IRA FLATOW: This is Science Friday. I’m Ira Flatow.

We’ve been talking about the current wave of bills attacking the rights of transgender adults and children in states like Arkansas, Alabama, and more than 30 other states this year. Many of those bills address medical care and would restrict access to medical care for kids under 18 and even those under 21 in the case of North Carolina. And that’s what we want to talk about next, that medical care and what gender-affirming care means to the people who receive it. Here’s just a short sample of what trans listeners have told us this week about their experiences.

AUDIENCE: About a year and a half ago, I finally came out as non-binary. Three weeks ago, I had top surgery. And immediately after having the surgery, I felt totally better. My body matched my understanding of my body and my feelings about who I was and how I presented myself.

AUDIENCE: Being on the right hormones, getting the surgery I needed, it’s allowed me to feel so much more comfortable in my skin and confident and less anxious in my day to day. I really feel like it’s given me my life, like that my life has now started.

AUDIENCE: Gender-affirming care isn’t simply hormones and surgery and trans-specific health care. Gender-affirming health care is being treated with respect and having the reality of my existence respected by a doctor regardless of their specialty. I’ve received that, but I’ve also definitely not.

AUDIENCE: All the research essentially boils down to this– provide a supportive, caring environment for trans kids and they do fine. The research shows that it’s not anything inherent in being trans that causes depression, anxiety, and suicide. It’s the lack of acceptance.

AUDIENCE: The only really regret I have is that I couldn’t have access gender-affirming care earlier as a teenager because to me it’s like looking back on those years that I could have started living my life earlier.

IRA FLATOW: Thank you, listeners, DB Alex, and Sammy and therapist Laura Jacobs for your contributions. And here to talk with us about gender-affirming health care are my guests, Dr. Alex Iantaffi, PhD, a family therapist who works with trans and gender nonconforming adults and children as well as their families. Dr. Iantaffi is also host of the Gender Stories Podcast. Dr. Iantaffi joins us from Minneapolis.

And Dr. Kara Connelly, MD, a pediatric endocrinologist and medical director for the gender clinic at Oregon Health and Science University’s Doernbecher Children’s Hospital in Portland. Welcome to Science Friday.

ALEX IANTAFFI: Thank you for having me here.

KARA CONNELLY: Thank you so much. I’m happy to be here.

IRA FLATOW: Well, let’s get right into that. What is gender-affirming health care for children, Kara?

KARA CONNELLY: Yeah, so gender-affirming health care is actually a little bit hard to define in just one or two sentences. It is all encompassing. It is providing basic health care, primary care for children and adolescents. It can mean just being affirmed and supported in their gender. It doesn’t necessarily mean medications that are changing the hormones in their bodies, but it can.

So for some children who are starting at puberty that they were born with if it’s not in alignment with their gender identity and if their body is starting to change in ways that are not in alignment with their gender identity, we have medicines that can prevent those changes from happening. It’s a category of medicines that we often refer to as pubertal suppression or puberty blockers or hormone blockers. And they’re very effective at stopping puberty or pausing puberty. We often say it’s like pushing the pause button on puberty so that their bodies don’t continue to change in those ways.

IRA FLATOW: Can you be specific about that? How does– is it for hormonal therapy? Is that how it works?

KARA CONNELLY: Yeah. So basically what these medicines do is they suppress the puberty hormones that are produced by the pituitary gland in the brain so that there’s no message being sent down to the testicles of the ovaries telling them to make testosterone or estrogen. Those hormones– those puberty hormones cause changes to the body like chest or breast development for somebody who has ovaries and makes estrogen and eventually menstrual cycles. And then for kids who have testicles and make testosterone, those changes that come along with puberty are voice deepening and changing of the bone structure, facial and body hair. So these medicines will suppress those hormones so they’re not causing those changes to the body that are permanent and maybe really distressing to kids.

IRA FLATOW: Is there anything else that you need to factor into a young person’s care when they’re on puberty blockers?

KARA CONNELLY: When they’re– when kids are on puberty blockers, the main thing that we think about is just the fact that we are pausing puberty hormones in the body. the main thing– effect that puberty hormones can also have on is on the bone, so we take great care in thinking about bone health. We recognize that bones eventually do need hormones, so we support young people in making decisions about when and whether to start cross hormone therapy. And we want to make sure that we keep bones healthy and all other ways so making sure that they get enough calcium and vitamin D, regular weight bearing exercise, and then we can monitor bone density using bone density scans.

