As anti-trans health bills surge in U.S., some Canadian experts are expressing concern

LGBTQ2S+ advocates, including Human Rights Campaign president Alfonso David and representatives from Equality Texas, the Transgender Education Network of Texas, Texas Freedom Network, ACLU of Texas, Lambda Legal, medical and health care professionals, and parents of transgender children rally at the Texas State Capitol on May 4, 2021, in Austin to stop proposed medical care ban legislation that would criminalize gender-affirming care. (Erich Schlegel/AP Images for Human Rights Campaign)

Last week, hundreds of people packed into the Ohio Statehouse to share testimony with one goal in mind: stopping a bill that would strip health care that many see as life-saving from trans youth.

One Ohio parent told lawmakers that her 14-year-old trans child had “heightened anxiety” at the prospect of this legislation being passed.

“She spent the weekend in tears … knowing that if things change, we don’t know if we can stay in Ohio, where she has her friends and her family and closest people to her,” Shannon Scott-Miller testified at the Nov. 16 public hearing.

Ohio is contemplating a bill called the Save Adolescents from Experimentation (SAFE) Act, which would ban gender-affirming care for all minors, including puberty blockers and hormone therapies.

Those who testified in support of the bill, including around 30 physicians, politicians and parents, say they’re worried that patients of this age group are too young to make permanent decisions regarding their health. More than 250 physicians, social workers, trans people and parents of trans youth who gave testimony last week say this bill only brings harm to an already vulnerable community.

According to more than 20 leading medical organizations in the U.S., including the American Academy of Pediatrics (AAP), gender-affirming care is the standard of care for trans and gender-diverse people.

Ohio is not an outlier. A similar scene has been playing out across the U.S. as legislation targeting the transgender community — particularly trans youth — increases.

Around 350 anti-LGBTQ2S+ bills have been introduced in the U.S. in 2022 so far, according to a count by the Human Rights Campaign (HRC), a U.S. based non-profit that focuses on advocacy and lobbying for more LGBTQ2S+ rights.

According to HRC, 79 pieces of anti-transgender legislation were introduced in the U.S. in 2020, which jumped to 147 bills in 2021, 13 of which were passed into law, a record for this type of legislation.

Last year also saw an unprecedented 43 bills introduced aimed at eliminating or restricting gender-affirming care for minors. So far in 2022, 25 bills flagged by HRC as anti-LGBTQ2S+ have been passed into law across 13 states, with more than half targeting trans people.

“Approximately 145 of (the bills) are specifically targeting transgender people,” Sarah Warbelow, HRC’s legal director, told CTVNews.ca in a phone interview, adding that they’ve seen “a significant increase in the past couple of years (in these bills).”

This ranges from legislation instructing teachers to tell families if their students identify as trans, to bills seeking to punish parents with jail time if they attempt to get their trans child gender-affirming care, even if recommended by medical experts. According to the American Civil Liberties Union (ACLU) some families have been forced to leave states that have enacted or are considering legislature that criminalizes trans health care.

Some Canadian trans people and activists say they’re worried that this wave of what they describe as anti-trans rhetoric and legislation could move into Canada — even more than they feel it already has.

“It’s absolutely happening (here),” Florence Ashley, a doctoral candidate at the University of Toronto Faculty of Law and Joint Centre for Bioethics whose work focuses around trans rights, told CTVNews.ca.

They said that there is a “homegrown” movement of anti-trans sentiments in Canada, which is “selectively drawing from the resources of the United States.”

“That's really scary,” Ashley said. “That sentiment has been spreading for a while, but it's getting worse and worse. And what sucks is the feeling that nobody cares.”

Barbara Perry, director of the Centre on Hate, Bias and Extremism at Ontario Tech University, said that securing health care and support is already difficult in both the U.S. and Canada, with trans people reporting long wait times to be assessed or access hormones or further care.

Seeing legislative attempts to make accessing health care even more difficult is causing “concern” for many Canadians, she told CTVNews.ca in a phone interview.

“There's a pretty widespread awareness in the Canadian context that trends, patterns that emerge in the U.S. will eventually make their way up here, and that they will influence our own narratives,” she said.

