https://www.chron.com/news/houston-texas/article/texas-gender-affirming-care-doctors-hospitals-18204182.php

Texas doctors fear a new era of government intrusion into medicine as lawmakers ban transition care for kids following prohibitions on abortion.

By William Melhado,The Texas TribuneJuly 17, 2023

People gather in front of the Texas Capitol during a protest against bills limiting transgender kids’ access to puberty blockers and hormone treatments in March.

Lauren Witte/The Texas Tribune

At least once a day Dr. Ximena Lopez sees a parent crying in her clinic. They’re crying because Lopez just told them they need to find a new way to get transition-related care for their children — by leaving Texas or sourcing treatments outside the state — because the state outlawed these treatments for trans youth.

After a yearslong barrage by activists and lawmakers, the state has won the battle against the use of transition-related care, like puberty blockers and hormone therapies, for transgender youth. While the war over this health care remains in question — and a legal fight to block the new law begins in Texas — clinics have closed and some doctors have stopped providing this care.

“The reason why I’m leaving Texas is that it’s unbearable for me,” Lopez said. “It’s so devastating that I just can’t bear living in a state where I feel oppressed and where I’m just seeing my patients suffer.”

Lopez formerly provided gender-affirming care to trans youth as the director of the GENder Education and Care, Interdisciplinary Support (GENECIS) program, which was jointly run by the Children’s Medical Center and the University of Texas Southwestern Medical Center in Dallas. By the end of July, she’ll no longer practice at the Dallas hospital and plans to move out of Texas.

In light of the state’s ban on gender-affirming care for kids, The Texas Tribune spoke with over half a dozen doctors who practice this type of medicine about the fear of losing their jobs, scaring away medical providers from working in Texas and — most importantly — revoking this critical health care for transgender children.

From state-launched investigations into the families of trans youth, to threats of actual violence, doctors are fearful to speak out against the attacks on transgender health care. Physicians raised concerns that the state is driving physicians away from Texas and inadequately training the next generation of medical professionals.

[In a political era of “parental rights,” Texans raising trans kids say new law strips them of choice]

Many said Texas was treading into a new era of medicine — marked by restrictions to gender-affirming care and reproductive health care — one in which the government tells doctors how and who they can treat.

Many doctors the Tribune spoke with declined to share their names for fear of harassment. Some likened the conversations with parents informing them that they can no longer provide this type of care to their children to cancer diagnoses or impending hospice care.

Medical providers say this type of care is lifesaving for transgender youth who face higher rates of suicide attempts and mental health problems than their cisgender peers. One in five trans and nonbinary young people attempted suicide in the past year, according to a 2023 survey conducted by The Trevor Project, a suicide prevention organization that focuses on LGBTQ+ youth.

Last month Gov. Greg Abbott signed legislation that restricts transgender youth from accessing puberty blockers and hormone therapy, two treatments used to address gender dysphoria, the medical term for the distress someone experiences when their gender identity doesn’t match their body.

“In Texas we must protect children from making permanent, life-altering decisions before they have the mental capacity to do so, and Senate Bill 14 does just that,” Andrew Mahaleris, a spokesperson for Abbott, said in a statement to the Tribune. Medical providers say puberty blockers are reversible and hormone therapy is partially reversible.

Mahaleris pointed to a recent survey from the Washington Post and the Kaiser Family Foundation that found a majority of the Americans surveyed oppose the use of puberty blockers and hormone therapy to treat transgender youth.

Senate Bill 14 was the forerunner in a broad swath of bills, aimed at reshaping the lives of LGBTQ+ Texans, that lawmakers pushed through this legislative session. Republican politicians also passed restrictions on drag shows and transgender athletes this session, but the implications of SB 14 are long reaching and profoundly affecting the lives of Texas families, said doctors who practice gender-affirming medicine. Families of trans youth have already fled Texas, but those who remain in the state must grapple with the consequences of losing health care access.

In recent months, many patients — including adults — have lost access to care as providers have left the state, a spokesperson for Texas Health Action, a nonprofit health care provider with clinics in Dallas, San Antonio and Austin, told the Tribune.

Dr. Anita Vasudevan, a primary care physician from Texas who chose to continue practicing in California instead of returning to her home state because of the ban on gender-affirming care and abortion, said the loss of Lopez and the GENECIS program highlights the issue of specialized providers leaving the state. This translates to missed learning opportunities for medical professionals in training, which will result in worse care for patients, she said.

“We’re building a generation of providers that just, unfortunately, won’t receive the level of training that they need in order to take care of patients in the ways that they need to be taken care of,” Vasudevan told the Tribune. “That’s a hard pill to swallow.”

An onslaught of interventions

For children already receiving puberty blockers and hormone therapy under the guidance of their medical team, SB 14 taking effect presents a daunting transition.

Lawmakers decided doctors must “wean” their patients under 18 of these treatments “in a manner that is safe and medically appropriate.”

