Gender-affirming care saves lives.
That’s the message from medical professionals who say that inclusive and affirming healthcare for transgender and gender-diverse (TGD) youth is essential to mental health and wellbeing.
Recently, there has been a lot of attention on policies and practices impacting TGD youth, whether at school, in the community, or in healthcare settings.
Clinical experts say the medical case for supportive and inclusive gender affirming practices is clear.
According to the Canadian Pediatric Society, TGD youth are at elevated risk for adverse health outcomes, including depression, anxiety, and self-harm – but the “risk may be mitigated by affirming experiences and environments…”.
Dr. Lauren Riggin is a youth and adolescent psychiatrist at Sunnybrook Health Sciences Centre. She spoke with Your Health Matters about the importance of gender-affirming care.
How would you define gender-affirming care? What does it look like?
I think it’s important to start with what is it not. It is not exclusively hormone therapy or hormone blockers. To me, gender-affirming care does includes those clinical components but it also includes treating people with basic respect and dignity, and creating an environment where they feel heard, included, and supported regardless of their gender.
An example of what I mean by that is using more gender-affirming language. For instance, instead of asking, ‘Are you male or female?’ care providers could ask, ‘What gender identity is the best match for you?’ or ‘How would you define your gender identity?’ Questions that are more broad and open-ended allow the adolescent to answer for themselves.
It also includes listening to people and treating them how they want to be treated. That means if they have a preferred pronoun or name, use it when addressing them. To me, gender- affirming care is as much about that supportive and respectful approach as hormone therapy, medication, or surgery.
What do you think people need to know about gender-affirming care involving hormones?
First, there is no pressure to pursue gender-affirming medical options. It is very much the youth’s decision based on what feels right to them. There are youth who choose to start treatment right away and others who prefer to delay it, and that doesn’t really mean anything in terms of their gender identity or gender expression. In other words, it doesn’t make young people less trans if they are not pursuing hormone treatment.
Treatment usually starts with hormone blockers which are thought to be mostly reversible with no long-term consequences – so that is good to know, especially for younger youth who are maybe more uncertain.
And gender-affirming hormone therapy (prescribed estrogen or testosterone) is a partially reversible intervention. This is often a big concern for parents who wonder, ‘What if my youth is not making the right decision for themselves?’
It is also important to note that there is a lot of evidence that suggests that physically appearing more similar to your identified gender is tremendously helpful for your mental health and reduces the risk of depression, anxiety, and suicidal behaviour.
As a youth and adolescent psychiatrist, what can you tell us about the mental health impacts of gender-affirming practices for trans and gender-diverse youth – whether at the doctor’s office, school, or home?
The research has mostly focused on what happens without gender-affirming care. What we know is that people who are not supported — who are not accepted within their home, school, or healthcare environment — have much worse mental health outcomes. That includes things like depression and anxiety, suicide attempts, and eventual suicide deaths. That evidence has been very well documented. And researchers believe it’s because of what’s called ‘minority stress’, in other words that people who experience discrimination are at much higher risk of depression and suicidal thoughts.
The opposite has been studied as well, although slightly less so. The evidence tells us that gender-affirming care does mitigate some of these problems. People are less likely to experience depression and suicidal thoughts if they are treated with gender-affirming care. A study conducted in the U.S. and published in the Journal of Adolescent Health in 2018 found that even something as simple as addressing someone by their chosen name leads to a reduction in depression, suicidal ideation, and suicidal behaviour among transgender youth.
I also point to the Canadian Pediatric Society position statement called “An affirming approach to caring for transgender and gender-diverse youth”, which describes the ‘minority stress’ effect and how affirming care can help reduce it.
