“I worry about what might happen to my patients if these bills are passed and worry about going to jail myself.”
Dr. Stephanie Ho, a family medicine physician in Fayetteville, Arkansas, said she’s had state legislators in her exam room before.
Ho, who has provided gender-affirming care to transgender people in the state since 2015, is also an abortion provider, so she is familiar with lawmakers’ restricting the care she provides. She said she wasn’t surprised when the Legislature overrode Gov. Asa Hutchinson’s veto of a bill last month that would ban puberty blockers, hormones and surgery for transgender minors.
“I think that it’s kind of ridiculous that we’ve gotten to the point that we’re letting politicians dictate how health care is delivered and what kind of care can be given to whom,” said Ho, a fellow with Physicians for Reproductive Health.
“I think the last thing I’ve ever wanted, being an abortion provider or somebody who provides gender-affirming care, is to have a politician in the back of my mind in the exam room making me think about ‘Oh, I wonder if I should do this, if it’s OK,’” she said. “They’re essentially trying to practice medicine without a license. And that’s incredibly wrong.”
Arkansas was the first state to pass a ban on transition care for minors. Tennessee Gov. Bill Lee last week signed a similar bill barring prepubertal youths’ access to transition care like hormone therapy. Advocates say no doctors in the state provide hormone therapy for prepubertal youths, The Associated Press reported.
So far this year, state legislatures have considered 35 bills to ban or limit gender-affirming care for trans minors, according to the Human Rights Campaign. Physicians say that the bills negatively affect their patients’ health before they even become law and that they require doctors to go against medical standards of care. Legal experts say the bans could also open providers and hospitals up to lawsuits or put them at risk of losing federal funding.
Ho is trying to support her patients as best she can until Arkansas’ law takes effect this summer.
“It’s just a matter of making sure that my patients know that, whether I can provide them hormones or not, we’re still here for them to support them in any way that we can,” she said. “Of course, I’m going to practice within the bounds of the law, whether I agree with it or not, because me being in jail doesn’t help any of my other patients at all.”Creating ‘contingency plans’
Some physicians, like Dr. Izzy Lowell, who founded a telemedicine practice called QMed in Atlanta in 2017, started planning for the bills months ago.
Dr. Izzy Lowell, second right, founder of QMed.Bonnie Heath
In April, Alabama’s Senate passed a bill that would have made it a felony for doctors to provide minors with gender-affirming care. The bill died Monday after the House missed the deadline to vote on it. Lowell said that when it first passed, the minor patients she treats in Alabama were scared and frustrated.
“It was clear that the state of Alabama was coming after transgender teens, and we talked about some contingency plans,” she said. “Based on each case, I tried to give them as many refills as possible and told them: ‘Go pick up as much of your medicine as you can. I don’t know when I’ll see you again.’”
Lowell is licensed and practices in 10 states via telemedicine, so she also talked with her legal team and with patients in states considering bans about how her patients could continue care should their states ban it. She said her patients’ parents would have to drive to other states, which would “place an extraordinary burden on these families.”
“If they were, for example, able to get over the border into Tennessee or South Carolina and sit in a parking lot somewhere, I could see them technically with my South Carolina license or Tennessee license or my North Carolina license and perhaps find a local pharmacy there and have them pick up the prescription, but it would be a day’s worth of driving for them to get somewhere where I could see them legally,” she said.
Many minors whose parents don’t have the time or money to drive out of state would be forced to stop transition care if their states passed laws like Arkansas’, which comes with potentially life-threatening health risks, physicians say.
Major medical organizations, including the American Medical Association, the American Academy of Pediatrics, the Endocrine Society and the American Psychological Association, support gender-affirming care for trans youths and oppose efforts to restrict access.
Supporters of the Arkansas bill argue that transition care for minors is “experimental” and that trans minors often change their minds about their genders and detransition later in life. Medical experts say neither of those claims are backed by scientific evidence. On the contrary, research has found that access to gender-affirming care such as puberty blockers reduces the risk of suicide among trans youths.
Ho said the danger is evidenced by what happened when Arkansas’ bill passed through one legislative chamber. Dr. Michele Hutchinson, a physician at the Arkansas Children’s Hospital Gender Spectrum Clinic, testified before the state Senate in March that there were “multiple kids in our emergency room because of an attempted suicide, just in the last week,” after the House passed the bill.
Ho said that “since then, I have had one of my own patients attempt suicide,” adding that she has talked to her patients about what would happen if a judge doesn’t block Arkansas’ law from taking effect. The law also bars her from referring her patients to other physicians who provide gender-affirming care. Unless her patients were able to leave the state, they would be likely to lose access to hormones, so she talked to them about what that would mean.
Lowell said forcing people who were assigned female at birth to stop testosterone would cause them to suffer symptoms of low testosterone, which include inability to concentrate and low energy. “They would start doing badly in school most likely, until their bodies started producing estrogen a few months later, and then they would restart their periods, restart breast growth, and it would undo all of the changes that we tried to achieve with testosterone.”
If people assigned male at birth were forced to stop taking estrogen, it “would be like going through instantaneous menopause,” Lowell said. For about a year, they could have symptoms like hot flashes, night sweats, irritability and mood swings, among other issues, such as negative impacts on emotional well-being.
Doctors worry that minors who already receive and rely on transition care would get hormones illegally if they had to. Dr. Ricardo Correa, a board member of GLMA: Health Professionals Advancing LGBTQ Equality, treats trans veterans in Phoenix, where, he said, trans people have traveled to the border to buy hormones illegally when they can’t get them. He said state bans would worsen the problem.
“It will just create chaos in the system from black markets that are going to start selling this kind of medication in that state,” he said.
Lowell said that hormone therapy is safe when it is monitored by a doctor but that using it without medical supervision could cause health problems, such as liver failure, kidney failure or heart problems.
“There’s very serious consequences of completely unmonitored, sort of black market medication use in this situation,” she said.‘A form of medical malpractice’
Legal experts and advocates say that in addition to having dangerous health impacts, bans on gender-affirming care for transgender youths could expose health care providers to legal and regulatory problems.
Valarie Blake, a law professor at West Virginia University specializing in health care law, said there’s “a pretty strong case” that Arkansas’ law is discriminatory under Section 1557 of the Affordable Care Act, which protects against discrimination based on sex.
