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What is gender-affirming health care? The Missouri GOP is dead set on limiting it

The sign on top of St. Louis Children's Hospital in the Central West End is lit up at dusk.
Brian Munoz
St. Louis Public Radio
The Washington University Transgender Center at Children's Hospital in St. Louis is one of the only places in the region that provides gender-affirming care to people under 18.

Missouri Republicans in recent months have attacked health care options for transgender minors in the state, launching legislative, investigative and media campaigns to drastically curtail gender-affirming care in the St. Louis area.

Legislators in the Senate last month passed bills to bar children under the age of 18 from receiving puberty blockers or hormone treatments. House GOP leaders have said passing their own version of the legislation will be a priority in the waning weeks of the legislative session. Trans minors and their parents are bracing for those bills to become laws.

Also last month, Attorney General Andrew Bailey announced plans to issue temporary restrictions that would prevent doctors and other clinicians from providing gender-affirming medical treatment to minors unless they met several stringent requirements, including prohibiting care for patients with mental health problems.

Bailey and U.S. Sen. Josh Hawley, both Republicans, have launched investigations into one of the only clinics in the region to provide such care. The efforts followed the publication of an op-ed essay by the Free Press and a sworn affidavit by a former caseworker at Washington University Transgender Center at Children’s Hospital, alleging the center overlooked mental health needs of patients and did not inform adolescents and their parents of potential side effects of treatment. Transgender patients and medical professionals say those descriptions don't match their own experience at the center.

As the campaigns against gender-affirming care are pressed across the nation, often lost is an explanation of what it entails. Here are some basics:

What is gender-affirming care?

Gender-affirming care includes a variety of medical and mental health care treatments and social support for people whose sex at birth doesn’t match their perception of themselves.

The practice is supported by major professional medical associations including the American Academy of Pediatrics, the American Medical Association and the American Psychiatric Association, among dozens of others. Studies show gender-affirming care is correlated with lower risks of suicidal thoughts and depression. 

“There is a limited but growing body of evidence that suggests that using an integrated affirmative model results in young people having fewer mental health concerns whether they ultimately identify as transgender," according to a 2018policy statementfrom the American Academy of Pediatrics. 

For Tony La Mantia, who told his parents he was a transgender boy when he was 12, gender-affirming care looked like wearing men's clothing and using different pronouns around his Webster Groves home. He eventually came out at school, and after years of therapy and visits to doctors, he began taking testosterone hormone treatment at 16. That deepened his voice and allowed him to grow a mustache. At 18, he had surgery to remove his breasts.

La Mantia changing his name and clothing, taking hormones and undergoing surgery are all examples of gender-affirming care.

Because everyone’s perception of their gender is different, care plans won’t look the same, said Jason Rafferty, a pediatrician who wrote the American Academy of Pediatrics policy statement on gender-affirming care.

Some transgender people may only want to transition socially, without medical interventions or procedures. Common types of medical interventions that trans people seek include:

  • Hormone therapy — administering testosterone, estrogen or other sex hormones through patches, gels or injections.
  • Puberty blockers — medications that delay the onset of physical developments in prepubescent children .
  • Top surgery — removing or constructing breasts.
  • Bottom surgery — reconstructing genitalia.

Some transgender people seeking medical interventions may only be interested in one or two of those treatments. “A lot of trans men that I know only want hormones; a lot of trans men I know, maybe only want a mastectomy,” said E.H., a trans man from south St. Louis who began transitioning in his teens. St. Louis Public Radio is not using his full name because he fears discrimination.

“Gender-affirming care can mean so many things,” E.H. said. “It can mean just changing your pronouns, it can mean just changing your name. When it comes to actual medical transitions. There is a whole world.”

E.H. is one of the many Missourians who have faced a barrage of anti-transgender legislation — including attacks on access to gender affirming care. St. Louis Public Radio is not using his full name because he fears discrimination. He was photographed Friday, March 31, 2023, at St. Louis Public Radio’s headquarters in Grand Center.
Brian Munoz
St. Louis Public Radio
E.H. is one of the many Missourians who have faced a barrage of anti-transgender legislation — including attacks on access to gender-affirming care. St. Louis Public Radio is not using his full name because he fears discrimination.

What is the Wash U trans center? What happens there?

The Washington University Transgender Center at Children’s Hospital in St. Louis that opened in 2017. It’s one of the only places in the region that provides gender-affirming medical care to people under 18. Endocrinologists and adolescent medicine doctors opened the clinic after observing an increase in young people seeking treatment.

The center will accept new patients until they’re 18 and will treat existing patients through their early 20s.

The center offers a spectrum of care to kids and teens, including birth control, puberty blockers and hormone replacement therapy. According to the center’s website, the clinic offers surgical treatment to people 18 and older.

The center also offers legal advice, voice therapy, community education and referrals to therapists and other mental health specialists. The center’s stated goal is to not sway patients to move from one gender identity to another or push people to transition. Wash U did not make someone available for an interview for this story.