“Transgender or gender-diverse (TDG) youth are at elevated risk for adverse health outcomes, including depression, anxiety, eating disorders, self-harm, and suicide. This elevated risk is thought, in part, to be attributable to ‘minority stress’, defined as the ‘distinct, chronic stressors minorities experience related to their stigmatized identities, including victimization, prejudice, and discrimination’. Consistent with this theory, Canadian TGD youth report high levels of exposure to harassment and violence. Risk may be mitigated by affirming experiences and environments, such as supportive parents, early social transition for those who express this desire, and inclusive and non-judgmental interactions with the health care system.”
– Canadian Pediatric Society position statement, June, 2023
What do you hear from the transgender and gender-diverse youth you care for about what it feels like when they are not supported?
The youth that I see feel tremendously ostracized. They feel they are not living their authentic lives because they feel like they have to fake it in front of other people. That disconnect between the true authentic version of themselves and the masks that they show to other people is very distressing for them. Anyone can imagine how it would feel to not be treated with respect.
What are some of the common symptoms of depression and anxiety?
For youth with depression and anxiety, it means they are not able to enjoy the life they want to live. It could mean social withdrawal and spending less time with friends, spending less time doing preferred activities like sports, arts, or other extracurriculars, having a hard time focusing in school or falling asleep at night, low energy throughout the day, or appetite changes. It could also mean feeling like life is not worth living, that it’s hopeless and will never get better. And that can ultimately lead to suicidal thoughts.
Recently we are hearing a lot about gender identity policies in schools, and the debate over whether parents should be informed if students request a change to their preferred names or pronouns. It has been framed as an issue of parental rights versus children’s rights and 2SLGBTQIA+ rights. If we apply a mental health lens to this topic, how might that add to our understanding of it?
If we apply a mental health or medical lens to this, it comes down to an issue of consent and capacity. In general, in medical care we are asked to assess individual youth and decide if they have the ability themselves to ‘understand and appreciate’ the consequences of a medical decision. In other words, doctors have to decide if individual youth can literally grasp the information of, say, the side effects of a medication and apply that information to themselves.
It’s the same concept for health information. Part of our job as doctors and healthcare workers is to assess whether or not a patient has the capacity to give consent about the sharing of their health information. Obviously, a five-year-old does not have the capacity to make treatment decisions or decide if they want their parents involved in any sort of medical discussion. But most teens do have that capacity – they can share with a healthcare provider whether or not they want their parents to be involved, and ultimately they can also make their own health decisions.
That has been very clear in the medical world for decades, and yet in the school system there seems to be a different culture. It’s a very different model than the medical system where we sometimes tell parents, ‘Sorry, you are actually not involved in this decision because your youth doesn’t want you to be and because they are able to understand and appreciate the consequences of a medical decision themselves’. Most youth psychiatrists encourage a family-based model of care, but ultimately, the youth gets to decide how involved their parents are in their medical treatment.
How concerned are you about the stress associated with being caught in the middle of a public divide like this for transgender and gender-diverse youth?
My own transgender and gender-diverse patients have told me how invalidating it feels to have this very public debate over something which to them seems as basic as just calling them by their preferred name. They say it feels like suddenly there is this problem with who they are and what their name should be and that feels very invalidating. They say, ‘Really, I can’t express myself the way that I want to and that’s true to me? Why does anyone else care what I call myself?’
What message would you like to offer youth and their families who may be navigating gender identity at this time?
What I say to patients and families is that this is a process. Understanding who we are at our core is actually a very normal developmental process for teenagers, and people who are gender diverse have an extra level they have to go through to try and figure out what is their place in this world and how do they best express themselves.
For parents, my message is don’t worry, you don’t have to make any big decisions right now. This is a process and your job is simply to love and support your child. And if they ask you to use a different pronoun or name, do it. They are confiding in you about how they feel and view themselves and being able to respect that is really important.
For youth, my message is we’re here for you, we are supportive. Living an authentic life, true to your own identity, can be tremendously liberating. If you need time to figure out who you are, that is okay too. If you need help with your mental health, we are happy to help you at Sunnybrook. We have faith that we can help you to build a life with meaning, authenticity, and joy.
