Gender-affirming care is life-saving, research says. Why is it so controversial?

Charlie Adams started taking testosterone four-and-a-half years ago. The 27-year-old's risk of cardiovascular disease increased slightly; it ticked up from someone assigned female at birth to someone who's male.

"That can be taken out of context pretty easily," says Adams, a medical student from the Midwest, who's all too aware of the debates around transgender health care.

Gender-affirming care is a valid, science-backed method of medicine that saves lives and that research shows results in better mental health outcomes, despite many states rolling back (or reconsidering) rights for transgender youth. Concerns about care are primarily targeted at kids, though can involve adults too.

Adams is someone whose life changed because of this care: "I almost have a second chance to finally be who I want to be, instead of going through the motions of work and school and everything." Those who question the care are bucking the support of major medical organizations including the American Medical Association, American Academy of Pediatrics, American Psychiatric Association, American Academy of Child & Adolescent Psychiatry and World Professional Association of Transgender Health.

But is it possible to have a conversation about the effects of this care – i.e. the potential for miscellaneous health risks such as cardiovascular disease – while also still supporting its use?

Experts say that gender-affirming care should be treated like any other form of medicine; there is room for discussion and debate on methods of treatment, but not on the validity of the care to begin with.

"In any medical field, we're continuously improving the care, changing the care, developing new guidelines, developing research," says Dr. Ximena Lopez, a pediatric endocrinologist in California. "So it should not be a surprise that it's the same in gender care."

But, Lopez adds, "I am worried that this politicized environment has limited our capacity to debate like we would in any other medical field." She's concerned the fear of being labeled transphobic – even though some people are not questioning the need for the care, just the methods of going about it – has made some afraid of speaking out.

What is gender-affirming care?

Gender identity is a spectrum, according to experts; someone who is born with male or female sex characteristics may actually be another gender. These people require care as they navigate their identities. This care saves lives, according to The Trevor Project.

Gender-affirming care includes everything from talk therapy to hormone therapy to surgical intervention; it's not a one-size-fits-all method. Keep in mind that transgender adults make up less than 2% of the U.S. population; about 5% of young adults identify as transgender or nonbinary.

Many are hung up on consequences of gender-affirming care – questions about bone density, the small possibility people might regret said care – despite studies consistently showing its safety. People must weigh risks with the reality: trans youth who have access to care are 73% less likely to be suicidal, according to a 2022 American Medical Association study.

"Even if we don't know all of the long-term effects, we know that in both the short-term and the long-term, receiving gender-affirming care, has huge benefits that, as we know it, outweigh the possible risks of receiving gender-affirming care," says Delia Sosa, a medical student living in the Midwest.

Debates continue in the field about what type of mental health care should accompany medical intervention. "There are people in the field that actually think that is a barrier to care, because there's not enough resources of mental health providers with expertise in the world," Lopez says.

'It's frustrating'

Talk to actual trans people, and you'll hear the same exhausted sigh when you bring up conversations about gender-affirming care efficacy. "The social and political parts of my trans identity are way more important than the 'medicalized part,'" says Carson Hartlage, an MD-PHD student in Ohio. "It's frustrating that is all what's focused on."

Many just have trouble accepting what they don't know: "People are so hung up on the fact that trans people who are taking gender-affirming hormone therapy or getting gender affirming-surgery, are doing something that depending on what they're getting, can permanently alter their bodies in a way that doesn't align with the constructed gender binary that exists in our society," Sosa says. "And I think that's really hard for people to wrap their minds around when they haven't had that lived experience."

The truth is "there's never going to be enough data" to satisfy those who disapprove of the care, says Vivian Topping director of advocacy and civic engagement at Equality Federation.

'Why are we so hyper-focused on this one group of people?'

When trying to hold productive conversations about gender-affirming care, it's important to lead with the facts: the care is safe, even if questions linger about how some patients might fare over time. "There's a very big difference between saying that we need more evidence in order to move forward, and we need to move forward in order to learn more," says Alex Sheldon, executive director of GLMA, an organization of health professionals advancing LGBTQ+ equality. "The former suggests that we require additional proof as a prerequisite for taking action. In contrast, the latter really emphasizes the importance of taking initial steps, maintaining access to care, while remaining open to gaining further knowledge as we progress."

It's not like patients are treated willy-nilly, either, where everyone who wants hormones walks in and suddenly gets them. "We need to take a step back from acknowledging yes, they might have side effects, but that's why they're not done so flippantly," says Dr. Ramiz Kseri, assistant professor in the department of clinical sciences at Florida State University College of Medicine. "That's why there is conversation about it, there is discussion, in terms of which outcomes are desired, and which outcomes are not desired."

Replace "gender-affirming care" with the way we discuss treatment for any type of disease. Hypertension. Diabetes. "There's a lot of unanswered questions in medicine, yet, we still go ahead and treat people," says Dr. Jonathan Appelbaum, chair of the department of clinical sciences at Florida State University College of Medicine.

One area where research lacks evidence is what happens when people suddenly lose access to the hormones they've been taking. The existing evidence about maintaining access to care suggests it would be very harmful to young people, according to Sheldon.

Remember, too, that it's not just transgender people taking hormones. Others take them too for all kinds of reasons, such as estrogen supplementation for those with PCOS. To that end, Sosa wonders why people are so focused on this community – especially kids: "What is the problem with transgender kids taking these medications? If we know that they're effective in kids who aren't trans, and we know that they're relatively safe in kids who aren't trans? What's the problem with trans kids specifically? Why are we so hyper-focused on this one group of people?"

Perhaps that's the real question worth answering.