Wash U officials said in February that they were alarmed by allegations of misconduct and descriptions of care at the clinic by Jamie Reed, a former case worker at the center, and would investigate those claims.

“Our highest priority is the health and well-being of our patients,” the Wash U statement read. “We are committed to providing compassionate, family-centered care to all of our patients and we hold our medical practitioners to the highest professional and ethical standards.”

‘There is nothing that I would change about being trans’
Gender-affirming care gave 22-year-old Joey Borrelli a chance to decide how he would transition during his teen years. Borrelli and his mother, Susan Halla, discuss their experience with gender-affirming care in this "St. Louis on the Air" episode.

What are the best practices for providing gender-affirming care for minors?

The World Professional Association for Transgender Health, an international organization of doctors and medical providers that treat transgender patients, distributes widely used guidelines considered by many to be the gold standard for providing gender-affirming care. Many providers that treat transgender patients say they consult these guidelines, though the Wash U clinic does not publicly say if the guidelines are used at the St. Louis center.

The association’s standards for children receiving care call for providers to not discourage kids from expressing their gender identity and recommend that children explore their gender expression through clothing and other social transitions. The standards also recommend providing therapy and supplying families information about potential medical interventions and their benefits and risks.

Once children begin puberty, the association’s standards say medical interventions are recommended when a person has sustained gender dysphoria or gender incongruity over time. A patient should be mentally and emotionally mature and able to provide informed consent for treatment, the standards say.

“It's quite clear that this is not something that you just wake up one day, walk into a doctor's office and get,” said Dr. Maddie Deutsch, the president of the association’s U.S. chapter and one of the dozens of authors of the latest guidelines. “I'll say that if there are clinics that are doing that, then they're doing it wrong.”

Once patients reach their mid-teens, they can potentially receive hormones with a doctor’s referral. Doctors say it’s rare to perform any kind of surgery on patients before they’re 18.

But Deutsch explained the standards of care are guidelines, not rules. Even people within the medical community sometimes disagree about whether they’re the best course to take.

Both the World Professional Association for Transgender Health and American Academy of Pediatrics have stopped short of prescribing appropriate ages or other concrete standards for different procedures. Such benchmarks can seem arbitrary, said Rafferty, the AAP pediatrician. “Instead, what we’ve emphasized is really the need to assess the physical readiness, cognitive readiness and emotional readiness of the child.”

Some critics say medical models of care can actually create more barriers to treatment that make health worse for transgender and gender nonconforming people.

“I’ve seen too many transgender people get turned away from hormones for being, ‘too depressed’ or ‘too anxious,’ when so much of that is tied in with our dysphoria, or the discrimination we face in our day to day lives,” said Jess Jones, who runs a consultant business that educates organizations about transgender issues.

Experts say they’d like to see more research that looks at the relationship between mental health and gender-affirming care and how those who receive it fare over their lifetimes.

“We know cross sectionally pretty well, at this point, that there's a relationship, it's pretty consistent across almost all studies,” said Jeremy Goldbach, a clinical social worker and a professor at Washington University's Brown School. ”What we what we still are trying to understand is the exact relationship over time.”

Antonio La Mantia, 19, holds his hands during an interview on Wednesday, March 29, 2023, at his family’s home in Webster Groves. La Mantia is one of the transgender Missourians who is questioning whether or not to stay in the state after a barrage of anti-trans legislation in Jefferson City.
Brian Munoz
St. Louis Public Radio
Tony La Mantia, 19, sits during an interview in March at his family’s home in Webster Groves. La Mantia is one of the transgender Missourians who is questioning whether to stay in the state after a barrage of anti-trans legislation in Jefferson City.

What does it take to get treatment as a minor?

St. Louis-area patients who received gender-affirming treatment as minors say they’re confused when they hear accusations that patients have been rushed through treatment:

“It took years to get some of the things I wanted. And so I was just kind of shocked when they were like, ‘it was very easy,’” Tony La Mantia said. “Even with everybody being supportive of my transition, it was an incredibly difficult process to get through.”

La Mantia said he went through years of therapy and even put a pause on medically transitioning to focus on treating other mental health issues before having hormone replacement therapy.

Because of a limited number of doctors who provide transgender care to minors, many patients wait months to get into the clinic

Joey Borrelli, who grew up in St. Louis, started taking hormones just before his 17th birthday, more than a year after he came out to his parents.

Not everyone can afford the costs and copays of multiple medical appointments, Borrelli said, which puts up another barrier to obtaining treatment quickly. He’s seen people on GoFundMe and other fundraising sites asking for money to finance health care.

“Do our politicians really think that people are going and getting medical care for fun all willy-nilly?” Borrelli said. “Months and months of therapy? Are you serious?”

Borrelli also had to wait months to get his treatment approved by doctors, therapists and insurance companies. Borrelli said he had to acknowledge the risks of every procedure before receiving treatment.

Sarah Fentem is the health reporter at St. Louis Public Radio.