The NewsThe gap in life expectancy between men and women in the United States grew to its widest in nearly 30 years, driven mainly by more men dying of Covid and drug overdoses, according to a new study in the journal JAMA Internal Medicine.In 2021, women had a life expectancy of 79.3 years, compared with 73.5 years for men, the study found.“It was unsettling to see,” said Dr. Brandon Yan, a resident physician at the University of California, San Francisco, and lead author of the study, which analyzed death data from the Centers for Disease Control and Prevention.“We need to understand which groups are particularly losing out on years of life expectancy so interventions can be at least partially focused on these groups,” Dr. Yan said.A Covid patient in an intensive care unit in Queens in 2020. Between 2019 and 2021, the overall life expectancy in the United States dropped from around 79 to 76 years.Victor J. Blue for The New York TimesBackground: The life expectancy gap has substantially widened — and shrunk — before.At the turn of the 20th century, women had a life expectancy just two years higher than men, Dr. Yan said. But over the next 75 years, that gap began to widen, largely because more men smoked and developed cardiovascular disease or lung cancer.As smoking rates declined, excess deaths reduced among men, in particular.But in 2010, that gender gap began to widen yet again, this time driven by opioid overdose death rates, which are more than twice as high for men. That year, the life expectancy for men was 76.3 years, while for women it was 78.1.Men had a greater risk of developing diabetes and heart disease, and also faced higher rates of homicide and suicide.The Findings: Covid caused huge drops in life expectancy across the board.More than 1.1 million people in the United States have died of Covid, a staggering death toll that has caused precipitous declines in life expectancy. Between 2019 and 2021, the life expectancy in the United States dropped from around 79 to 76 years.But men have died of Covid at a higher rate than women. The reasons for this are complicated. Biological factors, like differences in inflammation and immune responses, likely played a significant role.But social and behavioral differences mattered, too. Men are more likely to work in industries with higher rates of Covid exposure and fatalities, including transportation, agriculture and construction, or to experience incarceration or homelessness. Women are also more likely to be vaccinated.From 2019 to 2021, Covid was the leading contributor to the widening gap in life expectancy between men and women, contributing nearly 40 percent of the difference in years lost.Overdose and homicide deaths increased, too.Unintentional injuries — mostly drug overdoses — contributed to more than 30 percent of the life expectancy gap between men and women. But more men also died by homicide or suicide between 2019 and 2021.“All of these point to a picture of worsening mental health across the board, but particularly among men,” Dr. Yan said.Dr. Yan noted that his analysis did not include transgender or other gender identities, because death certificates do not record that information.

S.S.R.I.s, the most widely prescribed antidepressants, frequently cause sexual problems. Here’s what patients can do about it.Antidepressants have long been among the most widely prescribed drugs in the U.S. Their popularity only grew at the start of the coronavirus pandemic, when many people struggled with depression and anxiety. Some surveys have found a striking rise among adolescents, particularly teenage girls.For many people, the drugs can be lifesaving or can drastically improve their quality of life.But many of the most popular antidepressants, known as selective serotonin reuptake inhibitors, or S.S.R.I.s, come with sexual side effects. In many cases, the problems caused by the medications can be managed. Here’s what patients should know.A wide variety of symptoms has been reported.More than half of patients who take S.S.R.I.s report some problems having sex. They include low levels of sexual desire or arousal, erectile dysfunction, pleasureless or painful orgasms and loss of genital sensitivity.Many people also report emotional blunting after taking S.S.R.I.s. This may make negative feelings less painful but also make positive feelings less pleasurable.Don’t be shy about talking to a doctor.When S.S.R.I.s went on the market in the late 1980s, patients began telling their psychiatrists that they were having sexual problems. Initially, doctors were perplexed: As far as they knew, older antidepressants had never come with these issues. But they had been wrong.“Only in going back and looking more carefully and gathering more data did we realize that actually those serotonergic drugs, the older ones, also caused sexual dysfunction,” said Dr. Jonathan Alpert, head of the American Psychiatric Association’s research council. Doctors and patients just hadn’t been talking about it, he said.As S.S.R.I.s boomed in popularity, and social stigmas about discussions of sex eased, researchers began documenting the problem in the scientific literature. But some patients found it easier to talk about than others did. Men were much more likely to report sexual side effects to their doctors than women were, even though women are almost twice as likely to be prescribed antidepressants.“The charitable interpretation is that we simply have more treatments available for male patients, and so doctors are more likely to ask after things that they feel they can actually help with,” said Tierney Lorenz, a psychologist at the University of Nebraska-Lincoln who has studied antidepressant-induced sexual dysfunction in women. “The significantly less charitable interpretation is that we still live in a very sexist society that doesn’t believe that women should have sexual interest.”Doctors may first recommend waiting it out.For some people, the sexual side effects of S.S.R.I.s will show up almost immediately after starting the medications and then resolve on their own. So doctors may suggest waiting four to six months to see whether the patient adjusts to the drugs and the most distressing sexual effects subside.But the odds of spontaneous resolution of sexual side effects are low, happening in an estimated 10 to 20 percent of patients who report the symptoms.Other medications, including other antidepressants, can help.One common way to manage sexual side effects is to try another S.S.R.I. Research suggests that certain drugs, such as Zoloft and Celexa, come with a higher likelihood of causing sexual problems. Switching drugs, however, means enduring a trial-and-error period to try to find what works.If a patient is otherwise doing well on an S.S.R.I., a doctor may be hesitant to drastically change the drug regimen. Instead, the doctor might recommend adding an additional drug to the mix that could help counteract the sexual side effects.For example, adding the non-S.S.R.I. antidepressant Wellbutrin, which acts on norepinephrine and dopamine in the brain, has been shown to diminish sexual symptoms in many patients, Dr. Alpert said.For erectile dysfunction, doctors may also suggest adding phosphodiesterase type 5 inhibitors like Viagra, which acts on the vascular system, he said.‘Drug holidays’ can help. But be careful.Another approach that should be used cautiously and under the close supervision of a physician is temporarily stopping the S.S.R.I. or lowering the dose for 24 to 48 hours before having sex.But for many patients, this isn’t an ideal solution. Planning ahead can be annoying. And withdrawal from S.S.R.I.s can immediately cause other unpleasant symptoms, including dizziness, nausea, insomnia and anxiety. Some doctors are concerned that frequent use of drug holidays may make patients more likely to discontinue the medications altogether, which could lead to worsening mental health problems.In rare cases, sex problems can persist after stopping the drugs.A small but vocal group of patients is speaking out about sexual problems that have endured even after they stopped taking S.S.R.I.s. Some have reported low libido and numb genitals persisting for many years.Though studies are scarce, the risk appears to be low. A recent study estimated that about one in 216 men who discontinued S.S.R.I.s were subsequently prescribed medications for erectile dysfunction, a rate at least three times as high as that among the general population.But diagnosing this condition is tricky, in part because depression itself can dull sexual responses. Among unmedicated men with depression, 40 percent report a loss of sexual arousal and desire, and 20 percent struggle to reach orgasm.

