In Texas, my home state and where I practice as a primary care physician, the rights of transgender people have been continuously targeted in a battle for political power. In May 2022, the Texas Supreme Court ruled that the Texas Department of Family and Protective Services (DFPS) could continue their investigations of families of transgender children after a lower court that had temporarily halted the inquiries statewide. The inquiries started in February, when Governor Greg Abbott directed the DFPS to investigate parents who with transgender children, based on an opinion by Attorney General Ken Paxton that asserted that certain medically accepted treatments for transgender youth constitute child abuse.

On March 11, instead of seeing patients in clinic, I sat in the back of a large auditorium at the Texas Department of Family and Protective Services (DFPS) and listened to stories of trauma for hours. Each story started with the same phrase: “My name is—, and I’m here to read a statement from the family of a transgender child who is too terrified to be here.” One by one, community members stepped up to read statements to DFPS council members from transgender kids and their families submitted from across the state. Brave family members and transgender youth also stood up to speak themselves, despite the extremely personal nature of their testimony and the great personal risk.

One mother spoke of how she did not initially support her transgender son’s transition after he came out. She choked back tears as she described coming home one day to find her son unconscious on the floor of his room. I watched a council member blot away tears as this mother poured out her soul, explaining that his suicide attempt convinced her to listen to him and how, with treatment, he is now thriving and happy. Another family pleaded with the council, “Don’t make me read my child’s obituary.” These parents described making difficult decisions driven by an unconditional love for their children, and an intense fear that the unthinkable could happen—that a state agency could take their children from them for loving and supporting them.

I, too, was there on behalf of others. As an internist, I have provided gender-affirming care to adults in my practice for the past eight years, but I went to represent my colleagues in pediatrics who can’t risk putting their patients and themselves in danger by speaking up. Due to political and financial pressure, clinics that care for transgender youth have been shutting down to avoid persecution.

As of May 24, 32 states have passed or proposed anti-transgender legislation, including restricting access to gender-affirming care. Some bills carry severe penalties for healthcare providers and sometimes families, who provide or seek out gender-affirming care for minors. The UCLA Williams Institute predicts that more than 58,000 transgender youth are at risk of losing care because of these state bans. Even without making gender-affirming care illegal, clinics are under threat of having funding pulled and families are at risk of investigation, as is the case in Texas. Primary care doctors face a moral challenge in the face of unethical political overreach into the lives of patients and disruption of the patient-physician relationship. As the fight over transgender healthcare continues to get national attention, the public will be looking to physicians to understand what transgender healthcare is and is not. To ensure consistent and clear messaging, we must invest in education of our trainees and colleagues, most of whom are unfamiliar with gender-affirming care.

Ignorance does not always mean malintent, but it’s our responsibility to make sure physicians are knowledgeable and respectful when caring for transgender and gender-diverse patients. According to the 2015 National Transgender Discrimination Survey, one-third of those who saw a health care provider had at least one negative experience related to being transgender, such as being verbally harassed or refused treatment because of their gender identity. Additionally, nearly one-quarter (23%) of respondents reported that they did not seek the health care they needed in the year prior to completing the survey due to fear of being mistreated as a transgender person, and 33% did not go to a health care provider when needed because they could not afford it.

Clearly, our work is cut out for us. There is currently no AAMC requirement to teach medical students about health related to the entire umbrella of LGBTQI+ communities, much less transgender people specifically. In 2020, a staggering 52% of transgender youth reported considering suicide. More than a dozen studies have shown that gender-affirming care for youth improves anxiety, depression and thoughts of suicide, and is endorsed by every major medical organization, including the Texas Medical Association, the American Academy of Pediatrics, and the American Psychiatric Association. If we are to lean into health equity teaching, we must include dedicated training on inequities that affect transgender patients.

