In the United States, 1.4% of youths between the ages of 13 and 17 years (or approximately 300 000 adolescents) identify as transgender or gender-diverse (TGD),1 indicating that their gender identity, expression, or perception does not conform to the traditional gender roles and stereotypes associated with their assigned sex.2 The recent increase in adolescents and young adults reporting a TGD identity is thought to be due to increased awareness of the full range of gender identities, social acceptance, and improvements in medical care.14 Greater acceptance supports wellness.2 Indeed, in a study examining the health of those referred to care between 2000 and 2016, those recently referred seemed to have better psychological functioning than those referred previously, whereas a similar proportion across the study time period chose to initiate gonadotropin-releasing hormone agonists (GnRH-a; used for puberty suppression) or gender-affirming hormones.4

Similar trends have occurred in the Military Health System (MHS). The number of new pediatric-age patients presenting for gender-affirming care in the MHS increased from 109 individuals a year in 2010 to over 600 a year in 2016.3 In 2017, when gender-affirming medical care was included in the list of TRICARE benefits for about one year, at least 2500 children actively sought care for gender dysphoria through TRICARE Prime insurance at military or civilian treatment facilities, and 900 received GnRH-a or gender-affirming hormones.3

Approximately 918 000 youths aged 6 to 18 years have parents on active duty or ready reserve status, and one third of all military service members have children younger than 18 years.5 Military-affiliated youths are faced with unique challenges and stressors, such as family separation and lack of parental support during training and deployments, heightened risk of anticipated or actual parental injury and death, and frequent geographic relocations, leading to disruptions of peer networks, scholastic environments, and health care.6 The following sections examine the intersection between military-affiliated youths and gender-affirming care.

Military dependent and nondependent TGD youths are at high risk for chronic stressors that may lead to poor mental health outcomes and risk-taking behaviors.2,7 Compared with their siblings without gender dysphoria, TGD youths seen in the MHS had over five times greater odds of a mental health diagnosis and seven times greater odds of suicidal ideation or self-harm.7 The stressors encountered by TGD youths include experiences of discrimination, harassment, stigma, and marginalization at multiple social-ecological levels, and unaddressed gender dysphoria.2,8,9 Gender-affirming health care, such as puberty suppression and affirming hormones, mitigates these risks and optimizes patient-oriented outcomes, but many TGD youths have difficulty accessing services.2,811

Health care system barriers to gender-affirming treatment include discrimination, poor access, fear of mistreatment, and lack of trained clinicians willing to provide gender-affirming care.9 Among military-affiliated physicians in the MHS, 87% indicated they did not have sufficient training to prescribe gender-affirming hormones to transgender adults and 53% said they would not prescribe gender-affirming hormones regardless of training.12

TGD youths in some states also face new legal barriers to accessing gender-affirming treatments.13,14 Three states in the United States have outlawed all gender-affirming medical care for minors,15 and one state government has classified it as child abuse. Sixteen state public insurance programs (e.g., Medicaid) that serve persons of low income and a disproportionate number of racial/ethnic minorities do not pay for gender-affirming care. Nineteen state legislatures are considering laws to ban aspects of gender-affirming medical care, including creating criminal penalties for parents and clinicians who seek out or provide gender-affirming care for minors.14,15

Legislative efforts to restrict gender-affirming care for youths have been described as a public health crisis. New state laws directly harm TGD adolescents by denying access to potentially life-saving medical care and further exacerbating health care inequities, health risk behaviors, and preventable deaths.13,14

These current legislative efforts, along with efforts to exclude gender identity from legal discrimination protections, restrict sports participation, and regulate bathroom use, also harm TGD youths indirectly by increasing exposure to discrimination, stigma, and marginalization that underlie the mental health disparities associated with gender dysphoria.13,14 In a recent survey of 16 000 TGD civilian and military-affiliated youths aged 13 to 24 years across the United States, approximately half reported suicidality and 93% reported worry about transgender people being legally denied access to gender-affirming medical care.8 In a recent study of parents of TGD youths, the majority feared that laws prohibiting care would worsen their child’s mental health and decrease autonomy over medical decision-making for their children, including when they experience suicidality.16

These laws and regulations are especially harmful to youths who identify as Black, Indigenous, or people of color and those from disadvantaged backgrounds.9 Such youths may be more likely to depend on state-financed medical coverage, which specifically excludes coverage for gender-affirming care, and many families may not have the resources to travel or relocate to access appropriate care.