The Biden administration announced this month that it would interpret Section 1557 to protect against discrimination based on sexual orientation and gender identity — reversing a Trump-era policy that cut protections for transgender people.
Hospitals and physicians receiving federal funding, such as Medicare and Medicaid payments, are required to comply with laws like Section 1557, Blake said; otherwise, they risk losing the funding.
Arkansas’ law could trigger that risk by allowing physicians and hospitals to prescribe puberty blockers and hormones to cisgender minors for precocious puberty but not transgender teens.
“If the reason that they’re not doing it for transgender teens is because of the fact that they’re transgender, then there’s a very good case that the reason that they’re refusing the treatment is based on the gender identity and not anything else,” Blake said.
“It really puts health care workers in an untenable position when the federal government makes it plain that this is discrimination and has the money to back it up to basically say, ‘We can pull away all of the resources,’ and yet the state persists,” she said.
The American Civil Liberties Union argued in a lawsuit it filed Tuesday against Arkansas that the trans health restrictions are unconstitutional, but Blake said that’s not set in stone.
“We don’t have clear precedent on the books yet to suggest that LGBTQ categories are fully protected in that manner, which is why we’ve been seeing various kinds of Equal Rights Amendment-type laws trying to work their way through Congress,” she said, referring to the Equality Act, a bill that would protect LGBTQ people from discrimination in housing, employment, public accommodations, education and other areas of life.
The bill passed the House in February, but it has stalled in the Senate. “If something like that passes, then suddenly Arkansas as a state is in big trouble,” Blake said.
Lowell said thinking about the potential legal issues “keeps me up at night.” Physicians are required to give patients several months’ warning when they can’t see them anymore and to do their best to find other providers who can see them if they’re unable to.
But laws like Arkansas’ bar physicians from referring patients to other providers for transition care. “In this case, I can’t do any of those things, and I just have to say, ‘Bye,’ and ‘I’m not allowed to see you anymore,’” she said. “That’s patient abandonment, which is a form of malpractice.”
Lowell said that when the first restrictions were introduced several months ago, she felt angry and anxious all the time.
“I worry about what might happen to my patients if these bills are passed and worry about going to jail myself,” she said. “I struggle with the question of what I would do: continue to support my patients and risk going to jail for years or follow these hateful laws? Thankfully, I have not had to answer this question yet, but I will never abandon my patients.”
Criminalization of Gender-Affirming Care — Interfering with Essential Treatment for Transgender Children and Adolescents
Simona Martin, B.S., Elizabeth S. Sandberg, M.D., and Daniel E. Shumer, M.D., M.P.H.
On April 6, 2021, the Arkansas state legislature overrode a veto by the governor to pass legislation making it illegal for medical professionals to provide gender-affirming treatment to patients with gender dysphoria who are younger than 18 or to refer them to other clinicians for such treatment. Several other states have similar legislation pending. As physicians and a physician-in-training who provide gender-affirming care, we are deeply concerned that these political actions threaten the health and well-being of transgender children and adolescents. We have found that such young people are courageous and resilient, yet profoundly vulnerable. Moreover, they already have higher-than-average risk for suicidality and are disproportionately likely to experience violence.
Gender identity — the deeply felt internal sense of oneself as male, female, or somewhere else on the gender spectrum — may or may not align with the sex one was assigned at birth. When it does not align, the umbrella term “transgender” is often used to denote this incongruence. Although not all transgender young people feel distress related to their gender identity, when distress is present and persistent, a mental health professional with experience in gender-identity evaluations may diagnose gender dysphoria.
Gender dysphoria can be treated with both nonmedical and medical interventions. The former may include therapy, coming out to loved ones, or using a chosen name or pronouns and dressing or grooming in a way that matches one’s gender identity (making a social transition); the latter may include hormonal or (when age appropriate) surgical treatments to bring the person’s physical characteristics more closely in line with their gender identity or to prevent developmental changes that don’t align with this identity. Decisions regarding the appropriate treatment for each individual patient are made by the patient, the parents, and the health care team and are guided by evidence-based standards put forth by organizations such as the Endocrine Society, the World Professional Association for Transgender Health, and the American Academy of Pediatrics. Each person has their own gender journey, and there is no one-size-fits-all approach to this kind of care.
Pediatric gender clinics originated in the 1980s in Amsterdam. Dutch physicians recognized that transgender children tended to face mental health challenges during adolescence, as secondary sex characteristics developed, and that early intervention could be lifesaving. They also appreciated the value of delaying decisions that could have a permanent effect on a child. To resolve these conflicts, they created a protocol under which puberty would be paused using medications at Tanner stage 2 (the period during which signs of central puberty are first detected, most often between 8 and 15 years of age) if gender dysphoria had persisted, thereby forestalling the development of unwanted and potentially permanent secondary sex characteristics with a reversible intervention. Gonadotropin-releasing hormone (GnRH) analogues, or “puberty blockers,” have been used by pediatric endocrinologists for more than 30 years for the treatment of precocious puberty. These agents have well-known efficacy and side-effect profiles, and their effects are reversible. In later adolescence, treatment with gender-affirming hormones could be initiated if gender identity remained incongruent with the sex assigned at birth.
The Dutch-developed treatment model was shown to result in long-term improvements in the well-being of adolescents with gender dysphoria1 and was the basis for current guidelines formalizing the treatment of gender dysphoria. These guidelines recommend using GnRH analogues at Tanner stage 2 and prescribing hormone therapy later in adolescence if the patient, the parents, and the medical team all agree with this approach. Today, prescribing these therapies is coupled with education on the safe use of such medications and with close surveillance for potential risks associated with therapy — for instance, monitoring for changes in bone health in children taking GnRH agonists, for risk factors for blood clotting with estrogen therapy, and for polycythemia with testosterone therapy. With proper monitoring and education, the risks associated with these therapies can be mitigated, and the benefits are substantial: use of hormone therapy is associated with improved quality of life, reduced rates of depression, and decreased anxiety among transgender people.2
A recent survey of U.S. high school students conducted by the Centers for Disease Control and Prevention found that 1.8% of students identify as transgender. More than one third of transgender adolescents surveyed had attempted suicide in the previous 12 months.3 As clinicians caring for this population, we are alarmed by this statistic, but we see it as a call to action. We know that mental health disparities between transgender and cisgender children are not inevitable and that with support from their families and communities and access to evidence-based mental health and medical interventions, transgender children and adolescents can survive and thrive.