IRA FLATOW: And, Alex, let’s talk about your line of work, about when it comes to therapy and counseling. What does gender affirmation look like in your work?

ALEX IANTAFFI: The first and most basic rule of gender-affirming care I would say is to be able to see and recognize the person for who they are. So affirming their name, affirming their pronouns, that’s the most basic level of which we can meet somebody. And then also it’s about making sure that if there this desire to transition, whether that transition is social, so, for example, changing name and pronouns, legal, changing name and gender marker legally, or medical such as accessing puberty blocker or cross hormones that there is support for that young person and their families to fully understand the process and fully understand the options that they have.

Often One thing that I say to my clients is that I want this transition in their lives to bring them closer as a family rather than drive a wedge between them. And that’s very much my job as a family therapist. And as Kara said, hitting the pause on that puberty pattern can be so fruitful for therapeutic work because then it gives young people the chance to really explore their feelings if they’re experiencing any dysphoria, so a sense of dis-ease, lack of ease in their body, because of the pubertal changes, they can have all the space they need to decide for themselves what they want their lives to look like because often we think that transitioning looks one way, but there are many different options when we look at gender-affirming care.

Some people might want to change their name and pronouns. Some people don’t. Some people might want to access hormone therapy and maybe later in life even body modification such as gender-affirming surgeries, and some people don’t. And giving young people and their families the space to explore, the space to have challenging conversations around what do they want to do around their reproductive capacity, for example, as they get older and they’re contemplating cross hormones can be really helpful.

And nothing happens quickly. I also want to make it clear that– [CLEARING THROAT] sorry– that nobody is giving hormones or puberty blockers to children as young as four or five. What is happening in terms of gender-affirming care with those younger children is that they are telling us I’m a boy, I’m a girl, I’m a boy and a girl, and they might want to play with what clothes they’re wearing, how to do their hair, what name they’re using, and what pronouns people are using for them. They usually medical care doesn’t come in until much later when those pubertal changes start to come into the picture.

IRA FLATOW: That’s very interesting. Kara, all these kinds of treatments– mental health, medical– there is real science behind this is there not?

KARA CONNELLY: Absolutely. I think one of the misconceptions is that this– is that the care is not well researched, and in reality it is. First of all are treatments we’ve been using for over 50 years. These are not new medicines.

We– many of them– the puberty blocking medicines were developed for a medical condition called central precocious puberty for children who go into puberty at two young of an age so five or six years old. We can use those medicines to pause puberties for those kids. And so we have many, many years of experience and understanding how these medicines work and what their safety and efficacy are.

And we’ve been using these medications for kids who identify as gender diverse or transgender for over two decades and again have a lot of evidence that they are safe, they are effective, and they provide long-term benefits both emotionally, physically, psychosocially, and result in kids who are healthier with lower risks of depression, anxiety, lower risk of suicidal ideation or suicidality, and they’re able to be who they are authentically and thrive in their lives and their relationships.

In terms of hormones, hormone replacement therapy, or cross hormone therapy, again, we’ve been using the exact same hormones for many, many decades, over 50 years, for people who don’t make enough hormones on their own. And when we prescribe hormones, we’re prescribing them in replacement doses. So we prescribe hormones that would achieve hormone levels in the blood that would mimic what a person that age would naturally be producing, and we don’t exceed that. So for those reasons, we don’t see negative health consequences because we are simply replacing what the young person is not making enough of.

IRA FLATOW: One thing that people arguing for those bills keep saying this idea that trans kids aren’t ready to make decisions and they might regret the decision they do make, Kara, Alex– let me begin with you, Kara– how do you respond to that?

KARA CONNELLY: Yeah, I can appreciate that question. And I think one of the things that’s important to recognize and remember is that just like Alex said, these decisions are not taken lightly. We work with the whole family unit to help them make decisions and help the young person make the decision about whether this is the right thing for them and whether this is the right time for them. We– the care that we provide is interdisciplinary with integrated social work, behavioral health, medical, and in helping the young person make these decisions.