These restrictive state laws uniquely affect military TGD youths. Thirteen percent of the active-duty force lives in Texas, Arizona, Alabama, or Arkansas, states with the most restrictive laws on TGD-related care, and four of the five largest US military bases are located in states that have passed or are considering a ban on TGD-related care for minors.5,15 Military-affiliated TGD youths with parents assigned to these states may have limited or no access to gender-affirming care. This will make it difficult for youths in the MHS to initiate or continue GnRH-a or gender-affirming hormones. Military families have limited autonomy in geographic assignment and may not have any choice about moving into states that deny their children this potentially life-saving care, or the resources and commander support to regularly travel out of state to obtain care.5,15 Unwanted discontinuation of GnRH-a or gender-affirming hormones will lead to demonstrably harmful and nonsensical partial masculinization or feminization and may lead to depression, suicidality, poor quality of life, and other untoward outcomes.17

Providing gender-affirming care on a military base may not be a viable solution, as this may not protect parents or clinicians from criminal prosecution in states where rendering evidence-based, potentially lifesaving care to TGD youths is illegal or classified as child abuse. Similar to the case with local, non-military-affiliated clinicians, military clinicians who are qualified and willing to provide this care will be placed in a precarious and daunting situation when state laws conflict with ethical medical practice and the standard of care.12,14,18 Clinicians, many of whom are concurrently serving honorably as active-duty officers in the United States Military, may be forced to choose between withholding recommended and medically necessary treatments to act in accordance with state law, and providing ethical and evidence-based treatment while facing legal or financial persecution, dishonorable military service, or allegations of child abuse. Families serving the country may face similar dilemmas and consequences.

State laws banning gender-affirming care for TGD youths are currently blocked by court injunctions as they progress through litigation. However, given the “Originalist” judicial philosophy of the majority of the current Supreme Court and the recent rejection of substantive due process protections for private health care decisions, it is plausible that these laws may soon be enforced.

The family unit is the foundation of a strong military force.6 Threats to military-affiliated youths, parents, guardians, and clinicians are threats to military readiness. Service members frequently base their decision to reenlist or to extend military service on family factors, such as appropriate health care for dependents. Lack of health care services could affect the service member’s retainability, morale, performance, operational readiness, recruitment, and overall health; optimal care can reduce stress.6 For example, missed time at work, inability to deploy, and early return from deployment affect both home station and deployed missions.

In April 2022, a team of scholars at Yale University deconstructed the major arguments in which these laws are rooted.19 State legislation overstates uncertainties in the medical literature supporting gender-affirming care, exaggerates associated risks, falsely claims that medical standards authorize sterilization for minors, and fails to consider and acknowledge the substantial benefits of gender-affirming treatment.19 Current treatment guidelines describe the most effective and evidence-based treatment options, including the risks and benefits, based on four decades of research and clinical experience with TGD adolescents specifically, and substantially longer with TGD adults.2,11

These laws also assume that TGD adolescents and their parents are incapable of understanding the risks and benefits of gender-affirming medical care and then deciding what is in the youth’s best interest. Prior research has found that children can begin participating in their medical decision-making as early as age seven years with gradual increases in decision-making capacity, and adolescents prefer shared decision-making.2,2022 Furthermore, military-affiliated adolescents who initiate gender-affirming hormones continue their medication at rates similar to or higher than those of adults, reflecting a similar understanding and tolerance of the effects of hormonal therapy.23 Deontological and consequentialist reasoning, rooted in empirical evidence and human rights, suggests that youths with decisional capacity, in an informed consent model of care, have an inherent ability and right to consent to gender-affirming therapy.20

The United States Military has a long history of overcoming discriminatory policies affecting minoritized groups. In the case of gender diverse youths, the Department of Defense (DoD) can leverage its robust, intact systems to overcome evolving barriers to the provision of and access to care.


