Lawmakers in Arkansas are voting this week to restrict medical care for transgender children and punish doctors who treat them, in one of more than a dozen US states where Republicans are pushing sweeping bans on trans youth healthcare.
Proponents of the healthcare bans argue that kids are too young to consent to treatments like hormone therapy and puberty blockers and that the bills aim to prevent “medical experimentation” on children. Some bills claim that trans kids “will outgrow” their identities.
But supporters of gender-affirming healthcare, including major medical associations, human rights groups and affected families, say that the treatments are well established and part of a gradual process that has been shown to dramatically improve the mental health of the most vulnerable kids. The bills, they argue, misrepresent the care model with false and fearmongering narratives. Trans teens who have received treatments say they would suffer serious harm if they were stripped of the care.
“We’re talking about criminalizing doctors for providing best-practice medical care to their patients, and making it child abuse for parents to support access for their children,” said Kasey Suffredini, CEO of Freedom for All Americans, an LGBTQ+ rights group. “These bills are very, very extreme … and these are life and death issues.”
The bills are part of an escalating culture war involving trans kids. As Joe Biden has vowed to protect LGBTQ+ people and a 2020 supreme court ruling protected trans rights in the workplace, conservative legislators have introduced more than 80 bills restricting trans rights – most that would either block trans kids’ use of gender-affirming care or limit their access to certain sports teams. It is the highest number of anti-trans legislative proposals ever filed in a single year.
The affirming care model: ‘It made me feel so much better’
Corey Hyman, a 15-year-old boy from St Charles, Missouri, waited years to access the medical treatments that he said saved his life.
Corey said he had long known that he was a boy and came out to his mother as trans at age 12. She researched clinics that supported children like him, and after dozens of sessions with therapists and doctors over two years, Corey was approved to start taking testosterone hormones.
“I was being my true self and actually presenting as a male, and it just made me feel so much better,” said Corey, who previously struggled with severe psychological distress, including self-harm and suicidal thoughts. “Everyone told me that they could see me getting happier.”
The number of kids receiving gender-affirming care in the US is limited. Jules Gill-Peterson, professor of gender, sexuality, and women’s studies at the University of Pittsburgh, said that access to the treatment is extremely restricted, given that there are few clinics that do this work and that families often need significant time and money to advocate for and get treatment.
“We’re facing the proposition of banning forms of healthcare that almost no trans kids even have access to,” she said. She noted that at a clinic in Pittsburgh, some families drive from five hours away to get care. “We’re talking about healthcare that at the moment is generally accessible only to upper-middle-class families.”
Some families wait months to get an appointment, said Dr Jack Turban, a child psychiatry fellow at Stanford.
The gender-affirming care model targeted in the bills is aimed at alleviating the severe distress many trans children face while forced to present as the gender assigned to them at birth. They start by making clear that trans and non-conforming identities are not a mental disorder, and that the mental health challenges many trans kids face are often a result of facing stigma and discrimination. A Centers for Disease Control survey in 2019 found that 35% of high school trans students had attempted suicide in the previous year, compared with roughly 7% of cisgender students.
“Children are supported in their expressions of their identity,” said Dr Lauren Wilson, a pediatric hospitalist who works with trans children in Montana, where lawmakers have proposed a healthcare ban. She is also the vice-president of the Montana chapter of the American Academy of Pediatrics. For young children, she said, “Sometimes that means choosing different clothes, different haircuts, changing pronouns or presenting as a different gender at school and socially.”
When youth are “consistent, insistent and persistent” about their gender identity, families and doctors can consider further treatments. At the onset of puberty, some youth can be prescribed “blockers”, which suppress or pause puberty and allow kids more time before their bodies undergo changes.
Blockers are reversible but they have sparked contentious political debates, particularly in the UK, where a court has restricted their use, arguing that youth under 16 cannot give informed consent. Critics have called for more research on their long term impacts, but clinicians working with trans children say the treatment is safe and note that they have been used since the 90s to treat cisgender children who experience early puberty.
Research has shown that blockers have huge benefits for teens who have accessed them. One study found that when youth receive the medication, the odds of suicide decrease by 70%.
Older trans teens can be prescribed affirming hormones that initiate puberty to match their gender. These treatments, which are also linked to mental health improvements, are much more serious, with some irreversible impacts. Research has shown that only a small fraction of people who take them later “detransition”, with a comprehensive Dutch study finding that only 0.3 to 0.6% of trans people expressed “regret” about their treatment. Doctors say they generally work closely with families and youth before treatments are prescribed.
“These are not decisions that patients or families or providers take lightly,” said Dr Patty Pinanong, a clinical professor of medicine at University of Southern California, who works with trans youth. “It is a very thoughtful and intentional process.”
Christine Hyman, Corey’s mother, said her son had 82 visits with a therapist before he got a letter of support authorizing testosterone: “We had a caseworker, a whole team of doctors, and he had to wait almost two full years before he could start.”
Corey said the wait to access hormones had been frustrating but that his life had dramatically improved since: “It helps me be who I am, because I’m in the wrong body and I’m not myself without these hormones and all the gender-affirming care that I’m given.”
If care were banned, ‘I couldn’t handle it’
The GOP proposals seek to outlaw various components of affirming care, including blockers and hormones, in some cases with bills that misstate how treatments work or seek to ban practices that don’t actually occur. Several bills would also punish parents and providers who allow kids to access gender-affirming care, with some proposals threatening hefty fines, revoked medical licenses and jail time.
Most outlaw gender-affirming surgeries for minors, even though the standards of care that doctors follow establish that genital surgeries are not offered until adulthood, said Turban, the child psychiatry fellow at Stanford: “The bills themselves contain misinformation.”
Turban, who researches care for trans youth, warned that there would be mental health repercussions if treatment were outlawed: “There’s no question in my mind that all those kids would have worsening anxiety and depression.” If bans were enacted, some youth might seek access to hormones without doctors’ supervision, he added.
In Missouri, where Corey Hyman lives, lawmakers are pushing to outlaw gender-affirming treatment for trans youth and penalize doctors and parents who support them. Under one proposal, Corey’s mother could face years in prison.
“If I weren’t able to have the healthcare I’m currently provided, I’d probably be dead right now,” Corey said.
He can’t imagine what it would mean losing the treatment now: “I don’t know if I could even handle that. I wish people would understand that, although we’re kids, we’re still human, and we’re still able to talk for ourselves and we know what makes us happy and comfortable in our own bodies.”
“We want to give our kid life-saving healthcare, and you’re making that illegal,” said James Thurow, a St Louis resident whose 14-year-old stepson, Miles, is a trans boy who has been accessing blockers. He noted that there are laws that say denying children healthcare is child abuse: “They’ve stuck us between a rock and a hard place.”
“He’s the happiest that he’s been in 14 years,” Danielle Meert, Miles’s mother, said of her son. “He’s the most confident he’s been and we’re just so proud of him.”
Miles said he has understood that he was a boy from a very young age: “I can make my own decisions. Obviously my parents are there, but everything that goes on with my body or my health, it’s often a decision made by me, which may seem scary to people because I’m 14, but I’ve had a very clear awareness of my gender for about 13 years.”
If a healthcare ban were enacted, Miles said his family would have move to a new state where he could continue treatment: “I’d have to leave my grandparents, my friends, all these people who I love just because other people have an opinion about me.”