A multidisciplinary approach to treating transgender young people has been shown to alleviate gender dysphoria when treatment occurs in a supportive environment that attends to the patient’s mental, social, and physical needs. Young people who receive such gender-affirming care report improvements in their overall well-being, and their level of well-being is generally in line with that of their cisgender peers — and sometimes it’s higher.4 Having access to gender-affirming care in childhood and adolescence can have profoundly important mental health benefits: one study found that transgender adults who had had access to puberty suppression during adolescence had lower odds of suicidal ideation than those who wanted such treatment but hadn’t received it.5
Under the new Arkansas law, known as the Save Adolescents from Experimentation (SAFE) Act, physicians who provide gender-affirming therapy for transgender people younger than 18 will be subject to loss of licensure and could be sued. The law’s name implies that following evidence-based guidelines while working closely with patients and families is a form of experimentation. The law references inaccurate information about the care of gender-diverse young people, stating that genital surgeries are being recommended for people younger than 18. In reality, guidelines indicate that genital surgeries should be delayed until the person reaches the age of legal adulthood in their country, which in the United States is 18 years. The law also states that there are no long-term data on the use of puberty-blocking drugs for the treatment of gender dysphoria, when multiple studies have revealed long-term positive outcomes for transgender people who have undergone puberty suppression.4,5
The content of the Arkansas law, and that of similar bills that have been proposed in other states, is not based on data, medical literature, or correct information about the process of treating transgender adolescents. We believe these bills threaten the health, well-being, and survival of transgender children and young adults. By penalizing physicians for practicing evidence-based medicine, the legislation nullifies their expertise and interferes with therapeutic relationships among physicians, patients, and families. It strips power from patients and families who are already marginalized. And although the stated purpose of the legislation is to protect adolescents, we believe that criminalizing what has been shown to be lifesaving treatment will do the opposite — and that the consequences could well be tragic.
What is gender-affirming health care? Around the country, there’s a Republican campaign to legislate and regulate the lives of trans youth. The most destructive of these efforts would bar trans youth in certain states from accessing gender-affirming treatment. Dr. Izzy Lowell runs Queer Med, a private clinic that specializes in providing accessible health care to trans patients ranging from kids to adults. Her practice covers 10 states across the South – and half of those have anti-trans health care bills on the docket. If they pass, it would become criminal for her to provide this care to many of her patients. Dr. Lowell joins this week to break down what exactly we mean when we talk about gender-affirming care, how the decision is made for kids and teens ready to transition, and the potentially devastating impact this legislation would have on their lives.
Gov. Asa Hutchinson vetoed the bill denying medical care but said there is nothing he can do. This is heartbreaking for the children and families affected as they realize their State Government doesn’t want them there.
Dylan Brandt, 15, is a transgender teen from Arkansas who has been taking testosterone but will no longer be able to receive the hormone once a new state law takes effect this summer that bars gender-affirming medical care for minors.
If the Brandt family is forced to leave they will join a growing exodus of the gender diverse from states controlled by the extreme right.
Many, like the Spurriers, have chosen to go to New Mexico.
The Spurriers, a family of three in Central Arkansas took note of legislation introduced and passed by the Arkansas General Assembly that has directly targeted our son’s healthcare, education, and mental well-being. As a result,” the Spurriers wrote on their gofundme, “we are making a serious effort to relocate to a state that is more friendly to the LGBTQIA+ community”. Keeping closeness to family, post-secondary educational opportunities, and our own health in mind, we have determined that New Mexico is the best fit for us.
We’ve lived in Arkansas since 2005. Our child has grown up in that time, learning kindness, humor, and empathy. A year and a half ago, he hesitantly came out to us as transgender. Despite the love and acceptance, we have tried to embody, he was terrified of how we might react. He had heard horror stories of trans youth whose families responded with cruelty. We assured him of our unchanged love and understanding. Following that conversation, we reached out to his existing therapist and the wonderful staff at the Arkansas Children’s Hospital Gender Spectrum Clinic to begin the long journey to help him transition into an identity that felt right for him.
Counselors and clinicians confirmed his conviction that this new course was right. The medical staff at ACH-GSC helped our son take the first step toward easing his dysphoria, by administering common birth control injections to reduce or eliminate the monthly trauma of his periods. In most transgender males, two doses of such drugs achieves the completely reversible cessation of monthly cycles for a period of time. For our son, the duration and frequency of periods increased substantially, which made what was already traumatic an absolute hell for him. After a third Hail Mary dose, which failed to produce the desired effect, the doctor suggested that moving on to testosterone injections would be the best option.
We are a month and a half into weekly T shots, which our needle-shy teenage son has been self-administering (the surest testament to his commitment to this transition). His confidence and comfort have increased by leaps and bounds, and it is clear that he is elated with his progress so far. He has gone from being on the verge of suicide to excitement for his future.
The Arkansas General Assembly has taken action to return him, and his transgender male and female peers, to that brink of self-destruction. House Bill 1570 , explicitly prohibits not only gender reassignment surgeries—which are not performed on minors in Arkansas in the first place—but the puberty-blocking medications and hormone replacement therapies that help ease gender dysphoria in teens until they reach the age of majority and can make their own independent choices regarding surgery. Lacking a “grandfather clause” to exclude active hormone/blocker patients, the bill would cut off these teens…our teen…from their therapies, doing irreparable physical and mental harm.
Arkansas Governor Asa Hutchinson has vetoed HB1570, but members of the General Assembly have already pledged to see that the legislature overrides his veto. Even if the bill dies, it is but one of at least four (SB289, SB354, HB1570, & HB1749 so far) such bills, three of which have already been signed into law.
The Texas legislature is will likely pass a bill today denying transgender healthcare to minors. Not to be outdone by Arkansas the punishment for parents would be a sentence to prison as child abusers.
“I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”
Years ago, I donned a white coat and uttered these words. I gathered with other young doctors and pledged to provide comprehensive and compassionate care for all my patients.
Now the state of Alabama, where I practice, is on the verge of passing a bill that would make it a felony for medical professionals to provide essential care to transgender youth. This is unconscionable, especially in the middle of a public health crisis that has killed half a million Americans.
