Federal Guidance on Gender-Affirming Care

The National SOGIE Center stands in solidarity with our transgender community and their families, and will continue to work with our partners to challenge recent legislative and regulatory actions being taken by states limiting access to gender-affirming care and support.

Research has shown that affirmation from families is a protective factor against attempted suicide, depression, substance misuse, and other negative health outcomes (Ryan, et al., 2009). Further, any medical decisions about a young person’s needs should be made between a youth, their parent and their medical provider. There is growing evidence that puberty blockers and gender-affirming hormones can reduce rates of depression, suicidal ideation, and other serious behavioral health conditions (Tordoff, et al, 2022).

As a resource for all advocates of transgender and gender diverse youth and their families, this page includes summaries of federal protections, statements from professional associations, as well as supporting research. This page is continuously being updated, so please check back frequently.

Federal Protections

LGBTQ+ youth are overrepresented in foster care; studies have found that about 30% of youth in foster care identify as LGBTQ+, compared with 11% of youth not in foster care. It is important for agencies to provide programs and practices designed to improve outcomes for LGBTQ+ children and youth. The Children’s Bureau is committed to addressing disproportionality and disparity in child welfare. This new Equity Page shares a wealth of resources such as public statements and Information Memorandums that provide agencies with guidance on how to leverage federal funding, including grants that help implement and evaluate programs and interventions for LGBTQ+ children and youth in foster care.

In July 2022, a federal district court reversed a Trump-era rule that had prevented the Department of Health and Human Services (HHS) from requiring that service providers in its federal grant program not discriminate based on sexual orientation, gender identity or other characteristics.

In June 2022, President Biden signed the Executive Order Advancing Equality for LGBTQI+ Individuals. President Biden’s Executive Order builds on the historic progress he has made for LGBTQI+ people by:

  • Addressing discriminatory legislative attacks against LGBTQI+ children and families, directing key agencies to protect families and children; 
  • Preventing so-called “conversion therapy” with a historic initiative to protect children from the harmful practice;
  • Safeguarding health care, and programs designed to prevent youth suicide;
  • Supporting LGBTQI+ children and families by launching a new initiative to protect foster youth, prevent homelessness, and improve access to federal programs; and
  • Taking new, additional steps to advance LGBTQI+ equality.

In March 2022, HHS released an Information Memorandum to states and territories, advising the following regarding LGBTQI+ youth in child welfare:

Too often, systemic barriers and practices are created to deny such children and youth gender affirming medical care, especially to transgender and gender nonconforming children and youth. The Children’s Bureau does not support these barriers and practices, and we are unequivocal that they are counter to children and youth’s best interests. As such, each title IV-E agency should be particularly vigilant about placing LGBTQI+ children and youth in homes and child-care institutions where they are supported, safe, and can develop as a whole person. But the agency’s responsibility does not stop there: each agency also should provide LGBTQI+ children and youth with opportunities to participate in activities that further support their identity, resilience, and development, including activities related to being LGBTQI+. Additionally, we strongly encourage agencies to take advantage of opportunities to work internally to develop the capacity to identify, understand, and address some of the issues that often confront LGBTQI+ children and youth at different points in the child welfare continuum. An agency also should consider whether its data can inform appropriate services to LGBTQI+ children, youth, and families, including when a family is at risk of a child or youth entering foster care, once a child is in foster care, or after the child has been adopted. The agency must be prepared and competent to address trauma-related issues that have occurred as a result of the child or youth facing rejection, discrimination, or harassment because they are LGBTQI+, especially in their family of origin. Children’s Bureau also strongly encourages agencies to focus attention on ensuring that each LGBTQI+ child has access to affirming medical care. This includes working with and providing services and training opportunities to parents who are struggling to accept that their child or youth is LGBTQI+ or has a non-conforming gender identity, especially when that is either the cause of the child or youth being removed or a barrier to a safe, healthy reunification.

On March 2, 2022 HHS released the this Notice and Guidance document stating that Parents or caregivers who believe their child has been denied health care, including gender affirming care, on the basis of that child’s gender identity, may file a complaint with OCR.

HHS stands with transgender and gender nonconforming youth and their families—and the significant majority of expert medical associations—in unequivocally stating that gender affirming care for minors, when medically appropriate and necessary, improves their physical and mental health. Attempts to restrict, challenge, or falsely characterize this potentially lifesaving care as abuse is dangerous. Such attempts block parents from making critical health care decisions for their children, create a chilling effect on health care providers who are necessary to provide care for these youth, and ultimately negatively impact the health and well-being of transgender and gender nonconforming youth. The OCR will continue working to ensure that transgender and gender nonconforming youth are able to access health care free from the burden of discrimination. HHS understands that many families and health care providers are facing fear and concerns about attempts to portray gender affirming care as abuse. To help these families and providers navigate those concerns, HHS is providing additional information on federal civil rights protections and federal health privacy laws that apply to gender affirming care.

