A doctor explains the truth about gender-affirming care.
In the 2024 election circus, transgender issues took center stage, with candidates using these matters as political flashpoints. From fierce debates over healthcare and school policies to a flood of legislation targeting trans rights, this campaign turned personal identities into battlegrounds. As candidates rallied support, the media amplified the noise, shaping (and sometimes skewing) public perception.
To get more clarity on how gender-affirming care really works for trans youth, we talked with Joshua Safer, MD, FACP, FACE, the executive director of the Mount Sinai Center for Transgender Medicine and Surgery in New York. He gave us clear and vital info — on surgeries, puberty blockers, and how (and when) trans teens can receive care — which every parent should know.
Katie Couric Media: Trans issues have been a huge talking point throughout the election cycle, so we wanted to ask some straightforward questions about the reality of transitioning medically, emotionally, and logistically. First off, can you explain what gender-affirming care is?
Dr. Safer: People think that term refers to one specific protocol, but all it means is providing medical care for transgender and gender-diverse people. And it’s really individualized. Most trans people who come in for medical interventions come to their primary care provider or to some clinic that they think is going to be friendly and start to talk about what they want. And if we’re seeing young adults, we in the medical community are looking to see if they have “conventional” stories, which is usually that they’ve been aware of their gender identity for a long time — years — and have thought things through, maybe with therapists or maybe not.
Typically, the first things people look for are hormones, and we have various hormone regimens, classically masculinizing or feminizing hormone regimens, that we can offer. And those tend then to be individualized to the specific person.
We also consider the impact on fertility, and we’ve done what we can to preserve fertility even for people where that doesn’t seem like a priority for them at the moment — especially in situations where it’s hard to go back.
The usual situation is that people start with hormones and see how that goes before they consider surgical interventions. Those aren’t absolutely necessary — it depends on the circumstance. When somebody is looking for a gender-affirming surgery, usually we’re dealing with somebody who’s very established and aware of their gender identity, who’s had ample opportunity to think it through, and who has been on hormones for a significant period of time, and in contact with the medical establishment. Then, we embark on thinking about the kinds of surgery.
Let’s say a transgender woman, that’s male to female, is looking for facial feminization surgery or breast augmentation surgery. That’s a little more of a straightforward path [than] for someone looking for a genital reconstruction surgery.
For cases involving genital-reconstruction surgery, like a vaginoplasty, we add a readiness facilitation assessment that includes having a review in three categories: mental health, any medical concerns that might be relevant to surgery, and plans for recovery and ability to engage with the system. We at Sinai do these assessments in a holistic way — we’re very focused on making sure that the patients have the best experience, don’t have a mental health concern that we haven’t optimized, and don’t have a medical concern we haven’t optimized.
When it comes to trans young people, we’ve seen “puberty blockers” mentioned widely — what are they?
When people say puberty blockers, they mean what we medical folks call GnRH agonists. They’re a medication that, half a century or so ago, were developed with the thought that they would help with fertility. It was accidentally observed that when you get a big shot, they actually shut [your reproductive system] down for a period. And so they’re not really puberty blockers as much as they are puberty pauses or sex-hormone pathway pauses. Many years ago, we started using them for people who enter puberty earlier than we think is appropriate socially — something called precocious puberty. We simply pause puberty for typically a year or two until a young person is more in line with their peers. That’s the regimen we use for transgender kids, with a similar thought process: We use them for transgender kids who are already beginning physical puberty while we’re still talking about what to do and need to hold onto things while we’re making plans.
One big question that came up during the election was whether a minor can receive gender-affirming surgery or puberty blockers without parental consent.
It’s hard to envision how a minor could have surgery without parental consent. I don’t think states allow that, and I don’t know of any medical institution that would do that. And I can’t think of a situation where that would be otherwise. So that’s a no.