When I first took the Hippocratic Oath, I understood the obligation I was assuming. I knew I would become responsible for fellow humans’ lives and be a harbinger of the worst or best possible news a family could hear.
Never though, in all of my training, did I imagine that those in our highest offices of power would work to subvert our solemn oath, using their positions to make determinations about who can and cannot receive care. Yet here we are. If this law is enacted, I could face up to 10 years in prison just for doing my job.
The Alabama bill would be one of the most harmful pieces of anti-trans legislation in our nation’s history. But it’s far from the only attempt to discriminate against trans people and punish those who provide them care. Trans rights, and specifically trans children’s rights, are under brutal attack by state legislatures across the country. State lawmakers have proposed a record number of anti-transgender bills this year — from banning trans kids from playing on sports teams in nearly 20 states to criminalizing doctors who provide trans youth essential healthcare in a dozen.
Compounding these legislative attacks, COVID related clinic closures and travel restrictions have further limited access to medically necessary, gender-affirming care for transgender patients during the pandemic.
Moreover, about two-thirds of LGBTQ adults have pre-existing conditions such as diabetes, asthma, or HIV, conditions that put them at higher risk of severe illness from COVID-19. Access to essential care for trans Americans is more imperative than ever.
Even without this law in place, trans people face rampant discrimination in healthcare settings.
In Alabama, one in four transgender people who visited a healthcare provider had a negative experience related to being transgender, according to a 2015 survey. More than a third did not see a doctor when they needed to because they feared being mistreated as a transgender person. And 17 percent experienced issues with their insurance because of their gender identity.
The barriers to care for trans people are extensive and dangerous.
The evidence is irrefutable. Transgender children who receive gender-affirming care such as puberty-delaying medication and hormones when they are young have better mental health outcomes and report fewer cases of depression and suicidal ideation. As COVID-19 continues to take an enormous toll on the mental health of children, access to this care is critical.
The passage of this bill would make it nearly impossible for trans youth in Alabama to receive the care they need and jail doctors like myself who are committed to treating all people. And it’s not just Alabama. Bills like this are proliferating all across the country, and trans youth are relying on healthcare providers to fight for their rights.
“May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.”
I write today to uphold this oath — to preserve this fine tradition and fight back against hate. So to the lawmakers who insist on legislating intolerance, quit standing in the way of healthcare professionals who only seek to help.
Dr. Izzy Lowell is a family medicine physician whose clinic, QueerMed, specializes in transgender medicine and treats trans patients in Alabama and across the Southeast.
An Oklahoma transgender woman was refused her first covid-19 vaccination by Logan County Health Center due to a “mismatched id.”
She told the Logan County official that she was waiting for her updated ID but she hadn’t yet received it. The official told her she couldn’t get vaccinated and to ‘take it up with the state’.
The transgender victim decided wisely not to reveal her name to the local TV station.
They weren’t “aware” of the situation until they were embarrassed enough to answer a tweet.
Freedom Oklahoma verified that the transgender woman was able to get vaccinated Friday when she returned to the Logan County site.
Three Years To Life in prison for assisting a transgender person
Oklahoma state legislature has five anti-transgender bills in the works from trans healthcare to sports. The worst is SB 676 a bill that would make anyone knowledgeable of a person 21 years of age transitioning a felon. They would be punishable by imprisonment in the custody of the Department of Corrections for a term of not less than three (3) years nor more than life and a fine of not more than Twenty Thousand Dollars.
Tell me that is an isolated event. 21 GOP-controlled states have passed or in the process of enacting bills attacking transgender adolescents’ right to life. This is about the GOP controlling bodies that they hate.
A bill in the North Carolina House of Representatives would ban healthcare to minors diagnosed with gender incongruence. While other states focus on those under 18 like the law just enacted in Arkansas, North Carolina extended that age until 21 four years past the legal age with Senate Bill 514.
If this enacted it would force doctors to refuse treatment to trans people under the age of 21. The doctors and therapists who are suspected of treating gender-dysphoric youth, or anyone giving them haven, will be ordered to stand in front of a tribunal staffed by a board of medical professionals.
All stop.
It’s bad enough North Carolina Republicans are so hateful that they refuse to acknowledge that transgender youth exist but who exactly is going to be on the tribunals?
Certainly not the 60,00 medical professionals who belong to the 31 major American Medical associations who oppose legislation just like this.
And nor anyone from the 7000 member World Health Organization
That leaves about 600 People of which a fraction are doctors from the “American College of Pediatricians” or ACPeds which is designated a hate group by the Southern Poverty Law Center.
The SPLC identifies “The American College of Pediatricians (ACPeds) as a fringe anti-LGBTQ hate group that masquerades as the premier U.S. association of pediatricians to push anti-LGBTQ junk science, primarily via far-right conservative media and filing amicus briefs in cases related to gay adoption and marriage equality.”
ACPeds opposes adoption by LGBTQ couples, links homosexuality to pedophilia, endorses so-called reparative or sexual orientation conversion therapy for homosexual youth, believes transgender people have a mental illness and has called transgender health care for youth child abuse.
Is ACPeds really a hate group? They are by their own words and deeds. And you can bet if they weren’t they would have long ago won numerous lawsuits claiming libelous and slander against the SPLC and planet transgender.
These aren’t physicians and neither are neither are the politicians who copy these lies into legislation. They are criminals bent on killing our children.
North Carolina laws are another hate crime in the making.
The Arkansas Chapter of The American Academy of Pediatrics will be rallying in Little Rock Saturday to protest HB 1570, a bill to deny healthcare to transgender people under 18.
The legislature sent the bill to Arkansas Gov. Asa Hutchinson (R) for his signature on Tuesday; he has 5 days to decide what to do. He can either sign it, veto it, or let it become law without his signature.
The “Save Adolescents From Experimentation (SAFE)” Act states that “a physician or other healthcare professional shall not provide gender transition procedures to any individual under 18 years of age” and also shall not refer anyone under 18 for such services.
Violating the law “is unprofessional conduct and is subject to discipline by the appropriate licensing entity or disciplinary review board,” the law states. It also bars insurers from offering coverage for transition-related procedures for anyone under 18, and says that insurers are not required to offer any transition-related coverage.
