Restrictions on gender-affirming care proposed by Republicans in Congress and President-elect Donald Trump could be devastating for transgender youths, doctors say, especially for teens with eating disorders.

Gender-affirming care — which includes mental health counseling and sometimes puberty-suppressing medication and hormone therapy — is a critical part of care for trans teens with eating disorders, said Jessie Menzel, a psychologist and vice president of development at Equip Health, which provides virtual mental health care for people with eating disorders.

Eating disorders are pervasive among young people who identify as trans. Many starve themselves or develop other harmful eating behaviors to make their bodies conform to a masculine or feminine ideal. Studies estimate that 25% to more than 50% of trans people have had eating disorders, compared with 9% of the overall population.

Yet transition-related care is increasingly out of reach for minors struggling with gender dysphoria, the acute distress that results from a mismatch between one’s sex assigned at birth and one’s gender identity. Most U.S. medical associations consider transition-related care to be essential for minors struggling with gender dysphoria.

Twenty-six states already ban such care for people under 18, and Trump said he will implement nationwide restrictions. Trump has vowed to “stop” gender-affirming treatments for minors and punish doctors who provide them. A massive spending bill the House and Senate passed this month includes a ban on using military health insurance for gender-affirming care for children of service members.

Public opinion polls show that Americans are divided over transition-related care for minors. A Gallup survey published in June found that 51% of respondentsagreed that “changing one’s gender is morally wrong,” although 60% also oppose laws banning transition-related care.

Many people who oppose such care say that minors are too young to understand the risks of hormonal therapies and that they are concerned about the lack of long-term data on potential side effects. Although the effects of puberty-blocking medications are largely reversible, they can cause a temporary reduction in bone density. Taking the hormones estrogen or testosterone, which many trans teens eventually receive, restores most of that bone loss. Gender-affirming surgery is rarely performed on patients under 18, and hospitals require parental consent before they provide any transition-related care.

But forbidding that type of care can also cause harm, and state bans have been linked to increased suicide attempts by trans youths. Additional restrictions could lead more kids to develop eating disorders and make it harder for people with eating disorders to recover, Menzel said.

“We are absolutely going to see an increase in eating disorders amongst these individuals,” Menzel said.

Carsen Rhys Beckwith, 27, of Kansas City, Missouri, said they developed an eating disorder around age 14, as they began developing the curves typically associated with female bodies.

But Beckwith didn’t feel female. They wanted to look muscular and more masculine. 

“My body was developing in a way that didn’t match how my identity was developing,” said Beckwith, who identifies as nonbinary and transmasculine.

Beckwith began trying to change their body the only way they could: by losing weight and constantly working out at the gym.

“It started with counting calories,” said Beckwith. After a while, Beckwith was subsisting on a single piece of fruit a day. “I would give most of my lunch away to my friends and think, ‘I don’t need to eat until dinner.’”

Feeling more at home in their bodies

For trans teens with eating disorders, receiving gender-affirming care — a comprehensive approach that validates a young person’s feelings, provides psychological support and, in many cases, includes hormonal therapies — can reduce their need to lose weight, Menzel said.

“It’s life-changing for them to be able to have access to somebody who is willing to listen to them,” Menzel said. “Just having someone who is willing to affirm who they are can make such a big difference.”

Puberty-blocking hormones can give trans teens a temporary reprieve from developing more adult bodies, giving them time to explore their gender identities with therapy, Menzel said. Other hormonal therapies, such as estrogen and testosterone, typically taken later in the teen years, can help children grow into bodies that match their gender identities.

Dr. Ellen Rome, a pediatrician and head of the center for adolescent medicine at Cleveland Clinic Children’s Hospital, said gender-affirming care can help teens feel better about their bodies and their relationships with food.

“When a kid is living as who they want to be,” Rome said, “often the eating disorder symptoms are relatively easy to eradicate.”

Although Ohio’s ban allows children currently receiving gender-affirming care to continue the treatments, doctors are no longer allowed to prescribe the medications for new patients under 18.

“They have taken that tool out of our toolbox,” Rome said.

Starvation as a coping strategy

Gender-affirming care — like trans rights in general — has become a hot-button political issue.

During the presidential campaign, Trump falsely claimed that children were undergoing gender-affirming surgery during the school day.

Tiffany Justice, a co-founder of the influential conservative group Moms for Liberty, dismisses gender-affirming care for minors as “child abuse” and “snake oil,” and she said her organization is working to ban gender-affirming care for minors in every state.

Gender-affirming care is endorsed by every major U.S. medical association, including the American Academy of Pediatrics, the American Medical Association and the American Academy of Child  and Adolescent Psychiatry. The AMA notes that trans teens who receive gender-affirming care have “dramatically reduced rates of suicide attempts, decreased rates of depression and anxiety, decreased substance use, improved HIV medication adherence and reduced rates of harmful self-prescribed hormone use.”

Children who are desperately unhappy — and unable to delay puberty in any other way — may take matters into their own hands, said Dr. Jason Nagata, an associate professor of pediatrics at the University of California, San Francisco.

Trans boys, for example, sometimes avoid eating, because they know that without enough daily calories, they won’t begin menstruation, Nagata said.

“Some people will intentionally restrict their food intake to get rid of their periods,” Nagata said. “We have seen that a lot, particularly when people can’t get gender-affirming care.”

Trans girls also sometimes try to delay the effects of puberty through starvation, Nagata said. “If they really restrict their food intake, they can prevent themselves from developing facial hair or Adam’s apples.”

Eating disorders can be life-threatening, Nagata said.

Anorexia, a condition in which people severely restrict their calorie intake, has the second-highest mortality rate of any psychiatric disorder, behind only opioid addiction. It can cause abnormal heart rhythms, anemia, bone loss and brain damage. About 5% of people die within four years of anorexia diagnoses. Even with intensive treatment, relapse rates are high. Fewer than half of people with anorexia make full recoveries.

Research shows such state bans on gender-affirming care heighten the stress and anxiety with which many trans people already live. Calls to a mental health crisis line run by The Trevor Project, a nonprofit organization that works to prevent suicide in LGBTQ youths, rose 700% the day after the November election. A recent study in Nature found that suicide attempts among trans youths increased 72% in states that outlawed gender-affirming care for minors.

Both trans children and those with eating disorders have elevated rates of self-harm and suicide, Menzel said. If lawmakers ban puberty-blocking hormones, Menzel predicts, more trans teens will look for ways to stop the process themselves.

Finding peace

Beckwith said they owe their recovery to transition-related health care and the support of other trans people.

Eight years ago, Beckwith began taking testosterone, which they describe as “lifesaving.” Although they still sometimes need to be reminded to eat more, Beckwith said they are much healthier than they were in college, when they contemplated suicide.

“I still have days when I have thoughts that creep back in,” said Beckwith, a program director at Project HEAL, an advocacy group that aims to increase access to treatment for eating disorders. Thanks to mental health counseling, “I have so much more practice now in rewiring those thoughts and leaning on the people around me who can affirm me and lift me up.”