Some patients are speaking up about lasting sexual problems after stopping antidepressants, a poorly understood condition.Doctors and patients have long known that antidepressants can cause sexual problems. No libido. Pleasureless orgasms. Numb genitals. Well over half of people taking the drugs report such side effects.Now, a small but vocal group of patients is speaking out about severe sexual problems that have endured even long after they stopped taking selective serotonin reuptake inhibitors, the most popular type of antidepressants. The drugs’ effects have been devastating, they said, leaving them unable to enjoy sex or sustain romantic relationships.Listen to This ArticleOpen this article in the New York Times Audio app on iOS.“My clitoris feels like a knuckle,” said Emily Grey, a 27-year-old in Vancouver, British Columbia, who took one such drug, Celexa, for depression from age 17 to 23. “It’s not a normal thing to have to come to terms with.”The safety label on Prozac, one of the most widely prescribed S.S.R.I.s, warns that sexual problems may persist after the drug is discontinued. And health authorities in Europe and Canada recently acknowledged that the medications can lead to lasting sexual issues.But researchers are only just beginning to quantify how many people have these long-term problems, known as post-S.S.R.I. sexual dysfunction. And the chronic condition remains contested among some psychiatrists, who point out that depression itself can curb sexual desire. Clinical trials have not followed people after they stop the drugs to determine whether such sexual problems stem from the medications.“I think it’s depression recurring. Until proven otherwise, that’s what it is,” said Dr. Anita Clayton, the chief of psychiatry at the University of Virginia School of Medicine and a leader of an expert group that will meet in Spain next year to formally define the condition.Dr. Clayton published some of the earliest research showing that S.S.R.I.s come with widespread sexual side effects. She said patients with these problems should talk to their doctors about switching to a different antidepressant or a combination of drugs.She worries that too much attention on seemingly rare cases of sexual dysfunction after S.S.R.I.s are stopped could dissuade suicidal patients from trying the medications. “I have a really big fear about this,” she said.By the mid-2000s, the sexual effects of S.S.R.I.s were well recognized. In fact, the drugs so reliably dulled sexual responses that doctors began prescribing them for men with premature ejaculation.But sexual symptoms that endure after stopping the drugs haven’t received much attention in the medical literature.In 2006, a handful of cases of persistent genital numbness were reported in Canada and the United States. That same year, a newsletter for the American Psychological Association described emerging data on the lasting sexual effects of the drugs.Audrey Bahrick, a former psychologist at the University of Iowa, started taking Prozac in 1993, when she was 37 and struggling with a difficult job in a new city.Kathryn Gamble for The New York Times“I believe that we have barely begun to appreciate the pervasiveness and complexity of the impact on sexuality of these medications,” Audrey Bahrick, then a psychologist at the University of Iowa, wrote in the article.In an interview, Dr. Bahrick said she felt an ethical obligation to call attention to the condition because she had experienced it herself.She started taking Prozac in 1993, when she was 37 and struggling with a difficult job in a new city. Within one day of taking the pill, her clitoris and vagina felt numb. “It was like there was a glove over them — a very, very muffled sensation,” she recalled.For a while, she said, the trade-off was worth it: The antidepressant made her feel energized and more resilient. But after two years, she stopped taking it for the sake of her relationship. The sexual symptoms persisted, however, and the relationship ended.“It never occurred to me that this would be something that would in fact, in my life, never resolve,” said Dr. Bahrick, who is now 67.In the decades since, the use of S.S.R.I.s has soared, especially among teenagers. They are prescribed not only for depression and anxiety, but for a range of other conditions, including irritable bowel syndrome, eating disorders and premenstrual symptoms. Yet researchers are still struggling to understand how S.S.R.I.s work, and why the sexual problems are so pervasive.The drugs target serotonin, an important chemical messenger in the brain as well as other parts of the body. The molecule is involved in blunting sexual responses, including the orgasm reflex that originates in the spinal cord. Serotonin also affects estrogen levels, which in turn can affect arousal.But depression, too, dulls the sex drive. Among unmedicated men with depression, 40 percent report a loss of sexual arousal and desire, and 20 percent struggle to reach orgasm. Common conditions like diabetes and cardiovascular disease can also cause sexual problems.Drug trials rarely look at what happens when medications are stopped. And studying what happens after people get off S.S.R.I.s is particularly challenging because many people never stop taking them.Given the lack of data, “persistent sexual dysfunction caused by S.S.R.I.s is a hypothesis, not a proven phenomena,” said Dr. Robert Taylor Segraves, an emeritus professor of psychiatry at Case Western Reserve University School of Medicine who has studied the effects of antidepressants on sexuality.Still, some researchers have found ways to estimate the prevalence of the condition. A recent study in Israel reported that about one in 216 men who discontinued S.S.R.I.s were subsequently prescribed medications for erectile dysfunction, a rate at least three times as high as that among the general population.And when many patients report similar problems — like the distinctive symptom of genital numbness — the signal should not be dismissed, said Dr. Jonathan Alpert, head of the American Psychiatric Association’s research council.Roy Whaley, of Somerset, England, belongs to the PSSD Network, a global advocacy group formed last year. “We feel very neglected,” he said.Francesca Jones for The New York TimesSome patients who have taken finasteride, which treats hair loss in men, or isotretinoin, an acne medication, have also reported genital numbness and other sexual problems after stopping the medications. That may point to a common biological mechanism, Dr. Alpert said.“Everything begins with anecdotal reports, and science needs to follow,” he said.Other researchers are particularly worried about the growing number of young people who start the medications before their sexuality has fully developed.“People put on these drugs at a young age may just never know who they might otherwise be if they hadn’t been on this drug,” said Yassie Pirani, a counselor in Vancouver.In a new survey of 6,000 L.G.B.T.Q. young people that has not yet been peer-reviewed, Ms. Pirani and collaborators at Simon Fraser University in British Columbia found that people who had stopped antidepressants were 10 times more likely to report persistent genital numbness than those who had never taken the drugs.Ms. Pirani described one of her patients, age 33, who had taken S.S.R.I.s from age 11 to her mid-20s. “Her whole sexual history, she could have sex, but she never really felt anything,” Ms. Pirani said.Some of her patients, she added, wondered for years whether they were asexual before understanding that the medications may have played a role. When they turned to doctors for help, they were often dismissed.In recent years, many patients have found support for their condition online. About 10,000 people are members of a Reddit group for those with post-S.S.R.I. sexual dysfunction, up from 750 members in 2020. In 2018, dozens of patients and doctors petitioned regulators in Europe and the United States to add warnings about the risk of persistent sexual problems to drug labels, spurring the European Medicines Agency to do so the following year. (A spokeswoman for the U.S. Food and Drug Administration said the agency was still reviewing the petition.)“We feel very neglected,” said Roy Whaley, a 38-year-old from Somerset, England, who belongs to the PSSD Network, a global advocacy group formed last year.Mr. Whaley briefly took the antidepressant Citalopram at age 22 to treat his obsessive-compulsive disorder. Sixteen years later, his penis feels almost like it has been injected with a local anaesthetic, he said. He has lost his libido and feels no pleasure from orgasms. At times, he said, this loss of sexuality has made him feel suicidal.Over the years, doctors have repeatedly suggested that Mr. Whaley’s sexual problems were psychological, according to medical records reviewed by The New York Times. One record from 2009 noted that the Citalopram was “exceptionally unlikely” to be the cause.His current doctor does believe him, he said, partly because of the statement from European regulators.For Dr. Bahrick, who has continued to publish research on the topic, the recent recognition of her condition is cold comfort, considering the unknown number of people who have lost a core experience of being human.“It’s not just numb genitals,” Dr. Bahrick said. “It’s a reorientation to being in the world.”Audio produced by

