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On Wednesday, the Supreme Court will hear arguments in a case involving Tennessee's ban on gender-affirming care for transgender people under age 18. At least 26 states have adopted laws restricting or banning such care for minors, and most of those states face lawsuits. The nation's top court will be weighing whether Tennessee's law violates the equal protection clause of the 14th Amendment, requiring that people in similar circumstances be treated the same under the law. Both sides in the case claim they are acting to protect minors from harm. Gender-affirming care is supported by the American Medical Association, the American Academy of Pediatrics and other medical groups. Here's a look at what's typically involved: Evaluation and diagnosis happen first Young people who persistently identify as a gender that differs from their sex assigned at birth are often referred to clinics where teams from various medical specialties provide gender-affirming care. Such care begins with an evaluation, which can include a pediatrician and a mental health specialist who assess the degree of distress, if any, the young person is experiencing. Those who meet defined criteria may be diagnosed with what's called gender dysphoria if their distress is continuous and significant. Some young people and their families may decide to try a social transition involving a new hairstyle, clothing, name or pronouns. Experts agree that allowing children to express their gender in a way that matches their identity is beneficial. Chazzie Grosshandler, 18, of Chicago, said she was 9 years old when she told her parents she was a girl and "not just a boy who likes girly things." She started receiving care two years later. "The first-ever step of gender-affirming care for me was when I told my parents that I was a girl and that I had felt this way for a long time and that they accepted me," she said. "I think people get really confused when they hear the word 'care' that it has to be something medical. But the truth is that it's more than just medical. It's love and acceptance." Puberty blockers can be a next step A subset of young people may be offered additional interventions such as puberty blockers to ease distress and give them time to explore their gender identity. The drugs, known as GnRH agonists, block the release of key hormones involved in sexual maturation. They've been used for decades to treat precocious puberty, an uncommon medical condition that causes puberty to begin abnormally early. The medication starts after a young person show early signs of puberty - enlargement of breasts or testicles. This typically occurs around age 8 to 13 for those assigned female at birth and a year or two later for those assigned male at birth. The drugs can be given as injections every few months or as arm implants lasting up to a year or two. Many of the effects are reversible - puberty and sexual development resume as soon as the drugs are stopped. Researchers are exploring the effects of puberty blockers on bone development, but no research has shown an increased risk for bone fractures. Young people can stay on puberty blockers for several years. Some transgender youth may take hormones After puberty blockers, trans adolescents go through puberty either with or without hormone treatment. Some may choose to take hormones to make their bodies more closely match their gender identity. They take manufactured versions of either estrogen or testosterone - hormones that prompt sexual development in puberty. Estrogen comes in skin patches and pills. Testosterone is available in injections, implants or gels. Guidelines recommend starting these when teens are mature enough to make informed medical decisions. Many transgender people take the hormones for life. If the medication is stopped, some physical changes remain. Testosterone generally leads to permanent voice-lowering, facial hair and development of the Adam's apple. Estrogen can lead to permanent breast development. Research on long-term hormone use in transgender adults has found potential health risks including a modest risk for blood clots with estrogen and negative cholesterol changes with testosterone. Surgery is rare Gender-affirming surgery in transgender teens is far less common than hormone treatment. When it is done among transgender youth, it's almost always breast reduction surgery in older transgender males. Even so, that type of surgery is extremely rare. Perhaps surprisingly, breast reduction among minors is most frequently performed in males who are not transgender. This is for a condition called gynecomastia, which means having more breast tissue than usual. A study looking at millions of 2019 insurance claims found 151 breast reductions performed for U.S. minors. Nearly all - 97% - were not transgender. Hormones and well-being Research suggests that transgender youth are prone to stress, depression and suicidal thoughts. Some studies suggest treatment for gender dysphoria can improve young people's well-being, but some nuances remain unclear. In one study, researchers spent two years testing and tracking 315 transgender youth who received hormone therapy. Depression and anxiety symptoms eased and life satisfaction increased among those designated female at birth, but not among those designated male at birth. The researchers speculated that the youth designated male at birth might be more affected by stress from being different from most of their peers. In the same study, published last year in the New England Journal of Medicine, two participants died by suicide - one after six months and the other after a year. Longer term studies on treatment outcomes are underway.
