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A silicone chip lined with tissue from human donors could help scientists test drug treatments for bacterial infections in the vagina.Dr. Don Ingber makes organs for a living. Using flexible pieces of silicone carved with tiny channels, he grows tissues that can mimic the complex physical interactions between cells and fluids, creating malleable, three-dimensional models of organs.Over the past decade, Dr. Ingber, a bioengineer at Harvard, has made more than 15 of these organ chips, including those simulating lungs, livers, intestines and skin. And now, as described in a paper published last month, he has added a far less studied organ to the list: the vagina.The “vagina on a chip” was made from vaginal cells donated by two women. The model was grown inside of silicone rubber chips the size of a stick of gum, forming channels that were responsive to fluctuating estrogen levels and bacteria. The chip successfully mimicked key features of the vaginal microbiome, the swarming communities of bacteria that play a crucial role in the organ’s health, the study found.The chip is more realistic than other laboratory models of the organ, Dr. Ingber said: “This walks, talks, quacks like a human vagina.”He and other researchers are optimistic that the tool could offer a better way to test treatments for bacterial vaginosis, an infection of harmful microbes in the vagina which affects an estimated 30 percent of women every year.“This is a great development, this system,” said Dr. Ahinoam Lev-Sagie, a gynecologist at Hadassah Medical Center in Jerusalem who studies the vaginal microbiome and was not involved in the new study. Because of safety concerns, it is difficult for researchers like her to test new treatments for patients with recurring infections, she said.It’s not difficult to find women willing to donate vaginal samples, she said. “But when you want to explore which medications can work, it’s very, very difficult to find women who are willing to participate in these studies.”The study, which was funded by the Gates Foundation, used the vagina chip to mimic how a real vagina responds to good and bad bacterial environments. The researchers showed that the tissue inside the chip reacted positively to a cocktail of Lactobacilli, a type of bacterium that digests sugars and produces lactic acid, creating an acidic environment inside the human vagina that protects it from infections. When a different type of bacterium, one associated with vaginal infections, was cultured on the chip with no Lactobacilli present, inflammation increased and the cells were quickly damaged.The vagina chip mimics the arrangement of cell layers and the flow of bacteria in a human vagina.Wyss Institute at Harvard UniversityThat reaction is similar to what happens when someone contracts bacterial vaginosis, a condition in which harmful bacteria take over the vaginal microbiome, lowering its acidity and sometimes causing itching and increased discharge.Bacterial vaginosis is typically treated with antibiotics, but relapse rates are high. When left untreated, bacterial vaginosis increases the risk of sexually transmitted infections and cervical cancer. In pregnant women, it can raise the risk of preterm birth or low birth weight.Despite these risks, bacterial vaginosis — and the vagina itself — remains understudied.“We don’t really understand how these processes are triggered by bacteria in the vagina or often even which bacteria are responsible,” said Amanda Lewis, a professor at the University of California, San Diego, who studies the vaginal microbiome. “As you might imagine, such a crude understanding of such an important physiological system makes for crude interventions or none at all.”In 2019, Dr. Lev-Sagie and other researchers in Israel published the results of the world’s first vaginal microbiome transplants. They transferred bacteria-rich discharge from donors with healthy vaginas into the vaginas of five women who had struggled with recurring bacterial vaginosis. Screening the samples to make sure that they were safe and finding patients that were willing to participate was extremely difficult and took many years.Other models, in animals or in the lab, are not effective environments in which to test the vaginal microbiome. While the vaginas of healthy humans are made up of around 70 percent Lactobacilli, in other mammals Lactobacilli rarely constitute more than 1 percent of the vaginal microbiome. And when vaginal cells are mixed with bacteria in a flat petri dish, bacteria quickly take over and kill the cells.Similar drawbacks hamper the development of many drugs, which is why the organ chips are so promising, said Dr. Ingber, who holds a patent for the design of the silicone chip and founded a company that makes and tests them.“There’s been a search for better in vitro models that really mimic the physiological complexity, the structural complexity of tissues,” he said. “And so that’s what we’ve done with organ chips.”In another paper published this week, Dr. Ingber’s group showed that an organ chip of the liver was seven to eight times better at predicting human responses to 27 drugs than animal models.But the vagina chip has limitations, scientists said.Dr. Lev-Sagie of Hadassah Medical Center in Jerusalem noted that the vaginal microbiome shifts substantially in response to menstruation, sexual intercourse, hormonal fluctuations and antibiotic use. And other important types of cells in the vagina, such as immune cells, were not included in the study.“Real life is much more complicated than the vagina on a chip,” Dr. Lev-Sagie said.Having a more sophisticated model will require more studies of how exactly the vaginal microbiome works and how it responds to disease, she added. Unlike research on the gut microbiome, which has progressed rapidly over the past decade, work on the vaginal microbiome suffers from a lack of funding.“In the vagina, we knew that bacteria are crucial more than a hundred years ago,” Dr. Lev-Sagie said. “We do the research for many years, but we still lag behind.”