“The American Academy of Pediatrics (AAP) opposes the “SAFE” bill,” says Gary Wheeler, MD, a retired Arkansas pediatrician and president of the board of directors at the AAP’s Arkansas chapter. Doctor Wheeler told Medpage that the chapter has several concerns about the measure.
“There are generic concerns that involve decisions about patient care which are typically historically and in every other way — given over to the parent, the child, and the physician,” Wheeler said in a phone interview. “We’ve not had direct interference in a specific category of youth care in the past — it’s been so intrusive. We’re very concerned about that.”
The second issue is conflicts [that] we would all have were we to follow guidelines, practices, and principles that we are bound to as physicians,” he continued. “As pediatricians, we believe we should take care of all children and provide them the best evidence-based care there is … This bill prohibits us from following our guidelines and values as pediatricians.”
In addition, “many people who voted to support this bill have been misled into thinking this is something that will actually help children,” said Wheeler. “Unfortunately, it doesn’t reflect what will really happen. We know that when bills are passed targeting transgender people, there is ultimately harm. They feel systematically bullied, and that just worsens their mental health and leads to significant psychiatric issues like suicide.”
How often are pediatricians seeing children with this issue? “There are estimates of anywhere around 0.5% to 2% of the population of children who entertain some concerns or dysphoria around transgenderness,” Wheeler said.
The Arkansas Chapter of The American Academy of Pediatrics with 400 members will rally at 12:00 none on April 3, 2021, at the State Capitol in hopes that Governor Hutchinson will hear their concerns and veto HR 1570.
Dr. Lee Beers, the president of the American Academy of Pediatrics, with 67,000 primary care specialists said in a zoom call that she stands with the Arkansas Chapter and the ACLU to oppose legislation that would deny medically necessary health care services to transgender youth.
The only group to favor the legislation is The American College of Pediatricians (ACPeds), with 500 members. ACPeds is identified as an anti-LGBT hate group by the Southern Poverty Law Center.
According to the SPLC, “The American College of Pediatricians (ACPeds) is a fringe anti-LGBTQ hate group that masquerades as the premier U.S. association of pediatricians to push anti-LGBTQ junk science, primarily via far-right conservative media and filing amicus briefs in cases related to gay adoption and marriage equality.”
A long-term study that has now reached 2600 transgender patients across four clinics in Europe has yielded conclusive evidence that Hormone Therapy does not have detrimental side effects. Quite the opposite, indications are that HT regimens measurably increase a person’s sense of well-being and lower levels of anxiety.
The European Network for the Investigation of Gender Incongruence (ENIGI) is the largest study of transgender people in the world, and it’s unique: most studies are small and look at the outcomes of people who have already undergone hormone treatment and surgery. That has left scientists and physicians with little data about the long-term effects of such treatment on health, such as cancer susceptibility, or how the brain and body change as people transition both socially and medically.
In the European Network for the Investigation of Gender Incongruence (ENIGI) initial study, we prospectively collected data of 873 participants (451 transwomen (TW) and 422 transmen (TM)). At baseline, psychological questionnaires including the Positive and Negative Affect Schedule (PANAS) were administered. The PANAS, levels of sex steroids and physical changes were registered at each follow-up visit during a 3-year follow-up period, starting at the initiation of hormonal therapy.
The numbers mean that the ENIGI researchers can finally draw some significant conclusions about the effects of standard care. So far, hormone treatments seem to be safe, with few side effects. The most common complaint from people is that they experience lowered sexual desire and for trans women no voice change. But the most significant change the researchers have measured is something positive — a decrease in anxiety and depression after treatment.
Collecting all of these different data gives the ENIGI researchers a comprehensive look at how treatment affects different people. The impacts are complex, Defreyne says, and can be difficult to parse from those associated with the psychological counseling and the personal growth that many experiences.
Dr. Guy T’Sjoen discusses his involvement in ENIGI. Interesting that he was moved into focusing his doctorate in endocrinology on trans people after watching the film “Girl“.
Article courtesy of Mother Jones by Laura Thompson: Fight disinformation. Get a daily recap of the facts that matter. Sign up for the free Mother Jones newsletter.
Three years ago, when Marshall was 13 years old, he asked his mom if she would buy him a binder for his upcoming seventh grade graduation. She asked what he needed—three-ring? pockets? any specific color?—but couldn’t figure out exactly what he was describing. Finally, he sent her a link to the binder he wanted. It was a chest binder. He was trying to come out as transgender.
Marshall’s mother, Laura, took the whole thing in stride. She started addressing him with male pronouns and made him an appointment with a counselor so he had someone to talk with about his gender dysphoria. She bought him the binder to wear to his graduation ceremony. He wore it underneath a navy blue suit.
His friends were also supportive, as was his high school in Athens, Georgia. Administrators said he could use whichever bathroom he preferred, and his teachers were instructed not to deadname him.
I met Marshall, a soft-spoken teenager with a mop of brown hair that perpetually flops into his eyes, in February 2020 for his very first transition-related doctor appointment. His parents had driven him two hours to the private clinic Queer Med, the brainchild of Dr. Izzy Lowell, a 41-year-old family medicine doctor who has spent the past six years championing trans health care in the South. Marshall found the clinic thanks to a referral from his counselor, who had given him two recommendations. The other, which specialized in pediatrics, had a months-long waitlist. Though Lowell primarily treats transgender adults, about 13 percent of the practice’s patients are kids or teens, like Marshall. He was able to get a testosterone consultation within a week or two.“Marshall really is a smart kid who thinks about things,” Laura said. “I trust that he is making the best decision for himself.”
At the appointment, it had been nearly two years since Marshall had come out to his parents and more than three since he realized something about his body wasn’t right. “I was looking at myself one day and it felt like I couldn’t really recognize who I was looking at,” Marshall told a Queer Med nurse practitioner named Luke Scarborough. “I spent the next couple months questioning and trying to learn more about different gender identities. Then I spent a couple of years—a year or so—just trying to figure out names and how I wanted people to see me.”
What Marshall described was the very beginning of his “social transition,” a time when trans people—especially trans kids—begin living openly as the gender they identify with but have yet to start any medical interventions. (Not all trans people medically transition, for a variety of reasons.) He first started by asking a few close friends to call him by his new name and eventually built up to changing his name on a playbill for a local theater production he was in.
