pained. In the next moment she was whisked away by her friends.
What if someone had informed Holly’s parents that she was a trans boy? As strong-willed and precocious as she was when she was 10 or 11, I can only imagine how quickly she would have convinced her exhausted mother that she had better let her become a boy.
Surgery: There is no federal law setting a legal age for when a person can receive gender affirming surgery. It is generally determined by a combination of state laws, medical guidelines, and medical providers' policies. Most medical providers require patients to be at least 18. With all the turbulence that occurs throughout adolescence, in my opinion the earliest age a young person should have access to gender affirming surgery is 21.
The ideal age as suggested by research is actually 25. Brain development studies show that the prefrontal cortex, critical for long-term decision making, continues developing until about 25. A lot of the youthful confusion about life settles down by then. College, or trade school, is usually behind a person. It could be the perfect time for a different kind of gap year. When "graduation day" arrives, how exciting would that be?
At 60, when I came out trans, the urgency to arrive at my own surgery date steadily intensified. I squirm a little as I write this because I can understand first hand that excitement and the “need” to set things right. At least 21 is closer to the mark than 18. I admit that 21 sounds harsh but my struggle is that 18 doesn’t suddenly make a person wise. Surely we’ve known plenty of 18 year olds that we wish would act their age! I also understand that an 18 year old can enter the military (which I did). And now, as I consider that reality at this moment, I’d suggest 21 as the earliest age requirement to join the military!
In an ideal world, the formative years around planning for surgery could add a healthy aspect to gender transition. It could be framed as an important preparation time rather than just an agonizing time spent marking the calendar. I’m also of the mind that these potential trans kids should have some skin in the game in the planning years. They could work, save money and learn how to set up a budget for the time they would need to take off work during the surgery process. Maybe they’d want to travel a little after recovery. They could investigate and prepare for legal documentation. This kind of involvement could take a decade or more, which would set them up perfectly as the goal approaches. Think about kids who train for the Olympics. It takes years and years for them to reach their goals, all for a few moments of glory. Potential trans kids are planning for their entire lives! Why rush it? Why not make it interesting and engaging?
Regardless of the timeline, I think that potential trans kids can benefit greatly from regular therapy that deals with general identity development, like learning how to deal with difficult emotions, self awareness and social encounters. The “specialness” of gender identity isn’t really the top priority here in my opinion—I’ll get more into that question of “specialness” later in the series.
Another nagging concern I have is about those who insist that a parent has the signature rights to obtain gender affirming care for their child, and that it’s nobody else’s business but theirs and their doctor’s. What we don’t hear about is the mental health and stability of the parents making those decisions. How many of us have spent thousands of hours in our therapist’s office unpacking all the mistakes our parents made while raising us? Parents haven’t suddenly stopped screwing up (or, to put it more gently, stopped missing the mark with their kids). Isn’t it possible that some distressed kids may have learned how to manipulate their parents by threatening self-harm or running away? A terrified parent might well go against their better judgement in order to “save” their child.
Another astonishing notion that someone recently explained to me: there are apparently some parents who see their trans child as a status symbol to show how progressive their parenting skills are. Here, it becomes more about the parent’s identity, rather than the child’s true well being.
My pause about gender affirming care isn’t about denying care, it’s about accountability and honest comprehensive assessment of the entire environment the child is exposed to. Stability at home is key to all that’s wrapped up in how a teen learns to navigate the world. I think with good therapy, a trans kids’ true gender identity will naturally follow long before they need to even think about intervention, and probably in a more healthy way. Kids need time to grow up before concerning themselves with drastic measures. It’s important to remember that all teens go through enormous changes during this time, regardless of gender identity.
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Footnotes:
*US v. Skrmetti - If you would like to understand all the nuances of this case, I highly encourage you to listen to the full audio of the arguments and follow along with the transcript. It’s fascinating and eye opening. United States v. Skrmetti. The SCOTUS ruling is expected next summer (2025).
*WPATH (World Professional Association for Transgender Health) is an international organization that establishes Standards of Care for transgender and gender diverse people. They provide evidence-based clinical guidelines for healthcare providers regarding gender-affirming care, including medical and psychological support services. The current version (SOC-8) was released in 2022, updating previous standards to reflect evolving medical knowledge and best practices.
WPATH advocates for quality healthcare access while emphasizing individualized care based on each person's specific needs and circumstances. Their guidelines are widely used by medical professionals and institutions worldwide when providing gender-affirming care.