Small studies suggest that breast removal surgery improves transgender teenagers’ well-being, but data is sparse. Some state leaders oppose such procedures for minors.Michael, 17, arrived in the sleek white waiting room of his plastic surgeon’s office in Miami for a moment he had long anticipated: removing the bandages to see his newly flat chest.After years of squeezing into compression undershirts to conceal his breasts, the teenager was overcome with relief that morning last December. Wearing an unbuttoned shirt, he posed for photos with his mother and the surgeon, Dr. Sidhbh Gallagher, happy to share his bare chest with the doctor’s large following on social media.“It just felt right — like I’d never had breasts in the first place,” Michael said. “It was a ‘Yes, finally’ kind of moment.”Michael is part of a very small but growing group of transgender adolescents who have had top surgery, or breast removal, to better align their bodies with their experience of gender. Most of these teenagers have also taken testosterone and changed their name, pronouns or clothing style.Few groups of young people have received as much attention. Republican elected officials across the United States are seeking to ban all so-called gender-affirming care for minors, turning an intensely personal medical decision into a political maelstrom with significant consequences for transgender adolescents and their families.Gender-related surgeries, in particular, have been thrust into the spotlight. Arizona and Alabama passed laws this year making it illegal for doctors to perform gender-related surgeries on transgender patients under 18. Conservative commentators with large followings on social media have recently targeted children’s hospitals that offer gender surgeries, leading to online harassment and bomb threats.Genital surgeries in adolescents are exceedingly rare, surgeons said, but top surgeries are becoming more common. And while major medical groups have condemned the bans on gender-related care for adolescents, the surgeries have presented challenges for them.Michael is part of a very small but growing group of transgender adolescents who have had top surgery to better align their bodies with their experience of gender.Eva Marie Uzcategui for The New York TimesMuch research has shown that as adults, transgender men generally benefit from top surgery: It relieves body-related distress, increases sexual satisfaction and improves overall quality of life. A few small studies of transgender adolescents suggest similar benefits in the short term.But some clinicians have pointed to the rising demand and the turmoil of adolescent development as reasons for doctors to slow down before offering irreversible procedures. Although medical experts believe the likelihood to be small, some patients come to regret their surgeries.The World Professional Association for Transgender Health, an international group of gender experts who write best practices for the field, had been planning for months to set new age minimums for most gender-related surgeries, including endorsing top surgery for adolescents age 15 and up. Although the guidelines are not binding, they provide a standard for doctors across the world. But this month, the group abruptly withdrew the proposals, a shift reflecting both political pressures and a lack of consensus in the medical community.There are no official statistics on how many minors receive top surgeries each year in the United States. The New York Times surveyed leading pediatric gender clinics across the country: Eleven clinics said they carried out a total of 203 procedures on minors in 2021, and many reported long waiting lists. Another nine clinics declined to respond, and six said that they referred patients to surgeons in private practice.Dr. Gallagher, whose unusual embrace of platforms like TikTok has made her one of the most visible gender-affirming surgeons in the country, said she performed 13 top surgeries on minors last year, up from a handful a few years ago. One hospital, Kaiser Permanente Oakland, carried out 70 top surgeries in 2019 on teenagers aged 13 to 18, up from five in 2013, according to researchers who led a recent study.“I can’t honestly think of another field where the volume has exploded like that,” said Dr. Karen Yokoo, a plastic surgeon at the hospital.Experts said that adolescent top surgeries were less frequent than cosmetic breast procedures performed on teenagers who were not transgender. Around 3,200 girls aged 13 to 19 received cosmetic breast implants in 2020, according to surveys of members of the American Society of Plastic Surgeons, and another 4,700 teenagers had breast reductions.An evolving fieldDr. Gallagher’s office in Miami.Eva Marie Uzcategui for The New York TimesIn the past decade, the number of people who identify as transgender has grown significantly, especially among young Americans. Around 700,000 people under 25 identified as transgender in 2020, according to the Williams Institute, a research center at the University of California, Los Angeles, nearly double the estimate in 2017.Gender clinics in Western Europe, Canada and the United States have reported that a majority of their adolescent patients were seeking to transition from female to male.Because breasts are highly visible, they can make transitioning difficult and cause intense distress for these teenagers, fueling the demand for top surgeries. Small studies have shown that many transgender adolescents report significant discomfort related to their breasts, including difficulty showering, sleeping and dating. As the population of these adolescents has grown, top surgery has been offered at younger ages.Another notable change: More nonbinary teenagers are seeking top surgeries, said Dr. Angela Goepferd, the medical director of the Gender Health Program at the Children’s Minnesota hospital, who is nonbinary. (The program does not perform operations but refers patients to independent surgeons.) These adolescents may want flatter chests but not other masculine features brought on by testosterone, like a deeper voice or facial hair.After many months of deliberations over its new guidelines, the World Professional Association for Transgender Health initially decided to endorse top surgeries for adolescents 15 and up, part of a suite of changes that would have made gender treatments available to children at younger ages. But the organization backtracked this month, after some major medical groups it had hoped would support the new guidelines bristled at the new age minimums, according to Dr. Marci Bowers, a gynecologic and reconstructive surgeon and the president of WPATH, who is transgender.