Publicly declare a position. The DoD through the Defense Health Agency (DHA) should publicly declare a gender-affirmative position on this issue, in accordance with the recommendations from multiple major medical societies that voice support for patients, parents, caregivers, and clinicians. Alternatively, a less public approach could involve a statement voicing support for insurance beneficiaries receiving evidence-based medical care informed by relevant medical organizations, while simultaneously fostering access to the full range of services. This may lead to less resistance and politicization, which could work against the overarching goals. However, affirming care has only recently become politicized; protection of gender-affirming medical care for military-affiliated TGD youths may require a declarative position without tolerance for personal biases, as the DoD has historically achieved for other minoritized groups.


Clarify boundaries. Clinicians who care for military-affiliated TGD youths should be familiar with relevant state laws that may limit provision of care, and available local and nonlocal resources. This information may fluctuate. To protect patients, parents, caregivers, and clinicians, current guidance should be updated regularly on relevant DHA Web sites for transparency. Nuanced information related to legalities by location of care (e.g., military treatment facilities, perhaps based on receipt of federal funding) and care provision rules (e.g., permissibility of telehealth or medical temporary duty based on physical location of patient or clinician) should be clearly elucidated by DHA legal advisors. The DHA should also make a commitment to defending clinicians and families who render gender-affirming care to minors in accordance with DHA legal guidance from prosecution under state laws or policies that criminalize this care.


Leverage the Exceptional Family Member Program (EFMP). The DoD can codify specific and definitive policies through the EFMP, ensuring protections for youths with TGD identities, their families, and their health care teams. The United States Air Force has publicly discussed this strategy using command-driven personnel actions to move affected families to locations with available care; it has also discussed the robust use of the EFMP to prevent relocation of enrolled families to areas unable to provide indicated care because of state law.24 The DoD must ensure that members of all military services have equitable benefits.


Use medical temporary duty judiciously. In states that permit travel for care across state lines, patients should be allowed access to medical temporary duty central funding to travel to states with a full range of care for specialized services. This model has been proven; military-affiliated patients from countries with barriers to gender-affirming services have temporarily visited a specialized military clinic in the United States periodically for care.25 For example, an implantable puberty blocker, which is generally effective for at least two years, can be administered at a tertiary care military hospital, requiring only routine services easily accomplished in primary care over time. This could be a temporizing measure prior to relocation.


Foster telehealth capabilities. Telehealth has greatly evolved during the COVID-19 pandemic and has the potential to meaningfully increase access to care. The United States Air Force has piloted a telehealth program for transgender active-duty members and found high rates of patient satisfaction, suggesting the infrastructure is in place. Use of this platform will depend on details of specific state law, credentialing, and licensure.


Provide education and training. The extent to which gender-affirming care exists at each location of care varies.12 The DHA, in partnership with the Uniformed Services University, can boost educational efforts for medical students, residents, and clinicians at military treatment facilities. Use of evidence-based clinical guidelines,11 consultation with experts in military settings,25 or civilian training programs (e.g.,; can ensure relevant content.

 Some well-intentioned military- affiliated clinicians may not be aware that a “watchful waiting” approach has a different risk profile than a gender-affirmative approach (which allows for gender identity exploration), and that “conversion therapy” is unethical, harmful, and generally illegal.2 Patients may face “gatekeeping” and major delays in care, including protracted and pathologizing psychiatric evaluations that question patient motives. With proper training, clinicians can provide care in an informed-consent, longitudinal primary care model that integrates mental health, or multidisciplinary care, based on patient complexity and need, clinician comfort and training, state laws, and family preferences.2,11


Optimize treatment platforms. Clinicians serving military-affiliated TGD youths can ensure that their treatment platforms—such as their clinic environments, staff, and care recommendations—are welcoming, accessible, and evidence-based.2 Facility commanders can be empowered to ensure institutional cultural responsiveness and humility among its clinical and support staff.


Sponsor research. Longitudinal research is needed to better understand long-term patient, family, and military outcomes associated with access to timely gender-affirming care. An investment in further educational and population-based health services research through military and civilian funding sources is warranted.

