Texas has declared gender-affirming medical care for trans youth to be 'abuse.' Here's what it really is, say experts.
In his State of the Union address on Tuesday, President Joe Biden once again urged the Senate to pass the deadlocked Equality Act, which would provide broad antidiscrimination protections to LGBTQ Americans.
Then he added, "The onslaught of state laws targeting transgender Americans and their families is simply wrong. As I said last year, especially to our younger transgender Americans, I'll always have your back as your president."
It was excellent timing, considering that the past week has caused worry and whiplash for transgender youth and their loved ones: First, when Texas Gov. Greg Abbott directed state agencies, with the full support of Attorney General Ken Paxton, to investigate medical treatments for transgender youth as "child abuse" — and actually saw one such investigation, into the case of a 16-year-old transgender child of a state protective services agency employee, begin.
The American Civil Liberties Union of Texas and Lambda Legal tried to stop it in court, and on Wednesday night, a Texas judge issued a temporary restraining order that blocked the state's investigation. The order also set a March 11 hearing on whether to grant a wider-ranging injunction barring Gov. Greg Abbott's order.
Texas law, declared Abbott, who will run for reelection this fall following his win in Tuesday's primary, requires all licensed professionals, including teachers and doctors, to report any children "who may be subject to such abuse." It also, he said, requires the Department of Family Protective Services "to investigate the parents of a child who is subjected to these abusive gender-transitioning procedures" and calls on "other state agencies to investigate licensed facilities where such procedures may occur."
Abbott's order joined the attempts of more than 20 states to essentially ban such treatments, with two signing them into law. That's despite a slew of professional medical groups — including the American Academy of Pediatrics (AAP), the American Medical Association, the Endocrine Society and the American Psychiatric Association — fully supporting such transgender-youth treatment, known as "gender-affirming care." It's also in spite of the findings of many studies, with perhaps the most salient finding that gender-affirming care can significantly lower the suicide risk among transgender youth.
"Abbot is showing his ignorance and his bias by misrepresenting and demonizing a very proven and helpful process," Dr. Michelle Forcier, a professor of pediatrics and director of the Gender and Sexual Health Program at Brown University, tells Yahoo Life. "It's not life-threatening, but is, in fact, life-affirming."
Here’s what else gender-affirming care is — and isn't.
What gender-affirming care involves
The gender-affirming model of care is first and foremost about "creating a nonjudgmental space," explains Derrick Jordan, director of the Gender and Family Project at the Ackerman Institute for the Family in New York City.
"There's this huge misconception that it goes right to gender-affirming procedures that require surgery," he tells Yahoo Life. "But gender-affirming care starts when you walk into a provider's office and they use your pronouns. … When your correct name is used. … When you're able to participate in therapy or groups and feel safe, and are in an environment where you can express yourself and be yourself. It is not just a medical procedure."
Adds Dr. Stephen Rosenthal, a pediatric endocrinologist and medical director of the Child and Adolescent Gender Center at UCSF Benioff Children's Hospital in San Francisco, such care starts with patient discussions "because the only way you can know their gender identity is based on what they tell us. There is no blood test, no brain scan."
"It's listening to kids and following their lead," says Forcier, "in the sense of kids trying to figure who they are and we, as adults, providing an environment where they can explore that safely. It's not this idea of 'Just do whatever the kids says,' which has people up in arms. That's not the affirming model."
Instead, she explains, what happens when a parent brings a child in to see a doctor about any gender issues, is that "the health care provider talks with the child and parents and, depending on what the child says, they come up with a plan for that child to safely explore who they think they are what they think they need." That, she says, "takes a lot of time, intention and work."
From there, the possible next steps are as varied as the individuals seeking care.
"Some kids will want to play with hair and makeup or clothing or jewelry, and other kids will say, 'I'm a boy and I'm supposed to be a boy and I was born into this girl body, and that's why I'm here to see you — to talk about stopping puberty to be like the other boys,'" Forcier says. "Some kids will figure this out at 3 or 4 years old. They know who they are." But, she stresses, "at 3, no one is having surgery or taking medication."
