Middleboro Review 2: POLITICO NIGHTLY: The transgender care that states are banning, explained

Friday, March 25, 2022

POLITICO NIGHTLY: The transgender care that states are banning, explained

Presented by

LGBTQ activists and their supporters rally in support of transgender people on the steps of New York City Hall. | Drew Angerer/Getty Images

TRANS KIDS AND MEDICAL CARE — The makers of puberty-blocking drugs, which are used in transition-related medical care for minors, are now under investigation by Texas Attorney General Ken Paxton, part of a larger, national fight against such care for minors.

More than a dozen states are considering proposals that would penalize health care providers who provide what’s known as gender-affirming care to children and teenagers. Top Republican leaders in Texas, including Paxton, have said this type of care — which can refer to everything from counseling to surgery — amounts to “child abuse,” even as major medical organizations endorse it. Arkansas is fighting in federal court to preserve its ban on such treatments. “We cannot allow minors or their parents to make life-altering decisions,” Jonathan Covey, director of policy for the advocacy group Texas Values, told The New York Times.

But what is gender-affirming care, and why do some children receive it? Nightly reached out to three transgender health experts to talk through some of the biggest questions around it: Jason Rafferty, who helped write gender-affirming care guidelines for the American Academy of Pediatrics and practices at the Gender and Sexuality Program at Rhode Island’s Hasbro Children’s Hospital; Laura Taylor, medical director of the Keck Medicine of USC Gender-Affirming Care Program; and Stephen Rosenthal, medical director of the University of California, San Francisco’s Child and Adolescent Gender Center. All oppose recent state efforts to criminalize gender-affirming care. Rosenthal co-wrote an op-ed article in the San Francisco Chronicle that condemned the bills that are passing in statehouses across the country.

How many children receive gender-affirming care?

The number of minors who would be affected by these laws is unclear. In 2017, the Williams Institute at the UCLA School of Law put the number of transgender teens between 13 and 17 at 150,000 or .7 percent of kids in that age range. That same year the CDC estimated that 1.8 percent of high school students identify as transgender. Not all of those teens receive gender-affirming care.

Rafferty said he has a “stack of papers” on his desk from peer-reviewed studies that show the benefits of gender-affirming care, including lower rates of depression and suicidal thoughts. Kids who received puberty blockers and hormone therapy had 60 percent lower odds of moderate or severe depression and 73 percent lower odds of suicidality, according a study of 104 transgender youth published in February by a journal of the American Medical Association.

What exactly are states banning?

Most states targeting gender-affirming care are prohibiting medical interventions, including surgery, for transgender youth. Medical treatment can include puberty blockers and hormone therapy. Banned surgeries include chest masculinization, as well as procedures that leave patients sterilized, even though clinicians don’t perform sterilizing procedures on people under the age of 18.

Clinicians are worried that antipathy towards transgender medicine will migrate to mental health care, which is a key part of treatment. In Texas, health providers who have halted medical treatments still provide counseling, but at least one family sought emergency mental health care for their transgender teen in Oklahoma instead of Texas for fear of being reported to state authorities.

Is this experimental medicine?

Rafferty said it’s a quickly evolving field, but said that doctors have more than a decade of peer-reviewed research to guide their patient treatment. Puberty blockers, for example, have been used for decades to pause the process in very young kids. The FDA hasn’t approved puberty blockers for gender-affirming care, but such off-label use is not unusual or illegal.

The American Medical Association calls gender-affirming care “medically necessary” and “evidence-based.”The American Academy of Pediatrics, the World Professional Association for Transgender Health and other medical associations have published detailed guidelines for physicians and care teams.

How young are these patients?

“Kids as young as 3 or 4 can understand their gender,” Taylor said. “Kids that young wouldn’t be labeled as transgender, but they can often tell us if they identify as a boy or a girl.”

Before a child hits puberty, gender-affirming care is non-medical and non-surgical. It includes counseling and support with a social transition — when a child changes their hairstyle or clothes or pronouns to more closely match the gender they identify with.

Clinicians who treat transgender children wait until the start of puberty, which can begin as early as 8 or 9, before considering puberty blockers. Rafferty says most of his patients on puberty blockers are between the ages of 10 and 12. Clinical guidelines recommend starting hormone therapy only on patients who are 16 and older, but Rosenthal said his clinic might start placing 14-year-olds on estrogen or testosterone depending on their individual situation.