“We needed consensus,” Dr. Bowers said. “I just think we need more strength for our argument and a better political climate, frankly, in order to propose this at a younger age.”Instead, the guidelines kept the previous recommendations, published a decade ago, allowing surgeries for minors on a case-by-case basis.Because teenagers in most states must be 18 before they can provide medical consent, surgeons require parental consent and approval letters from mental health care providers. The two- to four-hour procedure costs anywhere from $9,000 to $17,000, depending on facility and anesthesia fees. The procedure is often not covered by insurance until patients turn 18.As demand has grown, Dr. Gallagher, the surgeon in Miami, has built a thriving top surgery specialty. The doctor frequently posts photos, FAQs and memes on Facebook, Instagram and TikTok, proudly flouting professional mores in favor of connecting with hundreds of thousands of followers.Her feeds often fill with photos tagged #NipRevealFriday, highlighting patients like Michael whose bandages were just removed. On her office windowsill sits a framed nameplate with one of her best-known catchphrases on TikTok: “Yeet the Teet,” slang for removing breasts.Dr. Gallagher said she performed top surgeries on about 40 patients a month, and roughly one or two of them are under 18. Younger patients are usually at least 15, though she has operated on one 13-year-old and one 14-year-old, she said, both of whom had extreme distress about their chests.The surgeon said that most of her patients, teenagers and adults alike, found her on TikTok. Her online presence has drawn sharp criticism from right-wing media, as well as from some parents and doctors who say she uses the platform to market to children.“She goes to the beat of her own drum,” Dr. Bowers said. “For a lot of us, that’s troubling.”Dr. Gallagher said she doubted she had the influence her critics ascribe to her. “Most of the time I’m just trying to deliver educational content,” she said.‘Comfortable in my own skin’Michael and his mother, Annie. He learned more about top surgery through Dr. Gallagher’s TikTok page.Eva Marie Uzcategui for The New York TimesWhen Michael first saw Dr. Gallagher’s TikTok page last summer, he was immediately intrigued. (Michael and others in this article asked to be identified by first or middle names because they were concerned about their privacy.) He liked the photos of her patients, observing that their scars had healed well, and liked that she seemed to be an ally of the transgender community.Michael’s mother, Annie, had gradually come around to the idea of surgery after years of watching him suffer, she said.Since hitting puberty at age 10, Michael said he felt a gnawing discomfort about his breasts. By the time he was 12, he wore hooded sweatshirts every day in their Miami suburb.In eighth grade, after he had several severe panic attacks at school, Michael said he started seeing a therapist, who encouraged him to talk about his body issues. He experimented with small ways to appear more masculine, such as tucking his long curly hair into a beanie and wearing boys’ clothes.“It was the first thing I ever did to try and make myself more comfortable in my own skin,” Michael said.He came out to his parents as a transgender boy when he was 14. A year later, at the start of the pandemic, he started weekly testosterone injections while doing remote school. He got into strength-training and his voice dropped, a second puberty he relished but was grateful to undergo privately.Michael started in-person school feeling “10 times happier,” he said, but his chest still tormented him. Testosterone and exercise had shrunk his breast tissue, making it easier to conceal with a binder. But the garment could restrict his breathing and give him panic attacks. He began seeing a psychiatrist, who prescribed antidepressants.When Michael was 17, Annie said, she decided that waiting another year for surgery would put him in too much pain. Because her insurance covered the procedure only for adults, she took out a loan to help pay for it.Michael’s psychiatrist initially wrote a letter signing off on the surgery. But he later revoked it, putting the surgery in limbo, Annie said. After Michael started a higher dose of antidepressants, the psychiatrist endorsed the surgery as planned.Now, nine months after the operation, Michael is in his senior year of high school. He said he is focused on the parts of his life that have little to do with his gender: doing theater tech at school, seeing friends, painting and applying to college.He also feels less pressure to prove his masculinity than before, he said. He’s growing out his hair and uses he, she and they pronouns. In June, he took his girlfriend to the prom, wearing a brown suit and a pearl necklace.Weighing the risksJamie, a college student in Maryland, began identifying as a transgender boy in the eighth grade, but has since returned to identifying as a woman.Cheriss May for The New York TimesIn 2018, doctors at the pediatric gender clinic at Children’s Hospital Los Angeles published a study of 136 transgender patients ages 13 to 25, half of whom had undergone top surgery. Adolescents who had not undergone the procedure reported significantly more distress because of their chests.Roughly one-third of those who underwent surgery reported ongoing loss of nipple sensation. Only one patient expressed occasional feelings of regret, when imagining wanting to breastfeed a future child.“There’s very few things in the world that have a zero percent regret rate. And chest surgery, clinically, I’ve experienced that,” said Dr. Johanna Olson-Kennedy, the lead author of the study and medical director of the clinic in Los Angeles, which began offering surgeries in 2019.But the study had caveats: Most patients were surveyed less than two years after their surgeries, and nearly 30 percent could not be contacted or declined to participate.Few researchers have looked at so-called detransitioners, people who have discontinued or reversed gender treatments. In July, a study of 28 such adults described a wide array of experiences, with some feeling intense regret and others having a more fluid gender identity.Because so few studies have looked at detransitioning, many doctors are asking young patients and their parents to provide consent without acknowledging the unknowns, said Kinnon MacKinnon of York University in Toronto, the researcher who led the study, who is transgender.“I know personally many, many, many trans men that have benefited and are happy with their medical transition and their top surgery. I would put myself in that category,” Dr. MacKinnon said. “But just as a researcher, I do feel like there are questions that are deserving of answers and have implications for clinical care.”Jamie, a 24-year-old college student in Maryland, was raised as a girl and began identifying as a transgender boy in the eighth grade. After being sexually assaulted and dropping out in her junior year of high school, she said she started taking testosterone. Three months later, just after she turned 18, she underwent top surgery at a private practice in Massachusetts.For the next few years, Jamie said, she thrived. Testosterone made her feel energetic, and her anxiety dissipated. She went back to school and got certified as an emergency medical technician.But when she was 21, her father, who was dying of Alzheimer’s, no longer recognized her. She fixated on her wide hips, which she worried stood out next to her facial hair and deep voice. After a date where she had sex with a straight man, she said, she realized she had made a mistake.