But in reality, these young people know who they are, and they are looking to us to help them to achieve those long-term goals so that they are able to express who they are to the rest of the world. But they know their gender identity. It’s deeply rooted internally as who they are, and when even so when we meet with young people, we always discuss the possibility that they may decide to change direction. So as Alex was talking about with the train, we often refer to somebody who’s pursuing medical interventions as being on a journey with many different paths that they can choose to take just like Alex was saying with the different interventions that they may or may not– that may or may not be part of their journey.

And if somebody is going down one path, they may change– decide to change course, and we support them in those decisions. We always bring up the possibility of them deciding that if they start a medicine that they don’t want to be on the medicine anymore, and when we– anytime we start a medication, we follow up with our patients very closely with return visits every three to four months. At those visits, we talk about how they’re feeling on those medications, how they’re feeling with the changes that they’re introducing to their body, and if changes aren’t feeling affirming to them at any point in time, then we can decide to stop it or change directions.

IRA FLATOW: I don’t think that’s something that people understand, Alex, very much.

ALEX IANTAFFI: I agree. Sometimes there are so many misconceptions out there about what gender-affirming care looks like at this point. And I think that one of the things that’s important to remember is that young people make decisions about their life all the time and they do make decisions about their medical care with their parents all the time, but somehow when it comes to transgender and/or non-binary children, we think that they’re somehow set apart from their cisgender peers. And one of the studies that I think was published in 2019 clearly identified that the gender identity development trajectory for transgender and non-binary children is very similar to that for cisgender children.

That means that most children know who they are in terms of their gender identity between the ages of three to five years old. And so if they are in an environment that’s affirming enough and safe enough for them to say to the world and announce who they are, that’s usually when a child says I’m a girl, I’m a boy, I’m a girl and a boy, or I’m not a girl and I’m not a boy. And, of course, they’re expressing their identity in a way that is age appropriate to them, and like I said, there is no medical intervention beside behavioral health support such as family therapy that happens at that stage.

As they get older, they develop an understanding of their gender identity and expression that grows with them just like all of us do. Probably most of us have a memory of being four or five or six years old and knowing what we wear, knowing what kind of toys we like to play with, what kind of clothes we like to wear, and it’s really no different for transgender children. I think people often seems to think that maybe there’s been undue influence on those children, and the reality is that even though now we do have the internet and children can access language to describe themselves at a much younger age, the reality is that children have always developed a strong sense of identity without those influences.

For example, I was born and brought up in Italy in the early ’70s. There were no transgender people around me, but I knew as a young child that when people thought I was a boy that made me happy. I didn’t know the terms gender euphoria, which I know now, but I realized that I was feeling seen and affirmed by my peers or by strangers of the park because I had a short haircut and some sweatpants on. I didn’t know that– I hadn’t read gender theory and I didn’t know that transgender people existed, but I knew who I was.

And that’s true for many children. They know who they are, and then when it comes to medical treatment, if they’re minors, the medical treatment is usually negotiated with the parents, which is why people like family therapists are so important during that negotiation. And the reality is that parents often don’t have any problem giving hormonal care to their children if they’re not trans. For example, if the child has acne, there might be hormonal treatment that’s recommended, and that is not seen as problematic. Or if the child is starting to hit puberty at eight years old or nine years old, again, there is no problem for them accessing puberty blockers.

But somehow when it comes to transgender children, it’s almost as if people put them on a different category than the rest of humanity, and I think that’s one of the main things to remember is that trans children are children first. And so as children, they know who they are, they need to be respected, they need to be listened to and heard, and they have the right to access the medical care that can be so helpful and that is evidence based and that is recommended by most professional association on an interdisciplinary level.

IRA FLATOW: If I’m a parent, what’s the best practice for responding to my child who is questioning their gender or realizing they are trans? Let me begin with you, Alex.

ALEX IANTAFFI: Absolutely. What a great question. Well, as a parent and a family therapist, I think when a child discloses something like that, the first answer needs to be thank you so much for trusting me with that information. I’m so glad that you felt you could come to me and share that with me. And then the next question needs to be what does that mean to you. What would you like me to do differently?

