Gender-Affirming Care and Health Outcomes Among Transgender and Gender Expansive Youth: Research Advances and Future Priorities

Transgender and gender expansive (TGE) youth experience some of the highest health disparities compared with their cisgender peers.^1,2 A growing body of research increasingly shows that gender-affirming hormone therapy (GAHT), pubertal blockers, and surgical interventions can significantly improve mental health, reduce suicidality, and enhance quality of life.^3–5 However, studies are often limited by small sample sizes, predominantly White and TGE masculine participant populations, and a lack of representation of Black, Indigenous, and People of Color (BIPOC). Although research on gender-affirming medical care has shown positive effects on mental health, quality of life, and improved psychosocial well-being in these youth,^3,6–8 there is an urgent need for more inclusive, large-scale studies focused on health outcomes of GAHT and that address the unique challenges faced by all TGE youth.

This special issue of Transgender Health proudly contributes to the growing body of research on health or patient-related outcomes of gender-affirming care (GAC) among TGE youth and features research from U.S. and international scholars in three key areas: access to care, health and psychological outcomes, and the safety and efficacy of GAC. Studies explore telemedicine versus in-person testosterone injection education, patient-reported barriers and facilitators to care, and persistent unmet mental health needs. Additional work examines the development of a patient-reported outcome measure (PROM) and the psychosocial impact of practices such as binding and voice training. Safety-related research addresses clinical monitoring, adverse effects of GAHT, subcutaneous estradiol efficacy, erythrocytosis risk in masculinizing therapy, and post-surgical pain.

The first area involves access to GAC, which has historically been limited for TGE youth due to a lack of knowledgeable clinicians, insurance exclusions, geographic limitations, and provider or institutional bias.^9,10 Studies by Kahn et al., Nightingale et al., and Kidd et al. in this issue indicate that school-based health centers, patient education programs, and support groups for families may improve access. Similar to other studies, telehealth can also expand GAHT availability.^11,12 Importantly, Kidd et al. found that young adults’ perceptions of their parents’ support needs varied by race, ethnicity, and geography, emphasizing the need for tailored resources. Tailoring resources through the creation of innovative GAC models, such as in school-based health centers, may help bridge inequitable access to care, particularly for TGE youth of color.

The second key area in the special issue is health and psychological outcomes. Medical interventions such as GAHT are critical for reducing dysphoria and aligning physical characteristics with gender identity.¹³ PROMs can enhance care by capturing patient perspectives and strengthening the clinician-patient relationship.¹⁴ Kennedy et al. found that TGE youth viewed their newly developed PROM as accessible and affirming. Shapewear and binding, especially among trans masculine youth, are also common tools to reduce dysphoria.^15,16 In an article from Turkey, Tüzün et al. reported that longer binding durations may offer psychological benefits, although the relationship between binding and mental health is complex.

Although GAHT and affirming surgeries support embodiment goals for TGE youth,¹³ the final key area highlighted in this issue focuses on the safety and efficacy of GAHT. Understanding potential adverse effects is essential to ensuring safe care. The study by Vehmas et al. in Finland aimed to describe the use, administration, and dosing of GAHT while assessing metabolic and anthropometric changes during treatment. The study also evaluated reported side effects. They found expected laboratory changes, such as a 16% increase in mean hemoglobin and hematocrit levels in participants treated with testosterone and a 10% decrease in these levels among those receiving estrogen, both of which plateaued after 1 year. These effects are common and consistent with anticipated outcomes in treatment regimens. In addition, no serious somatic side effects were reported in their relatively homogenous sample. Erythrocytosis, a known risk in adults on testosterone,¹⁷ was also observed in adolescents. McLean et al., in a study from Australia with a similarly homogenous participant population, examined this effect in adolescents. In their sample, erythrocytosis developed in 9.5% of participants, and 67% developed erythrocytosis in the second year of treatment. The study found that erythrocytosis risk increased with longer duration of testosterone use, underscoring the importance of regular monitoring as part of testosterone therapy. Despite these findings, data on the effects of gender-affirming medical interventions in more diverse TGE populations remain limited.

Post-surgical pain remains a key clinical concern that is underrepresented in TGE youth-related research. In this issue, Battison et al. found that although adolescents and young adults (AYAs) reported persistent pain following gender-affirming surgery, younger individuals reported lower mean pain interference in the postoperative period. AYAs using cannabis within 1 month of gender-affirming surgery reported higher depression and anxiety levels, highlighting the importance of educating patients on how substance use may affect surgical recovery.

These studies clearly add to the growing body of literature on patient outcomes in TGE youth. However, similar to the majority of prior work, most studies in this issue relied on racially and ethnically homogeneous samples, with limited representation of BIPOC TGE youth. This restricts our understanding of their experiences as well as that of their families and weakens the statistical power of research to examine health and other outcomes through a health equity lens. Although recent data show that BIPOC TGE youth are as prevalent as their White peers, they remain underrepresented in pediatric and other clinical gender programs.^18,19 BIPOC TGE youth may face heightened risks of depression, suicidality, discrimination, and victimization.^20–22 Vance et al. found that Black and Latine transgender students had higher rates of depressive symptoms and suicidality than cisgender youth of the same racial/ethnic backgrounds.²³ These disparities may reflect compounded stigma tied to both gender identity and race/ethnicity. As GAC becomes increasingly restricted, the inequities in both access and patient outcomes facing BIPOC TGE youth are likely to worsen.

To address these disparities, researchers must increasingly look for opportunities to disaggregate data by gender identity and race/ethnicity²¹ and include BIPOC TGE youth in health outcomes research. Large, representative datasets, such as the 2019 Canadian Trans and Nonbinary Youth Health Survey, can help identify disparities but often fail to capture the complexity of intersectional identities.²⁴ Health system data from sources such as PedsNet and the schoolwide representative Youth Risk Behavior Surveillance System dataset are limited by missing gender identity fields and inadequate sample sizes for smaller racial and ethnic groups.²⁵ This lack of representation creates an inability to ask important research questions through a health equity lens and limits the generalizability of findings on GAC. In the end, this could hinder clinicians’ ability to fully apply current research to their BIPOC TGE youth patients and may also hinder providing culturally responsive, evidence-based care to BIPOC TGE youth.

Improving representation will not be easy. It will require new models of health care and research as well as a renewed commitment to health equity in its broadest form. It will also require the use of new and targeted strategies, including the use of community advisory boards, social media recruitment, participatory research, oversampling, and multisite collaborations.^21,26 Mixed-methods and quasi-experimental designs can further be used to explore structural barriers, stigma-health associations, and provider biases, critical areas of research needed to improve both care and equity.²⁶

This is a call to prioritize and amplify the voices of BIPOC TGE youth through intentional research partnerships with their communities. In the current climate, those without intersecting privilege face greater health care inequities and worsening disparities.²⁷ Despite increasing research on GAC, outcomes data specific to BIPOC TGE youth remain critically lacking.²⁸ Public and private funding must support research that centers these populations, focusing on gender identity, race, and ethnicity through a health equity lens.

Abbreviations Used

AYAs

Adolescents and young adults

BIPOC

Black, Indigenous and People of Color

GAC

Gender-affirming care

GAHT

Gender-affirming hormone therapy

PROM

Patient-reported outcome measure

TGE

Transgender and gender expansive

Author’s Contributions

D.J.I.-B.: Conceptualization; writing—original draft (lead); writing—review and editing.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: Inwards-Breland DJ (2025) Gender-affirming care and health outcomes among transgender and gender expansive youth: research advances and future priorities, Transgender Health 10:4, 303–305, DOI: 10.1089/trgh.2025.0106.