Gender dysphoria is the feeling that your body is the wrong gender for you. The word “dysphoria” means distress and extreme discomfort. I love my job because I get to see people get relief from this distress that they’ve been trying to cope with their whole life. People who go through this process develop even more into who they are.

There’s a huge range of people who come to us for help. Sometimes people come to us in a position of strength. They are ready to go and excited to transition.

Unfortunately, a lot of teens come to us after a suicide attempt, failing out of school, self-harm, or extreme depression, with families who may not be accepting. They’re like, “We don’t know what else to do, so we’ll try this.” We have patients who are in their 50s and 60s coming to us saying they’ve wanted this their whole life.

Transgender medicine has a lot in common with medicine for everybody, with several broad categories and a few key differences.

First is primary care. Everybody should have access to primary care, but many people—especially those in marginalized populations, including trans and nonbinary people—don’t. When we talk about primary care for trans patients, people get really caught up in gender. The approach that I use is simpler: If you have it, get it screened. If someone has breasts, they need mammograms. If they have a colon, they need colonoscopies.

Then there’s hormone therapy, which is what I do. Someone who is a man but was assigned female at birth would need testosterone to help their body better match their identity. Someone assigned male at birth who identifies as a woman would be given estrogen. For teens who are in puberty or not yet in puberty, we could use puberty blockers to allow them a few more years to become clearer about their gender identity before beginning hormone therapy.

Another category of care we think about is surgery, which is often first and foremost in people’s minds but is a relatively small part of transgender medicine; many transgender and nonbinary people do not choose to have surgery or may be unable to access it. Mental health care is also very important for many people, whether you’re transgender, cisgender, or nonbinary.

If a patient is ready and clear about their gender identity, they should be allowed to start to transition as soon as their body starts puberty; that way they go through only one puberty toward the correct gender at the same time as their peers. For those patients, that is the ideal way to practice trans medicine.

But not everyone is ready to transition at the age when puberty begins, which can be as early as eight or nine years old for people assigned female at birth. In that case, we use puberty blockers to delay puberty until the patient knows what they want to do next. It’s a misconception that puberty blockers, which have historically been used when someone starts puberty too early, necessarily cause permanent changes. Puberty blockers are safe and reversible.

That said, puberty blockers are not a complete solution. Say someone assigned female at birth starts puberty at age nine, so we put them on puberty blockers and wait until they’re a legal adult—age 18 or even 19 in some states. What we’re doing is keeping someone prepubescent until they’re potentially in college. They’re completely taken off course from their peers. There could be potential long-term problems from keeping someone on puberty blockers for far longer than was intended. For example, it affects bone density, which is fully reversible after several years on puberty blockers; however, these medicines were never intended to be used for a decade. Additionally, puberty isn’t just about the body changing. It’s also about the emotional and intellectual growth that makes us into our adult selves, and testosterone or estrogen plays a key role in that brain development.

Quite frequently, I see young patients who have already gone through puberty. For them, the process looks more like an adult transition, except we go slower, just gradually increasing their dose to mimic puberty.

For the first few years, things were quiet. Nobody really knew my practice existed. More recently, we’ve been expanding into states where there’s a lot of controversy around trans medicine, like Alabama and now Texas. They’re reintroducing bills to make trans hormone therapy and puberty blockers illegal for minors. It’s been stressful. For my own sanity, I don’t listen to the news or go on any social media. I have people who do that for me so that I can just do my job.

I’d also like to touch on mental health therapy being required prior to transition for teens. If everybody had access to affirming, affordable, geographically accessible mental health care, I think that would be wonderful. What is shortsighted about the effort to make therapy a requirement is that access to care is a major issue and a huge obstacle. In my practice, we strongly suggest therapy. I had a patient in Mississippi who was under 18, and she called five different therapists trying to find somebody to see her. She was turned away because she was trans. It was a traumatic experience for her. She came back to me and said she couldn’t find anybody. Therapy is great for everyone, but it makes no sense for therapy to be an absolute requirement for care if therapy is not accessible, practical, or gender affirming.

The main concern from parents is that they don’t want to do anything permanent if they are not completely sure if this is the right thing for their child. There are other questions about reproductive organs and side effects, too.

Almost all the kids have done a ton of research these days. They know all about hormone therapy and what changes to expect, so they often already know most of what I go over in the visit.

Teens with supportive parents—or whose parents are catching up to wherever the child might be—are often very excited and don’t want to delay anything. They want to make sure they get started as soon as they can. Patients whose parents are not supportive but end up in my office anyway are hopeful but not necessarily excited, because they don’t know whether they are going to be able to start the transition or not. In general, the more parents learn about the effects of hormone therapy and how gradual the changes are, the more comfortable they become with supporting their teen’s transition.