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Child Male-To-Female Gender Affirmation And California bill highlighting gender affirmation in child custody cases moves forward. California lawmakers in the State Senate Judiciary Committee on Tuesday moved forward with a measure that would require courts to consider a parent's acceptance of their child's gender identity in custody or visitation cases. U.S.A. New Sharia Law Rules 2022 and Kids Gender Affirming Hormone Therapy Rules 2023 Kids Can Now Start At Age 8 Yrs. Old Puberty Blockers Drugs Per The President Biden's Administration has confirmed that the legal age of consent for oral sex and to marriage will be lowered to age 8 yrs old starting Feb. 14th. 2023

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“As the mother of a trans child, it is jarring to know that TGI youth are at a higher risk of depression, mental health crises, self-harm and suicide than their cisgender peers,” said Assembly member Lori Wilson, the bill's author, in a statement. “The TGI Youth Empowerment Act provides California the opportunity to take one step closer to building a safer, more dignified, and equitable world for TGI youth and their families.”

The bill, Assembly Bill 957, now heads to the Senate floor, despite concerns from lawmakers on both sides of the aisle as to how courts will interpret the measure.

Multiple Senators in Tuesday's hearing indicated they want Wilson to clarify in the bill if "gender affirmation" solely means acceptance and support for the child's identity, or if it also includes providing gender-affirming health care including surgery and medication. Others raised concerns about how the bill might affect those who practice certain religions.

Lawmakers in support of the measure noted gender affirmation would not be the ultimate requirement for judges to determine which parents get custody or how much visitation they receive. They noted a number of other factors will still be considered in those cases.

Republican Sen. Scott Wilk criticized the measure, noting that for now, this just applies to divorce cases while raising concerns that the requirement for parent gender affirmation might spill into other sectors of society. "If you love your children, you need to flee California Now.

AB-957 Family law and gender identity.

https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202320240AB957

Youth Access to Gender Affirming Care: The Federal and State Policy Landscape Numerous states have implemented or considered actions aimed at limiting LGBTQ+ youth access to gender affirming health care. Four states (Alabama, Arkansas, Texas, and Arizona) have recently enacted such restrictions (though the AL, AR, and TX laws all have been temporarily blocked by court rulings) and in 2022, 15 states are considering 25 similar pieces of legislation. At the same time, other states have adopted broad nondiscrimination health protections based on gender identity and sexual orientation. Separately, the Biden administration, which has been working to eliminate barriers and expand access to health care for LGBTQ+ people more generally, has come out against restrictive state policies. This analysis explores the current state and federal policy landscape regarding gender affirming services for youth and the implications of restrictive state laws.

https://s3.amazonaws.com/unoda-web/wp-content/uploads/2018/06/sg-disarmament-agenda-pubs-page.pdf#view=Fit

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Gender Identity - Gender identity is one’s internal sense of being male, female, some combination, or another gender. Gender identity may or may not align with sex or gender assigned at birth.

Transgender - Somebody who is transgender has a gender identity different from that traditionally associated with sex assigned at birth.

Gender Dysphoria - Gender dysphoria refers to “a concept [and clinical diagnosis] designated in the DSM-5 as clinically significant distress or impairment related to a strong desire to be of another gender, which may include desire to change primary and/or secondary sex characteristics. Not all transgender or gender diverse people experience dysphoria.”

Gender Affirming Care - Gender-affirming care is a model of care which includes a spectrum of “social, psychological, behavioral or medical (including hormonal treatment or surgery) interventions designed to support and affirm an individual’s gender identity.”

What is the status of state policy restrictions aimed at limiting youth access to gender affirming care?
Four states (Alabama, Arkansas, Texas, and Arizona) recently enacted laws or policies restricting youth access to gender affirming care and, in some cases, imposing penalties on adults facilitating access. Alabama, Arkansas, and Texas have been temporarily blocked from enforcing these laws and policies by court order.