On March 30, 2022, SAMHSA published this statement of support from the Assistant Secretary for Mental Health and Substance Use Miriam Delphin-Rittmon.

I stand with the incredibly brave transgender children, their parents, and families throughout around the country. I encourage all Americans to support and affirm LGBTQI+ youth – when it comes to loving our children as they are and following the science, we should all be on the same page.”

In June 2021, U.S. Department of Education’s Office for Civil Rights today issued a Notice of Interpretation explaining that it will enforce Title IX’s prohibition on discrimination on the basis of sex to include: (1) discrimination based on sexual orientation; and (2) discrimination based on gender identity. Title IX of the Education Amendments of 1972 prohibits discrimination on the basis of sex in any education program or activity offered by a recipient of federal financial assistance.

Statements of Support from National Organizations

To achieve health equity and ensure all communities thrive, we must identify and rectify discriminatory policies, laws, regulations, and practices that limit opportunity for health and well-being. This March 2023 issue brief, developed in collaboration with researchers at the University of Maryland and The Ohio State University, analyzes the 2023 landscape of state legislation banning gender-affirming medical care for transgender youth, and the potential impacts of these bans on the mental health, well-being, and futures of these youth, their families, and their communities.

Children and youth need to be affirmed in their identities in order to be healthy and to thrive. This is a statement of fact and not contested opinion; it is backed by research, and it is supported by the American Medical Association (AMA) and the American Academy of Pediatrics (AAP). In spite of this, Governor Abbott of Texas is using his power to intentionally harm children and youth by doing the exact opposite of what we all know is best. His actions directly endanger the health and well-being of the children of Texas and their families, and the health care professionals that support them by falsely stating that gender-affirming health care is equivalent to child abuse. This is patently wrong, politically motivated, and incredibly dangerous. For transgender youth—and all youth—to thrive, the environments where they learn and grow, the various systems with which they interact, and the adults who love, care for, and support them must affirm their identities and senses of self.

The American Academy of Pediatrics (AAP) and the Texas Pediatric Society (TPS), the Texas chapter of the AAP, strongly oppose the actions taken this week in Texas that directly threaten the health and well-being of transgender youth. On Feb. 22, Texas Governor Greg Abbott directed the Texas Department of Family and Protective Services and other state agencies to investigate certain gender-affirming services as child abuse, following a legal opinion that was issued by the Texas attorney general earlier this week. The AAP has long supported gender-affirming care for transgender youth, which includes the use of puberty-suppressing treatments when appropriate, as outlined in its own policy statement, urging that youth who identify as transgender have access to comprehensive, gender-affirming, and developmentally appropriate health care that is provided in a safe and inclusive clinical space in close consultation with parents.

The American Association of Child and Adolescent Psychiatry (AACAP) supports the healthy development of all children, adolescents, and their families, including transgender and gender-diverse youth and families. Recent state attacks on gender-affirming support and care for transgender and gender-diverse youth endanger the welfare of many young people across the country. These attacks undermine the right of parents and caregivers to access evidence-based and developmentally appropriate treatment. The goal of gender-affirming care is to help children and adolescents understand their gender as one facet of their identity while building resilience and increasing family and social supports. Attempts to criminalize gender-affirming care deprive youth and families of treatment and endanger the physician-patient-caregiver relationship, which is the foundation of pediatric healthcare. The allocation of scarce child protective services to these efforts further endangers youth who actually require those important services. Gender-affirming care is not child abuse.

The Society for Research in Child Development is committed to advancing developmental science and promoting its use to improve human lives. Developmental science makes clear that access to medical services and supportive gender-affirming environments benefit the health and wellbeing of transgender children and youth.

A group of organizations devoted to attending to the medical, educational and developmental needs of children released an open letter calling on state legislatures around the country to halt the flood of discriminatory, anti-LGBTQ+ legislation being advanced. The 22 groups, which collectively represent more than 7 million youth-serving professionals and hundreds of child welfare organizations, called on lawmakers to reconsider moving forward with policies that will endanger vulnerable, marginalized populations.

With at least 1.4 million adults and 150,000 youths living in the United States who identify as transgender, obstetrician–gynecologists should work to make their offices open and inclusive to all patients, and should be prepared to provide all individuals with compassionate, evidence-based care.

Providing gender-affirming care is neither child maltreatment nor malpractice. The child welfare system in the US, charged with “improv(ing) the overall health and well-being of our nation’s children and families,” should not be used to deny care or separate families working to make the best decisions for their children’s well-being. There is no scientifically sound research showing negative impacts from providing gender-affirming care. The decision for the child welfare system to become involved in the lives of families, potentially to the extent of removing children from their families and homes, should be wielded with the utmost care, grounded in evidence, and always prioritizing the well-being of children and preservation of families.

