With the flurry of legislation to restrict youths’ access to gender-affirming care, pediatricians are drawing attention to the impacts on patients.
Already facing rejection and bullying, many transgender youths have a higher rate of depression, anxiety and suicide. Meanwhile, the bans, inflammatory rhetoric and even the threat of restrictions take a toll on the entire family.
More state bans, yet key wins
More than 400 anti-LGBTQ+ bills have been introduced in state legislatures in 2023, half of which target transgender and nonbinary individuals, according to the Human Rights Campaign, an advocacy group. At least 20 states have enacted laws restricting or banning access to medical treatments.
However, after submitting amicus briefs on the rationale for gender care with more than 20 other major medical organizations, the AAP is celebrating a growing number of victories in which federal judges blocked laws or portions of laws that would have prohibited transgender youths from accessing care.
In Arkansas, for example, a federal judge issued a permanent injunction reversing a ban on gender-affirming hormone treatment, puberty blockers or surgery to anyone under age 18. The law also would have blocked medical professionals from referring patients elsewhere for care. Court victories in Florida, Indiana, Kentucky and other states also have blocked laws restricting care to youths.
“The AAP will continue to work with our chapters and members to defend evidence-based health care and those providing it,” said AAP CEO/Executive Vice President Mark Del Monte, J.D. “We will also sustain focus on the young people and what they need to be who they are and live happy lives — this is too often overlooked when politics intrudes.”
In a Florida ruling, a federal judge noted, “The great weight of medical authority supports these treatments.”
“It is fanciful to believe that all the many medical associations who have endorsed gender-affirming care, or who have spoken out or joined an amicus brief supporting the plaintiffs in this litigation, have so readily sold their patients down the river,” the judge wrote in the ruling.
Living with fears, uncertainty
In states where transgender medical care is under threat, the anxiety can be overwhelming.
“It pulls the floor out from under families,” said Morissa Ladinsky, M.D., FAAP, of Alabama, where a court-ordered preliminary injunction prohibits enforcement of a law that made it a felony to prescribe gender-affirming puberty blockers and hormones to transgender minors. A trial is scheduled for next April.
Until then, the future is uncertain, and “that’s a dark place to be,” she said. “When you take away hope, you take away health — not just for kids and families but for providers.”
In Virginia, Amy Dryer, M.D., FAAP, finds that “kids are very affected by these bans, whether the bans are happening in the state or not.
“I can tell you about a 14-year-old kid who just looked right at me and said, ‘Are they going to outlaw this in my state? Like, am I going to get started on this process and they’re going to tell me no?’”
Parents keep asking Dr. Dryer for assurances that gender-affirming care will continue to exist.
“Obviously, that is not an assurance I can give,” said Dr. Dryer, who also trains pediatricians in behavioral and mental health care through The REACH Institute, a nonprofit group. “The access to care we’ve had securely for a decade is suddenly in question again, and it’s a very strange conversation.”
Many transgender youths can be negatively impacted by misinformation and criticism about gender-affirming care.
Several patients have told Dr. Dryer they are afraid to even walk to school. Their siblings can end up as targets as well.
“I have 8-, 9-, 10-year-olds facing down bullies at school on behalf of their siblings,” she said.
In North Carolina, where two anti-transgender care bills were being drawn up at press time, staff and patients of a clinic remain in the dark about their future.
“It’s heartbreaking. I care a lot about my patients and their families and want to give them the best care. To have it outlawed is just incredible and painful,” said Deanna Adkins, M.D., FAAP, a pediatric endocrinologist and founder of a multidisciplinary gender clinic.
Younger patients who haven’t yet started their treatment are especially concerned, the pediatricians said. Some have begun asking to speed up their treatments.
“These bans are accelerating that pathway because kids are so terrified that they cannot get this care in the future,” Dr. Dryer said.
Moving out of state
Some families in states that have banned gender-affirming care are considering relocating to another state. But that brings financial concerns and guilt about how such a disruption would impact other children in the family.
“Having to pull them out of school, sports, their youth group and away from their peers because of a sibling — this is intensely painful for families to grapple with,” Dr. Ladinsky said. The clinic where she works saw some families relocate even though Alabama has been granted a reprieve for now.
Those parents told clinic providers: “‘We can no longer stay in a state where we’re having to fight an uphill battle every day for a child to exist,’” Dr. Ladinsky said.
Disadvantaged families have even fewer options, she added. “You’re absolutely seeing the disparity and the gaps widen between those with resources and those without. Families covered by state Medicaid plans don’t have the resources to relocate to another state, and their insurance coverage is not valid in another state, either. So you will see an acceleration in health disparities for already marginalized groups.”
Hope for the future
For some patients at Dr. Adkins’ clinic, receiving treatment was the only thing that stopped them from self-harm and not wanting to be alive, she said.
“And if they end up not being able to access them, it’s going to be really difficult for us. Right now, as far as we can tell, we have a grandfather clause (in North Carolina). But that’s not happening everywhere.”
On a positive note, she said she has seen how gender-affirming care can transform youths who were so anxious about their presentation not matching who they were inside.
“I’ve had patients go from literally never leaving the house for over a year to getting their GED and going to college — off to schools that are very prestigious, when they were (previously) struggling in school and not sure they were going to make it,” Dr. Adkins said. “Now they’re doing all these wonderful things. …It’s so amazing to see these kids just open up and blossom when they can be who they are.”
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