Alabama. In April 2022, the Alabama governor signed a bill into law that prevents transgender minors from receiving gender affirming care, including puberty blockers, hormone therapy, and surgical intervention. The bill makes it a felony for any person to “engage in or cause” a transgender minor to receive any of these treatments, punishable by up to 10 years in prison or a fine up to $15,000. The bill additionally states that nurses, counselors, teachers, principals, and other administrative school officials shall not withhold from a minor’s parents or guardian that their child’s “perception of his or her gender or sex is inconsistent with the minor’s sex” assigned at birth and shall not encourage a minor to do so. Shortly after enactment, a federal lawsuit challenging the law was filed by four Alabama families with transgender children, two healthcare providers, and a clergy member. Subsequently, the U.S. Department of Justice (DOJ) joined the case as an additional plaintiff challenging the law. This case has been consolidated with another lawsuit filed by two other Alabama families with transgender children, which raises similar challenges. In May 2022, a federal district court entered a preliminary injunction, blocking enforcement of several sections of the Alabama law while the litigation is pending. Specifically, the preliminary injunction applies to the sections of the law that prohibit puberty blockers and hormone therapy. Other sections of the law remain in effect, including the prohibition on surgical intervention and the prohibition on school officials keeping secret or encouraging or compelling children to keep secret certain gender-identity information from children’s parents. When deciding to grant the preliminary injunction, the district court found that the plaintiffs were substantially likely to succeed on their claim that the sections of the law that prohibit puberty blockers and hormone therapy unconstitutionally violate parents’ fundamental right to autonomy under the 14th Amendment’s due process clause by prohibiting parents from obtaining medical treatment for their children subject to medically accepted standards. The court also fond that the plaintiffs were substantially likely to succeed on their claim that these sections of the law are unconstitutional sex discrimination in violation of the 14th Amendment’s equal protection clause because the law denies medically necessary services only to transgender minors, while allowing those services for cisgender minors. Additionally, the court found that the plaintiffs were likely to suffer irreparable harm, in the form of “severe physical and/or psychological harm” and “significant deterioration in their familial relationships and educational performance,” if the law was not blocked. The state has appealed the district court’s decision to the 11th Circuit.
Arkansas. In 2021, on override of Governor Hutchinson’s veto, Arkansas lawmakers passed legislation prohibiting gender-affirming treatment for minors, including puberty blockers, hormone therapy, and gender affirming surgery. The law also prohibits medical providers from making referrals to other providers for minors seeking these procedures. Under the law, medical providers offering gender affirming care or providing referrals for such care to minors may be subject to discipline by relevant licensing entities. The legislation additionally includes a prohibition on private insurance coverage of gender affirming services for minors and a prohibition on the use of public funds, including through Medicaid, for coverage of these services for minors. In May 2021, four families of transgender youth and two physicians challenged the Arkansas law in federal court, arguing that the law is illegal sex discrimination under the 14th Amendment’s equal protection clause. They also argue that the law violates parents’ right to autonomy protected by the 14th Amendment’s due process clause and violates the families and physicians’ right to free speech under the 1st Amendment. The U.S. Department of Justice (DOJ) filed a statement of interest in support of the plaintiffs’ motion for a preliminary injunction in the Arkansas case. DOJ argued that the Arkansas law violates the Equal Protection Clause of the 14th Amendment because the state law “singles out transgender minors. . . specifically and discriminatorily den[ies] their access to medically necessary care based solely on their sex assigned at birth.” A preliminary injunction was granted in July 2021, temporarily blocking the state from enforcing the law while the case is pending. The court found that the plaintiffs were likely to succeed on all three of their Constitutional claims, and that the law was not substantially related to the state’s interest in protecting children or regulating physicians’ ethics because the law allows the same medical treatments for cisgender minors. The court also found that the plaintiffs will suffer irreparable physical and psychological harm if the law is not blocked. The court also denied the state’s motion to dismiss the case. The state has appealed both of those decisions to the 8th Circuit, where a decision is currently pending. A group of 19 states filed an amicus brief in support of the state’s appeal.1 They argue that states have “broad authority” to regulate gender affirming services, because they allege this area is “fraught with medical uncertainties,” contrary to the evidence from the American Academy of Pediatrics and the American Medical Association on which the lower court relied. Another group of 20 states and the District of Columbia filed an amicus brief in support of the plaintiffs.2 They argue that they and their residents are economically, physically, and mentally harmed by discrimination against transgender people. They also argue that their states “protect access to gender-affirming healthcare based on well-accepted medical standards” and that Arkansas’ law is unconstitutional sex discrimination and “ignores medical consensus as well as decisions made between doctors and their patients.” Litigation in the case continues in the district court, where the case is scheduled for trial during the week of July 25, 2022.
Texas. In February 2022, Governor Abbott of Texas issued a directive defining certain gender affirming services for youth as child abuse, and calling for investigation of and penalties for parents who support their children in taking certain medications or undertaking certain procedures, which could include the removal of their children. In addition, under the directive, health care professionals who facilitate access to these services could also face penalties and a range of professionals in the state would be mandated to report known use of the specified gender affirming services. While other states with proposed policies to limit youth access to gender affirming care include penalties for parents who facilitate access to these services (see below), no implemented policy ties the parental role to child abuse as the Texas directive does. In the wake of litigation, a state court entered a temporary injunction preventing the state from enforcing the directive while the case is pending. The court found that the governor acted outside his statutory legal authority in issuing the directive, and the plaintiffs will suffer immediate and irreparable injuries, including loss of employment, deprivation of constitutional rights, and loss of medically necessary care. However, the Texas Supreme Court subsequently modified the temporary injunction, finding that the courts lack authority to prevent enforcement of the directive statewide. Instead, the state is prohibited from enforcing the directive only against the plaintiffs involved in the lawsuit while the case is pending. The case is scheduled for trial on July 11, 2022.
Arizona. In March 2022, Arizona Governor Ducey signed legislation into law that bans physicians from providing gender-affirming surgical treatment to minors. The legislation does not address hormone therapy or puberty blockers.
In addition, since January 2022 15 states introduced a total of 25 bills that would restrict access to gender-affirming care for youth. Provisions in these bills varied considerably and include those that would:

criminalize or impose/permit professional disciplinary action (e.g. revoking or suspending licensure) on health professionals providing gender-affirming care to minors, in some cases labeling such services as child abuse
penalize parents aiding in youth accessing gender-affirming care
permit individuals to file for damages against providers who violate such laws
limit insurance coverage or payment for gender affirming services or prohibit the use of state funds for such services
Beyond these policies, states have also passed or considered other policies restricting access, including so called “bathroom bills” which restrict access to bathrooms or locker rooms based on sex assigned at birth, the recent Florida “don’t say gay” bill that would prohibit classroom discussion on sexual orientation or gender identity, and laws that limit transgender students’ access to sports. While these policies are not directly tied to health or health care access, their attempts to limit access to social spaces and services and present non-affirming sentiments could negatively impact LGBTQ+ people’s mental health and well-being. For instance, one recent study found that state laws permitting the denial of services to same-sex couples “are associated with increases in mental distress among sexual minority adults.” In addition, and directly related to health care, Florida recently released non-biding guidance recommending against gender affirming care for youth.

