What happens when trans kids are prevented from transitioning?

When Mae Sallean was a teenager, her body and mind began to slip away from each other. Her body and face began to sprout thick hair, her voice dropped, and she felt dissociated from her physical form. Something had gone wrong, and she could not reconcile the person she was with the person the world perceived her as. The disconnect left her profoundly depressed and deeply lonely.

Mae knew, somewhere deep down, that she needed to be a girl. She lacked the language for it. In Mae’s heavily religious Texas community, the existence of queer people was barely acknowledged, and trans people, she says, were only seen “in pornography and on Maury.” But she knew, all the same.

When Mae was 15, her mother discovered a secret box full of women’s clothing that Mae wore when no one else was at home. Though very Christian, Mae’s mother didn’t freak out. She wanted to help. So she found a Christian counselor for Mae. The counselor, who had no formal training, tried to convince Mae that being trans was one of the worst things she could be and that if she didn’t change her ways, she would go to hell.

“He framed it on the same level as pedophilia,” Mae says. “That was the number one thing that stuck from those meetings until I started transitioning: I am on the same level as a pedophile.”

The conversation about trans kids right now is fundamentally broken. Because it is led, by and large, by cis people, it focuses on the potential regret children and adolescents might have after transitioning, and ignores the social, physical, emotional, and psychological costs of not transitioning. It ignores the reams of studies that underline the need to support trans kids. It ignores the lived experiences of many trans people, who despair that they were kept from transitioning as youths.

Until this year, this conversation about trans kids had mostly been carried out in the media, with publications from the New York Times to the Atlantic to the Los Angeles Times publishing stories that suggested medical practitioners aren’t doing enough to vet potential transitioners under the age of 18.

Lawmakers were listening, and the 2022 legislative session introduced a new spate of bills aimed at stopping children from accessing trans-affirming health care, among plenty of other anti-trans legislation, especially against an incredibly small number of trans kids playing sports in school. In all, 34 states have considered anti-trans legislation in some form.

Steps taken by the state of Texas to prosecute providing health care to trans kids as child abuse mark the most extreme end of this push. Entered as supporting evidence for Texas’s measure? A recent piece on trans kids from the New York Times.

But those stories weren’t about passing legislation, at least on their face; they were typically aimed at a presumed audience of parents. The Atlantic emblazoned on a 2018 cover the words: “Your child says [he’s] trans. [He] wants hormones and surgery. [He’s] 13.” Only it didn’t use the right pronouns to refer to the real trans boy who served as its model.

Parents have been receiving an onslaught of messages about what could go wrong if their child was to transition; they’ve rarely been asked to consider what could go wrong if they weren’t able to. We are running, in real time, an experiment on what happens when you don’t accept trans kids.

For Mae’s part, she struggled gamely through her teen years and early 20s, trying as hard as she could not to be trans. But her relationship with her mother, the only other person in Mae’s circle of family and friends who knew Mae’s “secret,” deteriorated. Mae remembers occasionally wishing her mother would die, as she was the only other person who knew of Mae’s trans identity. Today, they have a relationship, but they can’t get back what they lost.

While it is easy to view the conversation about trans youth on a statewide or even national scale, it’s important not to forget that it is also a very intimate conversation, one had in individual houses across the country. For trans children, the stakes of those conversations — whether held in statehouses or in living rooms — are literally life and death.

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“Life in a transphobic society is hard for trans people; therefore, I hope my loved one is not trans” might be a train of thought that makes perfect sense to parents like Mae’s mother. It also treats transness as something fungible, akin to an aesthetic preference or a changing fashion.

The risks inherent in treating a child’s trans identity as a temporary fancy can be considerable. Most obviously, keeping a teenager from transitioning before puberty can make a teen’s mind and body seem as though they are traveling away from each other at light speed.

“I felt alienated from everyone around me, and I was constantly terrified of people finding out that I wasn’t who they thought I was,” says Nat Hunter, who first came out as a teen in 2013, then was prevented from transitioning by their parents.

Lily Osler (who is, disclosure, a friend) perfectly captures the terror of puberty for trans kids in a Waco Tribune-Herald piece exploring Texas’s ongoing crackdown on trans youth:

Puberty blockers are reversible, but the puberty that transgender kids would go through without them isn’t. Puberty writes itself into your bones. Without blockers and, at an appropriate age, hormones, it forces transgender girls, who are girls like any other, to grow facial hair and broad, angular features, and forces transgender boys to grow breasts and wide hips. Its effects can only be reversed by very expensive and difficult-to-access surgeries in adulthood, and even then only partially.

