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NH Health

Working to fill the gaps in transgender health care

A pediatric endocrinologist and an endocrinology nurse practitioner discuss their work at New Hampshire’s only pediatric and adolescent transgender health program.

Advocates for transgender youth rally outside the New Hampshire State House, in Concord, N.H., March 7.Holly Ramer/Associated Press

CONCORD, N.H. — Health care for transgender people has become a hot button political issue, and providers in New England say the political debate around gender-affirming care makes their jobs harder.

Dr. Frances Lim-Liberty, a pediatric endocrinologist, and Jessica Smith, an endocrinology nurse practitioner and program coordinator for the state’s only pediatric and adolescent trans health program at Dartmouth Health, spoke with the Globe about the care they provide. The program has grown steadily since it began in 2014, and now serves about 500 young people from New Hampshire, Vermont, and northern Massachusetts.

Lim-Liberty and Smith addressed the most common myths surrounding trans health care, how this care helps young people, and how terrified patients are of losing access to it.


Q: You say there’s no lower age limit about when you’ll start seeing patients at the clinics. When it comes to families with younger children, why are they seeking care?

Lim-Liberty: Many have questions. They want to know how to support their kids. They are seeking therapists and mental health specialists who understand childhood and gender identity development.

We spend a lot of time counseling. The biggest gender-affirming medical care we provide is guiding the family to resources, answering questions about puberty, where to find gender neutral clothing, where to find an understanding hairdresser. We have support groups, and a library with books and educational guides. We’re trying to fill the gaps.

Q: What kinds of medical care do you offer?

Smith: If someone is thinking about medical affirmation, they first meet with a social worker, a psychologist, an endocrine provider, and therapists. There’s a team ready before we start.

Lim-Liberty: We are really careful in our approach. By the time we’re ready to start a puberty blocker or estradiol [male to female hormone] or testosterone, we’ve had many conversations and discussions.


Q: How do you talk to parents who might not understand gender-affirming health care?

Smith: Usually those kids are really hurting by the time they see us. We try to engage parents by bringing in the mental health team and talking about the importance of treatment and what that’s going to look like. When we have a young person struggling with distress related to gender dysphoria, we have to treat that in the same way we treat any other medical diagnosis. Outcomes are good.

Lim-Liberty: The most important part is sorting out the myths they’ve heard, and the biases that they hold.

Q: What are some of the most common myths you encounter?

Lim-Liberty: That gender is binary. We’re all raised in a binary world. We have them start to think about gender as a spectrum and talk about what it’s like to have aspects of both masculinity and femininity.

Smith: We spend a lot of time talking about the fact that gender identity isn’t easily influenced. It’s normal that their teenager is hanging out with other trans kids. They find each other naturally, in the way athletes find each other and become friends.

Q: There’s a lot of talk about puberty blockers. What are they and when are they used?

Smith: There’s a big spread of disinformation about puberty blockers. Folks who have an anti-trans agenda are trying to use this as a scare tactic to say we are harming young people and that’s absolutely false.


Puberty blockers have been used in pediatric endocrinology for decades to treat precocious puberty so there is a very good amount of data demonstrating safety and efficacy. We use puberty blockers to pause puberty for young people who are exploring their gender identity.

These are completely reversible medications. If a young person wants to stop the blocker and go through their natal puberty, we can do that safely with no bad outcomes. If somebody decides to transition from a puberty blocker to gender-affirming hormone therapy, we can also do that.

Lim-Liberty: There’s lots of studies showing positive impacts on mental health: dropping depression rates, dropping suicidality and suicidal ideation. Jess and I experience that every day when we’re in the transgender clinic. We see these kids change, we see them blossom, we see them become the people that they talk about wanting to become at that first visit. We see them go from being reserved and quiet to being interested in activities or opening up about something they really like.

Q: The New Hampshire Legislature considered a bill this session that would restrict the kind of care you can provide. What’s it like to be doing this work now given the political climate?

Lim-Liberty: It’s very hard to be told that your work is wrong. It’s very hard to be told that the trans kids you take care of every day shouldn’t exist. Never have I, in any of the other endocrine conditions or diseases, had to defend someone for being who they are.


I don’t like fighting legislation. That’s not my training. That’s not something that I learned in medical school. While I’m honored to do that, it’s also robbing me of the clinical work I need to be doing here. It’s not fair to our kids.

We want our program to grow, and when we don’t have the time and the resources to do that because we’re in Concord explaining that what we’re doing is best practice medicine, it’s … I don’t even have the right word: maddening, frustrating, unfair.

Smith: Gender-affirming care is life-saving work, And to have folks without an ounce of medical training saying we are harming children — certainly that impacts us, but it has an incredible impact on our patients who are already marginalized and at risk. They’re terrified they are going to lose care: What happens if New Hampshire bans gender-affirming care? Where do we go? What do we do? We have to realize the impact this has on the trans community.

Amanda Gokee can be reached at Follow her @amanda_gokee.