What states have introduced protections related to sexual orientation and gender identity in health care?
Though not specific to youth access to gender affirming care, some states have adopted policies that provide health care protections to LGBTQ+ people, including:

prohibitions on health insurance discrimination based on sexual orientation and/or requirements that state Medicaid programs explicitly cover health services related to gender transition
What is federal policy regarding gender-affirming services?
The Biden administration has taken multiple steps to promote access to health care for LGBTQ+ people and to prohibit discrimination on the basis of sexual orientation and gender identity, including:

On his first day in office, President Biden signed an executive order directing federal agencies to review existing regulations and policies in order to “prevent and combat discrimination” based on gender identity and sexual orientation. The order states that “people should be able to access healthcare…without being subjected to sex discrimination” and views sex nondiscrimination protections as encompassing sexual orientation and gender identity, following the Supreme Court’s Bostock
On May 10, 2021, also in light of the Bostock ruling, the Biden Administration announced that the Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) would include gender identity and sexual orientation in its interpretation and enforcement of Section 1557’s prohibition against sex discrimination. Section 1557 of the Affordable Care Act (ACA) contains the law’s primary nondiscrimination provisions, including a prohibition on discrimination on the basis of sex by a range of health care entities and programs that receive federal funding. The May 2021 announcement marked both a reversal of Trump Administration policy, which eliminated gender identity and sex stereotyping from the regulations, and an expansion of Obama Administration policy, which included gender identity and sex stereotyping in the definition of sex discrimination but omitted sexual orientation. Following the Bostock ruling, two federal district courts issued nationwide preliminary injunctions, blocking implementation of several provisions of the Trump Administration’s regulations related to Section 1557. Biden Administration implementing regulations on Section 1557 are expected to expand on the May announcement.
In addition to establishing a foundation of nondiscrimination policies for LGBTQ+ people, and participating in the Alabama and Arkansas cases as noted above, the administration has responded specifically to the Texas directive, denouncing it as discriminatory and stating that gender affirming care for youth should be supported as follows:

Statement from President Biden: The statement from the president states that the administration is “putting the state of Texas on notice that their discriminatory actions put children’s lives at risk. These announcements make clear that rather than weaponizing child protective services against loving families, child welfare agencies should instead expand access to gender-affirming care for transgender children.”
Statement from Dept. of Health and Human Services (HHS) Sec. Becerra: Becerra’s statement reaffirms “HHS’s commitment to supporting and protecting transgender youth and their parents, caretakers and families” and details action items the administration is taking in response to the Texas directive including those that follow below.
Following the actions in Texas, HHS’s Administration on Children, Youth and Families issued an Information Memorandum to state child welfare agencies writing that child welfare systems should advance safety and support for LGBTQI+ youth, including though access to gender affirming care.
Also in response to Texas, HHS’s OCR issued a new notice and guidance which lays out federal enforcement policy for nondiscrimination related to gender identity. The guidance relies on ACA Section 1557’s prohibition against sex discrimination, including gender identity, in health programs and activities receiving federal financial assistance; Section 504 of the Rehabilitation Act, which prohibits discrimination on the basis of disability by entities receiving federal financial assistance; and Title II of the Americans with Disabilities Act (ADA), which prohibits discrimination on the basis of disability by state and local governments.
Specifically, the guidance states that categorically refusing treatment based on gender identity is prohibited discrimination under Section 1557. The guidance also states that Section 1557’s prohibition against sex-based discrimination is likely violated if a provider reports parents seeking medically necessary gender affirming care for their child to state authorities, if the provider or facility is receiving federal funding. The guidance further states that restricting a provider from providing gender affirming care may violate Section 1557.
The guidance states that in cases where gender dysphoria qualifies as a disability, restrictions that prevent individuals from receiving medically necessary care based on a diagnosis or perception of gender dysphoria may also violate Section 504 and the ADA.
It also articulates requirements under the Health Insurance Portability and Accountability Act (HIPAA) that prohibit health plans and providers from disclosing protected health information, such as use of gender affirming physical or mental health care without patient consent, except in limited circumstances.
OCR enforces each of these federal laws, and the guidance states that parents or caregivers who believe their child has been denied health care, including gender affirming care, and health care providers who believe they have been unlawfully restricted from providing such care, may file an administrative complaint for OCR to investigate.

What do major medical societies say about gender affirming services?
Most major U.S. medical associations, including those in the fields of pediatrics, endocrinology, psychiatry, and psychology, have issued statements recognizing the medical necessity and appropriateness of gender affirming care for youth, typically noting harmful effects of denying access to these services. These include statements from the American Medical Association, American Academy of Pediatrics, the Endocrine Society, American Psychological Association, American Psychiatric Association, and the World Professional Association for Transgender Health, among others, which in some cases were specifically issued in response to the Arkansas legislation and Texas directive. Further, 23 medical associations or societies, including those named above, together filed an amicus brief in the case filed against Texas Gov. Abbott opposing the state directive. The brief states that denying gender affirming treatment to adolescents who need them would irreparably harm their health and that enforcing the directive would irreparably harm providers who are forced to choose between potentially facing civil and criminal penalties or endangering their patients. A similar amicus brief was filed in the Arkansas case.

Additionally, the Endocrine Society supports gender affirming care for young people in their clinical practice guidelines, as does the World Professional Association for Transgender Health’s standards of care. Together these guidelines form the standard of care for treatment of gender dysphoria.

What are the implications of access restrictions?
State policies restricting youth access to gender affirming care could have significant health and other implications for LGBTQ+ youth, their parents, health care providers, and, in some cases, other community members:

LGBTQ+ youth: LGBTQ+ youth experience higher rates of depression, anxiety, and suicidality than their non-LGBTQ+ peers. In one CDC study of youth in 10 states and 9 urban school districts, a higher share of transgender students reported suicide risk outcomes across a range of metrics than cisgender students. These include, in the past 12 months: having felt sad or hopeless, considered attempting suicide, made a suicide plan, attempted suicide, or had a suicide attempt treated by a doctor or nurse. Inability to access gender affirming care, such as puberty suppressors and hormone therapy, has been linked to worse mental health outcomes for transgender youth, including with respect to suicidal ideation, potentially exacerbating the already existing disparities. Conversely, access to this care is associated with improved outcomes in these domains. Policies that aim to prohibit or interrupt access to gender affirming care for youth can therefore have negative implications for health in potentially life-threatening ways.

In addition, LGBTQ people report higher rates of negative experiences with medical providers, so creating barriers to gender affirming care could further challenge transgender people’s relationship with the healthcare system.

Finally, with the Texas directive specifically, and in several other states with bills under consideration, youth are vulnerable to secondary trauma, knowing that if they seek such care, their families and providers could be subject to penalties, and, in the case of Texas, children could be separated from their parents.