Military-affiliated youths with financial resources and strong parental support, as seen in other circumstances, may navigate the system to find appropriate solutions for lack of local care. Unfortunately, not all military-affiliated families or youths will have similar agency, leading to additional health care inequities among those without financial means or those at highest risk because of their multiple marginalization experiences. Low- or no-cost care through the TRICARE insurance program, including allowances for timely provision of GnRH-a—which can be cost-prohibitive for some nonaffiliated peers—already attenuates barriers to care. Additional supports from the DHA and local military commanders in the form of medical temporary duty sponsorship, as allowed, can further reduce risk.

A considerable worry is that for some youths with TGD identities, the stress of state laws and potential denial of necessary care will be insurmountable, resulting in poor mental health outcomes or suicide. The loss of these youths and the consequential suffering of the affected military families would be unfathomable and unacceptable. Those in immediate need can be referred to crisis resources (e.g., The Trevor Project;; military-specific resources are available as well ( In 2016, TRICARE formally approved coverage of care to TGD youths.3 We believe the DoD can continue to lead in this domain.


Children’s Mercy Kansas City funded open access fees.


The authors have no potential or actual conflicts of interest from funding or affiliation-related activities.


1. Herman JL , Flores AR , O’Neill KK. How many adults identify as transgender in the United States? The Williams Institute. University of California, Los Angeles School of Law. 2022. Available at: Accessed November 7, 2022. Google Scholar
2. Rafferty J , Committee on Psychosocial Aspects of Child and Family Health, Committee on Adolescence, Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness, Yogman M , Baum R , et al. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics. 2018;142(4):e20182162. Crossref, MedlineGoogle Scholar
3. Klein DA , Roberts TA , Adirim TA , et al. Transgender children and adolescents receiving care in the US Military Health Care System. JAMA Pediatr. 2019;173(5):491492. Crossref, MedlineGoogle Scholar
4. Arnoldussen M , Steensma TD , Popma A , van der Miesen AIR , Twisk JWR , de Vries ALC. Re-evaluation of the Dutch approach: are recently referred transgender youth different compared to earlier referrals? [erratum in Eur Child Adolesc Psychiatry. 2020;31(5):843.] Eur Child Adolesc Psychiatry. 2020;29(6):803811. Crossref, MedlineGoogle Scholar
5. Dept of Defense, Office of the Deputy Assistant Secretary of Defense for Military Community and Family Policy. 2020 Demographics profile of the military community. 2021. Available at: Accessed November 7, 2022. Google Scholar
6. National Academies of Sciences, Engineering, and Medicine. Strengthening the Military Family Readiness System for a Changing American Society. Washington, DC: National Academies Press; 2019. Google Scholar
7. Hisle-Gorman E , Schvey NA , Adirim TA , et al. Mental healthcare utilization of transgender youth before and after affirming treatment. J Sex Med. 2021;18(8):14441454. Crossref, MedlineGoogle Scholar
8. The Trevor Project. National Survey on LGBTQ Youth. 2022. Available at: Accessed November 7, 2022. Google Scholar
9. Chong LSH , Kerklaan J , Clarke S , et al. Experiences and perspectives of transgender youths in accessing health care: a systematic review. JAMA Pediatr. 2021;175(11):11591173. Crossref, MedlineGoogle Scholar
10. Chew D , Anderson J , Williams K , May T , Pang K. Hormonal treatment in young people with gender dysphoria: a systematic review. Pediatrics. 2018;141(4):e20173742. Crossref, MedlineGoogle Scholar
11. Hembree WC , Cohen-Kettenis PT , Gooren L , et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):38693903. Crossref, MedlineGoogle Scholar
12. Schvey NA , Blubaugh I , Morettini A , Klein DA. Military family physicians’ readiness for treating patients with gender dysphoria. JAMA Intern Med. 2017;177(5):727729. Crossref, MedlineGoogle Scholar
