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Dr. Meredithe McNamara: Gender transition in young people

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Some states are prohibiting minors from receiving medical care related to gender transition, or imposing other restrictions such as limiting transgender children’s participation in sports, their use of bathrooms or locker rooms, or any discussion of pronouns in schools.

On Thursday, June 8, 2023, SciLine interviewed: Dr. Meredithe McNamara, an assistant professor of pediatrics at Yale University. She discussed topics including: how these types of restrictions affect the mental health of transgender young people; how children develop a sense of who they are, including their gender identity; what exactly is involved in transition-related medical care for young people; scientific misinformation that is being included in policy debates relevant to transgender young people; what is known about outcomes for people who undergo any type of gender transition during childhood or adolescence.

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MEREDITHE MCNAMARA: My name is Meredithe McNamara, I am an assistant professor of pediatrics at the Yale School of Medicine, and I specialize in adolescent medicine. I provide clinical care for youth aged 11 to 25. And I also study the various factors that contribute to their health and well being.


Interview with SciLine

What is gender dysphoria?


MEREDITHE MCNAMARA: Gender dysphoria is a specific term in the DSM-5. It is a psychological term that describes the intense distress that emerges from a difference between one’s sex assigned at birth and one’s gender identity.

Some states are restricting minors’ access to medical care related to gender transition. How do such policies affect the mental health of transgender young people?


MEREDITHE MCNAMARA: They’re very harmful to the mental health of trans and gender-diverse young people. The intrusion of legal interference in standard health care is not something that we’re really used to. This is a brand new and dangerous force that’s infiltrating not only our health care but also our social networks. Young people are paying attention. It’s really causing a lot of existential dread. I see this in my clinical practice and in talking to colleagues throughout the country. And beyond just kind of like the widespread harms of these bans affecting everyone, within the jurisdiction of these bans themselves, they deprive young people of life saving health care that affirms who they are.

What is involved in transition-related medical care for young people?


MEREDITHE MCNAMARA: There are various paths that one might pursue, and every path is dependent on the individual. So, there are medical aspects of gender-affirming care that can be thought of in the reversible sense and then in the irreversible sense. Reversible treatments for gender dysphoria include puberty blocking medications to pause distressing physical change in youth who are undergoing puberty and may also include menstrual suppression—to put a pause on menstruation—which can be quite dysphoria inducing. There are other treatments, like the use of sex hormones—estrogen and testosterone—taken in a medication formulation, meaning not what the body makes itself. Taking those hormones can lead to appearance congruence, meaning that one’s identity is in alignment with how they look and then how they feel. Various aspects of those medications have been studied in a lot of different ways and have been shown to be beneficial to the mental health, social functioning, and overall well being of trans youth.

What can you tell us about the timeline and process before a young person’s medical transition can take place?


MEREDITHE MCNAMARA: This is a slow, individualized, and iterative process that happens over a long period of time. And that amount of time varies person to person and family to family. So, the clinical practice guidelines that we use from the World Professional Association for Transgender Health and the Endocrine Society call for exactly what I described, that staged iterative approach with multidisciplinary providers—mental health providers, physicians, social workers, involvement of families—and it takes time to clarify somebody’s gender goals. It takes time to have discussions that feel satisfactory to everyone involved. Being rushed into treatment is not something that is standard practice whatsoever. And I can just tell you from my personal experience, that this is something that patients and families welcome, too, because they want that time to make the right decisions and to feel safe and supported along the way.

What is involved in social transition?


MEREDITHE MCNAMARA: Social transition is again a very individualized thing people want to try to express themselves in very self-determined ways to align their livelihoods with their gender identity. So that might mean a haircut, changing the clothing style that they wear, adopting a chosen name, and using pronouns that align with their identity. Notably, social transition is not medical care. It’s not something that a physician prescribes. But it can be a very powerful factor in supporting a trans young person’s well being.

Can you describe any scientific disinformation included in policy debates relevant to transgender young people?


MEREDITHE MCNAMARA: Claims that emphasize that therapy, for instance, is an appropriate, solo treatment for trans youth who qualify for medical treatments based on a diagnosis of gender dysphoria are not based on any evidence whatsoever, but more so they’re really rooted in disbelieving that trans identity or gender dysphoria even exists—that’s akin to conversion therapy, which we know is distinctly harmful, in which many states in this country have taken measures to ban. There are other false claims about gender dysphoria, like social contagion, or identity spreading rapidly among peers. It’s never been shown to be true in the science. Other areas of disinformation—so, false claims about the safety of these treatments—I could I could run through some of those, but again, I don’t want to amplify the disinformation. Gender-affirming care is safe, and patients and parents who consent to this care have long, iterative discussions about the risks and benefits of the care and then they make an informed decision themselves.

What does scientific evidence show about the effects of transition-related care for transgender adolescents who qualify for it and want it?


MEREDITHE MCNAMARA: At this point, we are at nineteen studies and growing that show the benefits of gender-affirming care. With every new study, we’re learning more about the nuances of those benefits. These studies are getting larger, spanning longer periods of time, spanning multiple centers throughout the country. And what we’re seeing is that medical aspects of gender-affirming care, such as puberty, blocking medications, and estrogen or testosterone, lead to appearance congruence, which means that one’s external appearance feels aligned with their sense of self, with their identity, and that appearance congruence supports various aspects of mental health and well being. For a trans adolescent, this means improved social functioning, feeling more confident in their friendships, doing better in school, high school graduation, college enrollment, all of the things that cisgender youth kind of don’t deal with any extra obstacles about. And I think most importantly, it’s about mitigating the harms of depression and anxiety, non-suicidal self injury, suicidality, that that are so common in trans youth who don’t access this care. We have ways to prevent those discrete and tangible harms. And it’s with medical aspects of gender-affirming care for those who qualify and want it.

What is known about continued care for people who undergo any type of gender transition during adolescence?


MEREDITHE MCNAMARA: We know that the overwhelming majority of minors who receive medical aspects of gender-affirming care continue this care in adulthood—something like a 98% continuation rate—which really is just kind of astounding when you consider a lot of other medical treatments that youth undergo. I don’t have the hard data in front of me, but I think that’s much higher than you know, for diabetes or chronic medical conditions.

What health inequities exist among transgender young people?


MEREDITHE MCNAMARA: Trans people of color face some of the worst health outcomes in general in our country. They are overwhelmingly targets of hate and violence and their stories cannot be told enough. There are many different barriers to care that people of color deal with that white trans youth deal with less so. So, people of color tend to live in under-resourced areas without access to gender clinics. They tend to have more insurance issues, they may face more resource deprivation in their home and educational settings, more discrimination, and more complex trauma for other reasons that are not directly related to their gender identity. So, they’re a very kind of like delicate group of patients that deserve the extra mile when it comes to care. And these bans undoubtedly harm them the most.

How are reporters doing covering gender transition in young people?

[Posted June 8, 2023 | Download video]