Parents: In several states with bills under consideration, parents who facilitate access to evidence-based and potentially lifesaving gender affirming services for their children could face penalties. Under the Texas directive, because it is defined as child abuse, parents who facilitate access to gender affirming care for their children, could be subject to penalties, including losing custody of their children. This may place parents in the position of either supporting their children in accessing care supported by medical evidence and facing penalties or denying their children access in an effort not to make their family vulnerable to investigation and potential separation. Each option for parents in this scenario has the potential to be traumatic for the family, and for youth in particular.

Providers: Like parents, providers may be torn between what the medical literature supports is in the best interest of their patients or facing potential sanctions, including violating professional ethics around confidentiality, as in the case of Texas. The American Psychological Association said in a statement that a requirement such as the Texas directive is a violation of both patient confidentiality and professional ethics. Under such circumstances, providers may be forced to decide whether they will provide the highest standard of care for their patients and potentially face sanctions, or obey the state directive but withhold care and potentially violate patient confidentiality and professional ethics. Further, as noted above, the Biden Admiration has stated that HIPAA requirements prohibit providers from disclosing use of gender affirming care without patient consent, except as in narrow circumstances. However, following HIPPA requirements in this case may make providers vulnerable to state sanction under the directive.

Teachers and others: In Texas, in addition to health care providers, other mandated reporters, such as teachers, could also face penalties for failure to report youth known to be accessing gender affirming care. The directive also states that ”there are similar reporting requirements and criminal penalties for members of the general public,” extending the policy’s reach to practically anyone with knowledge of youth accessing these services.

Looking forward
The legal and policy landscape regarding youth access to gender affirming care is shifting across the country, with an increasing number of states seeking to limit such access and impose penalties. Such policies may have significant, negative implications for the health of young people. At the same time, these states are at odds with federal law and policy, and in two recent cases courts have temporarily blocked enforcement of such restrictions. Moving ahead, it will be important to watch how state bills still under consideration unfold and the final outcome of cases in Alabama, Arkansas, and Texas. Decisions in these cases could determine how such policies intersect with existing federal policies — including Section 1557’s prohibition on sex based discrimination in health care, federal disability non-discrimination protections, and HIPAA patient privacy protections — as well as providers’ professional ethics standards.

https://files.kff.org/attachment/Understanding-Trans-Identity-in-the-U-S.pdf

KFF/The Washington Post Trans Survey The latest partnership from KFF and The Washington Post project provides unique insights into the attitudes and experiences of trans adults living in the U.S. There are nearly 2 million people living in the U.S. who identify as transgender or trans, representing less than 1% of all adults. This group reports experiencing stigma and systemic inequality in many aspects of their lives including education, housing, and health care access. In addition, trans people are more likely to be victims of discrimination and violence including verbal and physical assaults and intimidation.

This project is the most in-depth, representative survey of transgender adults living in the U.S., interviewing 515 trans and gender non-conforming individuals, from diverse backgrounds and with differing experiences. KFF and The Washington Post also included a comparison survey of 823 cisgender adults. For more information about sampling and method of recruitment, see methodology.

This survey is the 36th in a series of surveys dating back to 1995 that have been conducted as part of the KFF/The Washington Post Survey Project and the first focusing on transgender, nonbinary, and gender non-conforming people.

https://www.kff.org/other/poll-finding/kff-the-washington-post-trans-survey/

Executive Summary
This survey of trans adults, including transgender adults, gender non-conforming people, and nonbinary adults, as well as the comparison survey of cisgender adults is aimed at better understanding the trans experience in the U.S. Six in ten trans adults do not identify as either a “trans man” or a “trans woman,” but rather say “trans, gender non-conforming” or “trans, nonbinary” are better ways of describing themselves. Consistent with these findings, about half of trans adults (48%) use they/them pronouns, and about one-third say they use a combination of they/them, she/her or he/him pronouns. Seven in ten trans adults identify as lesbian, gay, or bisexual. The trans adult population is also younger than the larger cisgender adult population, with the majority of trans adults are younger than 35 years old. One in seven trans adults say they are a Republican or a Republican-leaning independent, with most trans adults identifying as Democrats or Democratic-leaning independents. In addition, six in ten identify as political liberals, while three in ten say they are political moderates, and one in seven are conservatives. The survey identifies major themes in better understanding the trans experience in the U.S. (developing identity, coming out and transitioning, facing discrimination and barriers). Below is a brief overview of key findings by theme, followed by deep dives into each arena.

Developing identity: Many transgender adults report understanding their gender identity at a young age and face many difficulties during childhood.

Most trans adults say they knew their gender differed from their sex assigned at birth when they were a child or teenager, but few told others before the age of 18. Trans adults are more likely than cisgender adults to say they felt isolated as a child or teenager and many report serious difficulties growing up, including unsafe learning environments and mental health struggles. Trans people who report having a trusted adult to confide in while growing up were less likely to report adverse childhood experiences.

While most trans adults began to understand their own gender identity before they were an adult, only about four in ten of those who recognized their identity this early say they shared this information with others.
Trans adults are much less likely than cisgender adults to report they felt safe in their homes or at school as a child or teenager, and a minority of trans adults said they felt safe participating in youth sports (44%), youth activities (41%), or in religious gatherings (35%).
Three in ten trans adults say they experienced homelessness or got kicked out of their home while they were growing up, including nearly four in ten (38%) trans people of color. One in four trans adults say they attended religious services as a child or teenager that tried to change their sexual orientation or gender identity, and one in ten (11%) say they attended conversion or reparative therapy.
Trans people who report having a trusted adult to talk to about personal issues while growing up were less likely to report feeling unsafe growing up. Yet, a minority of trans adults say they had a trusted adult to talk to about personal issues including, about one-third (34%) of trans people of color.
Coming out and transitioning: Transgender adults report a diverse set of experiences in being open with others about their gender identity, as well as the ways they present their gender to others.