The NewsA state judge in Missouri on Friday denied a request to temporarily block a state law passed this year that restricts gender-related medical treatments for minors. The ruling was issued by Missouri Circuit Court Judge Steven Ohmer, three days before the ban is set to go into effect. A legal challenge to the ban brought by civil rights groups is ongoing.Protesters gathered at the Missouri Statehouse in March to protest the state’s ban on transition care for transgender minors.Charlie Riedel/Associated PressWhy It Matters: Adolescents and adults are likely to have difficulty accessing gender-related health care.Under Missouri’s law, clinicians will not be allowed to treat any minor who is not already receiving gender transition care, which includes drugs that suppress puberty; hormone treatments with estrogen or testosterone; and, in rare cases, surgeries. Minors currently receiving care can continue to do so.The law will also affect transgender adults, as it bans Medicaid coverage of gender transition care for people of all ages in the state. The law has a “sunset” provision and will be in effect for four years.The legal challenge to Missouri’s ban has been particularly high-profile. A whistle-blower from a pediatric gender clinic in the state, Jamie Reed, said earlier this year that doctors at the clinic had hastily prescribed hormones with lasting effects to adolescents with psychiatric problems. Ms. Reed filed an affidavit about her experience in February and testified on Tuesday in favor of the ban.Chloe Cole, a 19-year-old who has frequently testified to state legislatures about regretting gender treatments she received as a younger teenager in California, also testified on behalf of the state of Missouri against the injunction.The plaintiffs in the legal challenge include three transgender minors who are seeking medical care to transition and will no longer be able to do so once the law is in effect. The plaintiffs also include doctors in the state and two national L.G.B.T.Q. advocacy organizations. Doctors who violate the new law could lose their medical licenses or be sued.According to the Williams Institute, a research center at the U.C.L.A. School of Law, an estimated 2,900 minors in Missouri identify as transgender.Background: Legal challenges have seen mixed results recently.At least 20 states have banned or severely restricted transition care for transgender minors in a flurry of legislation, led by Republicans. Most of the bans were passed during this year’s legislative session.Legal challenges have been brought by civil rights groups in at least 13 states. In June, a judge struck down a ban in Arkansas — the first such law to be passed in the United States — arguing that the law unfairly singled out transition care and transgender children. The ruling was a significant victory for transgender minors and their families. On Friday, a state district court judge in Texas temporarily blocked a law that would ban gender-related treatments for minors.But a series of legal setbacks has clouded the picture. In August, a federal appellate panel ruled that a similar ban in Alabama could be enforced while the case proceeds. Other disagreements in the courts have signaled that these cases may ultimately be decided by the United States Supreme Court.The American Academy of Pediatrics last month reaffirmed its position that these types of medical treatments are beneficial for many youth, and has vehemently opposed any government interference in medical decisions that it says are best made by parents and doctors. But the group also took the unusual step of commissioning a review of medical research on the treatments.What’s Next: The legal challenge continues as the law goes into effect.The law will restrict any new patients from receiving gender affirming treatments while the case is heard in state court over the next year. And it will continue to prevent Medicaid coverage for the estimated 12,400 transgender people in the state.Judge Ohmer, who typically presides over juvenile cases, wrote that the science in support of gender-related medicine for youth was “conflicting and unclear,” adding that “the evidence raises more questions than answers.”In response to the ruling, the American Civil Liberties Union of Missouri said it would continue to fight to overturn the ban: “The case is not over and will go to a full trial on the merits.”

The small Midwestern gender clinic was buckling under an unrelenting surge in demand.Last year, dozens of young patients were seeking appointments every month, far too many for the clinic’s two psychologists to screen. Doctors in the emergency room downstairs raised alarms about transgender teenagers arriving every day in crisis, taking hormones but not getting therapy.Opened in 2017 inside a children’s hospital affiliated with Washington University in St. Louis, the prestigious clinic was welcomed by many families as a godsend. It was the only place for hundreds of miles where distressed adolescents could see a team of experts to help them transition to a different gender.But as the number of these patients soared, the clinic became overwhelmed — and soon found itself at the center of a political storm. In February, Jamie Reed, a former case manager, went public with explosive allegations, claiming in a whistle-blower complaint that doctors at the clinic had hastily prescribed hormones with lasting effects to adolescents with pressing psychiatric problems.Ms. Reed’s claims thrust the clinic between warring factions. Missouri’s attorney general, a Republican, opened an investigation, and lawmakers in Missouri and other states trumpeted her allegations when they passed a slew of bans on gender treatments for minors. L.G.B.T.Q. advocates have pointed to parents who disputed her account in local news reports and to a Washington University investigation that determined her claims were “unsubstantiated.”The reality was more complex than what was portrayed by either side of the political battle, according to interviews with dozens of patients, parents, former employees and local health providers, as well as more than 300 pages of documents shared by Ms. Reed.Some of Ms. Reed’s claims could not be confirmed, and at least one included factual inaccuracies. But others were corroborated, offering a rare glimpse into one of the 100 or so clinics in the United States that have been at the center of an intensifying fight over transgender rights.The turmoil in St. Louis underscores one of the most challenging questions in gender care for young people today: How much psychological screening should adolescents receive before they begin gender treatments?Shaped by ideas pioneered in Europe, these clinics have opened over the past decade to serve the growing number of young people seeking hormonal medications to transition. Many patients and parents told The New York Times that the St. Louis team provided essential care, helping adolescents feel comfortable in their bodies for the first time. Some patients said they were lifted out of grave depression.A rally at the Missouri Statehouse in Jefferson City, Mo., in March.Charlie Riedel/Associated PressBut as demand rose, more patients arrived with complex mental health issues. The clinic’s staff often grappled with how best to help, documents show, bringing into sharp relief a tension in the field over whether some children’s gender distress is the root cause of their mental health problems, or possibly a transient consequence of them.With its psychologists overbooked, the clinic relied on external therapists, some with little experience in gender issues, to evaluate the young patients’ readiness for hormonal medications. Doctors prescribed hormones to patients who had obtained such approvals, even adolescents whose medical histories raised red flags. Some of these patients later stopped identifying as transgender, and received little to no support from the clinic after doing so.Unwanted outcomes and regrets happen in every branch of medicine, but several clinics around the world have reported challenges similar to those in St. Louis. Pediatric gender medicine is a nascent specialty, and few studies have tracked how patients fare in the long term, making it difficult for doctors to judge who is likely to benefit.In several European countries, health officials have limited — but not banned — the treatments for young patients and have expanded mental health care while more data is collected. In the United States, health groups have endorsed what’s known as affirming care even as their peers in Europe have grown more cautious. And conservative lawmakers in more than 20 states have taken the draconian step of banning or severely restricting gender treatments for minors.Civil rights groups are challenging the Missouri ban in a hearing this week, and Ms. Reed testified on Tuesday in favor of it, describing her allegations in detail.Washington University created an oversight committee to carry out weekly reviews of the gender clinic’s operations. The school’s investigation claimed that none of the clinic’s 598 patients on hormonal medications reported “adverse physical reactions.” In a statement to The Times, the university said that it would not address specific allegations because of patient privacy, and that “physicians and staff have treated patients according to the existing standard of care.”But doctors in St. Louis and elsewhere are wrestling with evolving standards and uncertain scientific evidence — all while facing intense political pressure and an adolescent mental health crisis.An Affirming ApproachKim Hutton, a founder of a parents group called TransParent. “In Missouri there were no knowledgeable doctors on this subject,” she said. “It was left to the parents to try to figure it out.”Bryan Birks for The New York TimesAmerica’s first youth gender center opened in Boston, in 2007, after two clinicians — Dr. Norman Spack, an endocrinologist, and Laura Edwards-Leeper, a child psychologist — traveled to the Netherlands to observe a promising treatment for children with gender distress, known as dysphoria.The Dutch doctors were prescribing drugs that stalled puberty in order to prevent the physical changes that often exacerbate dysphoria. The approach, they reasoned, would give the adolescents time to consider whether to proceed with estrogen or testosterone treatments later on.Transgender children have high rates of anxiety, depression and suicide attempts. The Dutch found that for a specific group — adolescents with no severe psychiatric disorders who had experienced gender dysphoria since early childhood — their depression lessened after taking puberty blockers.When Dr. Spack and Dr. Edwards-Leeper opened the Boston clinic, they hewed closely to the Dutch approach. In its first five years, the clinic treated just 70 patients.Similar clinics opened around the country, diverging over time from the strict Dutch protocols into an affirming approach that prioritized a child’s inner sense of gender. It was unethical, some argued, to deny care to children with psychiatric problems when gender treatments could help resolve those issues.In 2012, parents in St. Louis began lobbying leaders of the children’s hospital to set up an affirming clinic. The parents invited Dr. Spack to town to talk about his experience in Boston.