What is the Basis for Restrictions on Gender-Affirming Care?

In the flurry of executive orders he signed shortly after he took office in January, President Trump directed federal agencies to  stop funding or supporting the “transition of a child from one sex to another.” The order is intended to stop gender-affirming care for people under age 19, including surgery and hormone therapy. It calls gender-affirming care for transgender people “chemical and surgical mutilation” and predicts that people who undergo gender-affirming surgery will regret having done so.

Already,  26 US states have either restricted or outlawed gender-affirming treatment for children and adolescents. Given the heated rhetoric from politicians about transgender and nonbinary people and gender-affirming care it is reasonable to wonder how many people this actually affects and what research says about this situation.

Fewer Than 1 Percent of Americans Identify as Transgender

According to UCLA’s Williams Institute, about 1.6 million people in the US aged 13 and up identify as transgender. That amounts to about 0.6% of the population, so a tiny fraction of people. Transgender people are those whose gender identification differs from the sex they were assigned at birth. Some but not all transgender people are nonbinary, that is, feeling that their gender identity does not fit neatly into the categories of “man” or “woman.”

Actual medical or surgical treatment of transgender children and adolescents turns out to be fairly uncommon.  A recent study found that fewer than one percent of adolescents in the US who are transgender or gender-diverse and have private insurance are prescribed puberty blockers or gender-affirming hormones. That study, which looked at more than 5.1 million claims for people aged 8 to 17 years between 2018 and 2022, also found that no children under 12 were prescribed gender-affirming hormones.  Puberty blockers delay the onset of puberty so that children experiencing gender dysphoria have more time to decide if they want to take more permanent steps to transition genders. Puberty starts or resumes if the medications are discontinued. Gender-affirming hormones involve giving medications like estrogen hormones to people assigned as boys at birth and testosterone to people assigned as girls at birth or drugs that block the naturally occurring hormones. This results in an outward appearance more aligned with the person’s gender identity. Gender-affirming hormone therapy does have some risks, like potentially interfering with future fertility, but these risks may be outweighed by the risk of untreated gender dysphoria, the condition in which the strong feeling that one has been assigned the wrong sex leads to substantial distress and impairment. Hence, the decision to administer gender-affirming hormones must be made carefully, weighing risks and benefits.

It is also important to note that gender-affirming surgery for adolescents in the US is rare. Moreover, it appears to be incorrect to claim that adults who have undergone transition surgery regret the decision.  Studies suggest that only about  1 percent express regret for having undergone gender-affirming surgery. This is actually lower than the number of cis-gender people who  express surgical regret for similar procedures, like mastectomy.

Gender-Affirming Care Has Clear Benefits

The benefits of gender-affirming care for people experiencing gender dysphoria have been studied. According to Kareen M. Matouk and Melina Wald of the  Columbia University Gender Identity Program, “Research demonstrates that gender-affirming care…greatly improves the mental health and overall well-being of gender diverse, transgender, and nonbinary children and adolescents.” Transgender and nonbinary children and adolescents have been shown to experience higher rates of anxiety, depression, and suicidal ideation compared to their cis-gender peers. Psychosocial interventions and hormone therapy have been associated with a  reduction in these psychiatric symptoms. Multiple medical groups, including the  American Medical Association and the  American Academy of Pediatrics, endorse gender-affirming care.

Contrary to their characterization by the executive order as  “junk science,” the research discussed here appears to have been carefully conducted by serious and professional scientists. We do not detect any ulterior motives; rather, the motivation seems clearly to be the desire to find safe and effective solutions for people suffering with gender dysphoria. As is the case with most research areas, there remain unanswered questions, legitimate differences of opinion among experts, and the need for further research. For example, studies that find a lack of regret for having transition surgery mostly queried research participants a short time after the surgery. It is conceivable that regret could develop in some after many years, so longer term studies would be welcome.

UK Report Criticized

Controversy was also injected into the gender-affirming care field last year by a report commissioned by the United Kingdom’s National Health Service. That report reviewed the literature on gender-affirming care interventions and concluded “While a considerable amount of research has been published in this field, systematic evidence reviews demonstrated the poor quality of the published studies, meaning there is not a reliable evidence base upon which to make clinical decisions, or for children and their families to make informed choices.” The report led to a ban on the prescription of puberty blocking medications for adolescents in the UK. The report has been cited by opponents of gender-affirming care and in some legislation addressing it, including a Tennessee law banning gender-affirming care for children and adolescents that is now before the US Supreme Court.

But this report has been roundly criticized by many experts and did not lead to any changes in recommendations or policies by American medical associations. In a Perspectives piece in the  New England Journal of Medicine in January 2025, Daniel G. Aaron of the University of Utah and Craig Konnoth, of the University of Virginia, wrote “if it had been published in the United States, where it has been invoked frequently, it would have violated federal law because the authors failed to adhere to legal requirements protecting the integrity of the scientific process.” They detailed a list of problems with the UK report, including failing to understand the regulatory processes involved for pediatric medications, lack of peer review and transparency of authorship, and exclusion of gender-affirming care experts and patients from the review process. Strikingly, they noted that “a third of health professionals whom the authors chose to interview agreed that ‘there is no such things as a trans child.’”

What Is the Motivation Behind Opposition to Gender-Affirming Care?

One might think that all these people opposing gender-affirming care have first-hand experience with transgender and nonbinary people and therefore are acting from a sincere desire to help them. But a  Pew Research Report finds that only four-in-ten adults say they know someone who’s transgender and only 23 percent know someone who is nonbinary. Democrats are more likely to know transgender and nonbinary people than Republicans, with only 33 percent of the latter knowing a transgender person and only 16% of the latter knowing a nonbinary person. In that survey, 65 percent of adults say a person’s gender is determined by a person’s sex at birth, while only 33 percent affirm that gender and sex are different. Scientists generally view sex and gender as different concepts. In terms of sex, most people are born physically as male or female, although a small number have genital ambiguity for genetic and hormonal reasons. Gender, on the other hand, is a psychological construct. One may, for example, appear biologically male but feel female or nonbinary.

What is striking from the Pew Research Report is that most people do not know any transgender or nonbinary people, especially Republicans, who are most likely to favor laws restricting gender-affirming care. So, we know that there are fewer people who identify as transgender or nonbinary in the US than some seem to think, gender-affirming medical and surgical interventions are uncommonly given to transgender children and adolescents, people who undergo surgical transition surgery usually do not regret making that decision, gender-affirming care reduces anxiety, depression, and suicidal ideation among transgender youth, and most Americans don’t actually know anyone who is transgender or nonbinary.

Why then is there so much attention being given to gender-affirming care and why has that attention turned increasingly vitriolic and political? It would be interesting to try to understand the real basis behind opposition to gender-affirming care. Perhaps the most important thing to do, however, is to try to understand it from the perspective of a young person struggling with gender dysphoria. As defined by the  American Psychiatric Association, gender dysphoria is associated with a strong desire to be the opposite sex assigned at birth and marked distress. Hence, these children and adolescents are convinced they have been assigned the wrong sex and they are suffering. The idea that some nefarious forces are convincing these young people to be unhappy with the sex assigned at birth is entirely unsubstantiated.

The important thing is that we offer transgender children and adolescents understanding, compassion, and hope. There are now plenty of skilled clinicians who are expert at helping these young people and their families navigate complex psychosocial and medical issues and make good, individualized decisions. This should be between patients and their healthcare providers. While experts can debate some of the medical research and more studies are needed, we know enough at this point to be clear that transgender people deserve evidence-based,compassionate care from medical experts. What they do not need is political interference, biased regulations, and mean spirited rhetoric.