Nearly 8 in 10 trans adults (78%) say living as a gender that is different from their gender assigned at birth has made them “more satisfied” with their life. Yet, some trans people are not out to family or friends and a small but significant share (16%) say they “never” physically present as a gender different from their sex assigned at birth. Being “out” is less common among older trans adults (ages 35 and older) as well as trans people of color.

While most trans adults have told at least some members of their immediate family (68%) or people in their friend group (78%) that they are trans, one in seven (14%) have not come out to any of their family members or friends. This increases to one in five (21%) among trans adults who are 35 or older.
Trans adults who present as a gender different from the one they were assigned at birth either “all” or “most of the time” are three times more likely to say they are “a lot more satisfied” living as a gender different than their sex assigned at birth compared to those who present as a different gender “some of the time” (62% v. 19%). White trans adults are more likely than trans people of color to present as a different gender than their gender assigned at birth at least most of the time (55% compared to 42%) as are younger trans adults compared to those 35 and older (56% compared to 43%).
What it means to “transition” differs widely among trans adults, and not all trans adults feel the need to transition in any one way. The majority (88%) of trans adults say they have taken at least one action in transitioning, with most reporting they have made changes to their physical appearance to better fit their gender identity or go by pronouns associated with their gender that are different from their sex assigned at birth.
Much smaller shares of trans adults report having attended counseling or therapy as a part of their gender transition (38%), using hormone treatments (31%), legally changing their names (24%), or undergoing gender-affirming surgery to change their physical appearance (16%). Notably these experiences are more common among trans men and trans women than those who identify as trans, gender non-conforming or trans, non-binary.
Facing discrimination and barriers: Trans adults report high levels of discrimination, including facing prejudice from health care providers, as well as barriers accessing mental health care.

More than six in ten trans adults have been discriminated against because of their gender identity and/or expression, with verbal attacks being the most commonly experienced form of discrimination reported. Trans adults also face discrimination in accessing health care with nearly half of trans adults saying the health care providers they have come into contact with know “not too much” or “nothing at all” about providing health care to trans people, and many reporting facing bias when getting care. Trans adults are more likely than cisgender adults to report recent mental health struggles as well as more likely to report difficulty accessing mental health coverage

A majority of trans adults (64%) have been verbally attacked because of their gender identity, gender expression or sexual identity and one in four report having been physically attacked. The share of trans adults who have been physically attacked because of their gender identity increases to 31% among trans people of color.
Trans adults face other types of discrimination beyond verbal and physical attacks, including being asked unnecessary or invasive questions at their place of work (49%) or being harassed or feeling unsafe in a restroom or locker room (41%). One in five trans adults report having been fired, denied a job or promotion (21%) or been refused health care from a health care provider (17%) due to their gender identity. One in eight trans adults (13%) say they have been evicted or denied housing because of their gender identity or expression, increasing to one in five (21%) among trans people of color.
Nearly half of trans adults (47%) say there was a time in the past year where they needed but didn’t get mental health services or medication (compared to a quarter of cisgender adults). Among those who did not get mental health services or medication, cost is the biggest deterrent from getting care.
Trans adults are more likely than cisgender adults to struggle with adverse mental health experiences including having suicidal thoughts in the past month (43% compared to 16%). In addition, 17% of trans adults say they harmed themselves over that period, compared to 3% of cisgender adults. The shares of trans adults who report having suicidal thoughts increases to half of those without supportive family members, and one in four of whom say they have engaged in self-harm in the past 12 months.
Understanding Identity and Coming Out to Others
Most trans adults (66%) say they began to understand that their gender was different from the sex they were assigned at birth before the age of 18, including a third (32%) who say they began to understand when they were ten years old or younger and another third (34%) who say it began between the ages of 11 and 17. A small share say this awareness happened between the ages of 18 and 25 (18%), 26 and 40 (10%), and 4% say it happened at age 41 or older.

There is a generational divide, with three-fourths of trans adults (73%) between the ages of 18 and 34 saying they were under the age of 18 when they began to understand their gender identity differed from their sex assigned at birth compared to 58% of trans adults who are 35 years old or older.

While most trans adults understood their own gender identity before they reached 18, only about four in ten of those who understood this also told others that they were trans or gender non-conforming before they turned 18. Overall, about one in ten trans adults say they began telling others before the age of 11, and an additional one in five (21%) say they came out to others when they were between 11 and 17 years old. One third of all trans adults say they began telling others when they were between the ages of 18 and 25, and a quarter say they began telling others when they were 26 years old or older. One in ten (12%) trans adults say they have not told anyone they are trans or gender non-conforming. The share of trans adults who haven’t told anyone about their trans identity increases to 18% among those who are 35 or older.

While most trans adults have told all, most, or some of either members of their immediate family (68%) or people in their friend group (78%) that they are trans, one in seven (14%) have not come out to any of their family members or friends. This increases to one in five (21%) who are 35 and older, who are less likely to be out to their immediate family members or to people in their friend group.

Among trans people who have told at least one immediate family member, most (69%) say their family members are at least “somewhat supportive” of their trans identity, including one-fourth who say their family members are “very supportive.” On the flip side, three in ten (31%) say their families are unsupportive, including one in ten (13%) who say their family members are “very unsupportive.” Majorities of white trans adults (68%) and trans adults of color (72%) who have told their immediate family members say their families are at least somewhat supportive, as well as majorities of trans adults who identify as non-binary or gender non-conforming (68%).

Most trans adults (83%) say they physically present as a gender different from the one assigned to them at birth at least some of the time, including three in ten who say they physically present this way “all of the time.” About one in seven trans adults (16%) say they “never” physically present as a gender different from their sex assigned at birth. This is largely driven by trans adults who identify as non-binary or gender non-conforming, with about one in five of this group “never” physically presenting as a gender different from their sex assigned at birth compared to 9% of trans men or women. White trans adults are more likely than trans people of color to present as a different gender than their gender assigned at birth “all” or “most” of the time (56% compared to 42%) as are younger trans adults as compared to trans adults ages 35 and older (56% compared to 43%).

