On May 8th at midnight, a new Alabama law went into effect. For the first time in US history, a state law levies felony charges on the provision of gender affirming care. In the weeks preceding May 8th, healthcare providers worked 14-hour days in order to ensure that their patients had a one year supply of all necessary medications. Healthcare institutions sent somber emails to their workforce, reminding them of the legislation, but staunchly opposing its content.
In February 2022, the Attorney General of Texas, Ken Paxton, issued a legal opinion (the Opinion) concluding that gender affirming care in minors constitutes forced sterilization and therefore, child abuse. The Opinion egregiously misrepresented the standard of care for gender diverse youth by (1) claiming the current use of medications that haven’t been available in the US in decades, (2) criticizing the use of exogenous sex hormones which are widely prescribed in conditions that affect trans and cis gender persons alike, and (3) falsely asserting that genital surgery occurs before the legal age of majority. In citing a retracted paper, the Opinion claimed that most youth with gender dysphoria will experience spontaneous regression without intervention. With no evidence, the Opinion stated that the prevalence of gender dysphoria is unknown and likely negligible.
In response, I joined an ad hoc policy working group colleagues in law, medicine, and psychology to rebut this Opinion and amplify the facts. Gender dysphoria affects almost 2% of American teenagers. Trans and non-binary youth who do not receive gender affirming care face a 40% lifetime risk of a suicide attempt. Mental health outcomes improve significantly with the medication aspects of gender affirming care. The vast majority of those who receive gender-affirming care do not regret transition in adulthood.
Treatment for gender dysphoria is accomplished with medications that are safely used in similar doses in cisgender people, some uses of which include testosterone deficiency, menopause, contraception, and heavy menstrual bleeding. Puberty blockers are safely and routinely used in the treatment of precocious puberty, allowing congruent physical and psychological childhood development. Beyond the corollaries to safe practice in cisgender populations, we cite 60- high quality, well-designed studies published in reputable journals that establish the safety and efficacy of gender affirming care in gender diverse youth.
For the first time, pediatricians in Alabama can be imprisoned for providing the standard of care.
In the medical community there is no longer a debate about the safety or the importance of treating gender dysphoria. To challenge this disturbing new reality, twenty-two leading medical organizations, including the American Academy of Pediatrics, American Medical Association, Association of American Medical Colleges, American College of Obstetricians and Gynecologists, and the American Academy of Family Physicians filed a supportive amicus brief to challenge the Alabama law. This is what consensus in the medical community looks like.
We as pediatric healthcare providers must speak out and let our communities and elected officials hear the facts. We must ensure that gender diverse youth have access to medically necessary and life-saving care.
Meredithe McNamara, MD
In clinical practice, I have cared for many Black and Brown young adults with gender dysphoria who begin a gender transition in their 20s. As children and teens, they faced insurmountable barriers. The toxic effects of systemic racism drain even the most basic resources, let alone access to mental health, hormonal treatments, and surgery. These patients have endured suicide attempts, self-harm, substance use, homelessness, and the adverse effects of street hormones. It is often a diagnosis of HIV that brings them to a physician, who then identifies and treats their dysphoria. I am not surprised to see the relief that comes with transition, but I am devastated when I take full stock of the cost.
It’s hard to imagine that these patients could be even more deprived, but that’s exactly what the Alabama legislation will do. It will do the most harm to those with the least privilege.
Practicing medicine according to the highest standard of ethics without interference from the law is no longer guaranteed. To my colleagues in states where gender affirming care is not limited, know that this is not a niche problem limited to two states. Developing legislation in other states is even more concerning. Trans and non-binary people everywhere are experiencing a deepening mental anguish and crisis calls are escalating. It is troubling to think about what new legislation can impose in other domains of medicine.
We as pediatric healthcare providers must speak out and let our communities and elected officials hear the facts. We must ensure that gender diverse youth have access to medically necessary and life-saving care.