“I realized I lost something about myself that I could have loved, I could have enjoyed, I could have used to feed children,” Jamie said. She said she grieved for months and contemplated suicide.This spring, after a year of fighting her insurance company to cover the procedure, she had surgery to reconstruct her breasts. She never told her original surgeon that she had changed her mind, partly because she also blamed herself. Sometimes, she said, “I still don’t like being a woman.”Many surgeons say that they rarely hear about patients with regret. But it’s unclear how many, like Jamie, never inform them.Dr. Gallagher of Miami said that she follows up with patients for up to a year. “I can say this honestly: I don’t know of a single case of regret,” Dr. Gallagher said in May, adding that regret was much more common with cosmetic procedures.But one of her former top surgery patients, Grace Lidinsky-Smith, has been vocal about her detransition on social media and in news reports.“I slowly came to terms with the fact that it had been a mistake borne out of a mental health crisis,” Ms. Lidinsky-Smith, 28, said in an interview.She had top surgery when she was 23. About 16 months later, Ms. Lidinsky-Smith said she called and emailed her medical providers, including Dr. Gallagher’s office, to tell them she had detransitioned.When asked about Ms. Lidinsky-Smith’s case, Dr. Gallagher amended her stance, recalling that years ago, a former patient had left a voice mail message saying they regretted their surgery.“At the time, we wondered, ‘Is it a hoax?’” Dr. Gallagher said.Chilling effectA clinic for transgender children in Dallas, Texas stopped accepting new patients for hormone therapy and gender affirming care under pressure from the Gov. Greg Abbott’s office.Shelby Tauber for The New York TimesRepublican politicians in states across the country are pushing to ban all gender-affirming care for adolescents, focusing much of their rhetoric on surgeries.In Florida, where the medical board is considering such a ban for minors, Gov. Ron DeSantis has argued that surgeons should be sued for “disfiguring” children. In Texas, where parents of transgender children have been investigated for child abuse, Gov. Greg Abbott has called genital surgeries in adolescents “genital mutilation.”Dr. Bowers, the president of WPATH, said that politicians should not be involved in personal medical decisions. “They just don’t understand this care, so they just want to shut it down,” Dr. Bowers said. “That is a very dangerous precedent.”Although most of the new state actions against gender care for minors are tied up in litigation, they have had a chilling effect.Earlier this year, a Dallas children’s hospital shut down the only pediatric gender clinic in Texas, citing political pressure from the governor’s office. This month, a woman was arrested on charges of making a false bomb threat to Boston Children’s Hospital after it was targeted online for its pediatric gender program. Dr. Gallagher also received threats online and said she might hire security guards for her office.Other clinics have dropped scheduled procedures. William, 14, who has identified as a boy since he was a young child, was supposed to see a plastic surgeon in Plano, Texas, for top surgery in May. But the surgeon canceled the appointment in March because the medical center’s malpractice insurer stopped covering top surgeries for minors.In August, William and his family flew to California, paying $10,000 more to get the procedure out of state.Two weeks later, William started ninth grade as just another boy in school. He looks forward to swimming with his shirt off and going to class without wearing a binder.“It’s like something was unburied,” William said. “My chest was just covering what was always there.”

The National Health Service is closing England’s sole youth gender clinic, which had been criticized for long wait times and inadequate services.The National Health Service in England announced on Thursday that it was shutting down the country’s only youth gender clinic in favor of a more distributed and comprehensive network of medical care for adolescents seeking hormones and other gender treatments.The closure followed an external review of the Tavistock clinic in London, which has served thousands of transgender patients since the 1990s. The review, which is ongoing, has raised several concerns, including about long wait times, insufficient mental health support and the surging number of young people seeking gender treatments.The overhaul of services for transgender young people in England is part of a notable shift in medical practice across some European countries with nationalized health care systems. Some doctors there are concerned about the increase in numbers as well as the dearth of data on long-term safety and outcomes of medical transitions.In the United States, doctors specializing in gender care for adolescents have mixed feelings about the reforms in Europe. Although many agree that more comprehensive health care for transgender youth is badly needed, as are more studies of the treatments, they worry that the changes will fuel the growing political movement in some states to ban such care entirely.“How do we draw the line so that we keep care individualized while maintaining safety standards for everyone? That’s what we’re trying to sort out,” said Dr. Marci Bowers, a plastic surgeon and the incoming president of the World Professional Association for Transgender Health, who is transgender. “It’s the people on the ground who need to make these decisions, not people in Washington or state legislatures.”The N.H.S. said current patients at the Tavistock clinic could continue to receive care there before transferring to two new hubs at children’s hospitals in London and Manchester. The new clinics will expand the country’s gender services while making sure children are adequately treated for autism, trauma and mental health issues. The specialists will also carry out clinical research on gender medications.There are “critically important unanswered questions” about the use of puberty blockers, wrote Dr. Hilary Cass, head of the external review of the country’s youth gender identity services, in a letter to the head of N.H.S. England last week.Puberty blockers, which are largely reversible, are intended to buy younger patients time to make weighty decisions about permanent medical changes. But Dr. Cass questioned whether most adolescents prescribed these drugs were given the support to reverse course, should they choose to.Tavistock received more than 5,000 patient referrals in 2021, up from just 250 in 2011. The types of patients seeking referrals have also shifted over the past decade. When the clinic opened, it primarily served children who were assigned male at birth. Last year, two-thirds of its patients were assigned female at birth.It is unclear why the number of patients has surged so drastically or why transgender boys are driving the increase.Transgender advocates in Britain welcomed the changes but emphasized that many questions still remained about how they would affect care for young people.