MEDICAL CONSENSUS BEING IGNORED, ADVOCATES SAY

Alabama, Arkansas, Arizona, Texas, Tennessee, Oklahoma, Ohio and Florida have all, within the last year, enacted or are considering legislation or other avenues to restrict or eliminate — and in some cases, criminalize — gender-affirming care for those under 18.

The proponents of these bills or rules offer a range of explanations depending on the scope of the bill. Some politicians openly state that they don’t believe trans people exist.

“I believe very strongly that if the Good Lord made you a boy, you are a boy, and if he made you a girl, you are a girl," Alabama Gov. Kay Ivey said when she signed a ban on gender-affirming care into law earlier this year.

In Canada, there are more than 100,000 trans or non-binary people, according to the 2021 census.

Others frame their opposition to gender-affirming care for minors as simply concern for their health, claiming that minors can’t consent to medical care that includes permanent changes to their bodies and that there is insufficient evidence to support it.

Florida Surgeon General Joseph Ladapo said in a statement this fall that banning gender-affirming care will “protect our children from irreversible surgeries and highly experimental treatments.”

Dr. Meredithe McNamara, a pediatrician and assistant professor at the Yale School of Medicine, who has worked with trans patients, testified in front of the Florida Board of Medicine in October, stating that gender-affirming care is not “experimental.”

“Gender-affirming care for youth is supported by every relevant major medical organization and this consensus is based on a solid body of evidence with more than 16 studies confirming that standard medical treatments for gender dysphoria are safe and effective,” she said at the time.

Accredited medical groups supporting the treatments in the U.S. include AAP, the American Medical Association, the Endocrine Society, the American Psychological Association, the Pediatric Endocrine Society, the American Psychiatric Association and the American Academy of Family Physicians, among others.

AAP, an organization of 67,000 pediatricians that provides guidance on medical care for children within the U.S., said in a 2018 policy statement that gender-affirming care means individual, age-appropriate health-care plans, “on the basis of the physical and cognitive development of youth who identify as trans and gender diverse.”

It stated that alternative care models such as “watchful waiting,” which advocates for holding off on affirming a child’s gender identity until “an arbitrary age (often after pubertal onset) when they can be considered valid,” are based on limited research and do not help patients.

Pre-puberty, gender-affirming care means social transition: respecting a child’s pronouns, manner of dress and chosen name, the AAP adds.

“Once a kid reaches the age of puberty, they can start puberty blockers, which can put things on hold for a little while to ensure that the transgender youth is confident in their gender identity,” Erin Reed told CTVNews.ca, adding that later on, teens and their doctors may consider hormone therapy. The effects of puberty blockers are reversible when treatment is halted.

Reed, a trans activist and legislative researcher who has been writing about legislation in the U.S. that affects trans people for the last three years, told CTVNews.ca in a phone interview that trans kids “know who they are,” and that when families affirm their gender, it has huge benefits.

“Allowing a transgender kid who is dysphoric to take puberty blockers and then to develop normally along their cisgender peers reduces their rate of suicide by anywhere between 40 and 73 per cent,” Reed said. “This care is life saving. But more than that, it raises their quality of life, it lowers anxiety, it lowers depression, and it allows transgender people to exist as they see themselves.”

Trans and gender-diverse youth have high levels of depression, anxiety and suicidal ideation due to gender dysphoria as well as a lack of societal acceptance, according to numerous studies, including a recent survey of 35,000 LGBTQ2S+ youth.

A 2021 study of 9,000 trans youth aged 13 to 24 found that receiving gender-affirming care was associated with a significantly lower rate of suicide attempts compared to youth who couldn’t receive it.

"Jeopardy!" champion Amy Schneider, a trans woman who grew up in Ohio, testified last week in opposition to the SAFE Act bill, stating that the only reason she survived her youth despite the constant distress of dysphoria was because she thought there were no other options.

She described it as living with an “alarm” droning on in her mind that was only silenced decades later when she came out as trans and began receiving gender-affirming care.