“This is not experimental care. This is care that’s been around, in a very formal fashion, for over 50 years,” says Michelle Forcier, a professor at Brown University’s medical school and co-editor of Pediatric Gender Identity. “We know that there are studies that demonstrate efficacy and safety.”

The recent hyperfocus on trans youth is largely a media invention, says Jules Gill-Peterson, a history professor at Johns Hopkins University. “Trans people and trans youth were never really objects of the media [until recently]. I really don’t think most people ever encountered the idea that they shared the world with trans youth until the last 10 years.”

The recency of that hypervisibility powers the notion that trans health care is somehow still experimental, abstracting something that is fraught with life-and-death stakes. For a trans person, the changes dictated by the body they were born into might prove incredibly painful, destabilizing, or even life-threatening.

“The risks of withholding gender-affirming care vary from patient to patient but often involve things like worsening anxiety, depression, and suicidality,” says Jack Turban, a professor of child and adolescent psychiatry at the University of California San Francisco. “Recent legislation to take gender-affirming medical care as an option away across the board is extremely dangerous and will lead to bad outcomes.” A 2022 study published in the Canadian Medical Association Journal found that trans teens were 7.6 times more likely to attempt suicide than their cis peers.

The risk of not allowing trans kids to begin living as themselves compounds the longer they are alive. In 2001, Anne Vitale, a California psychotherapist who has specialized in gender-nonconforming patients since 1984, published a groundbreaking paper in the journal Gender and Psychoanalysis surveying trans women at all stages of life who did not transition as young people. The picture she painted of these women in middle and old age is deeply sad. “This anxiety, if left untreated, is manifested in … confusion and rebellion in childhood, false hopes and disappointment in adolescence, hesitant compliance in early adulthood, feelings of self-induced entrapment in middle age, and if still untreated, depression and resignation in old age,” she writes.

There’s an existential component to going through unwanted puberty, too, because with every day that passes, it becomes harder to get the world to treat you as who you are instead of what it perceives. If you are a cis person, imagine for a moment that, all evidence to the contrary, everyone in the world becomes convinced your gender is not what it is. If you are a man, everyone starts using she/her pronouns for you and calling you by a woman’s name. One day, you start insisting to the world you are who you are, and the world insists otherwise, because it cannot conceive of a self that doesn’t begin from the body.

Are there people who later regret transition? Yes, but the data shows that the vast majority of people who pursue transition do not regret it. In the handful of studies conducted around this question, an average of about 2 percent of respondents express regret. A separate survey questioning why people detransition found the most common reason was social pressure, often from a parent. Many of those detransitioners retransitioned later, when it felt safe to do so. (See more on all of this data here.)

Not every trans person knows they are trans when they are young, and not every trans person decides to undergo medical transition. Decisions around how and when to come out as trans are private and can be made at any age. Ultimately, all medical decisions made should be between a patient and a doctor. However, for the trans people who know their gender identity from a young age and want to medically transition, every year spent not doing so often becomes all the more punishing.

“It’s hard to do this as an adult. I’ve had patients that have had 60 years of gender hormones affecting their body. They have that internal trauma of living in this physical entity that doesn’t necessarily reflect who they know themselves to be,” Forcier says. “If you look at the data of gender-diverse kids who grow up with parents who provide them the support and resources they need, their depression rates are equal to peers and siblings, and their anxiety rates are so much lower than what we’ve found for other gender-diverse persons [who aren’t supported]. It’s shocking.”

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What drives so many parents to insist their child simply cannot be trans? Turban theorizes that it stems from an overly rigid fear of gender nonconformity, one that arose from the gender exploration all children naturally indulge in being met with mockery or punishment.

“Those early experiences can stick with people and lead them to want to repress any nuance around gender, for fear that it may bring up difficult reflections about themselves,” Turban says. “Often, parents are afraid that their own children will be treated poorly by others due to their gender diversity, and so they may try to force their children to be gender-conforming, thinking they are protecting them.”