“We are optimistic, cautiously optimistic, about the news,” said Susie Green, chief executive of Mermaids, an advocacy group for transgender and gender-diverse youth. “There is a two-and-a-half-year waiting list to be seen for your first appointment. We’ve seen the distress caused to young people because of that.”But Ms. Green, who has a transgender adult daughter, said the group was concerned about whether mental health services would be prioritized over medical care. Gender diversity, she said, should not be treated as a mental disorder.“We would not want any further barriers to be put in place in terms of access to medical intervention,” Ms. Green said.In 2020, a former patient at Tavistock, Keira Bell, joined a highly publicized lawsuit against the clinic. She claimed that she was put on puberty blockers at 16 “after a series of superficial conversations with social workers,” and had her breasts removed at age 20, decisions she later regretted.A high court initially ruled that children under 16 were unlikely to be mature enough to consent to such medical interventions. But that decision was reversed in September of last year, with judges ruling that “it was for clinicians rather than the court to decide” whether a young patient could provide informed consent.In 2020, employees at Tavistock raised concerns about medical care at the clinic, prompting the N.H.S. to commission Dr. Cass, a pediatrician in London who was not affiliated with the clinic, for an external review. Her interim report was released in February of this year.Sweden’s national health service determined this year that gender-related care for young people should only be provided in exceptional cases when children have clear distress over their gender, known as dysphoria. All adolescents who receive treatment will be required to be enrolled in clinical trials in order to collect more data on side effects and long-term outcomes. Finland took a similar stance last year.“Our position is we cannot see this as just a rights issue,” Dr. Thomas Linden, director of the country’s National Board of Health and Welfare, said in a February interview. “We have to see patient safety and precision in the judgment. We have to be really to some degree sure that we are giving the right treatments to the right person.”While these European countries have put some limits around transgender care, their approaches are far more permissive than those in some conservative U.S. states. A recent Alabama law made it a felony for doctors to prescribe puberty-blockers and hormones to minors. In Texas, parents who allow their children to receive gender treatments have been investigated for child abuse. Both states are tied up in court battles with civil rights groups.Some American doctors worried that the changing standards in Europe would bolster the notion that gender treatments are dangerous for young people.“My fear is that this is going to be interpreted as another notch against providing gender-affirming care for kids,” said Dr. Angela Goepferd, medical director of the Gender Health Program at Children’s Minnesota hospital. More services are needed, they said, not less. “That’s our challenge here.”

New estimates based on C.D.C. health surveys point to a stark generational shift in the growth of the transgender population of the United States.About 1.6 million people in the United States are transgender, and 43 percent of them are young adults or teenagers, according to a new report providing the most recent national estimates of this population.The analysis, relying on government health surveys conducted from 2017 to 2020, estimated that 1.4 percent of 13- to 17-year-olds and 1.3 percent of 18- to 24-year-olds were transgender, compared with about 0.5 percent of all adults.Those figures revealed a significant rise among younger people: The estimate of transgender people 13 to 25 nearly doubled since the researchers’ previous report, published in 2017, though the reports used different methods.The data point to a stark generational shift. Young people increasingly have the language and social acceptance to explore their gender identities, experts said, whereas older adults may feel more constrained. But the numbers, which vary widely from state to state, also raise questions about possible cultural drivers, such as the role of peer influence or the political climate of the community.“It’s developmentally appropriate for teenagers to explore all facets of their identity — that is what teenagers do,” said Dr. Angela Goepferd, medical director of the Gender Health Program at Children’s Hospital Minnesota, who was not involved in the new analysis. “And, generationally, gender has become a part of someone’s identity that is more socially acceptable to explore.”Dr. Goepferd, who is nonbinary, noted that many teenagers would not necessarily want or need medications or surgeries to transition to another gender, as was typical of older generations.The surveys, created by the Centers for Disease Control and Prevention, did not ask younger teenagers about nonbinary or other gender identities, which also have been rising in recent years. But nearly one-quarter of the adults in the surveys who said they were transgender identified as “gender nonconforming,” meaning they did not identify as a transgender man or woman.“We as a culture just need to lean into the fact that there is gender diversity among us,” Dr. Goepferd said. “And that it doesn’t mean that we need to treat it medically in all cases, but it does mean that we as a society need to make space for that.”Transgender Estimates by AgeTeenagers and adults under 25 make up an estimated 43 percent of the transgender population.

The test leads people undergoing in vitro fertilization to discard thousands of embryos each year. The new research found implanting some “abnormal” embryos resulted in healthy live births.When they began their first two rounds of in vitro fertilization in 2015, Anna Dahlquist and her husband, Brian, took a common genetic test to determine the condition of the embryos they had created. The results were devastating: All 13 were “abnormal.”The embryos sat frozen at their fertility clinic in Seattle for six years as the couple underwent round after grueling round of unsuccessful I.V.F. After three years, they had a healthy daughter, using an embryo that they had decided not to test. Then, last year, they went to a new clinic — one that has questioned the reliability of the popular genetic test they took. The clinic implanted a round of the couple’s irregular embryos — two embryos with one chromosomal error and one with two errors. Last month, Ms. Dahlquist gave birth to a healthy baby boy.