And I think that’s a really important question that parents need to ask is how can I support you. What would you like me to do differently? And let their children know that there is space here for them to explore because gender is a journey and also we can change our mind throughout our life. The way we express our gender as five or seven years old is not the same way we express it when we’re 40 or 50 or 70, and that’s true for all of us, trans folks or not.

And so for a parent to just meet their child and know that they’re listened to, that they’re loved also, of course, I love you no matter what and I’m with you. You’re not alone because children can feel so alone and children are aware that all this anti-trans sentiments are going on because they access social media and they need to know that their families are on their side because research tell us that family support is the biggest factor for resilience. Family support lowers suicidality, lowers symptoms of depression, anxiety. It’s the thing that is most needed by trans youth.

IRA FLATOW: So both of you, how have you seen kids respond to receiving gender-affirming care?

KARA CONNELLY: It’s just an absolutely incredible experience to be able to work with these young people and their families and to be able to witness with our own eyes how they– our treatments help them to blossom and thrive and be successful in their relationships and do well in school and graduate and go on to pursue higher education and really wonderful jobs. And I think one of the most unique and special thing is just watching how this care strengthens their relationship with their family.

Almost every single young person that we see in our clinic after they receive our care come back to clinic with their parents telling us this is the first time that I’ve seen them come out of their room and interact with the family in years. They’re now developing new relationships. They’re going to school. They’re smiling for the first time. And that is just– it’s just incredible to witness, and that cannot be minimized when we’re thinking about these bills that are going to strip this away from them. This care is just– as Alex said, it’s life saving.

ALEX IANTAFFI: Likewise, I feel as– as Kara, I feel like I could have this conversation for hours as Christie knows because the other night I did her for a really long time. I, too, am sad that with my brain fog today I was like, oh, I didn’t talk about how gender-affirming care is actually lifesaving because of the high rates of suicidality in trans population. Our population has 10 times the rate of suicidality compared to the general population, so gender-affirming care is literally life saving for many trans people whether their children, youth, or adults.

And also that when people receive gender-affirming care, not only can they survive, but they can thrive. We see them connect with their parents better, connect with their peers better, participate in everyday experience that a lot of cisgender children and youth take for granted, whether it’s playing sports or going to prom or just hanging out with their friends, of course, when it’s not a pandemic maybe, that the really gender-affirming care allows children to be children and to blossom rather than being weighed down with dysphoria and depression and anxiety. It’s really liberating for many young people.

KARA CONNELLY: And that’s before any medical treatments even. It’s just simply using the child’s affirmed name and pronouns.

ALEX IANTAFFI: Absolutely. And I just want to add that sometimes when I work with families, if parents are not sure what does it look like to be gender affirming, I say, hey, let’s do a little science experiment. Why don’t you use your child’s names and pronouns that they’re asking you to use for a month and see if you notice any differences.

And often parents come back and it’s like– and say it’s like having my child back, exactly what Kara was saying. They’re coming out of the room. They’re engaging with the family. They’re feeling seeing and affirmed and listened to and therefore can relate to us in a completely different way.

IRA FLATOW: And that really shows a difference immediately.

ALEX IANTAFFI: Yes, it can be that immediate. And I really want to stress because sometimes people who are proposing those bills say, well, if that’s enough, then why do we need additional medical care. And what I would say is that that is the beginning to have that basic engagement. But then sometimes the onset of puberty can plunge children and young people back into depression and anxiety, and so being able to access medical care as well as this affirming care in therapy is really essential as well. It’s not an either/or. It’s very much of both/and. There needs to be an interdisciplinary team that works with the family.

IRA FLATOW: Are there cases where the parents who hear their children talking about this go to a psychiatrist who might say, oh, I’m just going to throw some medication at your kid. Your kid will be better in a few months.

ALEX IANTAFFI: Yes, that happens, and hopefully psychiatrists are competent and know that one of the areas they need to explore is how people and young people especially might feel about their gender because that’s often when pubertal changes hit and there is a big change. I think that most providers would know that one of the things to explore is maybe gender identity. Sometimes this can be missed, and it goes back to what one of the listeners was saying about the difficulties of accessing gender specialist and gender-affirming care. One of the things that we need to do and it is increasingly happening is to better educate our providers, whether they’re medical providers or therapy providers, because one of the things that can happen is that people don’t feel equipped to deal with gender.