That insistence is also fueled by the idea that trans kids are a new phenomenon that has popped up extremely recently, thanks to the increasingly flexible ideas about gender that have become popular online in the 21st century. Yet that notion, too, is inaccurate.

“When we make the assumption that trans kids just showed up in 2015, the least generous version of that is that there were no trans children, period, before that. That’s empirically untrue and easily [disprovable],” says Gill-Peterson. “The more sophisticated version of that assumption is, ‘Of course, there were trans kids, but they didn’t medically transition. That didn’t start until really recently.’ That’s also flat-out untrue. Trans youth have been transitioning as long as there has been medical transition.”

Gill-Peterson wrote the 2018 book Histories of the Transgender Child, which traces the last 100 years of trans childhood and the hidden history of American trans children who transitioned either socially or medically from the 1920s onward. The medicine we use to treat trans children today — often dubbed “experimental” — has, in actuality, been used to help trans youths transition with the support of parents and doctors since the mid-20th century.

The processes for treating trans children vary from clinic to clinic or even patient to patient. At present, most clinics draw from the World Professional Association for Transgender Health’s seventh edition of its standards of care. The organization published its eighth edition standards in early September, though they have yet to be widely adopted.

For much of childhood, no medical interventions are pursued. Trans children first begin what’s called a “social transition,” meaning that they may dress differently, wear their hair differently, or use a different name and pronouns. No changes with any permanence happen at this point.

Around the age of 10, if these kids’ gender identities remain consistent, they are often placed on puberty blockers, which delay the arrival of puberty. (Puberty blockers were first developed for cis children, and they have been used for early-onset or what is called “precocious puberty” since the 1980s, gaining approval from the Food and Drug Administration in 1993.)

It’s only after all of this that hormones that will trigger the changes the body goes through in puberty even begin to be considered. These hormones are not prescribed until well into adolescence, usually around the age of 16, long after most of the trans kid’s cis peers began puberty, though WPATH’s more recent guidelines suggest beginning hormonal transition earlier may be beneficial for some teens. Surgical interventions rarely happen before the age of 18, and the most common surgical procedure teens might undergo is “top surgery,” in which a transmasculine person undergoes a mastectomy.

Still, whether a trans person is able to access any of this care is dependent on a variety of factors, mostly stemming from parental approval and doctors trained in providing trans health care. The care is extremely similar to the care that already existed in the 20th century. Kids are just more likely to be aware of it now.

Children who transitioned in the 20th century often had to independently discover the terminology that helped them explain who they were to skeptical families and the medical establishment. Gill-Peterson says that what unites those kids with today’s trans youth is a relentless self-advocacy.

“Stuff that we think is a 21st-century mindset, there are trans kids in the 1960s espousing these things in handwritten letters to doctors,” Gill-Peterson says. “It shows how dogged and determined these kids were. They taught themselves the medical literature. They learned how to speak the lingo that adults needed to hear.”

Gill-Peterson points to a trans girl she dubbed Vicky for her book. Vicky lived in rural Ohio in the 1960s, and she learned of the pioneering New York endocrinologist Harry Benjamin, whose 1966 book The Transsexual Phenomenon made him someone Vicky hoped could help her. She wasn’t yet old enough to legally decide to begin transition without her parents’ consent, Benjamin informed her. When she asked, her father completely rebuffed her. She ran away to Columbus, where she roomed with another young trans girl. She was committed to a psychiatric ward, a fate that befell many trans people in the 20th century, before her father finally relented and allowed her to receive hormone treatment.

Gill-Peterson’s book is littered with stories like Vicky’s, those of trans people who found ways of being themselves, despite the system being stacked against them. She says Vicky’s story could easily take place in 2022. She just might find out about trans people from the internet rather than a newspaper story about a doctor in New York, and the forces keeping her from transition would most likely be her parents, but might also be the state she happened to live in.

Too often, parents make the assumption that, well, sure, maybe trans people exist, but it’s good to take a wait-and-see approach with kids, because that’s safer than those kids undergoing hormone therapy or more invasive procedures they might later regret. It seems to make intuitive sense in a society that privileges the cis experience, and it is natural for parents to want to protect their children at all costs.

Yet that protection can turn harmful if it removes the child’s agency. Leave aside, for a second, that the process for treating trans children does require extensive mental health screening to ensure the safety and certainty of the trans child.