Kids can’t get surgeries at any level, gender-affirming or otherwise, without their parents. In fact, here in New York — and I think in most states — you can’t even get medicines without your parents’ consent. There might be some specific exceptions involving mental health and maybe birth control since they might be considered sensitive. But gender-affirming care is part of mainstream medicine.
We’ve recently seen the claim that someone can obtain surgery during “the school day.” Can you speak on that?
Let me just talk about what really happens for a teenager. A teenager wants to have a gender-affirming intervention. That teenager is going to have to come in with the custodial parents. Again, my own institution is very conservative in this space and even more conservative with kids.
The so-called puberty blockers are actually a very conservative intervention to allow us time. So the whole process wouldn’t occur during a single day — this would go on for an extended period of time. And if we’re talking about a surgery for somebody under the age of 18, we’re usually talking about chest-masculinization [breast tissue removal] surgeries for older teens. That’s really the only thing that’s out there. And that would only be done on someone who has been in care for a very long time and is on hormones — and again, everybody, including the family and medical experts, is on board.
If I’m going to speculate about fears that people might have, it’s that things will happen to their children secretly without them being aware. And the short of it is that’s not how the medical establishment works. We don’t give medication without the parents knowing and supporting it. I’m a parent; I totally understand that fear. But we don’t do surgeries without the parents knowing and supporting them for anything across all healthcare. That’s just not a thing — we don’t do that.
There was quite a bit of other misinformation being spread recently about trans kids, including language that suggested they were having body parts “chopped off.” Can you tell us what the actual process is when dealing with children who may be having gender identity issues?
The reality is that when we say “children,” some think of little children before puberty. At that stage, we don’t have medical interventions at all. [For pre-pubescent kids], it’s all talk therapy and advice. As kids do hit puberty, even though hormones, in a perfect world, might be something we would consider, we’re very conservative. And that’s the whole point of puberty blockers. Surgery is almost entirely an adult thing with incredibly rare exceptions.
The other side of it is parents who are working very hard to advocate for their transgender children. They also need to be protected by society and need to feel safe bringing them in for care and not worry about being a target or not have access to care for their children.
There were concerns from voters that schools and teachers were somehow overstepping their roles in discussing gender identity with students when they’re too young. What’s your opinion on that?
I can only speak as a doctor, not as an educator. As a doctor, I think it’s important to be clear that the general rule across the United States is that we don’t give medicines to people under the age of 18 without permission from their parents and guardians. Medical treatment for transgender people isn’t an exception.
The ad by the Trump campaign was shown to be very impactful and stated that Kamala Harris supported using tax dollars for gender-affirming care for trans prisoners. In essence, the ad said, “Kamala Harris cares about they/them. Donald Trump cares about you.” Talk about that ad, if you will, and the veracity of its claims.
Speaking for medical professionals broadly, our oaths are to treat all with medical needs to the best of our abilities.
Can you talk about the dangers of failing to provide support to transgender teens or teens experiencing gender dysphoria?
Somebody who’s transgender has brain biology that tells them what sex they are that isn’t aligned with the rest of their biology to some degree. Somebody in that circumstance says that things will be better if I can change part of the rest of their biology to be a little more aligned with their brain biology.
That’s what we mean by medical treatment for transgender people or gender-affirming treatment. If we deny people medical treatment, then that’s a source of stress and mental health harm. We have statistics of people who’ve not had access to care who’ve really been in very unfortunate situations from a mental health perspective. I don’t know if that would be different from if we denied anybody their medical care. It’s not so much that they have a mental health concern that we’re alleviating — it’s that we’re treating them appropriately.
Can you elaborate on what a “mental health concern” would be?
Well, it’s a range. So conceptually, although pretty unlikely, some people have a mental health concern that interferes with their clarity that they’re even transgender. But like everybody else in the population, people commonly have mental health concerns. So if a person has anything that might be made worse by going through a major surgery — a pretty stressful event — then we want to protect them from that. That could include all the classical things you might think of for somebody who has depression and anxiety, somebody who requires more pain medication, anything that’s going to add complexity to surgery. It’s the same as for any other surgery, really — gender-affirming surgery isn’t different, but we’re being very intentional.