“I knew peace and quiet for the first time,” she said. “Please, don’t take that away from (trans youth). Please don’t force them to go back to that constant feeling of wrongness and danger.”

HEALTH CARE IN QUESTION

The most concerning bills for trans people, activists and the majority of medical experts are those that aim to restrict health-care options or punish families for supporting their trans children.

In April 2021, Arkansas became the first state to ban doctors from providing or referring patients under 18 for gender-affirming care, overriding the governor’s veto. Gov. Asa Hutchinson raised concerns that the new legislation would force patients already receiving care to detransition, something Reed said could be traumatizing for teens.

“You're a transgender girl, but you're not open (at school) about being trans, and then all of a sudden, you know that you're going to be forced to grow facial hair,” she said. “It's going to be terrifying.”

Alabama lawmakers also voted in April 2021 to approve legislation to ban gender-affirming treatment for minors. Both laws have since been paused amid court challenges, but numerous other states have introduced similar legislation since.

In Arizona, a bill banning only gender-affirming surgeries for those under 18 was later signed into law in March.

New Jersey has introduced an “Anti-Mutilation” bill criminalizing the provision of gender-affirming care, Oklahoma legislation withheld US$40 million in federal money from a children’s hospital until it stopped offering gender-affirming services, and Tennessee is proposing a ban on all gender-affirming care for minors that would allow doctors to be sued up to 20 years later.

“We’ve also seen a rise in administrative actions that bypass legislature altogether,” Warbelow said.

After legislation failed to pass a ban, the Florida Board of Medicine voted this month to draft a new standard of care barring those under the age of 18 from accessing gender-affirming care, marking the first time that a state board has ever pursued this type of rule. It allows teens who are already receiving care to continue to receive it.

The Endocrine Society said in a statement that “medical evidence, not politics” should inform treatment decisions.

“The move by the Florida Board of Health to ban gender-affirming care based on a political agenda rather than on science sets a dangerous precedent for all health care decisions,” the society said.

The Board of Medicine is made up of 15 members appointed by the governor and confirmed by the Senate.

Gov. Ron DeSantis has previously described gender-affirming care as doctors “chemically castrating young boys,” and asserted that “a lot of (trans kids)’ dysphoria resolves itself by the time they become adults.” It’s unclear what source of information DeSantis was citing but this assertion is one that 22 major medical organizations have stated “lacks scientific support.”

Numerous studies found that rates of transition regret and detransition are low. A recent study of 720 youth published in October found that 98 per cent of trans youth who went on puberty blockers were still continuing gender-affirming care years later into adulthood.

And it’s not just trans youth who are the focus of this new legislation — some states are going after their parents as well.

Michigan introduced a bill last month to expand the definition of child abuse to include if a parent, guardian or medical professional “consents to, obtains, or assists with a gender transition procedure for a child.”

If the bill passed, parents and doctors could face jail time over even just a prescription for puberty blockers for their trans child — medication which has been used for decades to treat precocious puberty in cisgender kids.

A similar bill has been introduced in Texas this month, after a judge blocked Gov. Greg Abbot’s order to state agencies to investigate parents for child abuse if they provided gender-affirming care for their child.

“It seems extremely egregious to take what is the medical consensus … and define that as child abuse,” Reed said. “And (to) potentially take kids away from their parents is extremely frightening.”

As these bills spread, some other states are responding to protect families internally displaced by anti-trans legislation. Nineteen states have committed to introduce “trans refuge bills,” according to a May press release.

One such bill passed in California includes a provision to protect “people that are fleeing from states that are criminalizing gender-affirming care,” Reed said, adding that she has personally helped people “escape Texas because of prior efforts to enforce this kind of action.”

FEAR SPREADING IN CANADA

The risk of legislation being tabled that would ban gender-affirming health care for trans youth or criminalize supportive parents seems distant in Canada — but as anti-trans views crop up more north of the border, activists and trans people fear the influence of the U.S.

“We're already seeing the discourses (but) we're seeing it more in the courts in Canada than elsewhere,” Florence Ashley said.