“I was 39 when I made his embryo,” Ms. Dahlquist said. “And I was 46 when I became pregnant with him. That’s a long time and a lot of valuable years in both my child’s upbringing and my life.”The genetic test, called preimplantation genetic testing for aneuploidy, or PGT-A, has, over the last two decades, become a standard add-on to already pricey I.V.F. procedures. But the test, which can cost anywhere from $4,000 to $10,000, has become controversial over the years as studies have cast doubt on whether it increases birthrates from I.V.F. at all. A growing number of scientists have questioned the widespread use of the test, which leads to tens of thousands of discarded embryos per year and causes many women to believe they may not be able to carry biological children.A new study published last week details 50 patients who underwent transfers of abnormal embryos at the Center for Human Reproduction in New York City. (The Dahlquists had their abnormal embryos transferred to this clinic, since their local clinic would not implant them.) The study reported eight births after 57 transfer cycles of embryos with abnormal genetic testing results since 2015. Seven of the babies were born healthy. The average age of the women in the study was 41 years old.The study is a follow-up to a 2015 study also led by the center that first showed that selected abnormal embryos could still be viable. Since then, other fertility clinics worldwide have also started to transfer such embryos.The research was funded by the clinic and by the Foundation for Reproductive Medicine, a nonprofit research organization also based in New York.The new study “supports concerns that I and others have had for several years now about the accuracy of these tests,” Josephine Johnston, a bioethicist and director of research at the Hastings Center who was not involved in the research, said by email. “The study strengthens the argument that PGT-A tests have been prematurely incorporated into fertility medicine and strongly suggests that these tests will have led patients to discard potentially viable embryos.”But the new study also shows the limitations of transferring such embryos. A vast majority of the 144 embryos transferred by the group had only one or two chromosomal abnormalities, but the transfers led to 11 miscarriages in addition to the eight live births.“There’s a lot of miscarriages in that ratio,” said Laura Hercher, director of student research at the Sarah Lawrence College genetic counseling program.The PGT-A test is used to screen for aneuploidy, which is when an improper number of chromosomes — either too few or too many — is detected in sampled cells. An abnormal number of chromosomes can, in serious cases, lead to genetic disabilities, like Down syndrome. More often, the wrong number of chromosomes can lead to failed pregnancies, either by preventing embryos from implanting or by causing miscarriages.But the problem with PGT-A, the authors of the study argue, is that it provides an incomplete picture that is often interpreted as a very definitive result. The test relies on sampling a handful of cells from the outer shell of the developing embryo and testing to see if each one has 23 pairs of chromosomes.“The point of PGT was to select embryos that would give somebody a better chance of achieving pregnancy,” said Dr. David Barad, an OB-GYN at the Center for Human Reproduction and a co-author of the study. “But doing genetic testing doesn’t make embryos better, it just kind of gives us some idea of who they are.”Though moving ahead with using these embryos with abnormalities may come with some risk, the authors of the new study, all of whom were connected to the clinic doing the transfers, argue that viable embryos are currently being disregarded, leaving many women to believe they have no other options to achieve a pregnancy.“The miscarriage rate is roughly what one expects at such advanced age,” Dr. Norbert Gleicher, director of the clinic and a co-author of the study, said by email. He added: “Ask women what they prefer. A risk of miscarriage or no chance of having a baby at all. The answer will be clear.”In one of the pregnancies in the study, the fetus was diagnosed with a heart defect in utero. The parents moved forward and had a live birth. After having surgery as a newborn, the baby is reportedly healthy. Dr. Gleicher said there was “no known connection whatsoever” between the birth defect and the chromosomal error.A bigger study of outcomes would make clearer whether there is a risk of birth defects, Ms. Hercher said. But this outcome also speaks to the complex level of uncertainty that fertility providers will have to face — and properly educate their patients about — when it comes to the potential risks involved with using these embryos.“We don’t really know what to tell them about the long term potential consequences to a child that’s born,” Ms. Hercher said. “Will there be an increased number of birth defects? Will we find that they have problems down the road? There’s a lot of ‘I don’t knows.’”Irregular numbers of chromosomes are surprisingly common, especially as women get older. For women over 35, there’s roughly a 50 percent incidence of aneuploidy in embryos produced during I.V.F. that increases with age. As the fertilized egg divides and multiplies into cells, errors that occur down the line can be replicated. But the normal cells might have a competitive advantage over the abnormal cells, leading the vast majority of the cells in the embryo to still have the correct number of chromosomes. Or some of those incorrect cells may eventually self-correct.Either way, the potential for this patchwork of cells means that any one picture of the embryo will be limited. A normal test result could miss irregular cells elsewhere, and one cell with the wrong number of chromosomes is enough to turn up abnormal results. By sampling just a small subset of cells at a very early stage in embryo development, PGT-A may cause some fertility clinics, wary of taking risks, to reject embryos that could lead to healthy pregnancies.False positives are also a problem for women who don’t undergo I.V.F. On Tuesday, the Food and Drug Administration warned that noninvasive prenatal tests, which look for signs of genetic abnormalities in the fetus, could lead patients to make decisions about their pregnancies based on incorrect information. Some researchers argue that PGT-A may still be useful for some people. For younger patients who produce more eggs, the test can help rank which embryos have the highest likelihood of succeeding, minimizing the number of procedures they have to undergo and pay for.But the Dahlquists, who were told that the “abnormal” embryos they produced in their first two cycles of I.V.F. could not be used, believe more nuance needs to be communicated to patients so they can be empowered to weigh the risks and make informed decisions.The fact that their fertility clinic would not allow potentially viable embryos to be used and forced them to wait six years to use them made her feel powerless, Ms. Dahlquist said. Few clinics will agree to transfer such embryos, and, at the time they took the test, the couple didn’t even know that was a possibility.“I just feel like it’s unfair,” she added. “They really are ruining a lot of people’s chances.”

