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Jennifer’s 15-year-old son had been on testosterone therapy for only two weeks when she got a call from his doctor. The exchange felt “very clandestine,” she said.
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“He calls from his personal number, calls my personal number [and] doesn’t use my child’s name because he’s scared somebody is recording the conversation,” Jennifer said.
The doctor told her he could no longer prescribe her son’s treatment. The medical malpractice insurance carrier, he explained, had stopped covering doctors who offered hormone therapy to minors.
The doctor’s call came a week after Gov. Greg Abbott ordered investigations into parents and licensed facilities that provide standard medical care to transgender teenagers. Abbott’s order was based on a nonbinding interpretation from Attorney General Ken Paxton that classified puberty blockers, hormone therapy and surgical care as child abuse.
Jennifer asked The Texas Tribune not to disclose her last name because she fears the state could launch an investigation into her family for obtaining hormone therapy.
Leading medical organizations across the country say gender-affirming care is the best way to provide care for transgender children. It primarily involves choices around name, pronouns and clothing that align with a child’s gender identity. It can eventually include puberty blockers and hormone treatment. Surgical care is rarely, if ever, performed on teenagers.
On Monday, a state appeals court reinstated a lower court’s injunction temporarily halting the investigation of transgender kids’ parents and medical providers. The court says the injunction will remain in place while an appeal of the decision plays out.
But in response to the Texas GOP’s recent efforts to limit scientifically backed gender-affirming care, LGBTQ advocates say hospitals, insurance companies and pharmacies across the state had already started restricting critical treatment for fear of legal consequences.
Health care providers worry they could lose their medical licenses if they don’t abide by Abbott’s directive.
U.S. Surgeon General Vivek Murthy told the Tribune that Abbott’s directive has had a chilling effect on health care practitioners, hospital systems and clinics.
“What’s happening right now is the state inserting itself between doctors, patients and families,” Murthy said. “That runs counter to the integrity of the doctor-patient relationship.”
Transgender teenagers now are grappling with narrowing access to medical care in a state where adequate, inclusive health care is already hard to come by. The lack of access has driven some to secure a substandard quality of care and others to stop seeking care altogether.
Jennifer said the doctor’s decision to stop hormone therapy was devastating for her family. She had searched for months for a pediatrician who would use her son’s correct pronouns and respect his identity. She had combed through parent Facebook groups and left voicemails with multiple health care centers before she met the doctor who started his treatment. Now she’s back at square one.
“You can’t find this care easily. Everyone is taking it off their website,” Jennifer said. “It’s like you got to know a secret handshake and then the secret knock and then the right phone number. It’s ridiculous what you have to go through to get your kid life-saving medical care.”
Providers roll back treatment
Teens who get approved for hormone therapy do so with great medical oversight. But before getting to that point, the standard approach to care for transgender youth begins with counseling and mental health evaluations.
Mental health professionals first help transgender clients navigate their gender identity. They can diagnose transgender clients with gender dysphoria by following a diagnosis tool published by the American Psychiatric Association. Therapists may later refer clients to doctors for hormone therapy and puberty blockers, and those doctors would complete a separate evaluation before prescribing medication. It’s a process that can span years.
The state’s largest providers of medical care for transgender children, however, have recently rolled back those services, bending to pressure from Republican leaders.
Texas Children’s Hospital, the largest pediatric hospital in the country, stopped providing hormone therapy to transgender children earlier this month. A spokesperson said the Houston-based hospital was assessing Abbott’s directive and that the decision to discontinue the service was made to avoid “potential criminal ramifications.”
Legacy Community Center, another major provider in Houston for transgender children, also paused hormone therapy for minors after the directive was announced, according to advocates for transgender Texans who work closely with the clinic. Legacy did not respond to multiple requests for comment.
And in Dallas, GENECIS — Gender Education and Care, Interdisciplinary Support — the state’s largest gender-affirming program, formally dissolved in November. The closure was in response to pressure from the governor’s office and a Texas House investigative committee, according to recordings of internal meetings obtained by The 19th. Existing patients can continue hormone therapy, but new patients at GENECIS can only access psychiatric evaluations and counseling, and be evaluated for gender dysphoria.
A doctor who headed the GENECIS program recently filed a petition against her employer, UT Southwestern Medical Center, to find out why the hospital cut care.
Gender-affirming medical and mental health care has always been in short supply in Texas, even before the GOP started targeting transgender children. So when the three major providers of gender-affirming care decided to halt their services, it was a huge blow for transgender Texans already struggling to find treatment, said Austin-based psychotherapist Monrovia Van Hoose, who often works with transgender youth.
The recent anti-trans efforts are “a backlash against what I would call pretty modest gains in access to care for minors in Texas,” she said. “I was very saddened to hear that GENECIS closed down. That was a big deal when that facility opened.”
Van Hoose said few doctors were willing to offer gender-affirming care in the state when she started working with transgender teenagers in 2008. More began to offer treatment after the GENECIS clinic opened in 2014.
But beyond GENECIS, Texas Children’s and Legacy, doctors who offer gender-affirming are still few and far between. Lou Weaver, a 51-year-old transgender man who works with health care providers to secure culturally competent care for LGBTQ communities, said Texas medical schools are not offering enough training on how to treat transgender patients, which means most local pediatricians are unable to provide appropriate care for transgender children.
Families often have to make hourslong drives to get medically backed gender-affirming care for their children. One family in the Rio Grande Valley told the Tribune they drive eight hours to Dallas to get care for their child.