Nearly 8 in 10 trans adults (78%) say that living as a gender different from the one assigned to them at birth has made them “more satisfied” with their life, including just under half (45%) who say they are “a lot more satisfied.” Trans adults who say they present as a different gender “all” or “most of the time” are three times more likely to say they are “a lot more satisfied” living as a gender different from the sex they were assigned at birth, compared to those who present as a different gender “some of the time” (62% v. 19%).

https://www.kff.org/report-section/kff-the-washington-post-trans-survey-trans-in-america/

Growing Up Trans
With most trans adults reporting that they began to understand that their gender identity differed from their sex assigned at birth when they were a child or teenager, the KFF/Washington Post survey asked trans adults to report on what it was like growing up. Overall, trans adults report more difficulties in childhood, less safe growing and learning environments, and more mental health struggles than their cisgender counterparts. Some of these differences are mitigated among trans adults who report having a trusted adult while they were growing up. Yet only four in ten trans adults say they had a trusted adult to talk to about personal issues, including about one-third (34%) of trans people of color and less than half (45%) of white trans adults.

About half (53%) of trans adults report having at least a “somewhat happy” childhood but cisgender adults are more than twice as likely as trans adults to say their childhood was “very happy” (36% compared to 15%)Half (46%) of trans adults describe their childhood as unhappy, including 17% who would describe it as “very unhappy.” While trans adults are less likely than cisgender adults to say they would describe their childhood as happy, two-thirds of trans adults (67%) who reported having a trusted adult to talk to say they had a happy childhood, compared to less than half (44%) of trans adults who didn’t have a trusted adult growing up.

While many trans adults report growing up in safe environments, a smaller share of trans adults compared to cisgender adults report they felt generally safe in their homes (69% v. 86%) or at school (55% v. 90%). In addition, they are also much less likely to report they felt safe participating in youth sports (44% v. 70%), youth activities (41% v. 64%), or in religious gatherings (35% v. 76%).

Once again, having a trusted adult did seem to matter for trans kids and teenagers. Trans adults who say they had a trusted adult growing up are more likely to report they felt safe as a child or teenager both at home (85%) and at school (65%), compared to trans people without a trusted adult growing up (60% and 48%, respectively).

ISOLATION AND MENTAL HEALTH STRUGGLES GROWING UP
Large shares of trans adults report adverse mental health experiences during their childhood. Eight in ten trans adults (78%) say growing up they experienced serious mental health problems such as depression or anxiety, and three in ten (29%) say they had alcohol or drug use problems as a child or teenager. Three in ten trans adults say they experienced homelessness or got kicked out of their home while they were growing up, including nearly four in ten (38%) trans people of color. One in four trans adults say they attended religious services as a child or teenager that tried to change their sexual orientation or gender identity, and one in ten (11%) say they attended conversion or reparative therapy. Trans adults facing adverse mental health challenges as children or teenagers was equally common, regardless of whether they had a trusted adult to talk to about personal issues.

The Diversity of Trans Experiences and Identity
Six in ten adults whose gender identity differs from their sex assigned at birth do not identify as either a “trans man” or a “trans woman,” but rather say “trans, gender non-conforming” (22%) or “trans, nonbinary” (40%) are the best ways of describing themselves. Nearly half of trans adults 18-34 say “trans, nonbinary” is the best way to describe themselves, compared to one-third of trans adults 35 or older. Given the majority of trans adults are younger than 35, non-binary or gender non-conforming identities may become even more prevalent among trans adults as the population ages.

Consistent with these findings, about half of trans adults (48%) use they/them pronouns, and about one-third say they use a combination of they/them, she/her or he/him pronouns. Seven in ten trans adults identify as lesbian, gay, queer, or bisexual. This survey finds trans adults and cisgender adults report similar household incomes, even when controlling for age, with four in ten trans adults reporting annual incomes of less than $40,000 (compared to 37% of cisgender adults). However, trans adults are much less likely than cisgender adults to have a college degree, even when accounting for the younger age of this population. About 15% of trans adults report having at least a college degree compared to 35% of cisgender adults. This includes 12% of trans adults under the age of 35 and one in five (19%) of trans adults over age 35 (compared to 31% of cis adults under 35 and 37% over age 35). Few trans adults say they are Republicans (10%) or Republican-leaning independents (4%), with most trans adults identifying as Democrats (42%) or Democratic-leaning independents (26%). Regarding political ideology, six in ten (58%) identify as political liberals, while three in ten (28%) say they are political moderates, and one in seven are conservatives (13%).

THERE ISN’T ONE WAY TO TRANSITION
What it means to “transition” differs widely among trans adults, and not all trans adults may feel the need to transition in any one way or seek the same types of gender affirming care. While the majority (88%) of trans adults say they have taken at least one of several select actions (described below) in the process of transitioning, these actions vary. Most trans adults report they have made changes to their physical appearance, such as changing the types of clothes they wear (77%) or changing their hairstyle or grooming habits (76%) to better fit their gender identity. Many also report going by pronouns associated with their gender that are different from their sex assigned at birth (72%), with slightly fewer, but still a majority, saying they use a different name than the one on their birth certificate (57%) – even if they have not legally changed their name. About four in ten transgender people report having attended counseling or therapy as a part of their gender transition (38%) (which is sometimes a requirement for other gender affirming care), and one-quarter (24%) having legally changed their name on identifying documents, such as a passport or driver’s license. Smaller shares report having used hormone treatments, HRT or puberty blocking hormones (31%) or having undergone gender-affirming surgery to change their physical appearance (16%).

While most trans adults who identify as nonbinary or gender non-conforming have changed their physical appearance in ways that reflect their gender identity, such as changing the types of clothes they wear (77%) or changing their hair style or grooming habits (76%) and most are going by different pronouns (73%), few from this group have used hormone treatments (17%), legally changed their names (15%), or undergone gender-affirming surgery or other surgical treatments to change their physical appearance (9%). In comparison, among those who identify as trans women or trans men, six in ten have used hormone treatments, just over four in ten (43%) have legally changed their name and three in ten (31%) have undergone gender-affirming surgery or other surgical treatments.

