In trying to argue for skepticism of the growing amount of gender-affirming care, Reuters reported data suggesting, ironically, that many trans youth are not getting the care they need. Here’s Reuters:

To get some idea of the increasing prevalence of these cases, Reuters asked health technology company Komodo Health Inc to analyze its database of U.S. insurance claims and other medical records on about 330 million Americans…The number of children who started on puberty-blockers or hormones totaled 17,683 over the five-year period, rising from 2,394 in 2017 to 5,063 in 2021, according to the analysis. These numbers are probably a significant undercount since they don’t include children whose records did not specify a gender dysphoria diagnosis or whose treatment wasn’t covered by insurance.

While being trans is not particularly common and thus the number of trans people newly receiving care will be fairly small, 17,683 struck me as a tiny number of people given the size of the U.S.

To check this intuition, we can estimate the number of adolescents seeking medical transition like so:

Filling in estimated numbers:

\( 86\,220 \approx 42\,000\,000 \cdot 0.6\% \cdot 66\% \cdot 54 \% \cdot 96\%\)

Then we can compare that figure to the number who received treatment.

\(\frac{\text{actual transitioners}}{\text{potential transitioners}}\)

\(20.51 \% \approx \frac{17\,683}{86\,220}\)

We can get a more accurate estimate. 17,683 covers new prescriptions over a five-year period, whereas the 42 million covers adolescents from 10 to 19 years. We can turn 42 million into a figure representing roughly the number of adolescents in a particular year by dividing by 10 and use the annual figures for hormones and puberty blockers Reuters also reported.

This is a conservative estimate and probably significantly underestimates the proportion of trans teens going without care. Notably, estimates for young people who are trans tend to be higher than for the population as a whole. It also doesn’t account for the fact that there is a backlog of teens who should have gotten care years ago. And there’s probably a greater percentage of teens today who realize they’re trans in time for puberty blockers and hormones than in the older studies I referenced. This data from Reuters also predates the recent wave of state bans on this care—at time of writing, the Movement Advancement Project lists 21 states with bans, although some have been blocked by courts and some have yet to take effect.

I also reduced the number of transitioners based on the number of people who regret it because this is meant as a conservative estimate, but I’m not sure I actually should. Even if we can identify some people at high risk of regretting transition, we can’t identify all people who do.

While I think it’s a conservative estimate overall, there are two factors going in the opposite direction. The data Reuters relied on looks only at insurance claims, meaning it doesn’t include treatments made out-of-pocket. It also excludes treatments provided without a diagnosis of gender dysphoria. However, puberty blockers are expensive and insurance often requires a related diagnosis before they approve treatment, so I’m inclined to guess these figures represent most of them. Some may be under a diagnosis other than gender dysphoria, however.

Even if the care gap were explained away by these factors, it would still be newsworthy, although it would make the situation dramatically less dire for trans youth. If basically all families manage to secure prescriptions for their kids but most have to pay out of pocket, that’s an unreasonable burden and increases the risk that kids will lose access if their parents’ financial situation ever got worse. The other possibility, that virtually all trans teens have access to puberty blockers or hormones paid through insurance but don’t have a gender dysphoria diagnosis, is the best case scenario. While dysphoria, broadly speaking, can be a useful concept, trans people have criticized its specific conceptualization in the DSM-V, and, if not required by insurance, the benefits of having dysphoria formally recorded as a diagnosis are are less clear. Unfortunately, this explanation seems unlikely given historical levels of gatekeeping.

Less conservative estimates push the amount of trans teens receiving hormone blockers to under five percent and hormones to under 20 percent even in 2021. These figures would indicate an enormous gap and a glaring failure of our health care system. Even the conservative estimate indicates that not having access to care is far too common. Journalists at Reuters and other mainstream outlets should not be questioning why more teens have gotten gender-affirming care but rather, why more teens are not receiving it.

What do other studies say? Unfortunately, they often suggest a number closer to the less-conservative estimates—in other words, the problem is worse than these estimates suggest. One survey of adolescents found only 11 percent. This survey didn’t account for respondents who didn’t want surgery. If we try to adjust the amount using that 66 percent figure, we get about 16 percent. The U.S Trans Survey, which surveyed trans adults, showed 1.5 percent had received puberty blockers. This study was done in 2015 so all respondents were adolescents well before 2021, but it makes sense that we might still have a low number if we were starting from such a minuscule baseline.