But now even those long drives might not be enough to access care as doctors weigh new legal liabilities. When Paxton said gender-affirming care can be considered child abuse, it put health care professionals in a tight spot because they are mandated to report child abuse.
Therapists, pediatricians and doctors could now lose their licenses if they don’t report the families of their transgender clients. Making such reports, however, would violate standards of care from health organizations such as the World Professional Association of Trans Health and the American Medical Association.
Areana Quiñones, executive director of Texas-based Doctors for Change, said health care providers are disappointed legal and political issues are getting in the way of providing science-based medical treatments.
“We’re put in a no-win situation no matter what we do,” said Renee Baker, a Dallas-based therapist. “We don’t want to lose our licenses and ability to practice.”
Weaver said the hospitals could have used their teams of lawyers to advocate for scientifically backed medical treatments, “and yet they’re caving.” Health care providers are failing to protect their patients when they pull back treatment in response to political pressure, he said.
Few good choices left
Weaver said many transgender teenagers in Texas, facing diminishing options for care, will turn to informal channels to get the puberty blockers and hormone prescriptions they need. Some could try to buy prescriptions off of friends or look to the state’s unregulated black market, he said.
“What are you going to do to get what they need? You find a way to get it,” he said. “Our leaders have made this a desperate time for people who need access to health care.”
One teacher said in a written testimony at a Texas Department of Family and Protective Services meeting this month that some of her transgender students have rationed their hormone prescriptions over weeks because of inadequate access to medical care.
Some parents are traveling beyond Texas to get access to gender-affirming medical treatment. Some may also travel out of state to get any kind of medical care out of fear that going to a Texas health provider may require disclosing gender-affirming therapy and lead to a child abuse investigation.
Carrie Jackson drove her 17-year-old transgender son to Oklahoma to get emergency mental health care one week after Abbott issued his directive. Her son woke her up in the middle of the night because he was preparing to attempt suicide. Her son told her Abbott’s directive had made him feel like his existence was creating a threat for his family, she said.
Carrie Jackson stayed up with him through the night and scheduled multiple virtual assessments the following morning. Medical providers told her he needed to be admitted to a hospital.
She wanted to get him help as soon as possible, but she held back from taking him to a local hospital because she was afraid that DFPS, the state child welfare agency, would learn about the gender-affirming care her son has received and open an investigation.
“I don’t want my child in a hospital being interrogated by [DFPS] and without me being able to have any access to him to be there as a support for him,” she said.
Carrie Jackson did some research and found a mental health facility in Oklahoma, about three and a half hours away from their Denton home. Her son was admitted for six days and is stable now.
Some families that cannot leave the state have avoided seeking care altogether.
Jackson, a 15-year-old transgender teenager in North Texas, was supposed to increase his testosterone dosage six months ago. Jackson is not related to Carrie Jackson and did not disclose his last name out of fear that his family would be reported to the state for child abuse over his medical treatment.
He has been a GENECIS patient for two years, but since the clinic formally dissolved, he’s experienced additional barriers to obtain routine medical treatment. Increasing his prescription dosage used to entail a single appointment with his doctor at GENECIS and bloodwork, but he now has to meet with three doctors at three clinics.
What’s more, he and his family are terrified to book an appointment while Abbott’s directive is still being litigated. If DFPS gets a report about his medical care, Jackson might have to stop taking testosterone until his 18th birthday.
Greater risks with delayed care
But Jackson can’t wait another three years for hormone therapy. Gender dysphoria, he said, was an intolerable sense of discomfort that pervaded every part of his life. Since he started testosterone, he has experienced an increasing sense of comfort with his body.
“To be taken off of the one thing that has really changed my life for the better so far — it’s terrible,” Jackson said.
Waiting until adulthood to get hormone therapy may put transgender patients at greater mental health risk. A recent study found that access to gender-affirming hormone therapy in adolescence is associated with better mental health outcomes later in life.
If access to hormones like estrogen and testosterone is disrupted, transgender youth may undergo unwanted puberty changes and experience bodily functions like menstrual bleeding that can be distressing, according to Caroline Davidge-Pitts, an endocrinologist who specializes in trans health care.
When transgender youth experience unwanted changes to their bodies that do not affirm their gender identity, endocrinologists say it will likely lead to more surgeries later in life that otherwise could have been avoided. If a transgender boy, for example, experiences breast growth because he lost access to puberty blockers, he would need chest surgery later, said Joshua D. Safer, an endocrinologist and executive director of the Mount Sinai Center for Transgender Medicine and Surgery in New York.
“The point of puberty-delaying medication and hormone therapy for transgender youth when possible is to avoid permanent characteristics that will have to be addressed later,” Safer said.
Kamryn Shelton, a transgender 19-year-old, said his younger peers have attempted suicide when they have not been able to access the medical care they need.
Shelton, who supports teenagers in the Dallas-Fort Worth area through the organization Youth First, worries about youth who become disconnected from their hormone therapy or can no longer get an appointment with a gender-affirming doctor.
“Their mental health will rapidly decline. And if you stop taking your hormone shots or hormone blockers, it’s not only going to mess you up mentally, it’s going to mess with you physically as well.” Shelton said. “It’s going to kill people. If it goes any further, it will literally kill children. And that’s terrifying to me.”
Disclosure: Facebook and UT Southwestern Medical Center have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.