Every year March 31 marks Transgender Day of Visibility, a day when we should be celebrating the accomplishments of people who are trans, honoring their resilience and advocating loudly for their rights. Yet the growing onslaught of anti-trans legislation targeting the health-care decisions that families make with their doctors threatens to cast a shadow over this day.
In 2021 I lost a family member to the mental trauma of transgender discrimination, so I speak from a place of watching someone I love suffer from lack of support. These recent and proposed laws, none of which are grounded in evidence-based medicine, will affect the mental and physical health of adults and children and the families who support them.
I am in medical school, and I plan to specialize in psychiatry with the hope of working with people who are transgender or nonbinary. Instead of making me feel empowered to serve, the intent behind these laws makes me fearful for my future patients. The directive in Texas that calls gender-affirming health care “child abuse” makes me afraid to practice and outraged that any state can insert itself into the clinical decision-making that we spend thousands of hours honing over several years. There are so few doctors who treat people who are transgender, let alone specialize in the physical and mental medicine specific to their needs. These laws could dissuade clinicians from entering this line of work.
Instead of enacting laws that deny the basic health rights of the trans community—and signal to trans individuals that they are not safe, accepted or supported—policy makers, clinicians and advocates need to work together to create laws that counteract and prevent the health disparities that are exacerbated by the enduring discrimination against this community.
One of the biggest points of misinformation in the lobbying for these laws is what constitutes gender-affirming health care. Gender-affirming care is defined as treatments that either delay the onset of physical changes associated with puberty or create physiological and physical changes that affirm one’s gender identity (for example, hormone therapy or surgery). It is important to note that transitioning is a spectrum—not everyone who is transgender chooses hormone therapy, and not everyone chooses surgery. Yet all options are at stake with some of the laws that have passed or been proposed.
Doctors do not offer gender-affirming therapy rashly, and they prescribe puberty blockers only after working with a younger transgender person considering transition for a long time. Access to puberty blockers is critical because puberty’s effects on certain body parts cannot be easily reversed by hormone therapy later in life (for example, testosterone’s effects on voice). Altogether, the process requires coordinated counseling and medical oversight from a multidisciplinary clinical team that can include psychiatrists, endocrinologists and urologists, among others.
About 25 percent of transgender and nonbinary people choose gender-affirming surgery. Medical guidelines do not recommend surgery (such as facial reconstruction, mastectomy or phalloplasty) until a person is 18 years old, a point purposefully misrepresented by politicians who falsely say doctors are operating on young children.
More than 58,000 transgender teenagers who are transitioning are at risk of losing access to their medical care, according to a report from the University of California, Los Angeles, School of Law’s Williams Institute. The effects of these bills and laws would be devastating. A large survey published in Pediatrics in 2018 found that 30 to 50 percent of young trans and nonbinary people reported a previous suicide attempt, compared with less than 9 percent of all adolescents.
Experts hypothesize that this greater suicide risk among trans youth is linked to internalized rejection and shame. In contrast, transgender youth who are supported by their families and receive gender-affirming care have markedly lower rates of depression: gender-affirming care has been associated with a nearly 40 percent reduction in depression and in attempting suicide in the past year. Furthermore, trans youth who have access to puberty suppressants have a much lower risk of lifetime suicide as adults.
As Texas’s legislature debated anti-trans bills in 2021, the Trevor Project, an organization focused on LGBTQIA+ youth suicide prevention, received more than 10,800 total crisis contacts. Transgender or nonbinary youth made up more than 3,900 of those crisis contacts, and many of them reported feeling stressed, turning to self-harm and considering suicide as a result of the anti-LGBTQIA+ laws proposed by politicians in their state. Between 2020 and 2021, the Trevor Project recorded a 150 percent increase in LGBTQIA+ youth in Texas contacting the organization in crisis and seeking support. As a future psychiatrist, I find it incomprehensible that state lawmakers would willfully harm the mental health of so many young people.
All this legislation is at direct odds with the medical guidance of the American Psychiatric Association, the American Medical Association (AMA) and the American Academy of Pediatrics (AAP). These medical organizations recommend these medications and procedures for transgender individuals because there is a corpus of scientific literature affirming their benefits when medically indicated. These treatments are far from new and untested: puberty blockers have been used in medical care since the 1990s.
Calling me a child abuser will not stop my future patients from seeking care. Similar to the effects of efforts to stop abortion, transgender people and their families are liable to turn to unregulated black market products outside the purview of the Food and Drug Administration’s monitoring of hormone product safety and quality. I can’t fulfill the Hippocratic oath knowing that my inability to provide gender-affirming care might force patients into unsafe situations.
Numerous bills also propose criminalizing physicians if they offer transgender hormone therapy. In medical school, we had lectures on the importance of providing gender-affirming care, as well as panels specifically on the health-care experiences of transgender patients.
The closure in 2021 of Texas’s only multidisciplinary clinic for transgender youth, GENECIS, in response to pressure from the governor is evidence of the stifling effect these laws have already had on medical professionals. [Editor’s Note: A court order allowed GENECIS to start taking patients again in May 2022, pending any appeals.]
As highlighted by the pandemic, a dangerous risk factor for burnout among physicians is when they cannot control the health outcomes of their patients. Yet these bills go one step further, creating preventable negative health outcomes, and would introduce a new level of powerlessness and morale loss among providers. The AMA and AAP have both issued statements opposing recent anti-trans bills.
When speaking out against an anti-trans bill in Arkansas in 2021, Michele Hutchinson, a pediatrician at Arkansas Children’s Hospital, said, “I guarantee you, if this bill passes, children will die. And I will call you guys every single time one does.” In April 2021 that bill passed.
The day when police came to my house to tell my family that my uncle was found dead from an overdose after years of struggling with her identity, I felt like I was living through a nightmare.
In the painful days after, I committed myself to partnering with transgender communities to provide medical care and advocacy. Yet as legislators continue to signal that they would rather see people like my uncle dead than happy, alive and thriving, my grief has not subsided. Reading Texas Governor Greg Abbott’s letter declaring gender-affirmative care “child abuse” and understanding that a growing number of legislators seek to bar me and other physicians from providing lifesaving care, I know my family’s nightmare hasn’t ended.
Despite these legal battles underscoring the transgender community’s perseverance in the face of harrowing challenges, suffering is not what Transgender Day of Visibility is about. Unfortunately, brazen and medically uninformed politicians denying basic human rights over binary ideas of gender have left us no choice but to rally and continue to fight. My uncle, who was a transgender woman but liked being called “uncle,” deserved more in life. This is what I can do for her in death.