“Number one, why would you ever toss aside your kid like that?” Forcier says. “Number two, not allowing your kid to transition or saying, ‘I’m not going to make a decision about this,’ that’s not a neutral decision. That’s a choice that has significant consequences.”

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For all the justified concern around the tenor of the media conversation and especially around anti-trans laws, the single biggest gatekeeper holding trans kids back from transitioning is their parents. In every story about a trans child trying to come out, there is a moment when they tell a parent. In most of the stories I have heard, that moment goes poorly, and that parent reacts badly. Given some of the dark statistics surrounding trans identities, a bad reaction by a parent might be understandable. Yet by far, the quality that most unites trans youth who are not at risk of suicide is parental support.

Alex Taylor, for instance, grew up surrounded by queer people, thanks to parents with a wide, diverse friend circle. But when they tried to come out to their parents at 13, they were rebuffed and sent to summer camps that, they say, toed the line of conversion therapy. Now, they no longer speak with their parents. Throughout their adolescence, Alex says, their parents kept asking them to be patient. Alex says that’s an undue expectation to place on any child.

“They’re my parents. I’m not supposed to need to have patience for them. And if I am going to have patience for them, that’s a gift, and they don’t get to expect that from me,” Alex says. “They were never going to be okay with me being my own person. And they forced me through a puberty that I didn’t consent to.”

Mae, the trans woman from Texas who tried to come out as a teen, can appreciate that everyone, from her mother to her Christian counselor, thought they were doing what was best for her. She also isn’t sure why they projected what they thought was best for her onto her without really talking to her about it first.

“Everybody wants what’s best for their kid. Even the most malicious reactions, I believe that, ultimately in their brains, somehow they’re rationalizing it as doing the right thing,” Mae says. “There’s a strong desire for a lot of people to mold their kids into being good people, but they’re not working with unformed clay.”

I talked to a half-dozen trans people prevented from transitioning as youths for this article, and in those conversations, I asked them to think about how the supersize anti-trans conversation being driven by lawmakers made them think back on their own teenage experiences. Yes, they said, the focus on anti-trans laws is important. Just as important, however, is recognizing that one of the implicit targets of those laws and of the trans skepticism in the media is parents who might otherwise be supportive.

Raise enough doubt about the effectiveness of trans health care for youth, and you can convince plenty of parents who might even live in otherwise progressive havens, says Nat Hunter. They tried to come out at 14 but were pushed back into the closet at every step by their purportedly progressive parents. Now they have a relationship with their parents, who finally accepted them after years of transition, but the damage was done in the moment they failed to accept their child.

“People create the scenario that they fear through their own actions. They don’t want to say, ‘I hate my child. I don’t accept them.’ They want to say, ‘I don’t want my child’s life to be worse, and I’m scared of them being trans,” Nat says. “But acting that way is what makes kids feel unloved, and that is what causes them to be hurt. People need to understand that once you open that door, that’s it for the rest of your kid’s life. They know that you won’t love them no matter what.”

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The conversation around trans kids has now stepped fully outside of the home. Anti-trans laws use the power of the state to strip both children’s and parents’ agency completely, and the media’s discussion of trans kids and trans people in general too often focuses on the wrong questions.

“The center-left media and the right-wing media are having the exact same conversation about trans people [right now], which is: Are there too many? What number of trans people is the right number? That’s a really strange question to be focused on,” says Ari Drennen, the LGBTQ program director for Media Matters for America.

What might happen if, in this conversation, we centered the voices of those whom it’s actually about? As a society, we struggle to listen to children when they tell us what they need. This problem extends beyond trans kids to queer kids of all stripes, to children who tell us about abuse in their homes, to even the archetypal son who wants to play music when his dad wants him to play football. We claim to prioritize children, but we actually prioritize the idea of them, an imagined ideal that allows them as little autonomy as possible.

“We don’t listen to children. We treat children as manifestly inferior to adults. We give them less rights,” says Gill-Peterson. “We make them economically and politically dependent on adults. We put them in dangerous and vulnerable situations all the time. They have no control or participation in authoring the world they live in, the schools they go to, the doctor’s offices they visit, the adults they’re left alone with. And then we say they’re incapable of knowing anything. Therefore, they have no ability to hold adults to account. That’s a very disturbing way to treat a group of people.”