It was a slow process, which reassured Marshall’s parents. “Marshall really is a smart kid who thinks about things—he’s very thoughtful, not impulsive,” Laura said at the appointment. “You know, saves his money, spends it carefully, plans for the future. I trust that he is making the best decision for himself.”
During Marshall’s consultation, Scarborough went through the ins and outs of what testosterone does and doesn’t do to a young body. It does: permanently thicken your vocal cords, lowering your voice; stimulate body hair growth; redistribute body fat and make it easier to put on muscle mass; mildly increase red blood cells and liver enzymes. It doesn’t: sterilize you—testosterone is not a substitute for birth control, and trans men who want to have children can typically conceive (assuming there are no other, underlying fertility issues) within a few months of going off T.
Marshall mostly sat quietly between his parents, listening, looking at his hands in his lap. When he did speak, he whispered, his voice shaky. He only smiled once, when Scarborough, a trans man himself, started guessing what color beard Marshall would grow.
By most metrics, Marshall is one of the lucky ones: a kid who saw the kind of life he wanted for himself and, with the help of his family and compassionate doctors, is making it a reality. But even with all the right support and resources, transitioning—especially for a kid in the South—can be like building a house of cards. All it takes is a bit of wind and the whole thing is at risk of tumbling down.
In Marshall’s case, the gust is a conservative lawmaker keen on “preserving a way of life.”
In February, for the second year in a row, Georgia state Rep. Ginny Ehrhart proposed a bill that would make gender-affirming care for minors illegal. This week, a procedural rule killed the proposal’s chance of passing this year, but Lowell and her patients at Queer Med still aren’t in the clear. Over the last three years, Republican legislators across the country have pivoted away from calling trans kids predators for using the bathroom of their choice to a new fear-based campaign. Rather than going after queer people overtly, “family values” conservatives are now targeting trans kids by going after their closest allies. This year alone, legislation like Ehrhart’s has popped up in at least 17 other statehouses across the country, more than half of which are in the South. In Alabama, where Lowell also practices, a similar bill is quickly progressing. If passed, Lowell could lose her medical license and face felony charges with up to 10 years in prison.
Gillian Branstetter, media manager for the National Women’s Law Center, says politicizing trans health care is not only bad for doctors—it could tear families apart. “You’re talking about parents who are scared, who want to do right by their kid, but are now being told, ‘Don’t listen to your doctor, listen to this Facebook post you saw, listen to the state senator you’ve never heard of.’ It’s a wedge issue not necessarily because it’s going to drive people away from one party or another. It’s going to drive a wedge between parents and their kids.”
Even Marshall, who has full family support, worries about the damage these bills could do. “For me and other trans kids,” he says, “it’s much more abusive to allow [us] to keep living in pain.”
Data on trans-inclusive health is scant, in part because of how rare it can be: An estimated 30 percent of trans people have postponed or avoided going to the doctor for fear of discrimination. National Center for Transgender Equality surveys have found that about half of trans people have had to teach their doctors how to care for them. In one survey, 28 percent of respondents said they’d been harassed in a medical setting, and another 19 percent said they’d been refused service, even for procedures that had nothing to do with their gender identity.
Facing this landscape, in the early 2010s, Lowell created her own elective to practice gender-affirming care as a medical resident in Massachusetts and trained at the Mazzoni Center, a longstanding LGBTQ-focused medical practice in Philadelphia. In 2013, she landed at Emory University’s Family Medicine Department in Atlanta. Health care access was imperfect for the folks she served in the northeast, but still, she was shocked by how much worse it was down South.
In 2015, she pitched the idea of a family medicine clinic that catered to transgender patients, but the university’s administration was skeptical. She offered to do the work unpaid until the clinic turned a profit. “They were like, sure, but there aren’t any transgender people in Atlanta,” Lowell remembers. (Emory declined to comment for this story.)
“There’s hubs like Boston, San Francisco, Philadelphia, LA, that have great gender centers,” Lowell says. “And so everybody’s like, ‘Oh, just go to one of those.’ But this is as common as Type 1 diabetes. And you would never tell a diabetic, ‘Just go to San Francisco every three months—they’ll take really good care of you. You’re all set.’” https://ebb335832378b092acc98dd0f9ac1967.safeframe.googlesyndication.com/safeframe/1-0-37/html/container.htmlAdvertise with Mother Jones
Despite the university’s initial resistance, the clinic filled up quickly, Lowell says, and turned into one of the most profitable teaching clinics at Emory. It also had the lowest no-show rate, despite the fact that many of her patients came from outside the Atlanta area. “This one patient stands out in my mind,” Lowell says. “It was right before lunch and my patient was late—it was cutting into my lunch hour.” When he got there, he apologized profusely, explaining that he’d driven more than five hours from central Tennessee for this appointment. “And I was like, okay, that’s a legitimate reason to be 15 minutes late for your appointment. It just kind of put everything into perspective.”
In 2017, Lowell left Emory and opened Queer Med with the goal of giving trans people more flexibility. Rather than making patients trek hours to see her, she wanted to bring the hormones and puberty blockers to them. Lowell borrowed some office space from a local therapist, but the location didn’t really matter. She got licensed in four other states—Alabama, North Carolina, South Carolina, and Tennessee—and conducted most of her appointments via video call. But testosterone is a Schedule III drug, so she had to do all of her primary consultations with trans men in person. She crisscrossed Georgia in her Subaru to make house calls on some patients; others came to her at out-of-state pop-up events at community centers and the occasional church. Within two years, Lowell had more than 1,000 patients. Her practice grew so popular that she moved to a dedicated office space in Decatur, Georgia, and got additional licenses in Florida, Kentucky, Maine, Mississippi, Virginia, and West Virginia.“I feel different,” Lily told me after six months on blockers. “In my dreams, I see myself different—like what I look like.” Her hair is longer, like she’s always wanted.
“She’s really, in a lot of ways, single-handedly transforming what the landscape looks like for trans folks in the South,” says Ivy Hill, the community health program director for the Campaign for Southern Equality, who met Lowell in 2019 when Lowell came to see patients at an annual summer camp for transgender people. “I think that telemedicine just does by its very nature remove a lot of the barriers that our folks have in accessing care, but then she’s gone the extra length to get licensed in extra states. She is going to do everything she can to remove barriers for people, even if that means showing up at trans summer camp and being in a room without any air conditioning and just, like, writing letters for everybody to change their gender markers and start” hormone therapy.