13. Barbee H , Deal C , Gonzales G. Anti-transgender legislation—a public health concern for transgender youth. JAMA Pediatr. 2022;176(2):125126. Crossref, MedlineGoogle Scholar
14. Park BC , Das RK , Drolet BC. Increasing criminalization of gender-affirming care for transgender youths—a politically motivated crisis. JAMA Pediatr. 2021;175(12):12051206. Crossref, MedlineGoogle Scholar
15. Movement Advancement Project. Equality maps: healthcare laws and policies. 2022. Available at: Accessed November 7, 2022. Google Scholar
16. Kidd KM , Sequeira GM , Paglisotti T , et al. “This could mean death for my child”: parent perspectives on laws banning gender-affirming care for transgender adolescents. J Adolesc Health. 2021;68(6):10821088. Crossref, MedlineGoogle Scholar
17. Wu SS , Raymer CA , Kaufman BR , Isakov R , Ferrando CA. The effect of preoperative gender affirming hormone therapy use on perioperative adverse events in transmasculine individuals undergoing masculinizing chest surgery for gender affirmation. Aesthet Surg J. 2022. CrossrefGoogle Scholar
18. Warling A , Keuroghlian AS. Clinician-level implications of bans on gender-affirming medical care for youth in the US. JAMA Pediatr. 2022;176(10):963. Crossref, MedlineGoogle Scholar
19. Boulware SD , Kamody R , Luper L , et al. Biased science: the Texas and Alabama measures criminalizing medical treatment for transgender children and adolescents rely on inaccurate and misleading scientific claims. Yale University. 2022. Available at: Accessed November 7, 2022. Google Scholar
20. Clark BA , Virani A. “This wasn’t a split-second decision”: an empirical ethical analysis of transgender youth capacity, rights, and authority to consent to hormone therapy. J Bioeth Inq. 2021;18(1):151164. Crossref, MedlineGoogle Scholar
21. Dubin S , Lane M , Morrison S , et al. Medically assisted gender affirmation: when children and parents disagree. J Med Ethics. 2020;46(5):295299. Crossref, MedlineGoogle Scholar
22. Vrouenraets LJJJ , de Vries ALC , de Vries MC , van der Miesen AIR , Hein IM. Assessing medical decision-making competence in transgender youth. Pediatrics. 2021;148(6):e2020049643. Crossref, MedlineGoogle Scholar
23. Roberts CM , Klein DA , Adirim TA , Schvey NA , Hisle-Gorman E. Continuation of gender-affirming hormones among transgender adolescents and adults. J Clin Endocrinol Metab. 2022;107(9):e3937e3943. Crossref, MedlineGoogle Scholar
24. Youn S. Air Force offers help to LGBTQ personnel, families hurt by state laws. Washington Post. April 16, 2022. Available at: Accessed November 7, 2022. Google Scholar
25. Van Donge N , Schvey NA , Roberts TA , Klein DA. Transgender dependent adolescents in the US military health care system: demographics, treatments sought, and health care service utilization. Mil Med. 2019;184(5-6):e447e454. Crossref, MedlineGoogle Scholar


No related items




David A. Klein, MD, MPH , Natasha A. Schvey, PhD , Thomas A. Baxter, DO , Noelle S. Larson, MD , and Christina M. Roberts, MD, MPH David A. Klein is with the Departments of Family Medicine and Pediatrics, Uniformed Services University, Bethesda, MD, and the Department of Family Medicine, David Grant Medical Center, Travis Air Force Base, CA. Natasha A. Schvey is with the Department of Medical and Clinical Psychology, Uniformed Services University. Thomas A. Baxter is with the Department of Family Medicine, David Grant Medical Center, Travis Air Force Base, CA. Noelle S. Larson is with the Department of Pediatrics, Uniformed Services University, and the Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda. Christina M. Roberts is with the Division of Adolescent Medicine, Children’s Mercy Kansas City, and the Department of Pediatrics, University of Missouri-Kansas City School of Medicine. Note. The opinions and assertions expressed herein are those of the authors and are not to be construed as reflecting the views of Uniformed Services University (USU), the Department of the Air Force, the Department of the Army, the US Department of Defense, or the US Government. “Caring for Military-Affiliated Transgender and Gender-Diverse Youths: A Call for Protections”, American Journal of Public Health 113, no. 3 (March 1, 2023): pp. 251-255.

PMID: 36480769