Evolving sociopolitical changes have highlighted the importance and difficulty of providing gender-affirming care (GAC) to transgender and gender-diverse (TGD) individuals. More than ever, there is a critical need for clinician-educators, especially those in child and adolescent psychiatry, to prioritize advocacy and education in GAC provision. As future leaders in the generation of physicians who have learned from and led discussions about GAC, we write to urge our peers to engage in gender-affirming education and advocacy efforts to improve care for our TGD patients. Here, we highlight this critical need and provide examples for advocacy and education across many levels of intervention, from intrapersonal to national contexts.

GAC is a comprehensive approach that encompasses myriad social, psychological, behavioral, and medical interventions to support and validate an individual’s experience of gender. GAC can include social affirmation, like using a person’s chosen name and pronouns, and supporting navigation of legal or institutional barriers to medical interventions like puberty blockers and feminizing or masculinizing hormone therapy, as well as surgical procedures that align physical appearance with gender identity, including chest, genital, facial, and laryngeal surgical procedures. Although gender diversity has been recognized since before the common era, GAC in medicine started in the mid-20th century, and only in the late 20th century did it emerge in adolescent patient populations. The Endocrine Society and the World Professional Association for Transgender Health developed current practice guidelines and standards of care for GAC, which are endorsed by multiple major medical and mental health professional associations nationally and globally.1 These guidelines underscore the importance of interprofessional, interdisciplinary collaboration when caring for the unique physical and mental health needs of gender-diverse youth.

The need for gender-affirming education for physicians and trainees has never been greater. Liu et al2 demonstrate how mental health outcomes in TGD individuals have worsened from 2014 to 2022, reporting a striking and disproportionate increase in the prevalence of frequent mental distress in TGD adults compared to cisgender adults over the 8 years (38.9% of TGD adults compared to 15.5% of cisgender adults in 2022). This trend was also noted in the prevalence of depression, which more than doubled among TGD adults from 2014 to 2022.2 These mental health problems contribute to and complicate the care of TGD youth, emphasizing the need for inclusive care provision. Of note, this study investigates a time when we were trainees in medical school and residency, and during this time, we witnessed significant societal changes. Despite the well-documented and significant mental health challenges faced by this population, medical students and resident and fellow trainees in psychiatry have limited opportunities to learn about GAC in their training. A recent study notes that trainees report a lack of robust clinical experience and paucity of formal didactic curricula in GAC as barriers to gender-affirming education.3

We have been trained as part of a generation where using pronouns has become an essential part of day-to-day interactions, professional meetings, and clinical care settings. We have seen the evolution from a time before LGBTQ+ topics were discussed in educational settings to an environment that has begun to incorporate lectures on these areas in medical education. We have worn pride pins and rainbow lanyards in alliance and solidarity with our communities and with our patients and their families. We have learned how to update medical records to accurately document our patients’ sexes, genders, pronouns, and names. We have led challenging conversations with family members of TGD children and adolescents, navigating these spaces with compassion to facilitate a safe space for disclosure and understanding. We are the generation of learners who have grown up with the increase in discussions about GAC in our clinical training, our communities, and our nation. And yet, the legislation targeting GAC for youth stands in stark contrast to this progress and feels fundamentally misaligned with the direction society and the medical community are moving. Importantly, we have made these strides even within a deeply hostile sociopolitical climate, which reminds us that progress has been made in the face of adversity, and that it can be again.

Despite growing recognition of the importance of GAC, numerous barriers continue to limit access for TGD youth. Since 2021, 27 US states have enacted laws or policies restricting access to GAC, with 7 new policies introduced since 2024, despite clear recommendations from professional societies for collaborative and compassionate care.4 State-level legislation has increasingly targeted both supportive treatments, such as psychotherapy, and medical interventions, including puberty blockers, hormone therapy, and gender-affirming surgical procedures.5 Additional bills have sought to impose stricter parental consent requirements, mandate provider reporting to state authorities, and restrict public funding for GAC, including Medicaid and state-funded insurance coverage.6 Some proposals go further, aiming to defund children’s hospitals, pediatric clinics, and training programs affiliated with institutions that provide GAC.7

Proponents of restrictions on GAC for youth often cite concerns about long-term outcomes and the potential for regret. These arguments have gained traction in part due to recent European reports, most notably the United Kingdom’s Cass Report, which have been critical of youth GAC. However, these critiques have drawn significant pushback from experts who point to methodological limitations, including selection bias, lack of protocol transparency, and limited applicability to today’s more diverse and affirming clinical environments. Additional concerns have been raised about the scarcity of long-term outcome data, the adequacy of informed consent processes, and the integration of psychological care.8,9 Despite these debates, a growing body of high-quality research consistently demonstrates that GAC leads to substantial improvements in mental health for TGD youth. For example, initiation of puberty blockers and/or gender-affirming hormones is associated with 60% lower odds of moderate or severe depression and 73% lower odds of suicidality or self-harm thoughts.10 A large, prospective multicenter study in The New England Journal of Medicine found that over 2 years, transgender and nonbinary youth who began gender-affirming hormones experienced sustained improvements in mental health and well-being, particularly when care was initiated earlier in puberty, with appearance congruence identified as a key driver of these benefits.11

Psychiatry trainees working in health systems are also affected by these policies. The majority already receive limited education on GAC, which often emphasizes the social and cultural nuances of gender identity development, illuminates the disproportionate mental health challenges experienced by TGD youth, and reviews well-established guidelines for the care of these individuals. These legislative efforts, coupled with a paucity of educational opportunities for clinicians, invariably threaten the sociodevelopmental well-being of TGD children and adolescents. As trainees committed to our current and future TGD patients, we urge physicians and health professionals to advocate for and accept GAC as a necessary component of health care and clinical training.