And so maybe a child is seeing a therapist and then– or a psychiatrist and they come out as trans, and the therapist or psychiatrist says, oh, you need to go to see a gender specialist. And then that can be really harmful because then the child feels, oh, I’m not like other children. I need to see a specialist. There’s something so wrong and weird about me that now an average psychiatrist or an average therapist cannot treat me.

And that’s why it’s so important for every medical provider and every psychotherapy provider to have that basic level of education around gender so that they can keep treating their clients and maybe consult with a gender specialist, but this shouldn’t disrupt the care of the client just because they come out as trans. And if the psychiatrist is missing the signs, well, maybe that just needs a little additional continuing education.

IRA FLATOW: I’d like to talk about some issues that would be applicable for all trans people of all ages. And one listener, Kay, shared many frustrations with their ability to access health care.

AUDIENCE: I think these letter requirements for insurance that say that you’ve been diagnosed with a thing in order to qualify for a surgery, diagnosed mentally with a thing, it’s [BLEEP] honestly. A cis woman wishing to get breast enhancements does not need to be diagnosed in a clinical like there’s something wrong with you way, essentially what the insurance agencies are asking for. You don’t need that to make decisions about your body if you’re cis and yet you do if you’re trans.

ALEX IANTAFFI: I agree. I agree with Kay, and although I am a double-part certified provider, as I work for the professional association for transgender health. I think many of us, especially actually trans and cis providers alike, but definitely trans providers like myself feel that this shouldn’t be a mental health rubber-stamp that we put on people to address medical care. As long as somebody’s capable of providing the informed consent, they should be able to access the medical care that they need.

I think this is a long-standing struggle of the trans community and the legacy of how medicalized our communities have been. And I think there are changes that are coming down the pipeline hopefully with the standards of care version 8, which are being worked on currently. I think some of those things might change for people, but literally honestly the way I address in the writing a letter for a client is first of all affirming that we shouldn’t need this letter because I shouldn’t have to prove that you need to access this medical care.

But the way I approach is let’s be collaborative and let’s look at this as a portal for you to access the medical care that you need. And maybe let’s also use this as a moment of reflection to make sure that you’ve thought through everything that you need to think through that you are prepared for the medical appointments that are to come and that you are prepared to make an aftercare plan, for example, when it’s gender-affirming surgeries.

And so I think there is still a role for therapists, but I would like for people not to feel forced to see me but to choose to see me because I didn’t become a therapist to become a gatekeeper. I want to be supportive of people rather than having to just put a rubber stamp and say yes you are who you say you are and now off you go to the endocrinologist or to the surgeon.

KARA CONNELLY: I have to say I completely agree with Alex. And I think– I only work with young people, but I see and I fear that by having these requirements that doesn’t leave space for the conversations to happen authentically. Kids learn– kids and adults I’m sure learn what the words are that they need to say in order to get the letters.

What we want to do is to create relationships with medical provider and the patient and their parents or the behavioral health provider to give them space to– for them to be authentic, for us to ask them– to tell them you know who you are. What does that mean for you? And how can we help you achieve those goals so that they can say actually I’m not comfortable with my chest tissue, but I don’t want to go on hormones. And we can help them achieve those goals rather than just having them feel like they need to say a prescribed statement in order to be able to access the care that they want or need.

IRA FLATOW: What else would be on your wishlist for improving access to gender-affirming care.

KARA CONNELLY: Well, insurance is a huge barrier. It’s something that as a medical provider I have to deal with all day every day of my practice in trying to help to convince the insurance companies to cover care. I’m fortunate I practice in a state where the state Medicaid, Oregon Health Plan, covers all aspects of transgender health care from pubertal suppression to therapy to hormones to surgeries, but this is– that is– Oregon is not one– is a rare state that has the state Medicaid that’s covering these treatments. Many states don’t have coverage through the state Medicaid.

Many commercial insurance companies have barriers or exclusions, and that really affects an individuals’ ability to access care. The care is expensive, and for our purbertal suppression medicines, the– there are cost prohibitive without insurance coverage. So we need more inclusive insurance policies, number one, but number two is just as Kay was mentioning, we need more expansive understandings of what this care means and not have barriers that are specific to trans care when it’s offered– the same care is offered and covered more easily to cisgender people seeking the exact same treatments.