“We condemn these acts of violence and intimidation in the strongest possible terms. LGBTQIA+ people have the right to live safely in their communities without fear. Transgender and gender diverse children and adolescents and their families have a right to quality, gender-affirming health care. Attempts to terrorize LGBTQIA+ people through violence and attempts to intimidate social workers, clinicians, and others who provide health care, support, and services are unconscionable.”

Supporting Research

This study evaluated the association of familial factors and suicidality among transgender adults in the U.S. by estimating the odds of lifetime suicide ideation and attempt using the 2015 U.S. Transgender Survey. Predictors include family support, family rejection, and specific experiences related to both. About 79% of sample respondents have experienced suicidal ideation and nearly 43% have made a suicide attempt. The predicted probability of suicide attempt is 0.35 for those with no family rejection experiences, 0.75 for those who have had all five experiences in the models. Rejection predicts both outcomes and experiences of rejection have a cumulative impact.

This report from the Journal of the American Medical Association examines how receiving gender-affirming care impacts the mental health of transgender and nonbinary adolescents and young adults, who are often at risk of suboptimal mental health outcomes due to discrimination and stigma. The investigators concluded that receiving gender-affirming medical interventions were linked to lowered risks for negative mental health outcomes over the course of 12 months. The results contribute to a growing collection of evidence that indicates that gender-affirming care is linked to overall improved well-being to transgender and nonbinary teenagers and young adults.

The use of gender-affirming hormone therapy (GAHT) is significantly related to lower rates of depression, suicidal ideation and suicide attempts among transgender and nonbinary youth, according to a study published in the Journal of Adolescent Health in December. The peer-reviewed study is the first large-scale study to examine GAHT’s impact on trans and nonbinary young people. The study examines data collected in a Trevor Project survey of over 34,000 LGBTQ youth between the ages of 13 and 24 across the U.S. from October to December 2020. Of the respondents, 12,000 identified as transgender or nonbinary. The study found that young people receiving GAHT reported a lower likelihood of experiencing depression and suicidal ideation compared to young people who wanted the treatment but were not able to access it. Notably, the study found that among young trans and nonbinary people under 18, receiving GAHT was associated with nearly 40% lower odds of having had a suicide attempt in the past year.

Over two-thirds of LGBTQ+ youth said recent debates over state laws that target transgender people have negatively impacted their mental health, a poll released in Janauary 2022 by the Trevor Project shows. Seven in 10 LGBTQ+ youth said they regularly follow news related to the issues that impact the trans community, and as a result, 66% of all LGBTQ+ young people polled said their mental health had been negatively affected by recent debates about state laws restricting the rights of transgender people. The impact is even greater among trans and nonbinary youth: 85% of those polled — four in five of this group — said their mental health had been negatively affected. 

Regular physical activity is essential for the health and well-being of children, adolescents, and adults. The emotional, social, and physical benefits of exercise and sports participation are indisputable: physical activity during childhood and adolescence has lifelong positive impacts on both physical and mental health. Additionally, transgender and gender-diverse youth (TGD) are particularly vulnerable to mental and physical comorbidities that are mitigated by physical activity. Thus, the benefits of exercise may be particularly significant for TGD youth. The past year has seen widespread legislative efforts to exclude TGD youth from organized sports, even though organized sports represent one of the most important opportunities for youth to engage in regular physical activity.

Prevention and intervention efforts aimed at building support and positive self-concept, decreasing victimization, and treating depression are likely to partially reduce suicide ideation and attempt in TGNC adolescents and young adults. Comprehensive interventions with younger adolescents are particularly critical.

Prevention and intervention efforts aimed at building support and positive self-concept, decreasing victimization, and treating depression are likely to partially reduce suicide ideation and attempt in TGNC adolescents and young adults. Comprehensive interventions with younger adolescents are particularly critical.

This is the first study in which associations between access to pubertal suppression and suicidality are examined. There is a significant inverse association between treatment with pubertal suppression during adolescence and lifetime suicidal ideation among transgender adults who ever wanted this treatment. These results align with past literature, suggesting that pubertal suppression for transgender adolescents who want this treatment is associated with favorable mental health outcomes.

For transgender youth who choose a name different from the one given at birth, use of their chosen name in multiple contexts affirms their gender identity and reduces mental health risks known to be high in this group.

Consultation & Technical Assistance

The National SOGIE Center is available for consultation and technical assistance to support states, tribes and territories in implementing the guidance from this page. For consultation or technical assistance, please fill out our TA Request Form.

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