Advocates Worry Misinformation Is Driving Proposed Ban On Trans Care For Kids
At a committee hearing in the Texas House of Representative last month, GOP lawmakers questioned witnesses about House Bill 1399, legislation that would strip physicians of their license or liability insurance if they provide transition care for transgender kids and teens.
Republican members of the House Public Health Committee expressed skepticism in their questioning. But many also publicly admitted it was subject matter they weren't familiar with.
“I don’t know the language here, I’m just a simple country lawyer from Sherman, Texas," said state Rep. Reggie Smith. "I’m just trying to figure this out."
Despite their unfamiliarity, lawmakers voted 6-4 to pass the legislation out of committee.
That lack of understanding is what advocates and trans care providers fear is informing a group of bills seeking to criminalize transition health care for transgender youth in Texas. The bills have gained traction in the past few weeks, with at least three voted out of committee.
"It's basically, to be blunt, uninformed lawmakers, superseding best practice, evidence-based practice," said Dr. Aliza Norwood, who treats transgender adults at Vivent Health in Austin.
The Pediatric Endocrine Society has warned lawmakers across the country that "implementation of these bills will worsen mental health, increase the risk of suicide, and contribute to poorer overall health in (trans and gender diverse) patients."
Research on trans health care is still a burgeoning field, and experts say they're still learning about the effects of transition care. But many major medical organizations, such as the American Academy of Pediatrics, the American Medical Association, the American Psychiatric Association, the American Psychological Association and the World Professional Association For Transgender Health, have also spoken out against these bills.
They're worried that the legislation might exacerbate an ongoing mental health crisis among transgender youth. Research shows major disparities between transgender and cisgender kids and teenagers. One national survey found that trans high school students are five times more likely to attempt suicide.
"In individualized cases, providing access to medications actually reduces the risk of suicidal ideation and suicide," Norwood said. "So when they say it’s life-saving, it means that their child was miserable. So miserable, in fact, that they were thinking about ending their lives."
Indigo Giles, 19, went through gender-affirming top surgery in high school — a breast reduction. Multiple medical and psychological evaluations, as well as delays, meant they waited about a year before getting the surgery at 17.
All the while, Giles, who is gender non-binary, was dealing with severe clinical depression and anxiety. They say it largely came from gender dysphoria, or the distress experienced when one's gender doesn't match their sex assigned at birth.
"I was like, ‘I hate that I look like a woman,'" Giles recalled. "There were just times where I would look in the mirror and I felt like I couldn’t recognize myself. I was like, ‘This isn’t who I am.'"
Giles tried wearing a binder to flatten the appearance of their chest, but it wasn't very effective. Binding even tighter could lead to bruising and breathing problems.
The surgery's impact on their body satisfaction, confidence and overall mental health was immediate, Giles said.
"Oh, my gosh, it was like magic," they said. "My parents say they could see the weight lifted off of me. I looked at myself in the mirror, just wearing a regular t-shirt. I started crying because I was so happy."
Last week, the Texas Senate passed SB 1646, which would change the definition of child abuse to include parents who allow their children to receive puberty blockers, hormone therapy or gender-affirming surgeries.
State Sen. Charles Perry, who authored the bill, argued that children are not old enough to make life-changing choices about their bodies and parents shouldn't make "irreversible" decisions for their kids.
"When adults give children the drugs, they set a path for the child that they might not have chosen and a path that may never be able to reverse," Perry said.
Puberty blockers, which pause puberty and give minors more time to make treatment decisions, are reversible. Some effects of gender-affirming hormone therapy are permanent, while others will go away if treatment stops.
On the Senate floor, Perry cited research saying that transgender children who begin puberty blockers often change their minds, referring to it as "trendy." He also contended that transgender people who transition often live to regret it.
But doctors who specialize in transgender medicine strongly disagree, arguing that the research shows detransitioning is quite rare.
A study from 2020 found that trangender people who wanted puberty blockers and were able to access them as children had lower odds of lifetime suicidal ideation. A 2014 study that followed 55 teenagers through their transitions found that none regretted their decision.
“Speaking with gender clinics around the country, broad clinical experience suggests that transition regret is rare,” said Dr. Jack Turban, who researches transgender adolescent mental health at Stanford University School of Medicine.
Turban said the studies often highlighted by GOP state lawmakers have flaws in methodology. They include cisgender kids that come across as "tomboys" or boys acting traditionally "feminine."
These studies also recruit children that are too young to qualify as candidates for medical treatments. It's not until the very beginning stages of puberty that gender identity becomes more stable, Turban said.
Sen. Perry emphasized that his bill had no impact on transition care after 18, when he believes young people are old enough to consent.
But Dr. Norwood, of Vivent Health in Austin, said starting these treatments before puberty can have major benefits. For example, transgender adults who start transitioning earlier may not need to endure such invasive procedures later in life.
"I have a lot of adult patients who told me, ‘man, I wish I had access to puberty blockers because I wouldn’t have had a mastectomy or other aggressive surgeries,'" Norwood said.
Treatment can also have mental health benefits, according to Dr. Ximena Lopez, a pediatric endocrinologist in Dallas and one of the few youth trans care providers in Texas.
Puberty blockers and hormone therapy have improved the lives of transgender children suffering from gender dysphoria, depression and anxiety, Lopez said.
"All medications have risks — an aspirin has risks," she testified in front of the House Public Health Committee. "In our experience, the benefits of treating outweigh the risks of not treating."
Even though her patients are minors, Lopez said these decisions aren't made haphazardly. Her clinic has a thorough informed consent process, during which providers explain the effects hormones can have on fertility and other health impacts.
She said minors who begin puberty blockers and hormone therapy are routinely monitored for physical and psychological health.
Gender-affirming surgeries are not common among minors, Lopez added. Bottom surgery almost never happens and is not part of standards of care. In a few rare cases, top surgeries take place for trans males and non-binary people.
"Breasts are the single most distressful and dysphoric thing for (those patients)," Lopez said. "They don’t have friends. They don't get out of the house. And removing the chest is life-changing for them."
Several lawmakers have expressed suspicion of whether clinicians testifying against the bills have a financial incentive to see this care continue, including Perry, who described clinics as "high-profit centers in Dallas and Houston."
State Rep. Reggie Smith directly asked Lopez if the bills would be detrimental to her clinic's bottom line.
"I'm surprised you're saying that because we're actually losing money," Lopez said in her testimony. "All these clinics in the country are losing money. So we don't do this for the money. We're helping kids."
Similar bills have been filed in state legislatures across the country as a "nationally coordinated attack," according to Ricardo Martinez, CEO of Equality Texas.
The advocacy group has tracked more than 30 anti-LGBTQ bills filed this session, compared to 19 in 2019.
"We think about this as bathroom bill 3.0," Martinez said. "It’s been tried before in 2017. It’s been tried in 2019."
Lawmakers have filed legislation around other transgender-related issues in past sessions, but this is the first year health care access has been up for debate.
Many members and allies of the LGBTQ community went to Austin to testify against the bills, including transgender teens and children as young as 10. Some also spoke at a press conference held by Equality Texas, during which several onlookers at the statehouse started heckling them.
"The LGBTQ community, they’re scared, and to be honest, they’re tired," Martinez said. "This is a traumatic session. You're in this holding pattern waiting to get clarity on whether or not your rights are going to be different by the end of this session."
Sara Willa Ernst is a corps member with Report For America, a national service program that places journalists into local newsrooms. Sara’s work at Houston Public Media is made possible with support from KERA in Dallas.