A Texas clinic for transgender adolescents closed last year amid pressure from the governor’s office, hospital officials said in phone recordings.On a tense conference call last November with half a dozen doctors and executives at the University of Texas Southwestern Medical Center, Dr. John Warner relayed a somber message: The only specialty clinic in the state to treat transgender adolescents was facing unrelenting political pressure to close.State lawmakers had already sent formal inquiries about the clinic, Genecis, which was financed by the public university and housed at Children’s Medical Center in Dallas. Activists calling the clinic’s treatments “chemical castration” had shown up at the office of one of the children’s hospital’s board members.And then there was Gov. Greg Abbott.“We received a reach from the governor also requesting information about the clinic,” said Dr. Warner, an executive vice president at the medical center, according to a recording of the call obtained by The New York Times. “And with that came an expectation that something different would occur.”“Time is not on our side,” he added. “The conversation is intensifying — not the reverse.”The next week, hospital executives closed the clinic, taking down its website before staff members or patients were informed of the change.The demise of the clinic, which saw around 500 patients in 2021, shows how treatments for transgender minors have become a highly contentious issue in Republican-controlled states across the nation, with elected officials challenging widely accepted medical practices in an echo of the debate over abortion.That fight has reached a fever pitch in Texas.Days before he won a contentious Republican primary last week, Mr. Abbott and the Texas attorney general directed the state’s child welfare agency to investigate “‘sex change’ procedures and treatments” as child abuse, arguing that even hormone therapy should be considered an “abusive procedure.” The directive drew sharp criticism from medical groups and a swift lawsuit from civil rights groups, which said the directive violated the rights of transgender adolescents and their parents.But months ago, before these moves were making national headlines, executives at U.T. Southwestern were discussing closing down Genecis because of what they described as direct outreach from the governor’s office, according to recordings of several phone discussions among hospital executives obtained by The Times.What the governor’s office purportedly said to pressure the hospital’s leadership is unclear.When asked about these interactions, U.T. Southwestern said in an emailed statement that the governor was not personally involved. But the hospital did not answer questions about whether Mr. Abbott’s office had contacted hospital executives. “Inquiries regarding actions by the Governor’s Office should be directed to the Governor’s Office,” the statement said.Mr. Abbott’s office did not answer questions about the substance of these conversations or whether they took place, but it denied involvement in U.T.’s decision to close Genecis.“The Governor’s Office was not involved in any decision on this issue,” Nan Tolson, a spokeswoman, said in an email. Genecis, the only pediatric gender clinic in Texas, was housed in the Children’s Medical Center in Dallas.AlamySince its founding in 2014, the Genecis clinic had offered patients aged 5 to 21 counseling, pediatric care and, starting at adolescence, puberty-blocking drugs and hormones. (The clinic did not perform surgeries.) With no other options for such comprehensive care, the clinic was sought out by families across the state. It also published scientific research about its patients.“The Genecis clinic has been a leader in producing data about the youth they see — data that everyone on every side of this issue has argued that we need,” said Kristina Olson, a psychologist at Princeton University who studies gender development in children.Early evidence suggests that these hormone treatments, part of what’s known as “gender affirming” care, improve the mental health of trans teenagers. But few studies have looked at the long-term outcomes of adolescents who take these medications, which may also come with risks, like fertility loss.Gender-affirming care has been endorsed by major medical groups in the United States. Although some doctors have debated which adolescents will benefit most from such treatments, many say that the decision to take them should be made by patients, their parents and their health care providers, not the state.Legal experts have also questioned whether shutting down the clinic could constitute discrimination under federal statutes. Pediatric endocrinologists around the country — including those at U.T. Southwestern — routinely prescribe similar drug regimens to children with hormonal disorders who are not transgender.“The U.S. Supreme Court has held in the ‘Bostock’ case that discriminating because of sex does include gender identity,” said William Eskridge, a professor at Yale Law School. “Ultimately they are denying medical care based upon gender identity.”The federal government has taken a similar stance. “Denials of health care based on gender identity are illegal, as is restricting doctors and health care providers from providing care because of a patient’s gender identity,” according to a statement released last week by the Department of Health and Human Services.On the campaign trail in Texas, transgender health care has often come to the forefront. Last summer, after legislation that would have banned such treatments for minors failed in the state legislature, Mr. Abbott’s primary opponent, Don Huffines, attacked the governor for not taking a bolder stance in favor of the bills.Weeks later, Mr. Abbott said on a conservative radio program that although the bills had not passed, he could “game the odds” and had “another way of achieving the same exact thing.”On a call with other hospital leaders around the same time, Dr. Warner said that hospital executives had been responding to “some questions from the governor’s office” as well as from state lawmakers, according to a recording obtained by The Times. The executives discussed how they would try to keep the clinic open in some capacity despite political pressure to close it.“There is the possibility that we as a state agency cannot provide this care,” Dr. Warner told the group on the July call. “So the question we’re going to be asking of ourselves is what should U.T. Southwestern do as a state agency that provides the most benefit to the kids but also protects the institution.”But in another call several months later that was also recorded, any possibility of the clinic staying open seemed gone.“I do not think that in our current circumstances that — without some modification of the clinic — that it would be allowed to continue,” Dr. Warner said on the November call. “People will come after it until it’s gone.”U.T. Southwestern and Children’s Health took down the Genecis website on Nov. 11. A week later, staff members were told that existing patients could still be treated at the hospital, but no new patients could be accepted. The decision was made without consulting the medical center’s ethics boards.Texas’s Push Against Gender-Affirming TreatmentsCard 1 of 6Limiting trans care.