Lowell’s day-to-day looks a bit different now. Because of the pandemic, the Drug Enforcement Administration waived the requirement for an in-person evaluation before being prescribed testosterone, so all of Queer Med’s appointments happen remotely. Pop-up events have temporarily stopped, but she’s still gained another 1,000 patients in the past year.
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Queer Med sees patients as young as 7 years old. The practice’s youngest patients have only socially transitioned, and come by once a year or so to check in. Twelve-year-old Lily started coming to Queer Med about three years ago, mostly to build rapport with her provider and keep tabs on her development so they know when to start medical intervention. Prepubescent patients who are still exploring their gender identity often take puberty blockers, a completely reversible treatment that does just what the name suggests. The idea is that it buys kids time to explore their gender identity before their body starts to change in ways that may exacerbate their gender dysphoria. The American Academy of Pediatrics, the Endocrine Society, the American College of Obstetricians and Gynecologists, and the American Psychological Association all endorse puberty blockers and hormone therapy as safe treatment options for minors experiencing gender dysphoria.
Dr. Izzy Lowell meets with Taylor, a 15-year old trans patient, during a virtual visit in her office. Elijah Nouvelage
“I feel different,” Lily told me after six months on blockers. “In my dreams, I see myself different—like what I look like.” Her hair is longer, like she’s always wanted.
For kids who decide to move forward with hormone replacement therapy or, like Marshall, have already started puberty, Queer Med prescribes a low dose of testosterone or estrogen, which is slowly ramped up over a year or two.
Though the long-term effects of hormone therapy are unclear—some studies suggest it could lead to a decrease in bone density or increased cardiovascular risk—most experts say the benefits outweigh the risks. As Dr. Jack Turban, a child and adolescent psychiatry fellow at Stanford, wrote in a 2018 Vox op-ed: “Every decision in medicine involves weighing risks and benefits. Lipitor, a medicine doctors use to prevent stroke, also increases the risk of rhabdomyolysis, a condition of muscle breakdown that can damage the kidneys. However, the potential benefit of preventing stroke far outweighs the potential risk of this unlikely event. The same is true for transgender youth and gender-affirming care.
When I asked Dr. Madeline Deutsch, director of the University of California, San Francisco’s Transgender Care clinic, about the medical professionals who dispute the safety of hormone therapy for minors, she replied simply, “Yeah, and 1 percent of scientists believe that climate change is a hoax.”
Lowell also tries not to dwell on the fringe physicians or the political narrative. She doesn’t read the news; she doesn’t own a television. She’s a stoic, keep-your-head-down-and-do-the-work type, primarily focused on making sure her patients have the information and tools they need to feel better.
That singular attention continues to lead her far beyond the confines of her office. When I visited Queer Med last year, Lowell and I were exchanging niceties in the lobby between appointments, while Marshall was rushing back to Athens, hoping to get to the lab for a blood test before it closed. A nurse poked her head out from an office: A patient had called, saying he didn’t think he could make his appointment that afternoon; a suspicious package had been found outside an office building a few blocks away from the clinic, and parts of downtown had been evacuated and cordoned off.
“Does he want a ride? I’ll go pick him up,” Lowell offered. “Just text me an address. Tell him we’ll be there, we’ll make an effort. Expect us in about 15 minutes.”
“This doesn’t normally happen,” she assured me before heading out the door.
This legislative battle over health care for trans kids is the culmination of decades of “family values” messaging from the GOP. It combines the right wing’s obsession with policing uteruses and the bogus, offensive stereotype that queer people and their allies are up to some dark agenda involving pedophilia and indoctrination. The modern attacks on trans children are essentially a rhetorical spear that conservative strategists have sharpened over time.
The anti–trans health bills are most directly descended from the trans bathroom panic of the last decade, in which conservatives used the completely hypothetical threat of predatory men in dresses lurking around women’s restrooms to galvanize the Republican base. Over several years, at least 21 states considered bills banning transgender people from public restrooms corresponding to their gender identity. North Carolina led the charge and faced intense backlash that likely cost the state billions in business revenue.
Eventually, the bathroom effort was largely dropped, but by 2018, conservatives had started directing their trans panic toward a new cause. Two states—New Hampshire and Pennsylvania—took up bills that sought to limit or outright ban gender-affirming health care for trans kids. Neither passed. In 2019, two more states made the effort.
“Young people are not old enough to make these sorts of permanent, life-altering decisions,” said Illinois state Rep. Tom Morrison of his 2019 proposal. He told a local NPR affiliate at the time that minors shouldn’t be given the choice to become “permanently sterile.” Critics called the bill “reprehensible” and “based on personal objections and beliefs and junk science.”Advertise with Mother Jones“You’re asking me to someday put handcuffs on these people that are heroes in my life and arrest the people that saved my daughter? Please don’t ask me to do that.”
That year, this new version of the trans panic became a rallying cry on the right, and conservatives latched onto another strategy: punish the parents. In December, two parents in Texas were fighting for custody of their kid, who, according to reports, had been identifying as a girl for years. The child’s father claimed that the girl’s mother was forcing her to transition in some sort of elaborate scheme to revoke his parental rights. A local news website run by a former Republican state senator covered the story, which was then picked up by the Daily Caller. Then Fox News pundits joined in, warning of “chemical castration,” even though the child was only socially transitioning. Soon, the story had been tweeted out by Donald Trump Jr.
Shortly after, Texas state Rep. Steve Toth vowed to introduce a bill barring minors from receiving transition-related care by redefining it as child abuse. Texas state Rep. Matt Krause made a similar pledge. Both made good on their promises. Fourteen other states followed suit with bills banning trans health care for minors, including Ehrhart in Georgia, who was reportedly motivated by the Texas custody battle. The flurry has only continued this year, with lawmakers in at least 18 states introducing so-called Vulnerable Child Protection bills, four of which include provisions that could be used to investigate and punish parents. Lowell works in seven of those states: Alabama, Florida, Georgia, Kentucky, Mississippi, Tennessee, and West Virginia.
