Pediatrician Michelle Collins-Ogle, MD, already has a busy practice helping young people address questions about their gender identity. She has treated more than 230 patients over the past 2 years at Children's Hospital at Montefiore in the Bronx, New York.
Collins-Ogle specializes in adolescent medicine in New York, a state without the restrictions on such care that have been enacted in roughly half the country.
On December 13, 2023, Ohio lawmakers passed a bill banning gender-affirming medical care to minors which Gov. Mike DeWine vetoed on December 29. Another 26 states have similar restrictions in place, according to a tally provided to Medscape by the Human Rights Campaign, which tracks this issue.
Clinicians like Collins-Ogle are feeling the impact. In her practice, Collins-Ogle met a couple that moved from Texas to New York to allow their child to access gender-affirming medical care.
"They wanted their child to be able to receive medical care, but they also were afraid for their own safety, of having their child taken from them, and being locked up," Collins-Ogle told Medscape.
With patients have also come protestors and harassment. In fact, many physicians are reluctant to speak on this topic amid a recent spate of threats. Psychiatric News reported that conservative pundits and high-profile social media accounts have targeted physicians who provide gender-affirming medical care, spurring harassment campaigns against clinics in cities such as Akron, Boston, and Nashville. "The attackers asserted that the clinics were mutilating children and giving them 'chemical castration drugs,' among other claims," the Psychiatric News reported.
Medscape contacted more than a half dozen organizations that provide gender-affirming care for adolescents and teens seeking interviews about the effects of these restrictions.
All but Montefiore's Collins-Ogle turned down the request.
"If my kids are brave enough to come see me, I can't cower," Collins-Ogle said.
But Collins-Ogle emphasized she understands why many fellow physicians are concerned about speaking publicly about gender-affirming medical care.
Dissenters Spread Misinformation and Threats
Recent years have seen increasing politicization of this issue, often due to inaccurate depictions of gender-affirming medical care circulating on social media.
In 2022, the American Medical Association (AMA), the American Academy of Pediatrics (AAP), and the Children's Hospital Association asked the Justice Department to investigate what they called "increasing threats of violence against physicians, hospitals, and families of children for providing and seeking evidence-based gender-affirming care."
The three organizations also called on X (formerly known as Twitter), TikTok, and Meta, which owns Facebook and Instagram, to do more to address coordinated campaigns of disinformation.
"We cannot stand by as threats of violence against our members and their patients proliferate with little consequence," said Moira Szilagyi, MD, PhD, then AAP president in a statement.
Medical Groups Defend Care to Prevent Suicide
The AAP, AMA, and other influential medical associations are banding together to fight new legal restrictions on gender-affirming medical care for teens and adolescents. (These briefs do not discuss surgeries typically available for adults.)
Since 2022, these medical organizations have filed amicus briefs in cases challenging new restrictions put in place in Arkansas, Alabama, Florida, Georgia, Idaho, Indiana, Kentucky, North Dakota, Oklahoma, Tennessee, and Texas.
Other signers to the amicus briefs:
- Academic Pediatric Association
- American Academy of Child & Adolescent Psychiatry
- American Academy of Family Physicians
- American Academy of Nursing
- GLMA: Health Professionals Advancing LGBTQ+ Equality
- American College of Obstetricians and Gynecologists
- American College of Osteopathic Pediatricians
- The American College of Physicians
- American Pediatric Society
- Association of Medical School Pediatric Department Chairs, Inc.
- Endocrine Society
- National Association of Pediatric Nurse Practitioners
- The Pediatric Endocrine Society, Societies for Pediatric Urology
- Society for Adolescent Health and Medicine
- Society for Pediatric Research
- The Society of Pediatric Nurses
- World Professional Association for Transgender Health
In these amicus briefs, the medical groups argue that evidence-based guidelines support the use of medication in treating gender dysphoria. The amicus briefs in particular cite an Endocrine Society guideline and the standards of care developed by the World Professional Association for Transgender Health (WPATH).
Research shows that adolescents with gender dysphoria who receive puberty blockers and other medications experience less depression, anxiety, and suicidal ideation, the groups have said.
"In light of this evidence supporting the connection between lack of access to gender-affirming care and lifetime suicide risk, banning such care can put patients' lives at risk," the AAP and other groups said.
Debate Over Source of Gender Identity Concerns
Having doubts and concerns about one's gender remains a relatively rare phenomena, although it appears more common among younger people.
Among US adults, 0.5% or about 1.3 million people identify as transgender whereas about 1.4% or about 300,000 people in the 13-17–year-old group do so, according to a report issued in 2022 by the Williams Institute of the UCLA School of Law.
Questionable Diagnosis Drives Bans on Care
The term "rapid-onset gender dysphoria," referring to young people who suddenly question their gender as part of peer group dynamics, persists in political debates. The conservative Heritage Foundation has used the term as well as "social contagion" in its effort to seek restrictions on gender-affirming care for young people.