SEEKING ACCEPTANCE
At least one in four (27%) trans adults say they have moved to a different part of town, a new city or a new state because they thought it would be a more accepting place for someone who is trans to live, including 35% of trans adults who now live in urban areas. Moving to a different town, city or state to find a more accepting environment is more common for trans adults who say they had an unhappy childhood or unsupportive immediate family. One-third of trans adults who say they had unhappy childhoods (36%) report moving to a more accepting place later in life, compared to one in five (21%) who had happy childhoods. Similarly, nearly half (48%) of trans adults who report having unsupportive families say they moved to a more accepting place, compared to three in ten trans adults with supportive families and one in ten trans adults who are not out to their families. Similar shares of trans adults across race, ethnicity, age, and income report moving to a more accepting place.

https://www.kff.org/report-section/kff-the-washington-post-trans-survey-trans-in-america/

In Their Own Words: Is there anything else that you would like to tell us about your experiences of acceptance or discrimination as a trans adult so we can better understand your experiences?

“My gender affirmation process was gradual. It was helpful to have more language for what I call gender expansiveness than 20 years ago when I first came out. This language helped me identify my gender more clearly and further medical options to affirm my identity as a masculine nonbinary person.” – Trans masculine nonbinary, D.C., Black, age 36

“I have never told anyone how I feel about my gender identity.” – Trans, nonbinary, Ohio, White, age 55-64

“I have been fortunate to have found support groups in my area that are accepting of all gender-nonconforming individuals. This was instrumental in developing a clearer understanding of my identity as a trans person, and in providing a means to socialize with other individuals across the transgendered spectrum.” – Trans, gender non-conforming, Florida, White, age 65

“Misgendering day to day. Having gender affirmation surgeries being denied by insurance. Not getting jobs because the manager wasn’t LGBTQ friendly.” – Trans woman, Missouri, White, age 25-34

“My experience is unique because I am trans and Black. Trans is hard without family support but you can create your own family through friends. Trans women does not mean you will be alone. People are interested in relationships. Sometimes we are seen as objects to use.” – Trans woman, Virginia, Black, age 39

“There are social and financial reasons why I haven’t come out as trans to my family and people around me. While I know my family would accept me, the process of them really understanding my situation and changing their behavior feels too exhausting in the short term to be worth it, while I’m already dealing with other mental health issues. I’d be interesting in pursuing top surgery and perhaps HRT, but I’m not in a financial situation where I could do that. Also, I work as a coach in youth sports, in cross country and track and field, and I’m afraid of my community’s reaction towards me…” – Trans, nonbinary, Connecticut, age 28

“When using some services, like an emergency room, I’ve had medical professionals get angry when hearing my husband use my correct pronouns. In those cases, I don’t want to end up in a situation where I might be mistreated, so I have my husband just stop gendering me correctly and kind of passively let the person pretend I’m a woman (I’m a trans man). I don’t like it, but it feels like the safest way forward.” – Trans man, Ohio, White, age 30

“Everyone who is gender nonconforming deserves the treatment I received from my therapist and doctors. They were extremely helpful, understanding, and patient. They encouraged me to experiment, think, then act. It was a profoundly simple but healthy way to approach the subject of transition…” – Trans woman, California, White, age 25

Trans Adults in U.S. Report High Levels of Discrimination
Despite taking steps to lessen experiences of stigma and discrimination, such as moving to places believed to be more accepting, more than six in ten trans adults (63%) say they feel discriminated against because of their gender identity and expression at least sometimes. Trans people of color report experiencing discrimination on multiple intersectional fronts, with most feeling discriminated against because of their gender identity (63%), their race or ethnicity (59%), their income level or education (58%) and their sexual orientation (53%).

Verbal attacks are the most commonly experienced discrimination measured in the poll. A majority of trans adults (64%) say they have been verbally attacked because of their gender identity, gender expression or sexual identity. One in four trans adults say they have been physically attacked because of their gender identity, gender expression, or sexual identity. The share of trans adults who have been physically attacked because of their gender identity increases to 31% among trans people of color.

Trans adults face other types of discrimination beyond verbal and physical attacks, including being asked unnecessary or invasive questions at their place of work (49%) or being harassed or feeling unsafe in a restroom or locker room (41%) because of their gender or sexual identity. One in five trans adults say they have been fired, denied a job or promotion (21%) or been refused health care from a health care provider (17%) due to their gender identity. One in eight trans adults (13%) say they have been evicted or denied housing because of their gender identity or expression, increasing to one in five (21%) among trans people of color.

Experiences with discrimination are far more common among trans adults who physically present as a gender different from their sex assigned at birth at least most of the time. Three-quarters of those who present as a different gender all or most of the time say they have been verbally attacked for their gender identity or sexual orientation, compared with half of those who present as a different gender some of the time or less. In addition, three in ten trans adults who physically present as a different gender report being physically attacked.

Beyond verbal and physical attacks, trans adults who physically present as a different gender at least some of the time are more likely to report being asked unnecessary or invasive questions at work (61%), being harassed or feeling unsafe in a restroom or locker room (50%), being fired or denied a job or promotion (29%), or being refused health care (24%).

Trans adults living in urban areas are also more likely than their suburban and rural counterparts to report facing certain types of discrimination, including one-third of trans urban residents who say they have been physically attacked, despite being no more likely than those living in suburban and rural areas to say they physically present as a gender different from their sex assigned at birth at least some of the time.

Difficulty Accessing Health Care
Trans adults report significant issues accessing gender-affirming health care, that is health care that supports and affirms an individual’s gender identity when it differs from the gender they were assigned at birth. This includes counseling, routine health visits, medications, and surgeries, among other services. About three in ten trans adults say they have had to teach a doctor or other health care provider about trans people so they could get appropriate care (31%), had a doctor or other health care provider refuse to acknowledge their preferred gender identity and instead refer to their sex assigned at birth (31%), or been asked unnecessary or invasive questions about their gender identity unrelated to their visit (29%). About one in five (17%) trans adult say they have had a doctor or other health care provider refuse to provide them with gender-affirming treatment, such as hormone treatments (17%).