Knowing that it’s not monolithic, how is the transgender community feeling about an incoming Trump administration?
I can’t speak for transgender people in the community. What I can say is that we’re seeing patients reporting anxiety about their healthcare access, and we’re seeing people choosing to have interventions sooner than they might have originally planned.
Have you been privy to anybody who was falsely or incorrectly identifying as transgender?
Honestly, it’s not common, but I have seen people who have mental health issues not understanding their gender identity. And they come seeking gender-affirming hormones, but they’re wrong. In short, it’s very, very rare and usually pretty obvious. But I, of course, involve my much more expert mental-health colleagues when we have any suspicion of that sort.
How common is it for a person to “detransition” — to go back to their previous gender presentation after transitioning socially or medically?
It’s not common for people to stop taking treatment. The terminology is all over the place because, for some, “detransition” has a certain negative sound to it. But most people, per surveys that I’ve seen, who stop taking their treatment do so because of societal pressure — not because they’re changing their viewpoint. They weren’t being treated well in society, things like that. Some people do change their viewpoint, but in my career, I can count maybe two or three patients — it’s really infrequent. I have one person who just decided to stop treatment with no regrets — they had been doing it for years and decided not to do it anymore. So that does definitely exist, but it’s very rare.
Do you hear about young people regretting actual surgeries?
Not so much from young people. It’s more of a question of whether people regret anything that they do. I had a patient, not a young person, who had difficulty with how they were being treated and decided to change back. And I’m sure if you ask them, “Do you regret having the surgery?” they might say yes because the whole thing ended up not working well for them. Not that they weren’t transgender, but society was hostile, and they couldn’t get around it.
We and some other large academic centers are following specific groups of our patients and trying to see how they’re doing some years down the road. And so far, we’re having a very hard time finding any significant numbers of people who regret [transitioning]. I mean, the people you see interviewed in the media didn’t get made up — they’re people who had a bad experience. And I think that’s on us in the field to think about things that we could have done differently that would have helped them.
From a numbers perspective, how many people would laws about gender surgeries truly impact?
What I know so far is that between a half and 1 percent of the population says they’re transgender. Surveys suggest that maybe half of people who say they’re transgender are looking for medical interventions, and maybe half of them are looking for surgeries of any sort. All of it is a bit of a moving target.
I want to point out two things: First, as we create a safer environment, more people are coming to us. So we see the number of people in our clinics growing, although it still hasn’t reached that full half percent.
Two, I also see other surveys when they ask kids [about gender identity], and more of them report being gender diverse than they used to. I don’t know what we’ll actually see in terms of percentages shifting over time. People wonder, Is a high percentage of my kid’s class going to be trans? And my answer is that I don’t expect that we’re going to see more people coming for medical interventions, even if kids define themselves more broadly.
Where do the funds for gender-affirming care come from? Is this out of pocket from the patient’s insurance? Self-funded? Medicare?
Most medical care for transgender people is paid for by the exact same sources as medical care for everybody. So it’s all of the above.
There seems to be a concern that being trans or gender non-conforming is “trendy.” Is this something you’ve observed or are worried about?
Being transgender means that there’s a lack of alignment between the biology of your brain that tells you what sex you are — what we medical professionals mean when we say gender identity — and at least some of your other biology.
That said, we depend on people reporting to us that they are transgender. There’s no blood test or scan. To be conservative, we look to people who are durable in their understanding of their gender identity and consistent in their reporting over time. Even if there’s some broadening in society in how people label themselves, that shouldn’t change who requires medical treatment.
To learn more about medical care for transgender and gender-diverse people, visit the Mount Sinai Center for Transgender Medicine and Surgery webpage.