Dr. Izzy Lowell in her office during a meeting with a patient. Elijah Nouvelage
The lawmakers who support these proposals tend to go heavy on the theatrics and disinformation. Last year, a state representative in South Dakota compared doctors who offer gender-affirming care to Nazis. Another likened such care to lobotomies. Alabama’s bill describes puberty blockers and HRT as “dangerous and uncontrolled human medical experimentation that may result in grave and irreversible consequences.”
“The way that these laws are sensationalizing this experience is really putting a focus on an issue that doesn’t exist,” says Jen Bennett, a licensed professional counselor in Charleston, South Carolina, who often refers transgender adolescent patients to Lowell. “These services are really, really, really difficult to obtain in the first place. And secondly, they are, in every single way, validated—ethically, morally, empirically, scientifically—as the right choice. And by the right choice, I mean, if it’s chosen by the person who’s transitioning, and it is chosen by their parents, those are the people making that decision. And if it is also chosen by a doctor, that [decision] is going through three very, very concerned and interested parties about whether this is the best choice for this person.
For all the dog-whistling surrounding them, legal experts say that, like the bathroom bills, this new wave of legislation likely won’t get very far. Public opinion is steadily shifting in favor of treating trans people like, well, human beings, and the Supreme Court affirmed last year that prohibitions against sex-based discrimination also includes trans folks. The Biden administration has vowed to enforce the ruling.
“These types of measures have the same fatal flaws as the previous measures that failed,” says Alex Rate, the legal director of the ACLU of Montana, which has already fended off one anti-trans health care bill this year, although another watered-down version is now pending. “You’re talking about measures that are incredibly invasive, incredibly debasing to human dignity and privacy, and which are facially discriminatory on the basis of sex.”
And yet, these proposals aren’t exactly designed to succeed. As Andrew Reynolds, a political science professor at the University of North Carolina, Chapel Hill, told me when these bills popped up last year, gender identity is one of the last cultural wedge issues conservatives can rely on. “It’s the only lever, I would say, that still can drive conservative, religious, white voters—fearful voters—to Republicans.”
Nevertheless, the result is a target on the back of trans kids, their families, and their doctors. David Fuller, a police sergeant from Gadsden, Alabama, took a full day off work in February to ask lawmakers not to pass an anti-trans health care bill. Fuller’s now-adult daughter came out to him at age 16 and, after nearly a year of talk therapy and consultations, received transition-related medical care at the University of Alabama at Birmingham.
“I was probably like you guys,” Fuller told Alabama House Judiciary Committee members. “I didn’t like this, I didn’t understand it, I was ignorant to it. But I was a police investigator for a long time, so I put myself to the grindstone and started investigating. Unfortunately, the first thing I found was that half the kids, the teens that are transgender, try to kill themselves. I was terrified. But after a little more looking, I found out that number drops to just below normal for kids their age if they’ve got cooperation from their family, health care, and therapists.”
Fuller described his daughter’s doctors as “angels” and begged the lawmakers, “You’re asking me to someday put handcuffs on these people that are heroes in my life and arrest the people that saved my daughter? Please don’t ask me to do that.”
The Alabama bill is still being considered by the House Judiciary Committee; a nearly identical proposal passed the Senate and is being considered by a different House committee.
“It’s an attack on doctors and science, and a direct shot at trans youth—some of the most vulnerable folks who are trans,” says Hill from the Campaign for Southern Equality. “It worries me for them in terms of their actual access to care. But it also worries me for them when I think about trans youth suicide rates.” The evidence bears out Hill’s concerns: Trans Lifeline, America’s first helpline established specifically for transgender folks, for example, saw average daily calls double the week the Trump administration rolled back Obama-era protections allowing trans kids to use the bathroom of their choosing. A recent survey by the Trevor Project found that more than90 percent of respondents (all LGBTQ youth) said that recent politics had negatively influenced their wellbeing. “I think about the messages that this sends to them about who they are, and there being something wrong with just who they innately are and the shame that comes with that.
The bills make Lowell nervous, too: Some of them would make her a felon and bar her from practicing medicine. “It’s something that I worry about a lot,” she told me recently. “But I think that I’m too far in it. If they want to put me in jail, they probably could based on everything that I’ve already done. And if we say, ‘Okay, we’ll get out of Alabama,’ they’re going to come after Georgia, Mississippi, and half the other states we serve.”
Similarly, Marshall and his family said they worry about such bills but have never considered postponing his transition. “I have no doubt that I would find a way to get whatever he needed,” said Laura, Marshall’s mother. She said without hesitation that her family would cross state lines to fill his prescriptions, and even consider leaving Georgia permanently. “We would go to whatever state we needed to. I’m not afraid to break the law.”
When I checked in with Marshall in late November, after nine months on testosterone and a successful legal name change, he didn’t necessarily sound like a new person. He just sounded like the person he was supposed to be all along.
His voice was an octave deeper and, more noticeably, it was loud. “I’ve been feeling a lot better to be honest,” he said. “Back in January, February, for a variety of reasons, I was getting close to being depressed. I was anxious a lot of the time and just overwhelmed. And I guess partially because of transition and partially because of the pandemic and not having to go to in-person school anymore, I’ve been able to take a step back and feel better about myself.
Lowell and her team told me that emotional turnarounds are common, often showing up even before the physical manifestations of hormone therapy. For every kid I met at Queer Med like Marshall—a fragile first-timer—I met two or three who had been seeing Lowell for years and were absolutely exuberant.
“I’m not shy about sharing my story,” Marshall says. “It’s been helpful to me to see other trans people be able to live their lives confidently and bravely, and part of me wants someone else to see that there are other kids out there, to give them some sort of hope.”
Hormones don’t fix everything, Lowell says, but the “gender dysphoria, seeing that just evaporate is the coolest thing.”
“The times that I’m most reminded how much this is needed are families that come in with the kid, having wanted this for years, begging their parents who are very much against it. And then over time, the parents come to see how much it’s harming the kid to withhold therapy,” Lowell explained. “So they arrive here, still sort of against it, but not sure. And then we meet for an hour and talk through everything. By the end of it, the kid is practically in tears, because they’re going to get to do this thing that they thought was unattainable. And the parents are so relieved, just hearing the medical risks of hormone therapy, what it’s going to do, what it’s not going to do, how long it’s going to take, what the side effects are, and the medical risks.
“The whole thing just gets less scary,” Lowell said. “Everybody walks out feeling a ton better, and I get to have changed somebody’s life.”