“In Missouri there were no knowledgeable doctors on this subject,” said Kim Hutton, a founder of the group, called TransParent. “It was left to the parents to try to figure it out.”The clinic opened in 2017, led by Dr. Christopher Lewis, a pediatric endocrinologist, and Dr. Sarah Garwood, an adolescent medicine specialist, who had each attended TransParent meetings. They saw patients once a week on the second floor of the St. Louis Children’s Hospital, spending most days elsewhere in the sprawling complex.When Ms. Reed arrived, in 2018, she was the clinic’s only full-time employee. Eventually, the clinic would have about nine staff members, most part-time.Their patients were part of a striking generational change: Between 2017 and 2020, about 1.4 percent of 13- to 17-year-olds in the United States identified as transgender, nearly double the rate from a few years earlier.It’s clear the St. Louis clinic benefited many adolescents: Eighteen patients and parents said that their experiences there were overwhelmingly positive, and they refuted Ms. Reed’s depiction of it. For example, her affidavit claimed that the clinic’s doctors did not inform parents or children of the serious side effects of puberty blockers and hormones. But emails show that Ms. Reed herself provided parents with fliers outlining possible risks.Ms. Hutton’s son, who requested anonymity because of privacy concerns, is now in college, and said he was grateful he transitioned years earlier. “I have normal-people problems, which is all that I ever wanted,” he said.Another patient, Chris, now 19, who also requested anonymity to protect his privacy, recalled Dr. Lewis patiently drawing diagrams on the paper sheet of his exam chair, explaining how testosterone would redistribute his body fat and permanently deepen his voice. Chris felt “drastically improved” after taking the hormone, he said, but was still distressed by his breasts. At 17, he went to a surgeon in Ohio for a mastectomy.And Becky Hormuth, a teacher in St. Charles, Mo., praised the center’s doctors for their approach to her son’s mental health. The doctors diagnosed her 15-year-old with autism, she said, and connected him with a dietitian to help treat his eating disorder — before prescribing testosterone. Now, at 16, her son is “better than he’s ever been,” Ms. Hormuth said.A family therapist in St. Louis, Katie Heiden-Rootes, said she had worked with or supervised the counseling of roughly 30 of the clinic’s patients and had never seen problems with their care.“The biggest complaint I heard about the clinic was, ‘We can’t get in,’” Dr. Heiden-Rootes said.Katie Heiden-Rootes, a family therapist, said she had counseled about 30 of the clinic’s patients and had never seen problems with their care.Bryan Birks for The New York TimesBecky Hormuth’s son is a patient at the St. Louis clinic. “I’m worried everything we’ve fought for for our kid is going to come crumbling down,” she said.Bryan Birks for The New York TimesThe Red Flag ListWhen Ms. Reed, 43, began working at the clinic, she considered herself a fierce champion of the gender-affirming model. In her previous jobs — at Planned Parenthood, at an H.I.V. clinic and in the foster care system — she had also supported L.G.B.T.Q. young people. And her husband, a transgender man, had shown her how essential gender-affirming care could be.Ms. Reed’s job at the clinic was akin to that of a social worker — collecting medical histories, triaging appointments and supporting patients in the hospital, at school and in court.Her doubts about the affirming model arose in 2019, she said, after hearing from an upset patient who regretted their medical transition. She grew more concerned in 2020 as more new patients sought the clinic’s help, many with psychological problems exacerbated by the pandemic. She saw parallels with England’s youth gender clinic, known as the Tavistock, which was under investigation after employees complained about feeling pressure to approve children for puberty blockers as their wait-list swelled.The St. Louis center relied heavily on outside therapists to vet patients, emails show. Doctors there prescribed hormones to patients who had identified as transgender for at least six months, had received a letter of support from a therapist and had parental consent.Frustrated that the clinic had no system to keep track of patient outcomes, Ms. Reed and the clinic’s nurse, Karen Hamon, kept a private spreadsheet, which they called the “red flag list.” (Ms. Reed gave The Times a version of the spreadsheet without identifying information. Ms. Hamon and other clinic employees declined to comment for this article.)The list eventually included 60 adolescents with complex psychiatric diagnoses, a shifting sense of gender or complicated family situations. One patient on testosterone stopped taking schizophrenia medication without consulting a doctor. Another patient had visual and olfactory hallucinations. Another had been in an inpatient psychiatric unit for five months.On a different tab, they tallied 16 patients who they knew had detransitioned, meaning they had changed their gender identity or stopped hormone treatments.Ms. Reed saw parallels with England’s youth gender clinic, known as the Tavistock, which was under investigation after employees complained about feeling pressure to approve children for puberty blockers.Peter Nicholls/ReutersOne patient emailed the clinic, in January 2020, to say they had detransitioned and were seeking a voice coach for their masculinized voice. They also requested a referral for an autism screening, noting, “I have mentioned this before at appointments and over email, but it did not seem to go anywhere.”In another email thread, the center’s staff discussed a patient who regretted a recent mastectomy. The patient had messaged their surgeon at Washington University twice about wanting a breast reconstruction, but had not received a reply.The Times independently found another St. Louis patient who detransitioned, Alex, who posted on Reddit last year to “give a warning” about the clinic. (Alex shared medical records with The Times to corroborate her account.)Alex arrived at the center in late 2017 at age 15, she said, after identifying as transgender for three years. She had been referred by a therapist who was treating her for bipolar disorder and anxiety.Alex was prescribed testosterone, she said, after one appointment with Dr. Lewis. “There was no actual speaking to a psychiatrist or another therapist or even a case worker,” she wrote on Reddit.After three years on the hormone, she realized she was nonbinary and told the clinic she was stopping her testosterone injections. The nurse was dismissive, she recalled, and said there was no need for any follow-ups.Alex, now 21, does not exactly regret taking testosterone, she told The Times, because it helped her sort out her identity. But “overall, there was a major lack of care and consideration for me,” she said.The number of people who detransition or discontinue gender treatments is not precisely known. Small studies with differing definitions and methodologies have found rates ranging from 2 to 30 percent. In a new, unpublished survey of more than 700 young people who had medically transitioned, Canadian researchers found that 16 percent stopped taking hormones or tried to reverse their effects after five years. Survey responders reported a variety of reasons, including health concerns, a lack of social support and changes in gender identity.‘Disastrously Overwhelmed’Laura Edwards-Leeper warned in 2021 that American gender clinics were prescribing hormones to some children who needed mental health support first.Kristina Barker for The New York TimesNearly 15 years after bringing the Dutch approach to America, Dr. Edwards-Leeper, the Boston psychologist, had grown alarmed by the rise in adolescents seeking gender treatments.In a November 2021 Washington Post opinion piece, Dr. Edwards-Leeper warned that American gender clinics were prescribing hormones to some children who needed mental health support first.