Gov. Gavin Newsom of California on Sunday described the new pandemic plan he released last week as a “more sensible and sustainable” approach that would lead the state out of “crisis mode” now that Omicron cases had dropped significantly and many residents were eager to move on.His comments on MSNBC followed an announcement from state officials last week about a “next-phase” plan, which would prioritize strategies like coronavirus vaccination and stockpiling supplies while easing away from emergency response measures like mask mandates.“A year and a half, two years ago, we had a war metaphor and we were hoping there would be a day where there would be a ticker-tape parade à la World War II,” Governor Newsom said. “At the end of the day, though, I think we are realizing that we’re going to have to live with different variants and this disease for many, many years. And that’s what this plan does, it sets out a course to do it sustainably.”The Omicron variant sparked an enormous surge in California. Though the state has seen a sharp decline in known infections since mid-January, new cases are still hovering at more than 13,000 per day. Overall through the pandemic, the coronavirus has infected at least 1 in 5 Californians and killed more than 84,000, according to a New York Times database.California is among the many states to loosen masking requirements in recent weeks, with Hawaii as the last state holding onto a statewide mandate. Puerto Rico also has yet to announce upcoming changes.But federal health officials have yet to release any new recommendations that reflect the lifting of restrictions — including mask mandates in schools — in nearly every state, and the U.S. path in the next phase remains complicated.Dr. Rochelle Walensky, the director of the Centers for Disease Control and Prevention, last week cited the need to “remain vigilant” so that infections continue their promising decline nationwide. She said the C.D.C. would soon be releasing new “relevant” guidelines that would suggest adjusting restrictions, including for mask-wearing, based on factors like hospital capacity, not just case counts.Despite the rollbacks across the country, many people remain extremely vulnerable and feel left behind by the changes. More than seven million adults in the United States are considered to be immunocompromised, meaning they have diseases or are receiving treatments like chemotherapy that reduce their ability to fight coronavirus infections or respond well to vaccines. And tens of millions have other conditions that put them at greater risk for severe illness or death.California’s new plan emphasizes surveillance and preparedness, focusing on continuing to promote vaccines while stockpiling medical supplies, ensuring surge staffing, combating disinformation and increasing wastewater and genomic tracking to spot new variants. Under the plan, mask requirements would be subject to change based on the severity and volume of new infections.In his remarks on MSNBC, Mr. Newsom acknowledged the fatigue felt by people because of the “whipsaw component” of changing rules and policies depending on each surge or wave. “We’re exhausted. Everybody is exhausted. And at the same time we’re also a little bit anxious. What does the future hold?” he said.The Coronavirus Pandemic: Key Things to KnowCard 1 of 3Queen Elizabeth tests positive.

Sex differences in Covid death rates vary widely from state to state, suggesting they are rooted in behavior as well as biology.It’s one of the most well-known takeaways of the pandemic: Men die of Covid-19 more often than women do.Early on, some scientists suspected the reason was primarily biological, and that sex-based treatments for men — like estrogen injections or androgen blockers — could help reduce their risk of dying.But a new study analyzing sex differences in Covid-19 deaths over time in the United States suggests that the picture is much more complicated.While men overall died at a higher rate than women, the trends varied widely over time and by state, the study found. That suggests that social factors — like job types, behavioral patterns and underlying health issues — played a big role in the apparent sex differences, researchers said.“There is no single story to tell about sex disparities during this pandemic, even within the United States,” said Sarah Richardson, director of the GenderSci Lab at Harvard University, which studies how biological sex interacts with cultural influences in society.Dr. Richardson’s team began collecting sex data on Covid cases and deaths early in the pandemic, before the Centers for Disease Control and Prevention began collecting and sharing this information. Her research group logged on every Monday morning and checked each state’s data, maintaining it on a tracker on the lab’s website. The tracker, which stretches from April 2020 through December 2021, is the only source of sex-based weekly Covid-19 data by state.That data enabled the researchers to analyze Covid case rates and deaths across all 50 states and Washington, D.C. over a period of 55 weeks.Nationally, they found no significant differences in case rates between men and women. But the death rates — the number of deaths among men or women divided by the state’s total population of each sex — were often higher among men than women.Just how much higher depended on the state and the date. In Texas, for example, men died at a notably higher rate in every week the research group analyzed. In New York, men died at a higher rate than women — although the gap was not quite as large as in Texas — during all but three weeks. But in Connecticut, women died more than men in 22 of the weeks analyzed.“You can have states right next door to each other, like Connecticut and New York, that have a totally different pattern but yet experienced the same wave,” Dr. Richardson said.Cumulatively over 55 weeks, mortality rates were slightly higher for women in two states, Rhode Island and Massachusetts. In nine states, including Connecticut, the rates were roughly equal. And in the rest of the country, death rates were higher for men.Sex differences in genes, hormones or immune responses are not likely to explain these differences, the researchers said.“There would be no reason for biology to be that variable across time and space,” said Katharine Lee, a biological anthropologist and engineer at Washington University in St. Louis and an author of the new study.But social and behavioral factors, the researchers said, could help explain many of these patterns.For example, men are more likely to have jobs in transportation, factories, meatpacking plants, agriculture and construction — occupations with higher rates of Covid-19 exposure and fatalities. Men are also more likely to be incarcerated and to experience homelessness, increasing their risk of virus exposure.Women are more likely than men to report hand washing, mask wearing and complying with social distancing restrictions, all of which may lower their risk of contracting the virus. And women are more likely to be vaccinated.The researchers speculated that states with more public health restrictions might see reduced sex differences. In New York, which saw a significantly higher number of male deaths in the first six weeks of the pandemic, mortality rates evened out once restrictions were put in place. The observed differences in New York could also be partly explained by better data collection, as well as underreporting of deaths in long-term care facilities, where the majority of residents are women.Dr. Richardson’s research group did not have access to age data for each sex, an important factor since older people are more likely to die of Covid and different states have different age distributions. Even before Covid, men had a lower life expectancy, possibly driven by higher rates of certain chronic conditions, more risk-taking behaviors and more dangerous jobs. That “pre-existing mortality gap,” rather than a specific male vulnerability to the virus, could help explain the disparity with Covid, Richardson said.Still, independent experts said the new findings should not lead researchers to entirely discount the role of biology.The Coronavirus Pandemic: Key Things to KnowCard 1 of 4Omicron in retreat.