Trans law debates affect doctors and families in the South
BIRMINGHAM, Ala. – The issue of access to gender-affirming medical care for transgender teens has become the subject of intense public debate.
Alabama is among seven states in the South that proposed bills that would make it a crime for a health care provider to treat transgender patients under the age of consent, according to the Human Rights Campaign. Only about 0.7% of teens ages 13 to 17 in the USA identify as transgender, according to data from the Williams Institute at the UCLA School of Law.
In Alabama, the Vulnerable Child Compassion and Protection Act applies to transgender or gender-nonconforming people under 19.
Arkansas is the only state to pass a law barring doctors from providing gender-affirming treatment such as puberty blockers, hormones and gender reassignment surgery to transgender minors, including those with gender dysphoria, the term used by the American Psychiatric Association to describe feelings of discomfort and distress caused when a person’s gender identity doesn’t align with the sex assigned to them at birth. The law passed in April despite strong opposition from business groups, doctors and the LGBTQ community.
The American Civil Liberties Union of Arkansas said in a statement that it would fight the law in court. The debate has stirred so much opposition that similar bills died early in committee in Louisiana and Mississippi.
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This month, President Joe Biden's administration restored protections for the transgender community under the Affordable Care Act, reversing a Trump-era policy. The former rule defined “sex” to mean gender assigned at birth, which excluded transgender people from being protected by the law from discrimination on the basis of sex.
Health and Human Services Secretary Xavier Becerra said May 10 that discrimination leads people to forgo medical care, and “everyone – including LGBTQ – should be able to access health care, free from discrimination or interference, period.”
LGBTQ advocates said the Arkansas law and similar bills will probably be contested in court. Regardless of the trajectory of these laws, the public debates affect families with transgender children and have sewn confusion about what gender-affirming care means, they said.
“These bills help perpetuate the misunderstanding of what kind of care young transgender people receive,” said Asaf Orr, director of the Transgender Youth Project with the National Center for Lesbian Rights. “It creates this idea that they will be rejected by providers even though it is a standard of care.”
Orr said doctors treating a vulnerable population are forced to make contingency plans in case that treatment becomes restricted in their state.
Medical services sparse
Gender-affirming medical care includes a variety of services that help people align their body to their gender identity, such as puberty blockers to stop the development of secondary sexual characteristics in younger teens, hormone therapy and counseling. Such care is sparse in the South.
In Alabama, teenagers as young as 14 can consent to see a mental health counselor without parental permission. The goal is to eventually get the parents involved, said Katie Reese, director of counseling and support groups at the Magic City Wellness Center in Birmingham.
Reese, who facilitates a support group for families and transgender kids and teenagers, said counseling can be a lifeline for young people who don’t have support at home.
“If a young person is connected with an affirming therapist about how they are feeling and what gender dysphoria is like, they can also get plugged into a slew of lifesaving resources that will help decrease their anxiety, depression, and lower the risk of self-harm,” she said.
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Dr. Morissa Ladinsky said there has been an alarming uptick in the number of trans-identifying young people coming to the emergency room for psychiatric evaluation or exhibiting suicidal ideation.
Ladinsky co-leads the Youth Multidisciplinary Gender Team at the University of Alabama, Birmingham. She is one of three providers working with transgender adolescent and pediatric patients at the unit. They serve patients from across the state, as well as neighboring Mississippi.
Though resources are few, there is a strong network of providers working in neighboring states who can help treat her patients if she is unable to continue her work in Alabama, she said.
Ladinsky said she has tried to assure her patients and their families that they will be able to continue their medical care even if it means seeing a provider in another state.
Assurances go only so far.
“These are kids who have already faced the challenges of living in a part of the country where they are made to feel guilt and shame for who they are. I worry about my patients, but the kids I worry the most about are the ones I don’t know yet,” she said.
Queer Med telehealth
To reduce the patchwork availability of gender-affirming care, Queer Med, a telehealth clinic that provides hormone therapy and counseling for transgender patients of all ages, expanded to cover 11 states, including nine Southern states.
Dr. Izzy Lowell, founder of Queer Med, works with legal teams in every state that has filed a bill targeting health care access for young transgender people. The clinic reaches out to patients in these states to ensure they have their medication and contingency plans in place to continue care should their states follow Arkansas.
If they have transportation, this could mean driving to a neighboring state where Lowell is licensed to visit with their doctor via video. It could mean hours of driving, for what amounts to a 15-minute appointment, so Lowell can refill their prescription.
“It’s a huge disruption,” Lowell said. “To say this type of care is lifesaving is not an understatement. It has been well documented that access to affirming care dramatically reduces the risk of harmful behavior and helps them carry on a normal life.”
A study in 2019 commissioned by the Trevor Project found that transgender and nonbinary people experienced depression and anxiety at a rate 10 times higher than people who identify by their sex at birth. Consistent access to gender-affirming medical care, coupled with familial and social support, reduced those rates, according to the study.
Dylan Waguespack, an advocate with Louisiana Trans Advocates, described available services as a “health care desert for trans Southerners.”
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Waguespack was among hundreds of Louisianians who opposed a bill that would have criminalized gender-affirming care for minors in April. The legislation would have affected people across the Gulf Coast, he said. The measure was shelved.
“People get on buses and ride five hours because the providers (in New Orleans) are accessible in a way that isn’t available in their own community," he said. "The impact goes far beyond one state, especially when we’re talking about the pediatric and adolescent care that is targeted in these bills; there’s almost zero access.”
Patients travel more than 100 miles to see Michael Hennigan, an endocrinologist in Destin, Florida. Many are from southern Alabama, where he is also licensed to practice, and range in age from 14 to their late 60s. Hennigan, who began working with transgender patients nearly 30 years ago, said few endocrinologists are willing to work with the trans community.
“Some are very well educated on this topic but fear the public perception. Others, not so much,” Hennigan said.
Legal issues limit care
Public debates around health care access could limit doctors considering treating these patients, Hennigan said.
“Doctors aren’t lawyers. When you have multiple states debating this issue at the same time, it could put a freeze on physicians venturing into this out of fear of running into legal issues,” he said.
It’s unclear whether the Alabama bill will be signed into law. The state’s legislative session ends Monday. If it does, advocates have said they will fight it in court.
Follow Maria Clark on Twitter: @MariaPClark1.