Over 20 states are considering legislation to restrict options for transgender youths. Many seek to limit medical treatment for gender dysphoria-the feeling of distress that may be experienced by people whose gender identity differs from their sex assigned at birth. Others aim to prevent transgender youths from fully participating in school athletics, using bathroom facilities in keeping with their gender identity, or obtaining identification documents with their name and gender. A proposed bill in Arkansas, for example, would "create the vulnerable child protection act to prohibit reassignment services for minors" (including hormone treatment and surgery), while another in Texas would require "public school students to participate in interscholastic athletic activities based on biological sex."

Figure. Transgender teenager Rebekah Bruesehoff, 14, competes on her middle school field hockey team and hopes to keep playing in high school. "It's all been positive," she says. "The coaches have been really helpful." Photo by Matt Rourke / Associated Press.

Medical treatment-which can range from fully reversible treatment such as puberty-suppressing gonadotropin-releasing hormone analogues to partly reversible treatment, to surgical removal of genitalia and reconstruction of new ones-presents complex bioethical challenges, as discussed in a 2018 literature review in BioMed Research International. "Children usually do not have the power to make legal decisions and actions at the initiation of cross-hormonal therapy," write the authors. "Nevertheless, their judgment and opinions should not be disregarded. . . . Patients who are denied treatment can develop serious psychological consequences."

Indeed, in a large-scale study in the October 2018 Pediatrics, between 30% and 51% of transgender adolescents reported having attempted suicide, with transgender female to male and nonbinary adolescents reporting the highest rates (nearly one in two transgender female to male and two in five nonbinary adolescents). Conversely, a study in the February 2020 Pediatrics found that treatment with pubertal suppression during adolescence was associated with lower odds of lifetime suicidal ideation.

The debate about school athletics is equally fraught. In Connecticut, for example, the families of three female high school runners filed a federal lawsuit last year to block transgender athletes in that state from participating as girls, arguing that competing against transgender students (who, they contend, have biological advantages) skews the playing field. In February, the U.S Department of Justice withdrew support of the lawsuit, which it had joined during the Trump administration.

Multiple health organizations have released position statements on transgender youths. Among them is the Pediatric Endocrinology Nursing Society, which advocates, among other policies, that youths who identify as transgender have access to an interprofessional team of qualified health and mental health care providers, evidence-based medical treatment, and gender-inclusive schools. The National Association of School Nurses likewise encourages comprehensive care for lesbian, gay, bisexual, transgender, and queer or questioning youths, "guided by the principles of cultural humility, in safe, inclusive, and affirming school environments."

Jan Oosting Kaminsky, an assistant professor of nursing at the CUNY School of Professional Studies in New York City, urges nurses to educate themselves on the care of transgender youths. Sensitive care, she has argued, includes using the young person's preferred name and pronoun, and reevaluating gendered assumptions in health care settings-for example, automatically handing out a princess sticker to a patient whose sex at birth is female. Instead, Kaminsky advises, the child's preferences should be noted.-Dalia Sofer