Surgery to enlarge or decrease breast size or to change facial features might occur before a person is 18, but surgeries involving reproductive organs are not carried out on people under the age of 18, according to these doctors and guidelines on gender-affirming care.

Welcome to POLITICO Nightly. Keep reading for more questions and answers on gender-affirming care for minors. Reach out with news, tips and ideas at nightly@politico.com. Or contact tonight’s author at rrayasam@politico.com, or on Twitter at @RenuRayasam.

A message from Altria:

Moving beyond smoking. Altria’s companies are leading the way in moving adult smokers away from cigarettes – by taking action to transition millions toward less harmful choices. We are investing in a diverse mix of businesses to broaden options beyond traditional, combustible cigarettes. See how we’re moving.

Where do parents fit into the guidelines for gender-affirming care?

In all states, minors who seek transgender treatment need parental consent. “I’ve had lots of patients who make an appointment the week of their 18th birthday because they are sitting at home, identify as trans and have dysphoria,” or the discomfort or distress some transgender people experience when their bodies don’t align with their gender, Taylor said. “Even though legally they could have seen a pediatric provider, it requires parental consent.”

The AAP guidelines stress the importance of parental involvement in care decisions, and also stress the importance of family-based counseling.

Is gender-affirming care reversible?

It depends. Puberty-blocking medications are used temporarily, and they help young people and their families figure out next steps, these doctors said. They prevent adolescents from developing gender characteristics that might be hard to later reverse, like full breast development. But they also give people time to decide whether to pursue interventions like hormone therapy. Puberty blockers come with side effects — potentially an impact on future fertility and a loss of boss density, but recent studies have shown those effects can be reversed, Rosenthal said.

Hormone therapy is partially or non-reversible depending on the stage of treatment.

Surgeries are not reversible.

Taylor said it’s important not to think of medical interventions on a continuum that ends in gender transition — some people might want to remove their breasts but not take hormones. She had one adult patient who wanted a more masculine chest, but sang in a choir and didn’t want a changed voice. Other patients identify as nonbinary, with genders other than man and woman.

“There is no finish line where people have done X, Y and Z therefore they have transitioned,” she said.

Do children ever change their minds or stop receiving this care?

A small minority of patients stop hormone therapy, Rafferty said. “That is OK,” he said. “Gender affirmation is about going through a process to figure out the end point.”

“What I tell all parents, is that you really need to focus on the here and now,” Rafferty said. “Today your child is coming in and trying to have an open and honest conversation about who they are. If a child rethinks that, they have to be able to navigate that with parents in a medical setting with trusted providers.”

WHAT'D I MISS?

— U.S., EU to seek new natural gas supplies to displace Russia: President Joe Biden and European Commission President Ursula von der Leyen pledged to ramp up liquefied natural gas shipments to Europe to help the continent wean itself off of Russian energy, but it wasn’t immediately clear where they would get the extra fuel supplies. The United States will work with international partners to supply an additional 15 billion cubic meters of LNG to Europe this year, and Europe is also committing to receive 50 bcm of LNG from the United States.

A woman and her dog behind the smashed windscreen of her car after arriving at an evacuation point in a large convoy of cars and buses carrying hundreds of people evacuated from Mariupol and Melitopol in Zaporizhzhia, Ukraine. | Chris McGrath/Getty Images

— Russia’s Kyiv offensive stalls, as Ukrainians counterattack in the south: Russian forces are shifting their focus away from the Ukrainian capital of Kyiv as they prepare to undertake a renewed effort to consolidate control on Donbas in the east, Russian and U.S. officials said today. For weeks, Western analysts and government officials have said they expect Russian forces to adjust their tactics and strategy in the face of fierce Ukrainian resistance around the capital, but today’s admission by a top Russian official that the Kremlin was scaling back its war aims marks a significant moment in the month-long conflict.

— McCarthy nudges convicted Rep. Fortenberry to resign: House Minority Leader Kevin McCarthy suggested today that Rep. Jeff Fortenberry should resign from Congress, hours after the Nebraska Republican was convicted of lying to the FBI over illegal campaign contributions . “I think when someone’s convicted, it’s time to resign, ” McCarthy told reporters at a press conference on the final day of the House GOP retreat. Minutes after McCarthy’s remarks, Speaker Nancy Pelosi issued a more declarative statement on the matter, calling on Fortenberry to immediately resign.