“We may be harming some of the young people we strive to support — people who may not be prepared for the gender transitions they are being rushed into,” she wrote with Erica Anderson, the former president of the U.S. Professional Association for Transgender Health and a transgender woman.In St. Louis, Dr. Andrea Giedinghagen, the clinic’s psychiatrist, emailed the essay to her colleagues. “This basically encapsulates the (very complex, nuanced) views that the child and adolescent psychiatrists I know at various gender centers hold,” Dr. Giedinghagen wrote.The head of the clinic, Dr. Lewis, responded, adding a university administrator to the thread. “I DO think our clinic, and transgender care at large, exhibits some of the concerns mentioned,” he wrote, including being “disastrously overwhelmed.”But, he added, “No matter the approach there will be a percentage of patients that should have been started that weren’t and vice versa.”By the end of 2021, emails show, the clinic was getting calls from four or five new patients every day — a sharp rise from 2018, when it saw that many over the course of a month. And, according to an internal presentation from 2021, 73 percent of new patients were identified as girls at birth. Gender clinics in Western Europe, Canada and the United States have reported a similarly disproportionate sex skew that has bewildered clinicians.St. Louis Children’s Hospital, where the gender clinic opened in 2017. When Ms. Reed arrived in 2018, she was the clinic’s only full-time employee.Bryan Birks for The New York TimesOther parts of the St. Louis hospital were also seeing more transgender patients. In August and September of 2022, Ms. Reed and Ms. Hamon, the clinic’s nurse, conducted a half-dozen training sessions with the emergency department to explain their work at the gender clinic. At the trainings, E.R. staff shared concerns about their own experiences with their young transgender patients, which Ms. Hamon later relayed to her team and university administrators.The E.R. staff, she wrote in an email, had been seeing more transgender adolescents experiencing mental health crises, “to the point where they said they at least have one TG patient per shift.”“They aren’t sure why patients aren’t required to continue in counseling if they are continuing hormones,” Ms. Hamon added. And they were concerned that “no one is ever told no.”As similar mental health issues bubbled up at clinics worldwide, the international professional association for transgender medicine tried to address them by publishing specific guidelines for adolescents for the first time. The new “standards of care,” released in September, said that adolescents should question their gender for “several years” and undergo rigorous mental health evaluations before starting hormonal drugs.Dr. Lewis worried that his clinic would not be able to adjust to the new standards, known as the S.O.C.“Right now I have no idea how to meet what would be the most intensive interpretations of the SOC,” Dr. Lewis texted Ms. Hamon. (She took a screenshot of the message and sent it to Ms. Reed.) He suggested meeting with staff members to discuss how they could abide by the new guidelines.In its statement, the university said that the clinic prioritized mental health care and that licensed external therapists “make a vital contribution to that effort.” It also said that “patients have ongoing relationships with mental health providers.”Some former staff members said the clinic was doing the best it could for patients with complex psychiatric histories. Cate Hensley, a social worker who interned at the clinic from 2020 to 2021, said that the team had a weekly meeting to discuss such cases.She also said that U.S. hospitals and health insurers invested far too little in mental health, putting extra pressure on doctors and hurting patients.“This center is providing ethical care in an unethical system,” Mx. Hensley said.Political AgendasJennifer Harris Dault, a Mennonite pastor, moved her family to New York to ensure that her child could get gender treatments when she nears puberty.Lauren Petracca for The New York TimesBy the end of last year, Republican lawmakers in Missouri had turned gender care for minors into a rallying cry. And Ms. Reed, formerly a staunch defender of the affirming model, had become openly skeptical of it, raising concerns in internal emails and in meetings despite warnings from higher-ups.Her performance review in 2022 stated that she “responds poorly to direction from management with defensiveness and hostility.” In November, she left the gender clinic and started a new role at the university coordinating pediatric cancer research.Ms. Hamon raised doubts as well, according to text messages and emails provided by Ms. Reed. In January of this year, she emailed an administrator to explain why she did not want a management role at the center.“You know I have struggled with ethical dilemmas about how we do things for quite some time,” Ms. Hamon wrote.That month, Ms. Reed obtained a prominent parental rights lawyer, Vernadette Broyles. Shortly thereafter, she filed her complaint with the state and publicized her allegations in an essay in The Free Press. Ms. Broyles is a vocal proponent of gender treatment bans for minors and has said the “transgender movement” poses an “existential threat to our culture.”Ms. Reed said that she supported the rights of transgender adults like her husband, and that Ms. Broyles was the only lawyer who would take her case pro bono. Still, Ms. Reed does not deny that her views have hardened and become political: “I support a national moratorium on the medicalization of kids,” she said.One parent said that, perhaps in pursuit of this political aim, Ms. Reed had misrepresented her child’s experience.Ms. Reed’s affidavit describes a patient whose liver was damaged after taking bicalutamide, a drug that blocks testosterone. It makes a specific claim about what a parent had written to the child’s doctors: “The parent said they were not the type to sue, but ‘this could be a huge P.R. problem for you.’”The parent, Heidi, a data scientist in the St. Louis area who requested anonymity because of privacy concerns, said she was stunned to read this “twisted” description of her teenage daughter’s case.Heidi, a parent in the St. Louis area who requested anonymity, said Ms. Reed misrepresented her child’s experience.Bryan Birks for The New York TimesHeidi’s daughter indeed had liver damage, a rare side effect of bicalutamide. But she had been taking the drug for a year, records show, and had a complicated medical history. She was immunocompromised, and experienced liver problems only after getting Covid and taking another drug with possible liver side effects.In a message to doctors that was shared with The Times, Heidi actually wrote, “In our world, it’s like a P.R. nightmare” — referring to tensions in her family about the gender treatments. The message did not mention anything about suing the clinic. To the contrary, it said: “We don’t regret any decision.”Ms. Reed said that she learned about the case from Ms. Hamon, who helped compile examples for the affidavit, and that she regretted citing the case when she had not seen the medical record herself.“My daughter’s situation was exploited,” Heidi said, noting that the hospital told her that her records would be shared with the state.Missouri’s ban of gender care for minors will begin on Aug. 28 unless the hearing this week results in a preliminary injunction. If the law goes into effect, the clinic will not be allowed to enroll new patients.Some families are not waiting for the legal proceedings to play out. Jennifer Harris Dault, a Mennonite pastor, moved her family from St. Louis to New York in July to ensure that her 8-year-old transgender daughter could get gender treatments when she nears puberty.“The more I see coming out of Missouri the more I know we made the decision that was right for us,” she said.The attorney general’s investigation into the clinic’s practices is ongoing, as is an inquiry by Senator Josh Hawley, a Republican. While several families said they blamed Ms. Reed for the political fallout, others said the university bears responsibility, too.For decades, Dr. John Daniels was the sole endocrinologist in St. Louis prescribing hormones to transgender adults. He did so, he said, because he saw profound benefits in his patients and because, as a gay man, he appreciated the diversity of the human experience.When Ms. Reed’s allegations came out, he was shocked, and emailed her to ask if she had ever reported concerns to Washington University. She replied that she had, but was ignored.“I hate that the politicians have gotten involved with this, but I do have great concerns about how adolescents and preadolescents are being treated,” Dr. Daniels wrote. “That the higher-ups at W.U. didn’t take you seriously is now on them.”Kirsten Noyes