Many people who are "gender diverse," notes Rosenthal, won't want any medical or surgical interventions at all, and "are happy with just a social transition, where they modify how they express themselves, their pronoun, their chosen name, hairstyle, things like that."
But if a child is diagnosed with gender dysphoria — which the American Psychiatric Association says refers to as "the psychological distress that results from an incongruence between one's sex assigned at birth," based on external genitalia, "and one's gender identity," meaning one’s psychological sense of their gender — then other options get explored. That could include the use of puberty blockers.
Technically called gonadotropin-releasing hormone analogues (GnRHas), these work by temporarily pausing development in children who have entered puberty. Research, including a 2020 study published in the journal Pediatrics, has found the use of puberty blockers to be associated with decreased thoughts of suicide.
"If somebody has gender dysphoria, then going through the physical changes of puberty not aligned with their gender identity can cause great distress," Rosenthal says. Prescribing the blockers essentially puts puberty on pause, allowing the child to take some time to solidify their gender identity and think about what they want. They have been used "for over 30 years in transgender youth, and for even longer than that in treatment of 'precocious puberty' [when puberty begins before 8 in girls and before 9 in boys]," he adds.
Also, says Forcier, its effects are "completely reversible and offer huge relief. There is not one study that says the harms outweigh the benefits, and not one study that says gender affirmation offers negative health outcome."
Then, Rosenthal adds, a next step might be to try gender-affirming sex hormones — low doses of estrogen or testosterone — followed by, "for some individuals, and certainly not all, to consider genital gender-affirming surgeries, although they are not recommended before the age of 18." One rare exception of a surgery that may take place before 18 is that of top surgery, or the removal of most breast tissue and the reshaping of one's chest.
"There is a very small fraction of 16- or 17-year-olds having top surgery," Forcier notes, while also stressing that it can, for the "vast, vast, vast majority of folks," bring "huge relief from their gender dysphoria."
Child 'reassignment surgeries,' 'sterilization' and other misconceptions
Gov. Abbott's decree promotes many misconceptions and inaccuracies about what transgender medical care is, says Rosenthal, who notes that while some misconceptions may be honest, others can come across as "intentional."
Sometimes, for example, people refer to use of puberty blockers as "medical castration, which "whips up images of violence," and is inaccurate. Similarly, Rosenthal notes, Paxton tweeted that physicians "were doing sex-change operations on children, when nothing could be further from the truth. There are no sex-change operations for kids. … That means you are changing genitalia." Politicians use "sex change" phrasing, Rosenthal believes, "to work up the masses." And as they do, they are "throwing this very vulnerable population of trans kids into the crosshairs of a culture war."
Adds Forcier, "That's media hype. And it makes everybody anxious, so it's a great hot topic." But kids, she explains, are simply "not getting their ovaries or testes removed."
Another myth, says Rosenthal, is that pre-pubescent kids are being put on puberty blockers to prevent the onset altogether. First, he explains, since puberty can begin anywhere within a huge window, from 8 to 13, they'd possibly be taking the blockers "unnecessarily," for a long period of time. Also, he explains, some psychologists, based on a Dutch model of care, believe there is diagnostic value in evaluating how a transgender child experiences the early stages of puberty, because "not every child will necessarily persist" as trans, he says.
Not a fly-by-night process
Finally, the experts point out, providing any level of gender-affirming care is part of a deliberate, well-thought-out process, and not something that's based on whim.
As Rosenthal notes, the Diagnostic and Statistical Manual of psychiatric care says one must meet the criteria for gender dysphoria "for at least 6 months duration" before being diagnosed.
"It's an extraordinarily thoughtful process, and it takes several steps to pursue medical intervention. [It] certainly isn't like, 'I wake up one morning and am going to get this and this tomorrow,'" says Jordan. "There are standards of care, set by the World Professional Association for Transgender Health, which offers a comprehensive guide of what transgender health looks like, which is endorsed by the Endocrine Society, American Academy of Pediatrics, and so many different areas of study. … It's a misconception that this is a rushed process."
This post was originally published on March 2, 2022 at 11:56 a.m. ET and has been updated with new information to reflect that a Texas judge temporarily blocked Gov. Abbott's order.
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