ALEX IANTAFFI: I have to echo much of what Kara said about insurance as well being pretty discriminatory sometimes when it comes to trans folks. I would say that treatments that, as you pointed out as well, are accessible to is cisgender folks sadly are not accessible to trans people, and that’s really problematic. But in terms of what would be on my wishlist, the first thing would be to stop discriminating against transgender, non-binary people and just see us as people first who need access to necessary medical care because often what happens is as soon as that diagnosis of gender dysphoria flags in the system, people look at us as if we are completely different from the rest of humanity. And so I think that that stopping discrimination is the first step.

But then I think another important step is for all of us trans or cis people to really look at gender and understanding that gender is actually a complex biopsychosocial construct. Yes, there is part biology, part identity, and our sense of self so that psychological piece, and then there is a social piece that it’s also historical in how we think about gender. Because I think if all of us thought about gender a little bit more and realized how many of our ideas of gender come from family or history or teaching, there could be a little bit more space for everybody to be a little more expansive, to be a little bit more themselves. And I think that would go a long way to actually make life better for trans people.

Because often when people think, oh, let’s talk about gender, they think about just one category. Let’s talk about men or let’s talk about women or let’s talk about trans people. But the reality is that all of us have the relationship with gender, and all of us are impacted by this idea of gender as a binary, which is also pretty modern in a lot of ways. And if we can really challenge that, I think life could be a lot easier for all of us actually. We could all feel a little bit more liberated to be ourselves regardless of whether we’re trans or not.

IRA FLATOW: That sentiment is echoed in our last question from Tessa who sent us this via the SciFri VoxPop app.

AUDIENCE: Affirming health care is health care that backed by a wealth of data, research, and the medical literature. And while it’s been established that there aren’t any major negative side effects of medical transition, which is a good thing, beyond that, there isn’t even, for example, really consensus on what the full effects of hormone replacement therapy even are for trans people. And I would love to see that remedied. We are a criminally under researched demographic.

IRA FLATOW: Kara, comment please.

KARA CONNELLY: I agree. We have– well, we have a lot of research to back the care that we provide. It’s a growing– rapidly growing body of evidence, but studies that date back 15, 20 years, even longer about the positive effects and the lack of negative health effects from the treatments that we use. But we still need more research, and we need to center the voices of the community, the transgender and gender diverse community, in determining what needs to be studied and how the studies need to happen.

So I think that there’s an effort to pursue and support and fund research that does incorporate the voices of the communities that we need to study so that they can help establish priorities. And I think that funding agencies need to hear that as well. This is very necessary, and we need to make sure that we are hearing from the transgender and gender diverse populations including the young people and their families about what are the questions that remain that need to be answered and understood more thoroughly.

ALEX IANTAFFI: Absolutely. I would add putting my scholar hat on that we’re both an under researched and over researched population. I think from the point of view of the social sciences or psychology, sometimes cisgender researchers pursue things that are of interest to them because they’re not always well informed. And so we’re often over researched in certain areas and very much under researched in areas that matter to us. But one of the biggest changes that actually researchers can make is to include transgender folks in their larger studies.

So if there is a large medical study of cardiac health, for example, include a category for transgender, non-binary people. If there is a large study of bone health, include trans and non-binary as an option because then we’re going to start to have those larger data sets with longitudinal data, which is often what people are looking for. But as long as we’re assume that most of the population falls into this binary, we’re not going to really have the comprehensive data that we need in order to move the field forward.

IRA FLATOW: And that’s about where we’ll have to leave it. Very interesting discussion. I want to thank both of you for taking time to be with us today.

KARA CONNELLY: Thank you very much.

ALEX IANTAFFI: Thank you so much.

IRA FLATOW: You’re welcome. Dr. Alex Iantaffi, host of the Gender Stories podcast and a family therapist who works with transgender adults and children in Minneapolis, and Dr. Kara Connelly, MD, a pediatric endocrinologist and medical director for the gender clinic at Oregon Health and Science University’s Doernbecher Children’s Hospital in Portland. Thank you both for taking time to be with us today.

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