The American Academy of Pediatrics renewed its support of gender care for minors while commissioning a fresh look at the evidence.The American Academy of Pediatrics backed gender-related treatments for children on Thursday, reaffirming its position from 2018 on a medical approach that has since been banned in 19 states.But the influential group of doctors also took an extra step of commissioning a systematic review of medical research on the treatments, following similar efforts in Europe that found uncertain evidence for their effectiveness in adolescents.Critics across the political spectrum — including a small but vocal group of pediatricians — have been calling for a closer look at the evidence in recent years, particularly as the number of adolescents who identify as transgender has rapidly increased.The treatments are relatively new, and few studies have tracked their long-term effects. Health bodies in England and Sweden have limited access to the treatments after carrying out systematic reviews, the gold standard for evaluating medical research.“The board has confidence that the existing evidence is such that the current policy is appropriate,” said Mark Del Monte, the chief executive of the A.A.P. “At the same time, the board recognized that additional detail would be helpful here.”As for the policy changes in Europe, he said, “they engaged in their process, we’re engaging in our process.”After completing the review, he said, the group will issue additional clinical guidance for doctors and likely update its recommendations.All 16 board members of the A.A.P., which represents 67,000 pediatricians across the United States, voted to reaffirm the 2018 guidelines at a meeting on Thursday in Itasca, Ill. The vote comes at a time of intense political pressures on transgender people and the doctors who care for them.Over the past two years, Republican lawmakers across the country have banned what’s known as gender-affirming care, which can include psychotherapy, puberty-blocking drugs, hormones and, rarely, surgeries. Opponents of the care argue that it is experimental and children lack the maturity to consent to it.The A.A.P. has roundly condemned the legislative bans as a dangerous intrusion into complex medical decisions between doctors and families, and has filed amicus briefs to support the many legal challenges brought against the bans by civil rights groups.Much of the academy’s support for gender-affirming care rests on its 2018 previous position statement, which said the treatments were essential and should be covered by health insurers. Transgender adolescents have high rates of anxiety, depression and suicide attempts, and early evidence suggested that gender-affirming care could improve their mental health.Position statements like those voted on today remain valid for five years before they are up for review, at which point they may be reaffirmed, retired or revised in light of new evidence. One example of such a reversal is the academy’s 2017 endorsement of infant peanut consumption, based on a landmark study showing that early exposure could help prevent lethal allergies.Some scientists criticized the decision to continue to recommend the treatments for young people before completing a rigorous review.The move is “very clearly putting the cart before the horse,” said Dr. Gordon Guyatt, a clinical epidemiologist at McMaster University who helped develop the field of evidence-based medicine.Based on previous systematic reviews, Dr. Guyatt said, the A.A.P.’s report will most likely find low-quality evidence for pediatric gender care. “The policies of the Europeans are much more aligned with the evidence than are the Americans’,” he said.In June, England’s National Health Service announced that it would restrict the use of puberty blockers to clinical trials because “there is not enough evidence to support their safety or clinical effectiveness as a routinely available treatment.” Last year, Sweden’s national health care oversight body similarly determined that, on the basis of its systematic review, “the risks of puberty-inhibiting and gender-affirming hormone treatment for those under 18 currently outweigh the possible benefits.”In the United States, a small group of pediatricians has pushed for a similar review from the A.A.P., one of the few institutions with enough centralized power to influence health care practices. Dr. Julia Mason, a pediatrician in Gresham, Ore., co-founded a group called the Society for Evidence-Based Gender Medicine that has been highly critical of gender treatments for minors. Since 2020, she said, she has unsuccessfully lobbied the academy’s leadership to commission a systematic review.Dr. Mason said she was pleased the group finally decided to take a close look at the data. “We are making strong recommendations based on weak evidence,” she said.But Dr. Marci Bowers, a gynecologic and reconstructive surgeon and the president of the World Professional Association for Transgender Health, was heartened by the A.A.P.’s endorsement of the care, which she said profoundly improves many children’s lives.“They know this population,” said Dr. Bowers, who is a transgender woman. “They know the stories. Anecdotally, it’s overwhelmingly positive.”She also pointed out that doctors in many specialties, and particularly in pediatrics, routinely use medicines that haven’t yet been tested in large and rigorous clinical trials. And Europe, unlike many U.S. states, has not banned the care entirely.“What they’re saying is this population needs to be studied,” she said, referring to European policies. “And I agree with that.”

Using four decades of health data from Denmark, the study offers the clearest picture yet of the suicide risk among transgender people.Transgender people in Denmark have a significantly higher risk of suicide than other groups, according to an exhaustive analysis of health and legal records from nearly seven million people over the last four decades. The study is the first in the world to analyze national suicide data for this group.Transgender people in the country had 7.7 times the rate of suicide attempts and 3.5 times the rate of suicide deaths compared with the rest of the population, according to the records analyzed in the study, though suicide rates in all groups decreased over time. And transgender people in Denmark died — by suicide or other causes — at younger ages than others.“This is beyond doubt a huge problem that needs to be looked at,” said Dr. Morten Frisch, a sexual health epidemiologist at Statens Serum Institut in Copenhagen and a co-author of the new study.The findings, published on Tuesday in the Journal of the American Medical Association, come at a charged political moment in the United States, where Republican lawmakers across the country have enacted laws targeting sexuality and gender identity, restricting drag performances, bathroom use for transgender people and gender-related medical care.Studies of L.G.B.T.Q. people in the United States have shown that they have high rates of suicidal thoughts and attempts, putting them at high risk of death by suicide. But with scant data on actual deaths, suicide risk has become a matter of heated speculation and debate. Some Republicans have argued that suicides among transgender people are rare, while some L.G.B.T.Q. advocates have declared that the new laws could lead more young transgender people to die by suicide.“This offers a stark rebuttal to some of those political arguments suggesting suicide risk in these groups are exaggerated,” said Ann Haas, an emeritus professor at the City University of New York who has studied suicide risks among L.G.B.T.Q. people for two decades.But, Dr. Haas added, “This is not a time to use data for any political recrimination.”The United States, like most countries, does not have information about the sexual orientation or gender identity of people who die violent deaths because this information is not recorded on death certificates. A few death investigators are trying to collect such data by interviewing the friends and family of the deceased, though progress has been slow.Denmark, however, has a centralized data repository for all of its citizens, enabling researchers to conduct massive and rigorously controlled studies.The authors of the new report identified nearly 3,800 transgender people in Denmark by pulling data from two sources: hospital records and applications for legal gender changes. Among that group, nearly 43 percent had a psychiatric diagnosis, compared with 7 percent of the nontransgender group.The study identified 92 suicide attempts and 12 suicide deaths in the transgender group between 1980 and 2021, a rate considerably higher than what was found in the nontransgender group. The researchers said there were most likely other suicides that were not captured in the data because no records indicated the person’s gender identity. The study also found the rate of other, nonsuicide deaths in the transgender group was nearly double the rate of the nontransgender group.The United States and Denmark have comparable suicide rates — 14 per 100,000 people in the entire population — suggesting that the study’s findings may apply in the United States as well, researchers said.“Trans people face widespread poverty, widespread discrimination, they’re more likely to experience homelessness, they’re overrepresented in our nation’s prison system, our nation’s foster care system,” said Gillian Branstetter, a communications strategist at the American Civil Liberties Union who focuses on transgender rights. “That material lack has very real consequences on their lives, up to and including early deaths.”But the researchers cautioned against drawing overly broad conclusions about the calculated rates. For one thing, the raw number of suicides and attempts among transgender people was small.Based on their search tools, the researchers found that approximately .06 percent of the Danish population was transgender. In contrast, the Williams Institute at the University of California, Los Angeles, has estimated, using survey data, that the number of people who self-identify as transgender in the United States is 10 times higher than that. That might mean that a lot of transgender people in Denmark — and especially the increasing number of younger people who identify as trans or nonbinary — were not captured in the data, and perhaps that the true suicide rate is different than reported, the researchers said.“These surveys tend to include much broader spectrums of trans individuals, and we cannot be as certain that our results are as problematic in the broader group,” Dr. Frisch said.If you are having thoughts of suicide, call or text 988 to reach the Suicide and Crisis Lifeline or go to SpeakingOfSuicide.com/resources for a list of additional resources.