Other studies I found show a greater proportion of trans youth having received gender-affirming treatments, but they both include a substantial number of young adults (in these studies, 18 to 24 year olds):

• University of Michigan researchers found that 31 percent of respondents had accessed “accessed any medical interventions to affirm their gender.” This survey’s respondents had mostly completed high school. While respondents were recruited into a randomized trial, they weren’t randomly selected. Also, the majority of eligible respondents didn’t take the survey. Finally, because the primary study was looking at at-home HIV tests, there were several eligibility criteria: to participates, recipients had to either be HIV-negative or not know their status, be a U.S. citizen, be willing to receive an HIV test at home, and have a device that can support video-calling (for telehealth purposes). Taken together, these eligibility criteria probably also excluded at least some trans youth who would also struggle to get gender-affirming health care.
• Trans Pulse Canada found about 47 percent either had all needed care or were in the process of completing it. That sounds a lot higher, but given that 33 percent were in the process of completing it, it’s possible many of those respondents were only able to seek care after turning 18. The same study found only about 21 percent received financial help for gender-affirming medical care and 22 percent got help changing ID documents, which suggests many of that 47 percent did not transition before turning 18. Since it’s a convenience sample, it might also be biased toward trans people with more resources. And of course, the data is from Canada rather than the U.S.

I’m not the first to point out this implication of Reuters’ data¹. Evan Urquardt makes a similar point in his piece for Assigned Media challenging claims that gender affirming care is being widely overused:

The persistent narrative is that there are too many children seeking these specialists, and too many of those are receiving treatment to delay puberty or give them secondary characteristics of the opposite sex, but the numbers simply don’t support that view.

Fundamentally, I think teens are best positioned to weigh the risk of transition, with the help of supportive family, therapists, and doctors. Despite Reuters’ framing, their data—-plus data from similar surveys—-provides evidence that the majority of trans teens are unjustly denied that choice and, consequently, their bodily autonomy.

Further Reading/Viewing

• “Trans Youth: What Do We Want?” and “Trans Youth Get Healthcare Challenge (Impossible)” by Lily Alexandre covers the health care needs of trans youth in Canada and is based on the same survey as I mentioned. While my article calculates estimates for the U.S., there are similar issues for trans youth in both places.
• “The Report of the 2015 U.S. Transgender Survey,” chapter 7 (PDF)
• “Gender-Affirming Care for Trans Youth Is Neither New nor Experimental: A Timeline and Compilation of Studies” by Julia Serano

Sources

Percentage of Adolescents Who Are Trans

Estimates for adolescents and young adults range from 1.4 to 5 percent.

Percentage of Adolescents Receiving Treatment Who Regret

• This 2020 Study of a Spanish hospital found eight cases of “detransition and/or regret” among 796 people who received treatment, about 1 percent.
• This 2014 study of 767 Swedish trans people found a regret rate of about 2.2 percent.

Note that some studies cited to argue for a higher regret rate look at people who changed their mind before beginning treatment. Obviously, ensuring these teens have the follow-up care they need is still important, but that shouldn’t be confused with regret for a given treatment. And of course, knowing the extent to which people change their minds can help you reduce the regret. But you can’t treat them as interchangeable.

I tried to rely on studies focusing on regret, rather than stopping treatment, because it’s possible to stop treatment early without regretting it, even if stopping treatment is your decision, perhaps because the treatment helped you realize you don’t want it or if you stopped before the treatment had negative effects.

In keeping with my attempt at a conservative estimate, I chose the high end.

Percentage of Trans People Who Realized They’re Trans While Adolescents

The 2015 U.S. Trans Survey. Sixty-three percent of respondents realized they’re trans at the age of 20 or younger. The youngest participants would be 23 today.

A 2010 Graduate Journal of Social Science (PDF) study looking at trans adults found 76 percent were aware they were trans before leaving primary school. It also found that transgender people typically learned the term “transgender” around the age of 15, with the youngest cohort typically learning the term at age 14. It is unfortunately even older, meaning the youngest participants are 32 today. In looking at the full age range, it found “The age of acquisition of transgender-related vocabulary appears to have reduced by around 6 years in the last half century.” This study was relatively small (121 respondents) and was conducted online.

A few more studies looked at similar questions and suggest most people realized they’re trans even earlier:

• A 2015 study in the Journal of Adolescent Health found that trans youth seeking treatment “realized gender different from assigned” at 8.29 years. However, since these are patients seeking treatment, this study is probably skewed downward. Like many studies, it defines “trans youth” as including young trans adults from 19-24.

• A 2020 JAMA Network Open study found that trans adults almost always had their initial memory of gender dysphoria in childhood—96 percent had it at age 13 or younger. However, this study only looked at people receiving bottom surgery (gender affirming surgery on genitals). It’s possible that people who go on to get genital surgery differ from trans people as a whole. It’s possible that genital-related dysphoria both increases the likelihood of both early childhood memories of dysphoria and the odds of wanting bottom surgery. There will probably always be some percentage of trans people who experience (not to mention that some trans people may not experience dysphoria at all), but if dysphoria frequently begins early, it suggests that greater awareness of trans people might lead to a significant number of trans youth today having known for years prior to seeking puberty blockers or hormones.