But doctors who administer gender-affirming medical treatments say there is no such thing.

“This is comparable to asking a medical professional to wean a Type 1 diabetic off of their insulin — you would never do that,” Brett Cooper, an adolescent medicine physician from Dallas, said in a statement to the Tribune.

Cooper said SB 14 prohibits medical professionals from providing evidence-based, best-practice care to their patients. Including evidence that supports the use of these treatments and the recommendations of major medical groups like the American Medical Association.

He added that, like the state’s ban on abortions, this legislation will make it more difficult to recruit medical professionals to do business in Texas.

“There has been a chilling effect of the Legislature getting involved in the doctor-patient relationship and attempting to prevent physicians from providing the evidence-based and medically necessary care to their patients,” Cooper said. “Physicians know best how to care for their patients, not the Legislature.”

Texas Republicans’ effort to regulate the lives of transgender youth started long before Abbott signed SB 14 in June. Six years ago, the Legislature unsuccessfully tried to pass a bill requiring transgender people to use restrooms in public schools and governmental buildings that aligned with their sex assigned at birth.

In the years since, Republicans in the state have mounted a multipronged attack on gender-affirming care, in part, because issues like restrictions to medical care for LGBTQ+ people and drag shows had strong support from Republican voters.

In 2021, after the Legislature failed to restrict gender-affirming care, activists turned their attention to Lopez’s GENECIS program, targeting hospital board members and accusing the program of committing child abuse. Shortly after Children’s Health quietly closed the clinic, which was jointly run by UT Southwestern, Lopez was prompted to sue the hospital for shutting down operations to new patients.

The following year, Abbott directed the state’s Department of Family and Protective Services to investigate parents providing this type of care to their trans children for child abuse, terrifying families that they might be separated from one another.

More recently, suspended Attorney General Ken Paxton launched investigations against both Texas Children’s Hospital in Houston and Dell Children’s Medical Center of Central Texas for providing this type of care — even before SB 14 became law. Doctors working at Dell Children’s parted ways with the hospital after Paxton’s announcement, which left patients and their families scrambling to find specialty care, some of the needed treatments were unrelated to the gender-affirming treatments the state targeted.

Other states that have passed laws forbidding trans youth from taking puberty blockers and hormone therapy have encountered legal challenges. In Arkansas, a similar restriction to gender-affirming care was struck down as unconstitutional on the basis that it violated the due process and equal protection rights of transgender children and families. Legal groups in Texas have already committed to challenging SB 14.

Despite the rebukes of these laws in the courts across the country, the quiet closures of clinics and doctor departures in Texas have left medical professionals feeling alone in the fight for their patients’ best interests. Evidence shows access to gender-affirming care for young people improves the mental health of trans minors. Doctors said hospitals facilitating this type of health care are aware of its benefits, but are fearful of pushback from politicians.

“Many hospitals in these states, like Texas, I think are against these politicians and extremists and legislators, [but] they’re afraid of financial risks, they’re afraid of retaliation and they’re taking the easy way out which is to abandon their doctors and their patients and just subdue to this political pressure,” Lopez said.

Her employer, UT Southwestern, did not return requests for comment for this story.

While large hospital systems are not the only providers who treat trans youth, advocates say it’s evident that a chilling effect has reached physicians who prescribe gender-affirming care across the state.

In San Antonio, a city of nearly 1.5 million, only one doctor was administering gender-affirming care to trans youth in recent years, said Andrea Segovia, senior field and policy adviser for the Transgender Education Network of Texas. But after Abbott leveraged DFPS to investigate Texas families, the provider stopped providing these treatments, Segovia said.

She’s watched the number of providers who care for trans patients shrink. She said parents of trans youth are struggling to find pediatricians for their trans kids even for non-gender affirming care purposes, like routine vaccinations and physicals.

“People are being treated like they have a scarlet letter,” Segovia said.

De facto elimination of care

Prior to his graduation from UT Southwestern Medical School this spring, Antonio García was deliberating where to pursue his residency training in family medicine.

He could stay in Texas, where he grew up and his family lives, by leveraging his existing geographic connections to ”match” into a residency — a competitive process in which medical students are placed at specialized programs in hospitals or clinics for further medical training after graduating.

During medical school, García worked with providers in the GENECIS program, including Lopez, where he saw the positive impact the clinic had on patients and their families. He wanted to continue doing that important work, by providing gender-affirming care to trans people.

To do that García has decided to leave Texas.

“I also saw that as an opportunity to leave all of this behind and go somewhere where I knew that I was going to be able to get gender-affirming-care training, where I was going to be able to live my life openly, freely and not have to have all of these kind of concerns,” García told the Tribune. As a gay man, García said the state’s increasing hostility to the LGBTQ+ community prompted his decision to leave Texas.

[Twenty years after a breakthrough Texas case launched a new era of gay rights, trans people are still in the fight]

Seeing the backlash against individual providers and clinics has been devastating, García said. Noting Lopez’s departure, he said the animosity toward medical professionals and trans people is driving doctors away.