Despite fearmongering, gender-affirming care for youth follows well-established, age-appropriate standards of care. For young children, that care includes just supporting them socially, by using the name and pronouns they prefer. Adolescents with gender dysphoria are much more likely to identify as transgender when they are in adulthood; for them, temporary puberty blockers can be considered while they undergo counseling with trained mental health professionals and physicians before moving to less reversible treatments such as hormones. Genital surgeries, often referenced by legislators, are in fact not recommended for minors by current guidelines.

The real danger here is denying high-risk youth medically indicated, life-saving care while ripping them from supportive families. Family rejection is extremely common when transgender people come out to their family, something I hear about from most of my adult transgender patients. Transgender adults rejected by their parents are twice as likely to attempt suicide with higher odds of alcohol or drug abuse.

In keeping with the Hippocratic Oath, we cannot allow our hospitals and clinics to deny this care and leave patients to fend for themselves. What we can do is advocate for evidence-based medicine and support organizations defending transgender youth on the ground, such as OutYouth, the Transgender Education Network of Texas, Organización Latina de Trans en Texas, the National Black Trans Advocacy Coalition and Equality Texas, and others across the country facing similar threats. We can train the next generation of clinicians to be knowledgeable about transgender and involve transgender stakeholders in our curricular development. We can and should share resources to teach each other as we teach our colleagues and students. A group of SGIM members lead by Dr. Hedian published an easy-to-use Guide for Gender Affirming Hormone Therapy for primary care clinicians and trainees, accessible at https://bit.ly/GAHT-QUICK-GUIDE and featured in the June 2022 SGIM Forum.6 An example of involving transgender patients in curricular development and teaching was presented by myself and colleagues at the 2022 SGIM annual meeting. Together, and with the transgender community, we take a stand and defend the rights of patients to access gender-affirming care—care that could literally save their lives.

Note: An earlier version of this article appeared in Salon and may be accessed at https://www.salon.com/2022/03/29/dont-make-me-read-my-childs-obituary-texas-risks-lives-by-banning-gender-affirming-care/.

References

  1. Dey S. Houston hospital pauses hormone therapy for transgender children as threats of child abuse investigations loom. Texas Tribune. https://www.texastribune.org/2022/03/04/texas-transgender-children-hormone-therapy/. Published March 4, 2022. Accessed June 15, 2022.
  2. Conron KJ, O’Neill KK, Vasquez LA, et al. Prohibiting gender-affirming medical care for youth. https://williamsinstitute.law.ucla.edu/publications/bans-trans-youth-health-care/. Published March 2022. Accessed June 15, 2022.
  3. Turban J. The evidence for trans youth gender-affirming medical care. Psychology Today. https://www.psychologytoday.com/us/blog/political-minds/202201/the-evidence-trans-youth-gender-affirming-medical-care. Posted January 24, 2022. Accessed June 15, 2022.
  4. The Trevor Project. National survey on LGBTQ youth mental health 2020. https://www.thetrevorproject.org/survey-2020/?section=Introduction. Accessed June 15, 2022.
  5. Klein A, Golub SA. Family rejection as a predictor of suicide attempts and substance misuse among transgender and gender nonconforming adults. LGBT Health. 2016;3(3). https://doi.org/10.1089/lgbt.2015.0111.
  6. Hedian H, Streed C, Siegel J, et al. Gender-affirming hormone therapy: Lowering the activation energy for hormones in primary care. SGIM Forum. https://connect.sgim.org/sgimforum/viewdocument/gender-affirming-hormone-therapy-l. Published June 2022. Accessed June 15, 2022.

Issue

Topic

Advocacy, Health Policy & Advocacy, Medical Ethics, SGIM, Social Determinants of Health, Vulnerable Populations

Author Descriptions

Dr. Norwood (Aliza.Norwood@viventhealth.org) is assistant professor of internal medicine at the University of Texas Dell Medical School and the medical director at Vivent Health in Austin, Texas, where she provides HIV primary care, HIV prevention, and gender-affirming care. Her opinions are her own.

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