Medical Guidelines at Odds With Public Policy: Should There Be a Minimum Age for Gender Transition?

Crowd of people on opposite end of seesaw to transgender symbol
A highly publicized custody dispute in Texas has garnered attention from medical societies and policy makers alike.

A custody dispute in Coppell, Texas, is poised to become the next legislative battleground between the transgender community and politicians.

Numerous media outlets have covered this custody faceoff.1,2 At its center is a transgender girl, Luna Younger, whose mother, pediatrician Anne Georgulas, sought to modify a custody arrangement with father Jeffrey Younger amid his claims that his ex-wife would “chemically castrate” their child.3

The case has garnered interest in everyone from Texas Governor Greg Abbott, who tweeted that “the matter of 7 year old James Younger is being looked into” by both the Texas Attorney General’s office and the Texas Department of Family and Protective Services, to Senator Ted Cruz, who described the use of “life-altering hormone blockers” in a young child as “nothing less than child abuse,” to the Endocrine Society, which released a statement urging policymakers to follow science when it comes to transgender health.4

“The Endocrine Society’s Clinical Practice Guideline…recommends avoiding hormone therapy for transgender children prior to puberty,” the press released noted, adding that the guideline had been cosponsored by several prominent medical societies focused on endocrinology in the United States and abroad.4 “As noted in our evidence-based guideline, transgender individuals, both children and adults, should be encouraged to experience living in the new gender role and assess whether this improves their quality of life.”4

Until the late 20th century, the general consensus in the medical community was that transgender or gender-incongruent patients were living with gender identity disorder, a mental health condition asserting that gender identity was “malleable and subject to external influences.”5 Recent scientific advances, however, have demonstrated a robust biological element to gender identity, confirming that although transgender people may make decisions based on a number of factors, external forces do not cause individuals to change their gender identity.5

A substantial body of research also supports that, although the specific mechanisms and biologic underpinnings are not fully understood, being transgender is not a mental health disorder.5

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This evidence stems from several types of research, according to the Endocrine Society position statement.5 Investigators who conducted studies of intersex patients found that, in general, attempts to match gender identity to either external genitalia or chromosomes were typically unsuccessful.5-7 In addition, researchers who studied twins demonstrated that identical twins were more likely to both experience transgender identity compared with fraternal twins.5,8 Other research suggests that for people with female chromosomes, rates of male gender identity are higher in those who are exposed to elevated androgen levels in utero vs in those without such exposure.5,9

Published in 2017, the most recent edition of the Endocrine Society’s guidelines10 concluded that gender affirmation is a multidisciplinary treatment in which endocrinologists play a key role in concert with mental health providers and other clinicians. When gender-dysphoric patients seek endocrinology care, they should be provided with a safe and effective treatment plan based on several factors, including the patient’s age and pubertal status.10

This means that prepubertal patients — like Luna Younger — would not be eligible for what many of Mr Younger’s supporters assume is simply being prescribed hormones.