Nearly half (47%) of trans adults say the health care providers they have come into contact with know “not too much” or “nothing at all” about providing health care to trans people. Just 10% say their health care providers know “a lot,” which is the same as the share who say their providers know “nothing at all.” Larger shares of young trans adults (54% of those ages 18-34) say doctors and health care providers know “not too much” or “nothing at all” about providing health care for trans people compared to 38% of trans adults ages 35 and older who say the same.

Among trans adults with health insurance, about a quarter (27%) say their insurance covers gender-affirming treatment or health care, while 14% say their health insurance does not cover this and six in ten (58%) are unsure. More generally, one in five trans adults say they have had health insurance that would not cover gender-affirming treatments or health care (22%). About one in seven trans adults have changed jobs or health insurance in order to get gender-affirming treatments or health care.

Most trans adults (72%) say they currently have a doctor or health care provider they feel comfortable seeking health care from, however, trans adults report more difficulty accessing routine health care than cisgender adults. Nearly half of trans adults (46%) say it is difficult to find health care that they can afford, compared to 37% of cisgender adults. Nearly half of trans adults (47%) also report it’s difficult to find a health care provider they can get an appointment with quickly (compared to 37% of cisgender adults). Trans adults also more likely to say they have difficulty finding a health care provider who treats them with dignity and respect (37% trans adults vs. 24% cisgender adults), or health care at a location that is easy for them to get to (35% trans adults vs. 21% cisgender adults).

Difficulty accessing routine health care transcends age and racial identities among trans people. Significant shares of trans adults ages 18-34 and ages 35 and older say it’s difficult to get health care they can afford (46% for both groups), a quick appointment (51% v. 42%), a provider who treats them with a dignity and respect (42% v. 29%), or health care at an easy location to get to (39% v. 31%). In addition, at least one third white trans adults and trans people of color report difficulties finding health care they can afford (49% v. 41%), a quick appointment (48% v. 45%), a provider who treats them with a dignity and respect (39% v. 33%), or health care at an easy location to get to (39% v. 31%).

Mental Health
With most Americans saying the U.S. is facing a mental health crisis, and LGBTQ people having historically faced widespread mental health disparities, the KFF-Post poll also asked about mental health experiences and access to mental health services. More than four in ten trans adults report feeling anxious (56%), depressed (48%), or lonely (44%), either always or often in the past 12 months. The share of trans adults who report these feelings in the past year is larger than the share of cisgender adults (31% report feeling anxious, 21% depressed, and 21% lonely). Trans adults are also less likely than their cisgender counterparts to report feeling happy (40% compared to 59%) or hopeful (29% compared to 50%) always or often over the past 12 months.

Similar to overall life satisfaction, about half of trans adults with families that are unsupportive of their trans identities report feelings of depression, loneliness, and anxiety. Feelings of hopefulness are higher among trans adults who say they have supportive immediate families. Younger trans adults are more likely to report feelings of anxiety and depression, though these age gaps mirror those among the general public.

The KFF-Post poll finds large shares of LGBT adults, and specifically transgender adults, report struggling with serious mental health issues. This includes one-third (34%) of all LGBT adults as well as more than four in ten (43%) trans adults who say they have had suicidal thoughts in the past 12 months. Trans adults are about six times as likely as cisgender adults to say they have engaged in self-harm in the past year, and more than twice as likely to say they have had an eating disorder in the past year or had suicidal thoughts in the past year.

Similar to previous studies finding that younger adults are more likely to report serious mental health struggles, younger trans adults ages 18 to 34 are more likely than older trans adults ages 35 and older to report having had suicidal thoughts in the past year (50% v. 36%) or having self-harmed in the past year (25% v. 9%).

The shares of trans adults who report having suicidal thoughts increases to half of those with unsupportive family members. In addition, about one in four of these individuals say they have engaged in self-harm in the past 12 months.

ACCESSING MENTAL HEALTH CARE
Nearly half of trans adults (47%) say there was a time in the past year where they needed mental health services or medications but didn’t get them (compared to a quarter of cisgender adults who say the same). Among those who did not get mental health services or medication, three in ten say the main reason was because they could not afford them, 22% say it was because they were too busy, 17% say they were afraid or embarrassed to seek care and one in ten say they couldn’t find an appropriate provider. Relatively few say it was because they didn’t know how to find services (7%), that their insurance wouldn’t cover it (5%), that they had a long wait for an appointment (3%), that they didn’t want medication (2%) or were discriminated against or didn’t feel safe getting treatment (2%).

Trans adults under age 35 are more likely than those ages 35 and older to say they could not access needed mental health services at some point in the past year (55% vs. 39%). Among the younger trans population, cost was the biggest deterrent from getting needed mental health care. One-third of trans adults 18-34 who said they did not get the care they thought they needed, said they didn’t get this care due to the cost (14% of all trans adults). For older trans adults, cost was among a list of reasons for not getting care. One in four trans adults 35 and older said they didn’t mental health care due to cost (9% of total trans adults 35 or older), which is similar to the share who say they were too embarrassed or afraid to seek care (24%, 9%). The difficulty that younger trans adults report getting mental health care is similar to the reasons provided by younger cisgender adults.

Had I not been misled by media stories of sex change “success” and by medical practitioners who said transitioning was the answer to my problems, I wouldn’t have suffered as I have,’ he said.

‘You will hear the media say, “Regret is rare.” But they are not reading my inbox, which is full of messages from transgender individuals who want the life and body back that was taken from them by cross-sex hormones, surgery and living under a new identity. After de-transitioning, I know the truth: Hormones and surgery may alter appearances, but nothing changes the immutable fact of your sex.’ Current treatment protocols of hormones and surgery are experimental. There’s no proof they are safe or effective. We present articles and studies that shine a light on the risks of social transition, hormones and surgery for both adults and children .

https://youtu.