On Wednesday, the Supreme Court will hear arguments in a case involving Tennessee's ban on gender-affirming care for transgender people under age 18.
At least 26 states have adopted laws restricting or banning such care for minors, and most of those states face lawsuits.
The nation's top court will be weighing whether Tennessee's law violates the equal protection clause of the 14th Amendment, requiring that people in similar circumstances be treated the same under the law. Both sides in the case claim they are acting to protect minors from harm.
Gender-affirming care is supported by the American Medical Association, the American Academy of Pediatrics and other medical groups. Here's a look at what's typically involved:
Evaluation and diagnosis happen first
Young people who persistently identify as a gender that differs from their sex assigned at birth are often referred to clinics where teams from various medical specialties provide gender-affirming care.
Such care begins with an evaluation, which can include a pediatrician and a mental health specialist who assess the degree of distress, if any, the young person is experiencing.
Those who meet defined criteria may be diagnosed with what's called gender dysphoria if their distress is continuous and significant.
Some young people and their families may decide to try a social transition involving a new hairstyle, clothing, name or pronouns. Experts agree that allowing children to express their gender in a way that matches their identity is beneficial.
Chazzie Grosshandler, 18, of Chicago, said she was 9 years old when she told her parents she was a girl and "not just a boy who likes girly things." She started receiving care two years later.
"The first-ever step of gender-affirming care for me was when I told my parents that I was a girl and that I had felt this way for a long time and that they accepted me," she said. "I think people get really confused when they hear the word 'care' that it has to be something medical. But the truth is that it's more than just medical. It's love and acceptance."
Puberty blockers can be a next step
A subset of young people may be offered additional interventions such as puberty blockers to ease distress and give them time to explore their gender identity.
The drugs, known as GnRH agonists, block the release of key hormones involved in sexual maturation. They've been used for decades to treat precocious puberty, an uncommon medical condition that causes puberty to begin abnormally early.
The medication starts after a young person show early signs of puberty — enlargement of breasts or testicles. This typically occurs around age 8 to 13 for those assigned female at birth and a year or two later for those assigned male at birth.
The drugs can be given as injections every few months or as arm implants lasting up to a year or two. Many of the effects are reversible — puberty and sexual development resume as soon as the drugs are stopped. Researchers are exploring the effects of puberty blockers on bone development, but no research has shown an increased risk for bone fractures.
Young people can stay on puberty blockers for several years.
Some transgender youth may take hormones
After puberty blockers, trans adolescents go through puberty either with or without hormone treatment.
Some may choose to take hormones to make their bodies more closely match their gender identity. They take manufactured versions of either estrogen or testosterone — hormones that prompt sexual development in puberty. Estrogen comes in skin patches and pills. Testosterone is available in injections, implants or gels.
Guidelines recommend starting these when teens are mature enough to make informed medical decisions. Many transgender people take the hormones for life.
If the medication is stopped, some physical changes remain. Testosterone generally leads to permanent voice-lowering, facial hair and development of the Adam's apple. Estrogen can lead to permanent breast development.
Research on long-term hormone use in transgender adults has found potential health risks including a modest risk for blood clots with estrogen and negative cholesterol changes with testosterone.
Surgery is rare
Gender-affirming surgery in transgender teens is far less common than hormone treatment. When it is done among transgender youth, it's almost always breast reduction surgery in older transgender males.
Even so, that type of surgery is extremely rare. Perhaps surprisingly, breast reduction among minors is most frequently performed in males who are not transgender. This is for a condition called gynecomastia, which means having more breast tissue than usual.
A study looking at millions of 2019 insurance claims found 151 breast reductions performed for U.S. minors. Nearly all — 97% — were not transgender.
Hormones and well-being
Research suggests that transgender youth are prone to stress, depression and suicidal thoughts. Some studies suggest treatment for gender dysphoria can improve young people's well-being, but some nuances remain unclear.
In one study, researchers spent two years testing and tracking 315 transgender youth who received hormone therapy. Depression and anxiety symptoms eased and life satisfaction increased among those designated female at birth, but not among those designated male at birth. The researchers speculated that the youth designated male at birth might be more affected by stress from being different from most of their peers.
In the same study, published last year in the New England Journal of Medicine, two participants died by suicide — one after six months and the other after a year.
Longer term studies on treatment outcomes are underway.
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