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Delaying Gender-Affirming Treatments in Teens During Covid: What to Consider

Written by Evolve's Behavioral Health Content Team​:

Alyson Orcena, LMFT, Melissa Vallas, MD, Shikha Verma, MD, Ellen Bloch, LCSW, Lianne Tendler, LMFT, Megan Johnston, LMFT Meet The Team >

Gender-Affirming Treatment for Transgender Teens

When the coronavirus pandemic arrived in the U.S. in March 2020, we all quickly became aware of a variety of new phrases. We couldn’t avoid them. Print, TV, mobile, and online media repeated them daily, over and over, in all our public discourse regarding COVID-19. We learned about:

  • Shelter-in-place orders
  • Social distancing
  • Hand hygiene on a new level
  • Masks
  • Vulnerable populations
  • Essential and non-essential services
  • Essential and non-essential trips/travel

Many of us also learned a new way of working: online, from home. Our children had a similar experience: they learned how to go to school online. They also learned that a long list of the things they considered essential in their lives were no longer essential. Instead, they had to accept the fact that participating in these activities increased risk of exposure and illness, not only for them, but for friends and loved ones.

For most students, this meant everything fun outside the classroom – social lives, extracurricular activities like sports, music, clubs, and other special interests – were put on hold for the better part of a year. This had a significant impact. We should remember that for some teens, extracurriculars are the highlight of their days, weeks, and years. They make it through classes with one thought on their mind: get to the afternoon when the fun stuff starts. The absence of these activities was hard and took a toll on their emotional health as much as stress about coronavirus itself.

For many LGBTQI+ adolescents, these restrictions had an additional negative impact: they removed their go-to safe space. This hit transgender teens whose families did not support their gender identity hard. And families who support their teen’s non-conforming identity one hundred percent faced another question:

Is gender-affirming treatment essential?

The rest of this article addresses this question, beginning with a discussion of what, exactly, gender-affirming treatments are.

What Are Gender-Affirming Treatments?

For transgender people, health professionals divide gender-affirming treatments into two categories: physical and psychological. We’ll expand on those two categories now, beginning with physical gender-affirming treatments.

The University of California, San Francisco identifies the physical gender-affirming treatments for transgender people as follows:

Gender-Affirming Treatments: Physical

  • Nonsurgical medical interventions such as hormone therapy. This is the first gender-affirming medical treatment most transgender seek. Hormone therapy increases the presence of secondary sex characteristics that coincide with an individual’s lived gender identity.
  • Surgical medical interventions that include:
    • Feminizing procedures for genitals, chest, face, and voice. Feminizing procedures may include reducing the size of the male tracheal cartilage (Adam’s apple).
    • Masculinizing procedures for genitals, chest, face and voice.

These physical treatments are an important step toward total health and wellbeing for transgender people who want a complete transition. They decrease the complications of gender dysphoria, which includes psychological and behavioral symptoms related to depression, anxiety, alcohol and substance use disorder (AUD/SUD), self-harm, suicidal ideation, and suicidal behavior.

The relationship between lived gender identity and mental health is of critical importance to a transgender person. We’ll address psychological gender-affirming treatments now.

The American Psychological Association (APA) and The Trevor Project identify the core elements/topics of the psychological component of gender-affirming psychotherapy, typically addressed using cognitive behavioral therapy (CBT) or dialectical behavioral therapy (DBT), as follows:

Gender-Affirming Treatments: Psychological Topics

  • Trauma
  • Depression
  • Anxiety
  • Self-harm
  • Suicidal ideation
  • Suicidal behavior
  • Alcohol use disorder (AUD)
  • Substance use disorder (SUD)
  • Coming out
  • Sexuality
  • Living a transitioned gender identity

A paper published last year called “You Have to Wait a Little Longer”: Transgender (Mental) Health at Risk as a Consequence of Deferring Gender‑Afrming Treatments During COVID‑19 summarizes the importance of gender-affirming treatments for transgender people:

“The incongruence between gender identity and physical characteristics results in experienced dysphoria and severe mental health problems in a considerable share of this group…Gender-affirming treatments have repeatedly been shown to improve physical and mental health of [transgender] adults as well as in youth.”

It’s clear that gender-affirming treatment is important for transgender teens. However, many families wrestle with the question posed in the first section of this article. They understand it’s important – but is it, indeed, essential?

The Consequences of Delaying Gender-Affirming Treatment

The paper we cite above – “You Have to Wait a Little Longer” – discusses the negative impact of delaying gender-affirming treatment for transgender teens and adults. Like the treatments themselves, the negative consequences manifest in two categories: physical and psychological.

