Trans Youth With Access to Early Medical Care Have Better Mental Health Outcomes

Youth with gender dysphoria have better mental health outcomes when they can access gender-affirming medical care, like hormones or puberty blockers, earlier, according to a new study.

The research, published in Pediatrics, found that youth with gender dysphoria—or distress caused by having a different gender identity than the one assigned at birth—who received gender-affirming medical care at a later age had more mental health problems than those who received care earlier.

"In particular, being in the late stages of puberty upon presentation to care was associated with higher rates of anxiety and depression," says Dr. Julia Sorbara, MD, co-author of the study and a lecturer at the University of Toronto. "Our findings highlight that timely access to gender-affirming medical care is important for youth with gender dysphoria."

A Growing Body Of Evidence

The study was a cross-sectional chart review study, Sorbara explains, which means it analyzed patient charts to identify associations, but not cause-effect relationships, between mental health problems and a patient's age/pubertal stage when they first received gender-affirming medical care.

Researchers examined the charts of 300 youth, who were classified as younger-presenting youth under 15 years of age or older-presenting youth aged 15 or older. They found that "older age and later pubertal stage at the time of presentation to [gender-affirming medical care] are associated with increased rates of psychoactive medication use and increased rates of mental health problems...respectively," researchers wrote.

The results show that youth with gender dysphoria who can't access care until later in puberty "are a particularly high-risk subset of a vulnerable population."

"It has been well described that mental health problems are common among youth with gender dysphoria," Sorbara says. "Our findings add to this literature, suggesting that distress may be especially profound among youth who present to gender-affirming medical care at older ages and further along in puberty."

The research adds to increasing evidence that access to gender-affirming medical care is linked to better mental health outcomes for transgender people. A 2020 study of transgender adults 18 and older found that access to puberty blockers during adolescence was associated with a lower risk of suicidality. It also found that approximately nine out of 10 transgender adults who wanted puberty blockers but didn't receive them experienced suicidal ideation at some point in their lifetime.

"Many studies show that gender-affirming medical care provides significant psychological benefit and it is important for youth with gender dysphoria to have timely access to all options from which they might benefit," Sorbara says.

Why Access To Medical Care Impacts Mental Health

Medical care like puberty blockers, which delays the onset of puberty, gives a young trans person time to explore their gender and figure out what's best for them, says Katie Greeley, LCSW, a clinician based in Philadelphia who specializes in providing care for people who are trans, non-binary, and gender expansive.

"If we put that young person on puberty blockers, they're going to have time to process their identity and what feels most authentic to them," Greeley says. If that person doesn't have access to care, then they could experience increased dysphoria from going through puberty as their assigned sex at birth. Dysphoria can increase risk of depression, anxiety, and suicidal ideation, Greeley says.

Medical and behavioral health care providers, as well as health insurance companies and lawmakers in some states, have created many barriers to gender-affirming medical care. For example, some insurance companies require that someone receive psychological counseling for a few months to a year, while also requiring that they live as their gender identity for a certain amount of time before they can receive affirming medical care.

The many barriers to care exist in part because being trans is pathologized, Greeley says, or treated as a mental health condition itself even though it is not. Trans people "are not depressed because they're trans," Greeley says. "They're trans and they're depressed."

"There's so much training, communication, and gatekeeping that occurs between mental health clinicians and medical providers in terms of enabling trans people and especially young people access to care," Greeley says. "We want to help this person explore this identity, help them do so in a way that feels really authentic to them, but also trust that young people experiencing and questioning their gender know what they are doing."