The NewsThe National Health Service of England announced on Friday that it would limit the use of puberty-suppressing drugs to children enrolled in clinical trials. The change comes as the agency’s pediatric gender services have struggled to keep up with soaring demand.A document explaining the agency’s reasoning stated that “there is not enough evidence to support their safety or clinical effectiveness as a routinely available treatment.”The N.H.S. had released a draft of this policy change in October, but Friday’s announcement formally instituted the new approach after months of public comment. The policy will go into effect later this year.The N.H.S. announced last year it would shut down the Tavistock Gender Identity Development Service in London after the clinic saw a sharp rise of referrals.Peter Nicholls/ReutersWhy It Matters: Other countries have limited the drugs, tooThe change is part of a broader push in several countries to limit gender-related medical treatments for young people.After conducting evidence reviews, Finland has begun limiting who can access gender-related treatments and Sweden has restricted the use of puberty blockers and hormones to clinical trials. A Norwegian health body and the French National Academy of Medicine have also urged caution.In the United States, more than 20 Republican-led states have passed laws banning the use of puberty-blocking drugs and hormones, with some making it a felony for doctors to prescribe them. Hundreds of clinicians across the country — including some who have raised concerns about which adolescents should receive gender-related treatments — have denounced the bans, saying such decisions should be made by patients, their families and their doctors.Background: Data on the effect of blockers is sparseLast year, N.H.S. England announced that it would be shutting down the country’s only youth gender clinic after an external review showed that the Tavistock Gender Identity Development Service had been unable to provide appropriate care for the rapidly increasing number of adolescents seeking gender treatments. The clinic had seen a sharp rise in referrals, from 250 young people in 2011 to 5,000 in 2021.Puberty blockers, which work by suppressing estrogen and testosterone, were first tested on children with gender dysphoria in the Netherlands in the 1990s. The Dutch researchers published their first study on 70 children in 2011, finding that the adolescents reported a decrease in depression and anxiety after taking the drugs.But a British study of Tavistock patients published in 2021 showed that blockers had no effect on children’s scores on psychological tests. The study found that 43 out of the 44 participants later chose to start testosterone or estrogen treatments. One interpretation of the data is that all were good candidates for hormone therapy. But the numbers raised concerns at the N.H.S. about whether the drugs served their intended purpose of giving adolescents time to think.“The most difficult question is whether puberty blockers do indeed provide valuable time for children and young people to consider their options, or whether they effectively ‘lock in’ children and young people to a treatment pathway,” Dr. Hilary Cass, the pediatrician overseeing the independent review of the N.H.S. gender service, wrote last year.What’s Next: England will start a trial of children taking blockersThe N.H.S. is organizing a clinical trial for all children receiving puberty blockers from the health service, which it expects will begin enrollment in 2024.Although the Tavistock clinic has been closed, regional centers are opening across Britain to expand gender-related services for young people. The N.H.S. said that the new system for treating minors with gender-related issues will establish standardized assessments and incorporate much more mental health support.“The main objective is to alleviate distress associated with gender incongruence and promote the individual’s global functioning and well-being,” the N.H.S. guidance said.

Missouri has imposed sweeping rules to limit health care for trans adults. Other states have banned Medicaid coverage or introduced bills outlawing care for young adults.Missouri this month became the first state in the country to severely restrict gender treatments for people of all ages, following a series of quieter moves across the country that have been chipping away at transgender adults’ access to medical care.Last year, Florida joined six other states in banning Medicaid from covering some form of gender care for transgender people of all ages. These bans affect an estimated 38,000 beneficiaries of the public insurance program, according to the Williams Institute, a research center at U.C.L.A.’s law school.And in at least five states, Republican legislators have proposed bills that would abolish gender care for minors as well as young adults. Some are attempting to ban it for anyone under 21, and others for those under 26.Missouri’s sweeping new policy took a different approach. Citing consumer protection laws meant to regulate fraud, the state attorney general, Andrew Bailey, issued an emergency rule prohibiting doctors from providing gender treatments to patients — of any age — unless they adhere to a slew of significant restrictions, including 18 months of psychological assessment. The rule also said that patients should not receive gender treatments until any mental health issues are “resolved.”The onerous restrictions amount to a “de facto ban,” said Gillian Branstetter, a communications strategist at the American Civil Liberties Union, whose Missouri chapter announced its intent to file a legal challenge to the rule.“The political situation regarding trans people’s health care was always headed here,” Ms. Branstetter said.The rule excludes people who are currently receiving treatments, so long as they and their doctors “promptly” comply with the psychological assessments and other restrictions.Aro Royston, a 35-year-old transgender man in St. Louis, said he was shocked by the new policy. He said he had been taking testosterone for eight years, with monthly refills prescribed by his doctor. If he could no longer have access to the treatments, he would be “devastated,” he said, and would travel out of state to receive care.“I think what upsets me most is, I’m a functioning member of this society,” said Mr. Royston, a program manager at a U.S. defense contractor. “I’ve worked on defense programs to protect my nation. And my nation can’t protect me?”Missouri’s new policy goes into effect on April 27 and expires in February 2024, when the state legislature will be back in session. (Two bills that would have banned care for minors — and prohibited Medicaid from covering it for all ages — have not advanced in this year’s session.)Andrew Bailey, Missouri’s attorney general, issued the emergency rule prohibiting doctors from providing gender treatments to patients of any age unless they adhere to a slew of significant restrictions.Valerie Plesch/BloombergAlthough Mr. Bailey’s order applies to all ages, his public comments have focused on children, echoing the rhetoric of Republican politicians across the country and in Missouri. “As Attorney General, I will always fight to protect children because gender transition interventions are experimental,” Mr. Bailey said on Twitter.In February, his office launched an investigation of a youth gender clinic at Washington University in St. Louis after a former employee filed a whistle-blower complaint claiming that patients there were rushed into treatment and not given adequate psychological screenings. (The clinic said that it followed the accepted standards of care.)When asked why his order includes adults, Madeline Sieren, a spokeswoman for Mr. Bailey, said, “We have serious concerns about how children are being treated throughout the state, but we believe everyone is entitled to evidence-based medicine and adequate mental health care.”Fourteen other states — Alabama, Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kentucky, Mississippi, South Dakota, Tennessee, Utah and West Virginia and, as of Wednesday, North Dakota — have passed laws restricting gender care for minors.Although there is some debate among medical professionals about which children will benefit from gender-affirming care and when they should begin treatments, several large medical groups in the United States, including the American Academy of Pediatrics, have condemned the legislative bans.For transgender adults, many studies have shown that transition care can improve psychological well-being and quality of life.Terry Schilling, the president of the American Principles Project, a right-wing advocacy group pushing for restrictions on transgender rights, said in an interview earlier this year that focusing on minors had been a short-term political calculation. His organization’s long-term goal, he said, was to eliminate transition care altogether.“I view this whole issue the same as I view lobotomies or eugenics — it’s a bad medical fad,” he said.Mr. Schilling said policies might include outright bans for people of all ages, or bills to make it easier for people to sue medical providers if they regret transitioning. He also raised the possibility of classifying transition care as “consumer fraud” — the same approach put forward by Mr. Bailey — because he contends that it is impossible to change genders.Over many years, seven states — Arizona, Florida, Missouri, Nebraska, South Carolina, Tennessee and Texas — have enacted policies banning Medicaid from covering some type of gender-affirming care. (The federal insurance program for low-income people is partly funded by states, which also have wide latitude to determine eligibility.).State Senator Nathan Dahm of Oklahoma introduced a bill that would withhold Medicaid reimbursement for any procedure or treatment from any health center that offered gender care.Sue Ogrocki/Associated PressThe Medicaid bans are “on shaky legal ground,” said Christy Mallory, legal director of the Williams Institute. Courts in Wisconsin and West Virginia have ruled that such bans violate the Affordable Care Act, which prohibits sex discrimination, as well as other federal rules.But some legislators are introducing broader bills that would prohibit gender-related care at government-owned or operated health centers, or at those that accept state funding.In Oklahoma, for example, a bill introduced this year by State Senator Nathan Dahm would withhold Medicaid reimbursement — for any procedure or treatment — from any health center that offers gender care or works with a provider who offers it.In an interview in January, Mr. Dahm said that his only goal was to stop taxpayer money from covering transition procedures. “If an adult wants to make that decision and pay for it themselves, then they can do so,” he said. He also acknowledged, however, that the policy could spur some health care providers to stop offering care to adults.Over the past few decades, doctors have increasingly removed barriers, such as psychological evaluations, for adults to get hormone treatments, shifting decision-making to patients themselves.