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Pediatricians say state bills would harm transgender youths

March 9, 2021

Pediatric advocates across the U.S are battling state legislation that discriminates against gender-diverse and transgender youths, including in several states where AAP chapters worked to defeat similar bills last year.

The bills intend to prevent transgender youths from participating on athletic teams or in sports according to their gender identity or prohibit gender-affirming medical care. Bills in several states would penalize pediatricians and other physicians for providing gender-affirming medical care — the care model recommended in the AAP policy Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.

AAP chapters have argued that the bills discriminate against transgender youths. Pediatricians testifying against the legislation said it is based on myths and misinformation about transgender children and adolescents and a misunderstanding about medical and surgical aspects of gender-affirmative care. They are presenting science, explaining policies of national and international medical and athletic organizations and describing harms the bills would cause.

“As experts, pediatricians are uniquely positioned to advocate for and support these young people. Politics has no place here. These are individual conversations between clinicians, patients and families about what’s best. The AAP applauds the hard work of our chapters focused on protecting transgender youth at the state level,” said AAP CEO/Executive Vice President Mark Del Monte, J.D.

Alaa Al Nofal, M.D., FAAP, a pediatric endocrinologist and South Dakota Chapter co-vice president, said there are many misunderstandings about transgender individuals.

Last year, Dr. Al Nofal accompanied a group of pediatricians and pediatric residents from the South Dakota Chapter to advocate against and help defeat a bill that would have criminalized care for transgender and gender-diverse patients ( This year, a new bill was introduced that focuses on transgender youth athletes. In a letter to a state Senate committee, the chapter wrote that the bill is “discriminatory” and “will make a dire situation worse.”

Studies indicate that transgender youths are at an increased risk of mental health problems and suicidal ideation. According to a survey from the Centers for Disease Control and Prevention, about 1.8% of high school students identify as transgender; 35% reported that they had attempted suicide ( A Pediatrics study found that when individuals who receive medication to align their body with their gender identity, the risk of suicide decreases by about 70% (

“People are worried about males participating in females’ sport, which is not fair for the girls,” Dr. Al Nofal said. “This is not the case here.”

According to the letter from the South Dakota Chapter, “many experts would argue that the early blocking of puberty and the transitioning hormonal treatment minimize the biological effect of genetic sex.”

Some states with pending legislation have had no cases involving transgender athletes wanting to compete or being perceived as having a competitive advantage, according to Rebecca L. Carl, M.D., M.S., FAAP, a member of the AAP Council on Sports Medicine and Fitness (COSMF) Executive Committee.

“It is very political and it’s almost more theoretical,” she said, adding that the legislation exacerbates social and physiological barriers to physical activity for transgender youths and does not promote an inclusive approach for all children.

Dr. Al Nofal agreed. “I’m not saying the stories don’t exist. I’m not aware of any in the state of South Dakota.”

In 2020, Idaho became the first state to enact legislation prohibiting transgender females from participating on athletic teams according to their gender identity. Idaho’s Fairness in Women’s Sports Act would ban transgender girls from playing on girls’ and women’s sports teams. However, a U.S. district judge issued an injunction to block the Idaho law after the state was sued by the ACLU and a transgender female athlete. The U.S. district judge said the law stands in contrast to policies of national and global athletic regulatory organizations. Idaho has appealed the case to the 9th U.S. Court of Appeals, and the AAP filed an amicus brief with 12 other medical organizations in support of the ACLU and plaintiff. The AAP also has signed on to a letter with the Human Rights Campaign expressing opposition to the bills across the U.S. (

“What I know about transgender children is they’re just like any other kids; they want to fit in. Proposing not letting them fit in in sports will greatly impact their physical and emotional well-being — not just as athletes, as regular children,” Dr. Al Nofal said.

Most individuals identify as their desired sex very early in childhood, Dr. Al Nofal said. First, they go through counseling and psychological assessments. Hormonal intervention is not recommended until the child starts to enter puberty. The next step is to block hormone secretion. This allows time for the child to learn more about themself, receive counseling and gain an understanding of the concept or their feelings and how they identify, he said. The individual starts gender-affirming hormonal treatment at around 16 years of age.

Kathryn Lowe, M.D., FAAP, a member of the AAP Section on Lesbian, Gay, Bisexual, Transgender Health and Wellness Executive Committee, became an advocate for transgender children in Montana after witnessing a youth who transitioned about six years ago.

“It was an incredible experience to watch her truly blossom and come to life once her parents understood that she was transgender and allowed her to transition and live as her authentic self,” she said. “Seeing this (individual) go from struggling with depression and anxiety to being a happy thriving child is what inspired me to do all I can to support gender diverse kids as well as work to help build a society that also supports and affirms gender-diverse kids.”

Dr. Lowe and three other pediatricians have been testifying, emailing, writing letters and op-eds, and reaching out to organizations and businesses to express their concerns about bills in Montana for over a year.

In January, pediatricians there made phone calls to ask House members to reject legislation to ban gender-affirming medical and surgical care. One representative spoke with her child’s pediatrician and voted against it. Another answered Dr. Lowe’s call right before the vote and voted against it.

The legislation was defeated. New bills have been introduced, but Dr. Lowe said she has learned that she can make a difference.

“Many of us pediatricians often are nervous to speak up or to pick up the phone,” she said. “I really think the voice of pediatricians can be so powerful that many people really respect our voices … we are in a place to use our platform and our position to really make a difference in the lives of these vulnerable kids.”

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