As trainees committed to our current and future TGD patients, we urge physicians and health professionals to advocate for and accept GAC as a necessary component of health care and clinical training. Table 1 illustrates ways for health care providers and trainees to advocate for GAC, ranging from personal steps to public health-level actions, which can be tailored to individual skillsets and capacity. By cultivating supportive environments and recommending appropriate interventions, health care providers can help young patients feel comfortable and confident in their gender identities and substantially improve their mental and emotional well-being. As psychiatry trainees, we have seen that it is crucial to preserve affirming spaces for children and adolescents and advocate for comprehensive medical training. It is our duty, as future and current child and adolescent psychiatrists, to promote education and engage in advocacy efforts related to GAC.

Table 1.Actions Related to Advocating for Gender-Affirming Care by Level of Intervention
Intrapersonal (internal actions)
  • Educating oneself about transgender health, the effects of GAC on physical and mental health, and transgender joy
  • Increasing awareness of how health, social disparities, and structural barriers affect the delivery and receipt of care for LGBTQ+ people, to actively address these disparities and barriers
Interpersonal (actions improving relationships)
  • Using pronouns and gender-inclusive language
  • Empowering LGBTQ+ youth
  • Using gender-affirming trauma-informed approaches
  • Identifying and sharing community resources with children and families
  • Building a collective knowledge base to provide competent and high-quality care
Clinical and institutional
  • Instituting gender- and LGBTQ+-inclusive and nondiscrimination policies
  • Including inclusive language (avoiding gendered terms) in clinical documents and policies
  • Using accurate pronouns, sex, gender, and chosen name on electronic medical records
  • Advertising LGBTQ+ friendly signs and handouts
  • Providing all-gender restrooms; incorporating training for staff at all levels in LGBTQ+ health and GAC
  • Implementing visitation policies allowing for partners/chosen family
  • Identifying barriers and increasing access to GAC
  • Acknowledging and addressing ongoing discrimination
  • Providing protection and support for staff providing GAC
  • Conducting clinical quality improvement projects supporting LGBTQ+ identities and spaces
  • Promoting curricular reform to incorporate GAC
Community
  • Challenging stigma related to GAC bans
  • Advocating for formal LGBTQ+ curricula as part of health care training
  • Providing educational sessions for the community on GAC
  • Advocating for LGBTQ+ spaces and supporting the needs and efforts of LGBTQ+ colleagues, patients, and families
  • Participating in Pride events
  • Volunteering in spaces supporting LGBTQ+ patients
Research
  • Advocating for increased funding for LGBTQ+ and GAC research at the local, state, and federal levels
  • Ethically including LGBTQ+ people in health studies
  • Supporting LGBTQ+ investigators; focusing research efforts on transgender joy
  • Using an implementation science approach to bring results from research into practice
Public health
  • Advocating for state and federal protection of GAC
  • Advocating for access to GAC
  • Advocating for the decriminalization of GAC
  • Advocating for legislation and policies to decrease discrimination and violence against transgender individuals
  • Supporting ongoing insurance coverage for GAC
  • Supporting and protecting GAC in health care settings
  • Supporting gender-inclusive health education

GAC = gender-affirming care.

Plain Language Summary

This article calls on doctors, especially those working with children and teens, to learn about and speak up for gender-affirming care (GAC) for transgender and gender-diverse patients. GAC can include using a person’s chosen name and pronouns, providing counseling, and offering medical treatments like puberty blockers or hormone therapy. Research shows GAC improves mental health and reduces depression and suicidal thoughts. However, many states have passed laws limiting access to such care, and medical training often lacks GAC education. The authors outline practical steps for advocacy at personal, community, and policy levels to ensure all patients receive respectful, evidence-based care.

About the Authors

Julia L. Versel, MD, MSc, Department of Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts, USA; Department of Psychiatry, McLean Hospital, Belmont, Massachusetts, USA.

Sand Mastrangelo, MD, Department of Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts, USA; Department of Psychiatry, McLean Hospital, Belmont, Massachusetts, USA.

Jad E. Hilal, MD, Department of Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts, USA.

Mollie C. Marr, MD, PhD, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Psychiatry, McLean Hospital, Belmont, Massachusetts, USA.

Andrew R. Kittleson, BA, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Correspondence to:

Jad E. Hilal, MD; email: jadhilal@gmail.com, 83 Marlborough St, Apt 6, Boston, MA 02116.

Funding

No funding.

Disclosures

Dr Marr is supported by NIMH R25MH135837. Dr Versel, Dr Mastrangelo, Dr Hilal, and Mr Kittleson have reported no biomedical financial interests.

All statements expressed in this column are those of the authors and do not necessarily reflect the opinions of JAACAP Connect.

Author contributions

Conceptualization: Julia L. Versel (Equal), Sand Mastrangelo (Equal), Jad Hilal (Equal), Mollie C. Marr (Equal), Andrew R. Kittleson (Equal). Writing – original draft: Julia L. Versel (Equal), Sand Mastrangelo (Equal), Jad Hilal (Equal), Mollie C. Marr (Equal), Andrew R. Kittleson (Equal). Writing – review & editing: Julia L. Versel (Equal), Sand Mastrangelo (Equal), Jad Hilal (Equal), Mollie C. Marr (Equal), Andrew R. Kittleson (Equal).