Ashley mentioned a high-profile case from a few years ago in which a father went to court with the aim of preventing his child from continuing with gender-affirming care that the child’s doctor had assessed as medically necessary and the child’s mother had agreed to. The B.C. Supreme Court ultimately ruled in favour of the child.

However, Perry believes Canada won’t see legislation similar to those being proposed south of the Canadian border.

“I like to think that … we have a deeper commitment to equity in the Canadian context,” she said.

But in a world as interconnected as ours, the impacts are already being felt, Ashley says.

“I think for trans Canadians (…) they don't feel like there's much place for them outside of Canada anymore, and increasingly less and less place for them in Canada,” they said.

While some clinicians and parents raising concerns about gender-affirming care may be attempting to do so in good faith, the big picture being painted by the legislation in the U.S. right now is more sinister, Ashley said.

Those pushing this legislation are less concerned about kids’ safety and more concerned with “the very idea that anybody would transition, because they don’t think that’s OK at all,” Ashley believes.

“These bills exist alongside things like “don’t say trans” laws, bathroom bills, bans on sports inclusion, moral panics about drag queens that turn into calls to ban trans people from public spaces, and claims that LGBTQ+ people and especially trans women are ‘groomers.’ Taking all these pieces together, the movement tells a story of trying to eliminate trans people from the public sphere, pushing them back into the closet where they never have to think about their existence.”

YOUTH LEFT WITH FEW HEALTH-CARE OPTIONS

The alternatives to gender-affirming care don’t stand up to scientific scrutiny, according to some advocates and experts.

In an amicus brief filed to an Alabama court in opposition to the state's legislation banning and criminalizing gender-affirming care, 22 national and state medical and mental health organizations said stripping gender-affirming care away from trans youth will leave a damaging gap in health care for this vulnerable population.

“While some prepubertal children who experience gender dysphoria may go on to identify with their sex assigned at birth by the time they reach puberty, there are no [sic] studies to support the proposition that adolescents [sic] with gender dysphoria will come to identify with their sex assigned at birth, whether they receive treatment or not,” the brief stated.

“Using ‘watchful waiting’ with gender-dysphoric adolescents can cause immense harm by denying them treatment that could alleviate their distress and forcing them to experience full endogenous puberty, resulting in physical changes that may be reversed—if at all—only through surgery,” it added.

Aside from the "wait and see" approach, the term “gender-exploratory therapy” has emerged within the last few years, defined by proponents as an approach that explores all potential factors behind gender dysphoria.

Some medical experts and academics say this approach is too close to conversion therapy.

“Forcing someone to ‘explore’ as a condition for accessing medical care means that they’ll simply double down and tell you what you want to hear,” said Ashley, who has written on this topic for a peer-reviewed journal. “It doesn’t create the kind of non-judgmental, open environment that fosters genuine gender exploration.”

Gender-affirming care aims to offer the space for patients to understand on their own terms if transition is right for them or not, without there being a right or wrong answer, Ashley said, but gender exploratory therapy “tries to find reasons why you think you are trans but actually aren’t.”

As visibility of trans people grows in pop culture, media and everyday life, more people are able to feel comfortable coming out as trans earlier in life, Reed said.

“People are feeling more free to be themselves and as a result of the increased visibility, I also think that we're seeing an increased amount of backlash, and people not understanding who transgender people are, and what being transgender means,” Reed said.

Studies have shown that the number of trans youth being referred to gender clinics or identifying as trans or gender-diverse has increased in recent years, with some regions showing a larger increase among teens assigned female at birth — but while trans people like Reed and medical experts such as McNamara see it as a natural result of stigma against trans identities lessening with time, some clinicians and politicians believe this increase to be concerning.

Warbelow said there is a lot of misinformation regarding gender-affirming care out there, and worried parents “sometimes perpetuate these incorrect narratives … often because they don't know anybody who is transgender — or at least they don't know that they know someone who is transgender — and are not always interested in seeking out more accurate information.”

These bills, the vast majority of which are struck down, are “not really a reflection of the values and the beliefs of the majority of Americans,” she said.

“This is a select number of politicians pandering to a base, and a group of folks in the middle who we are working hard to educate, who just lack information on transgender people.”