The dangers of criminalizing medical care for trans youth

In the past month, at least six states have introduced bills to charge doctors with a felony for providing medical and surgical treatment to transgender youth. The bills’ titles appear to suggest they will protect vulnerable children, when in fact, they may accomplish the opposite.

I am a pediatrician and adolescent medicine specialist at Children’s Hospital of Philadelphia, where I co-founded a clinic that provides medical care and psychosocial support to more than 1,400 transgender youth. I know firsthand what legislation like this could mean for my patients and the more than 1  percent of U.S. youth who identify as transgender or gender-diverse. It would mean that youth in these states could no longer get lifesaving medications and surgeries. It would also send a signal to trans youth everywhere that affirming their identity can and should be illegal — further amplifying the stigma and discrimination these individuals already face.

To me, these bills are intended to insinuate that the care I provide to trans youth is harmful and abusive, and they interfere with the doctor-patient relationship. Let’s be clear; I provide lifesaving treatment that improves health, life, and well-being. I approach decisions about treatment carefully over time, with input from an interdisciplinary team, together with youth and their caregivers, and by established guidelines

For trans youth who cannot access this care, there are devastating consequences. More than 40  percent of adults who were not affirmed in their trans identity have attempted suicide. Due to the shame, stigma, and discrimination they face, trans youth are at substantially higher risk for mental health problems like depression and anxiety, and physical health issues like HIV and eating disorders. Unfortunately, all too many are victims of bullying and physical violence.

These statistics are sobering, but I see a story of opportunity for the young people in our clinic. Studies published in leading journals show that gender-diverse children who are allowed to socially transition — be called by their preferred name and pronouns and dress and wear a hairstyle of their choosing — have less anxiety and depression than their peers who were not affirmed and similar levels to their cisgender peers. 

Further, a study that followed trans youth from their early teens through young adulthood as they received puberty blockers, gender-affirming hormones, surgeries, and counseling showed excellent psychosocial outcomes and no negative medical consequences. And just this month, a new study of more than 20,000 transgender adults showed that those who received puberty-blocking treatment as adolescents were less likely to contemplate suicide than those without access to the medication.

The day that South Dakota’s bill was going to a vote, I saw Anthony, a 16-year-old born assigned female sex, but who identifies as male (I’ve changed his name and some details to protect his identity). He first came to our clinic at age 14, when he was experiencing chest dysphoria (emotional suffering due to his body, not matching his gender identity) from going through female puberty and developing breast tissue. This was causing him to spend most of his time in the basement, not socializing with friends, missing lots of school and never participating in gym class.

Once in our clinic, he and his parents worked with our mental health gender specialist, education coordinator, and myself over many sessions. The plan we developed is supported by evidence and considered the standard of care by the American Academy of Pediatrics and the Endocrine Society

After careful consideration, we decided together for Anthony to start testosterone so that he could experience puberty of the gender he identifies with alongside his friends. We then referred him for top surgery, or masculinizing chest surgery, to remove breast tissue that was causing him distress.

Unfortunately for Anthony, it took many hours of arguing with the insurance company to get the medically recommended procedure covered. Our research has documented the multitude of challenges trans youth and their families face when trying to determine whether recommended therapies, medications or procedures will be accessible. 

Despite a mandate for coverage under section 1557 of the Affordable Care Act, we found that few insurance companies indicated covering recommended services for trans youth. 

Thankfully, Anthony’s insurance company ultimately approved his surgery, and when I saw him in the clinic afterward, he was full of smiles. He was getting out of the house, skateboarding with friends and no longer missing school or gym class. It was such a joy for him, his parents, and I to see him feeling comfortable in his own skin and worrying about normal teen issues like mild acne rather than contemplating self-harm. 

Each of my patients has their own story and challenges, but all are thriving with the support and medical treatment our clinic provides. Attempts to limit their access to appropriate and needed care, and penalizing physicians like me who are providing the standard of care, is a misguided step. We need fewer barriers, not more, to trans youth getting the love, respect, dignity and medical treatment they deserve. 

Nadia Dowshen, M.D., MSHP is a pediatrician and adolescent medicine specialist who is co-founder of the Children’s Hospital of Philadelphia Gender (CHOP) and Sexuality Development Clinic, a faculty member at PolicyLab at CHOP and assistant professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania.


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