Ohio Rep. Gary Click, a Republican, said at an April 2023 hearing that his Save Adolescents from Experimentation (SAFE) bill would prevent teens from being harmed due to "social contagion" or " rapid-onset gender dysphoria."
The bill, which the Ohio legislature cleared in December, would block physicians from starting new patients on puberty blockers. (It also bars surgeries as part of gender-affirming medical care, although hospital officials and physicians told lawmakers these are not done in Ohio.)
Among the groups opposing Click's bill were the Ohio chapter of the AAP, the Ohio State Medical Association and several hospitals and hospital groups as well as physicians speaking independently.
Gender-Affirming Care 'Buys Time' to Avoid Impulsive Decisions
Kate Krueck, MD, a pediatrician with a practice in the Columbus area, testified about her experience as the mother of a transgender child who once attempted suicide.
"It wasn't always easy to reconstruct my vision of a baby with a vagina into the adolescent before me with a new name and changed pronouns, but they were still the same incredible person," Krueck said.
She urged lawmakers to understand how puberty blockers can "buy time" for teens to cope with a body at odds with their vision of themselves, noting that many of the effects of these medications are largely reversible. The side effects that are not reversible, such as facial hair growth and the growth of Adam's Apple, are certainly outweighed by the risks of withholding treatment, she said.
Bad Patient Experience Drives Detractor Activist
Arguing against that point was Chloe Cole, a detransitioner activist who had returned to a female identity. At the Ohio legislative hearings, Cole spoke of her experience in California as a teen treated for gender dysphoria.
"I was fast-tracked by medical butchers starting at 13 when I was given cross sex hormones, and they took my breasts away from me at 15 years old," she said.
Cole appears frequently to testify in favor of bans on gender-affirming medical care. In 2022, she told the Ohio lawmakers about her experience of attending a class with about a dozen other young people in the midst of female-to-male transitions. She now sees that class as having inadvertently helped reinforce her decision to have her breasts removed.
"Despite all these consultations and classes, I don't feel like I understood all the ramifications that came with any of the medical decisions I was making," Cole said. "I didn't realize how traumatic the recovery would be, and it wasn't until I was almost a year post-op that I realized I may want to breastfeed my future children; I will never be able to do that."
Cole also spoke in July before the US House subcommittee on the Constitution and Limited Government.
"I look in the mirror sometimes, and I feel like a monster," Cole said at the House hearing, which was titled " The Dangers and Due Process Violations of 'Gender-Affirming Care'."
During the hearing, Shannon Minter, legal director of the National Center for Lesbian Rights (NCLR), who also made a gender transition, thanked Cole but noted that her case is an exception.
A 2022 Lancet Child and Adolescent Health article reported that 704 (98%) people in the Netherlands who had started gender-affirming medical treatment in adolescence continued to use gender-affirming hormones at follow-up. Minter credits this high rate of continuation to clinicians taking their duties to adolescents seriously.
State legislatures and medical boards oversee the regulation of medical practice in the US. But a few Republicans in both chambers of the US Congress have shown an interest in enacting a federal ban restricting physicians' ability to provide gender-affirming medical care.
They include Rep. Mike Johnson of Louisiana, who in October 2023 became Speaker of the House. He chaired the July hearing at which Cole spoke. He's also a sponsor of a House bill introduced by Rep. Marjorie Taylor Greene (R-GA).
This measure, which has the support of 45 House Republicans, would make it a felony to perform any gender-affirming care on a minor, and it permits a minor on whom such care is performed to bring a civil action against each individual who provided the care. Sen. JD Vance (R-OH) introduced the companion Senate measure.
Reality of Gender-Affirming Care
The drive to pass laws like those in Ohio and Arkansas stem from a lack of knowledge about gender-affirming treatments, including a false idea that doctors prescribe medications at teens' requests, Montefiore's Collins-Ogle said.
"There's a misperception that young people will say 'I'm transgender' and that those of us who provide care are just giving them hormones or whatever they want. It's not true, and it doesn't happen that way," Collins-Ogle said.
At the Children's Hospital at Montefiore, Collins-Ogle said her work with patients wrestling with gender identity issues begins with questions.
"What's your understanding of dysphoria? Where's the incongruence between the gender you were assigned at birth and what you're feeling now? You have to be able to verbalize that" before the treatment proceeds, she said.
Sometimes teens leave after an initial conversation and then return later when they have a more clearly defined sense of what dysphoria means.
"There are other kids who clearly, clearly understand that the gender they were assigned at birth is not who they are," she said.
Children now wrestle with added concerns that their parents could be put at risk for trying to help them, she said.
"These kids go through so much. And we have these people in powerful positions telling them that they don't matter and telling them, 'We're going to cut off your access to healthcare, Medicaid; if your parents tried to seek out this care for you, we're going to put them in jail,'" she said.
"It's the biggest factor in fear mongering," she said.
Collins-Ogle said she wonders why legislators who lack medical training are trying to dictate how physicians can practice.
"I took a Hippocratic oath to do no harm. I have a medical board that I answer to," she said. "I don't understand how legislators can get away with legislating about something they know nothing about."