Legislators have found a new way to insert themselves into the physician-patient relationship. In October and November 2019, news stories regarding a parental dispute over the treatment of a transgender child prompted legislators in Texas, Kentucky, and Georgia to announce plans to introduce bills that would prohibit medical and surgical treatment of transgender children under age 18.
Since then, lawmakers in at least eight additional states have filed or proposed similar bills. If these laws are enacted, physicians who provide these services could lose their medical licenses or face criminal charges. One of the bills (Missouri General Assembly, HB 1721/SB 848) would also require that a parent who “obtains medical or surgical treatment prohibited [under this act] for his or her child” be reported to child protective services.
Unfortunately, news coverage of these laws may contain common misunderstandings; these include using the terms gender and sex interchangeably and thinking that gender dysphoric children receive treatments such as puberty blockers, sex hormones, and surgery at much younger ages than they do.
These misconceptions even show up in the title of a bill — Colorado’s HB 20-1114 is titled “Protection of Minors from Mutilation and Sterilization Act.”
Treatment of gender dysphoria in children and adolescents is guided by published practice guidelines, clinical experience, and ongoing research. Practice guidelines, including those from the World Professional Association for Transgender Health (WPATH) and the Endocrine Society, are regularly reviewed and updated. Both guidelines emphasize multidisciplinary treatment and highlight the importance of continuing conversations among providers, parents, and patients to ensure agreement on the family and patient’s goals of treatment.
In early childhood, treatment consists of assessment, observation, and counseling aimed at helping children explore their gender identity and related feelings. About 85% of children with gender dysphoria will have a resolution of symptoms by the time they reach early puberty. The remaining children will experience worsening psychological symptoms and distress as they develop secondary sexual characteristics inconsistent with their gender identities. These patients are candidates for suppression of puberty.
Puberty is suppressed using the same medications that are used to treat precocious puberty (puberty blockers). Although some stories may state that puberty blockers alone cause sterility, they only slow pubertal progression, and puberty resumes normally when they are stopped.
Fertility is normal in this situation.
However, patients who start puberty blockers early in puberty and continue them until they start cross-gender hormone treatment (usually around age 16) will likely become infertile.
Thus, pre-treatment informed consent includes information on fertility outcomes, fertility preservation, and alternative treatments in addition to information about the risks and benefits of the medications themselves.
Puberty blockers buy more time for patients and their families to determine if they wish to stop and allow puberty to proceed or continue with treatment; they also make sex reassignment surgery easier (guidelines recommend delaying surgery until the patient is at least 18 years old).
The most important effect of puberty blockers may be a decreased risk of suicide. Data from the CDC’s 2017 Youth Risk Behavior Survey showed that 1.8% of high school students identified as transgender. 34.6% of transgender students had attempted suicide within the last year, compared to 5.5% of cisgender boys and 9.1% of cisgender girls.
Another recent study found that adolescents who desired and received puberty blockers had a lower risk of suicide compared to adolescents who desired but did not receive them.
Treatment of children with gender dysphoria is complex, and must be tailored to the patient and family’s needs and goals. Blanket bans on whole categories of therapies make these goals difficult to achieve. Bans also and create a conflict for physicians: if enacted, such laws would require physicians to withhold potentially life-saving treatment, and in doing so violate their ethical duty to provide patients and their families with the best possible treatment. This is an unacceptable intrusion into the physician-patient relationship. These laws also intrude on parents’ rights to make medical decisions for their children, and in the case of the proposed Missouri law cited above would treat parents seeking treatment for their transgender children as child abusers.
Unfortunately, this type of legislative interference is not new. Over the last decade, multiple states have introduced laws that interfere with the physician-patient relationship.
These include a law that prohibited physicians from asking patients about firearm ownership (eventually overturned on first amendment grounds) and laws in several states that require pre-abortion counseling to include inaccurate information. Laws requiring physicians to knowingly provide inaccurate information violate patients’ autonomy and ability to give informed consent. Variations in laws from state to state create injustice, in that whether a transgender child could obtain appropriate treatment would depend on which state the child lives in.
In response to laws like these, an editorial in the New England Journal of Medicine stated, “Legislators, regrettably, often propose new laws or regulations for political or other reasons unrelated to the scientific evidence and counter to the health care needs of patients. Legislative mandates regarding the practice of medicine do not allow for the infinite array of exceptions — cases in which the mandate may be unnecessary, inappropriate, or even harmful to an individual patient.”
This last point, that such laws may damage physicians’ ability to provide the best care, is especially troubling. In the case of transgender health care for children and adolescents, there is already a robust system of practice guidelines, ongoing research, and professional organizations. Physicians prescribe medical treatments with deliberation and informed consent, and defer surgery until the patient is 18. Thus, there is no need for legislative intervention, which will likely achieve little good and has the potential to do significant harm.
I encourage readers to investigate whether their own states are considering such laws, and if so, to make your opinions known to your legislators. Here is where you can find a list of transgender health-related laws by state (with links to full information on each bill).
Amy Potter is a medical writer.
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