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The public comment period is open on the proposed ban on gender-affirming care for teens, and I have some thoughts

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Jen Cousins

Special to VoxPopuli

Monday, November 28, 2022

The public comment period is open on the proposed ban on gender-affirming care for teens, and I have some thoughts

Ted Eytan

Starting hormone therapy in early adolescence dropped trans teens' odds of developing severe psychological distress by 222 percent and suicidal thoughts by 135 percent, according to a Stanford Medical School study, the largest to date done on transgender people.

Earlier this month, on the first day of Transgender Awareness Week, the Florida Boards of Medicine and Osteopathic Medicine both published Notices of Proposed Rules regarding their proposed bans on gender-affirming care for minors diagnosed with gender dysphoria, the feeling that one’s body doesn’t align with their gender identity. Gender dysphoria can lead to anxiety, depression and thoughts of suicide.

We are now in a 21-day public comment period, open through Dec. 5, on the proposed rules. (Comment here for the Board of Medicine and here for the Board of Osteopathic Medicine.) This is the next step before another public hearing, possibly on the final day of the public comment period. 

If the rules become permanent, parents of trans adolescents will be unable to access puberty blockers, hormones and surgery. A ban on using Medicaid to pay for treatment for adults is already in place. These bans are not supported by any major medical association.

It’s a gross misconception that parents of trans kids are seeking surgical procedures for their children. This myth is a fever dream promoted by politicians like Gov. Ron DeSantis as part of his campaign against Florida's LGBTQ community; lawmakers in states like Texas, Arkansas and Alabama, and Georgia Republican Rep. Marjorie Taylor Greene who introduced the Protect Children’s Innocence Act, likely to get a hearing in the next Congress, which prohibits federal funding for health plans that cover gender-affirming treatment, prevents training physicians to use these treatments and makes it a felony for doctors to provide this kind of care to a minor.

To clarify, gender-affirming surgery is never for young children. And it’s highly unusual for adolescents under 18, according to an analysis of insurance claims done by Reuters and the health technology company Komodo Health Inc. Among adolescents 13 to 17 with gender dysphoria, Komodo found just 56 genital surgeries and 776 mastectomies in a three-year period (2019-2021) throughout the entire U.S.

Far more often, parents of trans kids are in the same situation as my friends Sarah and Scott, who asked to be identified only by their first names to protect their family’s privacy. They have an adorable, precocious child. While assigned male at birth, from age 2, the now 6-year-old told her parents she was a girl. She lives as a girl, dresses as a girl, goes to school as a girl. She has a girl’s name. Her friends have only ever known her as a girl. That’s called social transitioning. It's a key — and the first —component of gender-affirming care.

But her parents are looking ahead. They’re afraid that in a few years they won’t be able to access the puberty-blockers their daughter will need to avoid going through puberty as a boy, which could be traumatic, along with the hormones to continue her female transition after puberty. 

Scott and Sarah only bought their home a few years ago but now face the prospect of selling it and their business and moving to a state where the laws are less invasive and they’ll be able to access the healthcare their daughter will need. They’re not alone. Politico recently reported on families leaving red states for blue states to find the treatments their trans kids need. Trans adults are migrating because their hormone treatments have already been targeted.

I was at the Orlando meetings earlier this month after the physicians of both medical boards voted to ban treatment. When a demonstrator shouted that the blood of suicidal trans kids would be on members’ hands, a doctor flippantly responded, “That’s OK.”

The Hippocratic Oath, it bears repeating, says, “First, do no harm.”

Recently, the New York Times reported that emerging research suggested puberty blockers may be associated with bone loss in teens. But according to a joint statement from the U.S. Professional Association for Transgender Health and the World Professional Association for Transgender Health, the New York Times got the research wrong. Puberty blockers don't affect bone density directly. They temporarily suppress sex steroid production, which may affect bone health depending on how long blockers are used. But when estrogen, which promotes bone health, is used in tandem with puberty-blockers, there's no effect on bone density. The organizations also noted that study participants' baseline bone density hadn't been calculated, so it's impossible to know when bone loss occurred or if it was related to the treatment at all. 

Still, most parents decide that the benefits of gender-affirming care outweigh any potential risks because of the very real risks of self-harm and suicide when gender dysphoria goes untreated.

In a study done at Nicklaus Children’s Hospital in Miami, two-thirds of the trans and nonbinary teens were depressed. Rates of depression, suicidal ideation, self-harm  and substance abuse are routinely found to be higher among trans and nonbinary kids. One in five trans and nonbinary youth attempted suicide last year, according to the latest survey by The Trevor Project.

But earlier this year, in the largest study ever done on transgender adults, researchers from Stanford Medical School found that when trans people received hormones in their early teens, they fared better emotionally, with lower odds of psychological distress, suicidal thoughts, and alcohol and drug abuse, compared with trans people who started hormones in later adolescence and as adults. 

This may be why the American Academy of Pediatrics, American Medical Association, American College of Physicians, American Psychological Association, American Psychiatric Association and the American Academy of Child & Adolescent Psychiatry all back gender-affirming care for minors, as does the Endocrine Society, an international organization.

This adds to the growing list of reasons why these kinds of healthcare decisions should be family decisions, made based on evidence-backed science — not prevailing politics. 

Treatment is largely reversible. But suicide, that's forever.

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