We’ll list the negative physical consequences first.

Physical Consequences of Delaying Gender-Affirming Treatment

  • Interruption or suboptimal gender-affirming hormone doses “can increase the chance of developing osteoporosis or cardiovascular disease.”
    • If an individual initiated hormone therapy before the pandemic, and had that therapy interrupted by the pandemic, then this may be a serious problem.
  • Interruption of, or limited follow-up care after surgery can result in issues related to voiding (e.g. using the restroom) and increase the chance of needing repeat surgeries
  • Chronic stress due to delayed surgeries – which can exacerbate gender dysphoria – can have a negative impact on immune function, which can increase general health risk for transgender people

Now we’ll list the negative psychological consequences of delaying gender-affirming treatment.

Mental Health Consequences of Delaying Gender-Affirming Treatment

Delaying gender-affirming mental health treatment for gender dysphoria and other mental health issues among transgender teens can increase:

  • Anxiety
  • Depression
  • Feeling of isolation
  • Hopelessness
  • Self-medication
    • Alcohol use
    • Substance use
  • Self-harm
  • Suicidal ideation
  • Suicidal behavior

When we compare this list of the negative consequences of delaying treatment, we see it’s almost an exact match with the key topics addressed by mental health support for transgender people as described in the list provided by the APA. That means delaying treatment has a negative impact on everything a transgender person most often needs support for. Again, we’ll allow the authors of the “You Have to Wait a Little Longer” paper to summarize:

“Taking all those different aspects of mental health [into account], the deferral of gender-affirming treatments, and all the potential impacts into consideration, individuals will likely be suffering from a cumulative mental health burden during this global pandemic.”

In other words, the primary things to consider when parents of a transgender teen delay gender-affirming treatment are the psychological components. That’s where both the medical treatments and the psychotherapeutic treatments dovetail.

We’ll discuss that now.

Psychological Treatment is Essential

While the pandemic has caused many transgender people to delay medical treatments because of various rules and policies related to insurance benefits and coverage, CNN reports that a diagnosis of gender dysphoria – as a mental health disorder – means psychological gender-affirming treatment is a medically necessary, essential treatment.

To be clear, being transgender is not a mental health disorder. However, gender dysphoria is a mental health disorder. Many of the mental health disorders common among LGBTQI+ youth are, as well, including depression, anxiety, and alcohol/substance use disorders.

Therefore, decisions about whether to delay mental health treatment and support for transgender teens rest squarely on the shoulders of parents. Now that vaccines are available, and boosters for teens 12-15 are becoming available, parents must weigh the risks of their teen contracting COVID-19 against the risks of delaying gender-affirming mental health treatment.

A detailed discussion of the risks of contracting COVID-19 as a teenager are beyond the scope of this article: we’re medical professionals, but we’re mental health professionals, rather than experts in infectious disease and viruses. Please refer to the Centers for Disease Control (CDC) for the latest advisories, updates, and safety policies and procedures.

We can discuss the risks of delaying psychological treatment, though, as we have during this article. We’ll recap those risks again.

Delaying Gender-Affirming Treatment: Risks

  • Decreases:
    • Overall mental health and wellbeing
    • Sense of belonging
    • Self-esteem
    • Development of coping skills
    • Access to social and peer support
  • Increases symptoms of:
    • Depression
    • Anxiety
    • Alcohol use
    • Substance use
    • Self-harm
    • Suicidal ideation
    • Suicidal behavior

COVID-19 is a serious disease, not to be taken lightly. The consequences of delaying gender-affirming treatment are serious, too. We understand that this is not an easy decision to make. Parents of transgender teens should know that if and when they do decide not to delay, but to seek gender-affirming treatment for their transgender teen, we’ll be ready to welcome them with open arms. Our mental health services are essential. We’ve been open for the entire pandemic, and we’ll remain open to support LGBTQI+ teens for the duration of the pandemic, however long it may last.

Finding Help: Resources

If you’re seeking treatment for your teen, please navigate to our page How to Find the Best Treatment Programs for Teens and download our helpful handbook, A Parent’s Guide to Mental Health Treatment for Teens.

In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) is an excellent resource for locating licensed and qualified psychiatrists, therapists, and counselors in your area. Both the National Institute of Mental Health (NIMH) and the National Alliance on Mental Illness also provide and high-quality online resources, ready and waiting for you right now.

Our Behavioral Health Content Team

We are an expert team of behavioral health professionals who are united in our commitment to adolescent recovery and well-being.

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