SANTA CLARA — When Isaac Guerendo trots onto the field with the first team Sunday at Levi’s Stadium, he will equal the same number of starts he had in five years of college football. Hard to believe, but Guerendo started exactly one time, and it came in his final college game at Louisville. Against USC in the Holiday Bowl, Guerendo carried 23 times for 161 yards and three touchdowns and added five receptions in a 42-28 loss. In 40 other games at Wisconsin and Louisville, Guerendo played in a shared backfield –something he’s done with the 49ers this season behind Jordan Mason and Christian McCaffrey . With McCaffrey on injured reserve with a PCL strain and Mason to follow soon with a high ankle sprain, Guerendo should get his biggest workload since his last college game. “I’m excited, but really it’s whatever it takes to win,” Guerendo said Wednesday as the 49ers (5-7) began preparations to host the Bears (4-8). “Whatever the plan looks like is what we’ll bring.” Guerendo will be backed up by Patrick Taylor Jr., who was on the roster earlier this season when McCaffrey was dealing with bilateral Achilles tendinitis, then re-signed to the practice squad. Taylor was promoted Tuesday, and the 49ers also made a waiver claim on former Jets running back Israel Abanikanda. “I think he’s ready to go,” 49ers coach Kyle Shanahan said. “He had some ups and downs but got better through everything. I think he’s ready for this.” Guerendo, 6-foot and 219 pounds, has 42 carries for 246 yards and two touchdowns, averaging a gaudy 5.9 yards per carry. His 15-yard run in the third quarter was the 49ers’ lone touchdown in a 35-10 loss to the Buffalo Bills. The 49ers traded up to get Guerendo in the fourth round, only to see him sidelined with a hamstring strain in his first training camp practice. A speedy wide receiver at Avon High School in Indiana who also ran track and played basketball, Guerendo carried 10 times for 99 yards with a long run of 76 against Seattle and 14 times for 85 yards against Dallas. At Wisconsin, Guerendo played behind Jonathan Taylor, now a star running back for the Indianapolis Colts. He split time as a graduate student at Louisville with Jawhar Jordan, who rushed for 1,128 yards while Guerendo had 810 yards on 132 carries and a 6.1-yard average. The good news is Guerendo’s body hasn’t taken on the normal amount of abuse for a running back. And Guerendo feels he’s up to the challenge after playing 12 games with old-school running backs coach Bobby Turner. “I always give credit to Coach T for preparing everybody like they’re going to be the starter, so that when moments do come, you’re ready for it,” Guerendo said. McCaffrey appeared to have finally gotten untracked against the Bills, gaining 53 yards on seven carries before getting tripped up on a 19-yard burst in the second quarter. But the tackle injured his knee, Mason injured his ankle, and Guerendo became the lead runner for a team that is sixth in the NFL in rushing. Over time, Guerendo has become accustomed to the speed of the NFL game. “I think it takes guys some time,” Shanahan said. “You start to get a feel for it, if you’ve got the right stuff, you get more reps and the more you adjust to it. How hard you’ve got to hit stuff, how quick those holes close, how you have to hit it full speed and can’t hesitate. We’ve seen that stuff get better in practice and we’ve seen it carry over into games.” McCaffrey, meanwhile, took to social media in the form of a lengthy Instagram post to explain how he was feeling after his latest injury. He wrote of his love for football, how humbling it is and his desire to return. “This wasn’t my year, and sometimes when it rains, it pours,” McCaffrey wrote. “You can feel sorry for yourself and listen to the birds, or you can hold the line. I’m grateful for the support of everyone in my corner and promise I’ll work smarter and harder to come back better from this.” For those who dream big, Shanahan said with a six-week time frame, McCaffrey could conceivably return if the 49ers reach the postseason. THE INJURY LIST Those who didn’t practice Wednesday included edge rusher Nick Bosa (hips, obliques), left tackle Trent Williams (ankle), left guard Aaron Banks (concussion), Mason (ankle) and linebacker Demetrius Flannigan-Fowles (ankle). Cornerback Deommodore Lenoir (knee), linebacker Dre Greenlaw (Achilles) and safety Talanoa Hufanga (wrist) were limited. Defensive tackle Jordan Elliott has cleared concussion protocol after missing the Buffalo game. Hufanga joined Greenlaw as practicing during a 21-day window. Shanahan said it’s more likely Greenlaw would be activated before a Thursday night game against the Los Angeles Rams on Dec. 12 than against Chicago. HUFANGA AND THE CLUB After recovering from an ACL tear last season, Hufanga has played in just two games this season. First, he was felled by an ankle injury, and then a wrist injury that needed surgery. When activated, he’ll play with a protective club on his right hand. “I was still dealing with the ankle. I was about to get it re-wrapped and for some reason my hand wouldn’t open,” Hufanga said. Hufanga said he’ll try to use the protective device as a benefit rather than a detriment. “I had a good friend back in the day who played with a club who had three picks in one game, so you never know,” Hufanga said. MOORE FARES WELL Left tackle Jaylon Moore acquitted himself well for the second straight game in starting in place of Williams. “It was OK, but you can always get better and that’s what I’m focusing on — the things I can get better at,” Moore said. Tight end George Kittle noted last week that Moore was at left tackle all through training camp during Williams’ holdout, so it’s not like he hasn’t been with the first team. “It definitely did help, especially being comfortable with the group,” Moore said. “The quarterback’s cadence, the guy you’re next to, all the small stuff comes into play.”Uruguay's Presidential Runoff: A Battle of Conservatism and Progressive Change