“There’s very, very broad consensus that gender-affirming care for adults is appropriate and helpful,” said Erica Anderson, a clinical psychologist and former president of the U.S. Professional Association for Transgender Health.Dr. Anderson, a transgender woman, has publicly voiced concerns about the rising number of adolescents, especially those with complex psychiatric issues, seeking gender-related care. She has also supported the policies of certain European countries, including Sweden and Britain, that have recently limited when children can undergo certain medical treatments.But last month, Dr. Anderson joined hundreds of clinicians in signing a letter that emphasized gender-affirming care is beneficial and important for many transgender children and denounced the legislative bans in the United States. The efforts to extend such restrictions to adults will add significant harm, she said.“The blurring between youth and adult care is ominous,” she said. “It’s an ominous sign of overreach by people who think that the state should decide people’s personal lives.”The Missouri rule has also received pushback among some conservatives in the state. Secretary of State Jay Ashcroft, a Republican who recently announced he was running for governor, told St. Louis public radio that although he supported bans for children, he did not believe the state should restrict care for adults.“I don’t think people should do it,” Mr. Ashcroft said, referring to gender treatments for adults. “But there’s a difference between what I think and where I think the government should be involved.”Maggie Astor

Autism rates in girls have steadily risen in recent years. But as more women are diagnosed in adulthood, some wonder how many girls are still missed.Morénike Giwa Onaiwu was shocked when day care providers flagged some concerning behaviors in her daughter, Legacy. The toddler was not responding to her name. She avoided eye contact, didn’t talk much and liked playing on her own.But none of this seemed unusual to Dr. Onaiwu, a consultant and writer in Houston.“I didn’t recognize anything was amiss,” she said. “My daughter was just like me.”Legacy was diagnosed with autism in 2011, just before she turned 3. Months later, at the age of 31, Dr. Onaiwu was diagnosed as well.Autism, a neurodevelopmental disorder characterized by social and communication difficulties as well as repetitive behaviors, has long been associated with boys. But over the past decade, as more doctors, teachers and parents have been on the lookout for early signs of the condition, the proportion of girls diagnosed with it has grown.In 2012, the Centers for Disease Control and Prevention estimated that boys were 4.7 times as likely as girls to receive an autism diagnosis. By 2018, the ratio had dipped to 4.2 to 1. And in data released by the agency last month, the figure was 3.8 to 1. In that new analysis, based on the health and education records of more than 226,000 8-year-olds across the country, the autism rate in girls surpassed 1 percent, the highest ever recorded.More adult women like Dr. Onaiwu are being diagnosed as well, raising questions about how many young girls continue to be missed or misdiagnosed.“I think we just are getting more aware that autism can occur in girls and more aware of the differences,” said Catherine Lord, a psychologist and autism researcher at the University of California, Los Angeles.In the first study of autism, published in 1943, Dr. Leo Kanner, a psychiatrist at Johns Hopkins University, identified 11 children — eight boys and three girls — with “the powerful desire for aloneness and sameness.”It wasn’t until 1980 that autism was officially recognized in the Diagnostic and Statistical Manual of Mental Disorders, the primary classification system used by psychiatrists. But the diagnosis was narrowly defined, requiring a pervasive lack of interest in people, as well as language impairments and particular fixations, all detected before an infant was 30 months old.A card of Legacy and Dr. Onaiwu in Legacy’s room. The photo was taken just months after Legacy’s diagnosis.Annie Mulligan for The New York TimesOver time, as experts gained understanding of autism as a wide spectrum of behaviors, the D.S.M.’s criteria broadened. Children could have difficulty making friendships or imitating others; verbal or nonverbal communication delays; or restricted or repetitive interests, such as a preoccupation with specific topics.Most girls diagnosed with autism in those early days had intellectual disabilities, making it easier to identify them, Dr. Lord said.And many clinicians, she said, did not know that autism could manifest differently in girls who have less noticeable physical manifestations of the condition. Studies since have shown that girls with autism are more likely than boys to camouflage their social challenges, sometimes by mimicking the behaviors of the girls around them. What’s more, girls are often treated differently by adults, such as being told to smile or being encouraged to participate more in group play. Even the toys clinicians used to evaluate children for autism were later criticized for being more appealing to boys.“There have always been autistic girls,” Dr. Lord said. “I think people didn’t knock themselves out to be aware that girls might be treated slightly differently.”The most recent edition of the D.S.M., published in 2013, acknowledged an even broader spectrum of behaviors that might indicate autism and specified that autism in girls could go unrecognized because of “subtler manifestations of social and communication difficulties.”Kevin Pelphrey, a neuroscientist and autism researcher at the University of Virginia Brain Institute, said that more than 15 years ago, when his own daughter began to show signs of autism, even he didn’t recognize them. Pediatricians told him, “‘It’s probably not autism — she’s a girl,’” he recalled.The brain systems involved in social behavior develop more quickly in girls, he said, which may be a “protective factor” for girls with autism, especially in early childhood.But as they grow older and social relationships among girls become more complex, girls with autism begin to stand out more and are often bullied, Dr. Pelphrey said.“That leads to another big difference between boys and girls: Girls can be much more likely to develop anxiety and depression,” he said.Those psychiatric problems can also obscure the underlying autism and lead to misdiagnoses.Dena Gassner, 61, an autism rights advocate in Garden City, N.Y., had social and emotional challenges since she was young, but doctors never mentioned autism as a possible diagnosis. Like many girls with the disorder, Mrs. Gassner had been sexually abused, and her emotional problems were later attributed to the abuse. She was also incorrectly diagnosed with bipolar disorder.She wasn’t diagnosed with autism until she was 40, six years after her son was diagnosed. She was initially taken aback by the diagnosis, she said, partly because her son’s struggles — including language delays and fixations on certain activities and movies — were so different from hers.“I could never have looked at my son and seen myself in his reflection,” she said.A bound copy of Dr. Onaiwu’s Ph.D. thesis, “Bringing Fire to the People: Activist Scholarship, Creative Collaboration, and International Advocacy Through the Lens of Black Disability Studies,” alongside other accolades and awards earned by her children.Annie Mulligan for The New York TimesMrs. Gassner and Dr. Onaiwu are members of the Interagency Autism Coordinating Committee, a group of federal scientists, academics, parents and autistic adults who advise the Department of Health and Human Services on research and policies.Now that they have met many other women who were diagnosed in adulthood, both women said they suspect that autism’s true sex gap is smaller than what the data shows.“They’re not evaluating how many autistic girls exist,” Mrs. Gassner said. “They’re evaluating how many autistic girls we’re finding.”In a 2017 review of dozens of studies, researchers from Britain estimated that the true sex ratio was closer to 3 to 1. Some online surveys that include people who have self-diagnosed show an even lower skew of males to females.Although autism is no doubt underdiagnosed in girls, most experts say that it’s more prevalent in boys. Autism has strong genetic roots, and some studies have suggested that the sex differences may stem at least in part from innate biological differences. For example, girls with autism tend to carry larger genetic mutations than boys do. Girls may need a bigger “genetic hit” to be impacted, Dr. Pelphrey said, possibly because they carry protective genetic factors.The shifting demographics of autism are not limited to sex. The proportion of nonwhite children with autism has also grown swiftly over the past decade. In the C.D.C.’s new report, autism rates among Black and Latino 8-year-olds surpassed those of white children for the first time.“Autism was this thing that happened to little white boys, and sometimes those little white boys grew up to be Trekkies or Silicon Valley programmers,” Dr. Onaiwu said. “It didn’t happen to the rest of us — but it did.”