SUBSCRIBE TO NATIONAL SECURITY DAILY : Keep up with the latest critical developments from Ukraine and across Europe in our daily newsletter, National Security Daily. The Russian invasion of Ukraine could disrupt the established world order and result in a refugee crisis, increased cyberattacks, rising energy costs and additional disruption to global supply chains. Go inside the top national security and foreign-policymaking shops for insight on the global threats faced by the U.S. and its allies and what actions world leaders are taking to address them. Subscribe today.

— Maryland court strikes down congressional map as illegal Democratic gerrymander: A state court in Maryland has struck down the Democratic-drawn congressional map as an illegal partisan gerrymander , ordering the state legislature to redraw the lines for the 2022 election. The new districts — which were drawn by the Democratic-dominated legislature and passed over the veto of Republican Gov. Larry Hogan — could result in an 8-0 sweep for Democrats in the state in blue-leaning years. Seven districts in the state are solidly Democratic, while the lone Republican-held district in Maryland, the Eastern Shore seat currently occupied by GOP Rep. Andy Harris, was converted from a Republican vote sink into a hypercompetitive district. Biden carried the new version by less than a percentage point in 2020.

— Supreme Court Justice Clarence Thomas released from hospital: Thomas, 73, was hospitalized last Friday night with “flu-like symptoms,” according to an announcement that the court released on Sunday evening. That statement said Thomas was expected to be released “in a day or two,” but he wound up spending almost a full week under inpatient care . The Sunday statement said Thomas was being treated with “intravenous antibiotics” and that his symptoms were “abating,” but this morning’s one-sentence statement provided no further details on his illness. A court spokesperson did say earlier that Thomas’ hospitalization was not related to Covid-19.

A message from Altria:

NIGHTLY NUMBER

46 percent

The percentage of parents who believe masking in schools has hurt their children’s social learning and interactions, according to the new POLITICO-Harvard T.H. Chan School of Public Health poll. About 4 in 10 think it has hurt their general schooling experience (40 percent) and mental and emotional health (39 percent), and about one-third believe it has hurt their education (33 percent).

DON’T MISS POLITICO’S INAUGURAL HEALTH CARE SUMMIT ON 3/31: Join POLITICO for a discussion with health care providers, policymakers, federal regulators, patient representatives, and industry leaders to better understand the latest policy and industry solutions in place as we enter year three of the pandemic. Panelists will discuss the latest proposals to overcome long-standing health care challenges in the U.S., such as expanding access to care, affordability, and prescription drug prices. REGISTER HERE.

PARTING WORDS

President Joe Biden delivers remarks during the annual U.S.-ASEAN Summit via video link from the South Court Auditorium in the Eisenhower Executive Office Building in Washington. | Chip Somodevilla/Getty Images

MEET, GREET, DELETE — The White House has indefinitely postponed a special summit with leaders from across Southeast Asia that was initially scheduled for next week, according to four sources familiar with the schedule change, Steven Overly and Nahal Toosi write.

The gathering with the 10 countries that make up the Association of Southeast Asian Nations was set to take place on Monday and Tuesday at the White House, and it was meant to “demonstrate the United States’ enduring commitment” to a region that is critical to its commercial and security interests in Asia, the White House said in late February.

Today, a spokesperson for the National Security Council said in a statement to POLITICO that, “The President looks forward to welcoming the ASEAN leaders to Washington, DC for a U.S.-ASEAN Special Summit. To ensure invited ASEAN leaders can all participate, we are working closely with ASEAN partners to identify appropriate dates for this meeting.”

Biden will instead meet on Tuesday with Singapore’s prime minister, Lee Hsien Loong, to discuss both U.S. interests in the Indo-Pacific region, such as supply chains and maritime security, as well as the bloody conflict in Ukraine.

A message from Altria:

Moving beyond smoking. Altria’s companies are leading the way in moving adult smokers away from cigarettes. Today, we are taking action to transition millions toward less harmful choices.

From cigarettes to innovative alternatives. By investing in a diverse mix of businesses, Altria is working to further broaden options. Our companies are encouraging adult smokers to transition to a range of choices that go beyond traditional, combustible cigarettes.

From tobacco company to tobacco harm reduction company. And while Altria is moving forward to reduce harm, we are not moving alone. We are working closely with FDA and other regulatory bodies, and will work strictly under their framework.

See how we’re moving.