“[The doctors are] doing the right thing for these families, for these kids, and seeing that work be stifled and impeded has been just really unfortunate,” he said.

One area of particular concern, doctors said, is the worsening of an existing pediatric specialists shortage. In Texas, an estimated 17.4% of children have special health care needs that require attention from specialized pediatricians, according to the American Academy of Pediatrics. These shortages mean patients have to travel longer distances and wait for weeks or months to see subspecialists, which can result in delaying or forgoing treatment.

Lauren Wilson, a pediatric hospitalist and the president of the AAP Montana chapter, partially attributes this shortage of doctors for children to the disparity in pay between adult and pediatric specialists. According to a 2023 compensation report from the healthcare-related companies Doximity and Curative, endocrinologists make nearly $60,000 more annually than their pediatric specialist peers, who undergo commensurate levels of training.

Shortages in this speciality — pediatric endocrinology — is of particular concern to Wilson because these doctors treat a wide range of children. This area of medicine deals with hormones and associated issues and mostly treats children with diabetes or growth problems. But these physicians also often specialize in gender-affirming care treatments like puberty blockers and hormone therapies for trans children (less specialized physicians can also administer gender-affirming care.)

Wilson said these laws targeting pediatric health care — which could criminalize medical practices not even related to gender-affirming care — are unprecedented. In April, Montana became one of 20 states to ban trans youth from accessing gender-affirming care. It’s also the state that barred a transgender lawmaker from the Montana House floor for violating “decorum” rules after she told colleagues that voted in favor of restricting gender-affirming care would have blood on their hands.

Wilson also noted the de facto elimination of care by targeting clinics, by state leaders and extremists, has forced hospitals to stop this care.

“We’re in a position as physicians where we want to do what’s best for our patients, we want to follow all relevant guidelines. But we also want to not go to jail or lose our license to practice medicine,” Wilson said.

The Tribune asked Abbott’s office about the prospect of Texas losing medical providers because of the new law.

“Passed by a bipartisan majority in the Texas Legislature, SB 14 ensures access to appropriate and medically necessary services, with parental or legal guardian’s consent. Endocrinology treatments and procedures that are not intended to change the biological sex of a minor are unaffected by this law,” Mahaleris, Abbott’s spokesperson, said.

It’s not clear how many doctors have left or will leave Texas in response to restrictions on gender-affirming treatments, but states that have enacted other health care restrictions offer some clues.

States with abortion bans saw a 10.5% decrease in applications for obstetrics and gynecology residencies in 2023 compared to the previous year, according to data from the Association of American Medical Colleges.

Doctors, including Lopez, said they have already seen the effects with candidates deciding after the interview process not to accept positions in Texas “because of the politics.”

“Living in a medical dictatorship”

Treating gender dysphoria in Texas is not new. In 1965, the UT Medical Branch opened a gender clinic, providing treatment for hundreds of transgender people in the decades that followed.

Most major hospitals in Texas have been providing this type of care for over a decade. It only became widely controversial after lawmakers sought to criminalize doctors for providing this care, Lopez said.

Doctors lamented the spread of misinformation by lawmakers advocating against gender-affirming care during the most recent legislative session. Experts say this has further contributed to distrust between the public and the medical community, which worsened during the COVID-19 pandemic because of vaccine misinformation.

Hospitals across the country, including Children’s National Hospital in Washington, D.C. and Boston Children’s Hospital, have received bomb threats and violent messages after far-right harassment campaigns falsely accused the hospitals of performing genital surgery on minors.

Doctors say while transition-related surgeries are rarely performed on people under the age of 18, these procedures were also banned by SB 14. Conservative activists have incorrectly cast gender-affirming care as irreversible “genital mutilation” in an effort to restrict access to these treatments.

Several doctors declined to share their names publicly, citing a fear that false allegations would be directed at them. Doctors suspect threats of violence and harassment are why some Texas hospitals targeted by far-right activists chose to quietly stop providing these medical treatments, instead of standing with patients and doctors.

“No one feels particularly safe,” said one doctor who spoke with the Tribune on the condition that their name would not be published.

Lawmakers who oppose this type of care feel emboldened, Lopez said.

“It’s just also, again, a dangerous precedent because if politicians can tell hospitals what to do, then they can do that for so many things,” she said. “And then where is the patient’s autonomy? Where’s the voice of science and medicine at that point?”

Doctors pointed to an example of a trial court in 2021 that ordered doctors to administer the drug ivermectin, commonly used to treat parasitic worms in horses, after a patient’s relative sued the Fort Worth hospital to compel physicians to administer it. The treatment gained notoriety as a false cure for COVID-19 in right-wing circles, including from then President Donald Trump. The 2nd Court of Appeals reversed the lower court’s decision, but the attempt to supersede the doctor’s expertise was clear.

Doctors worry that the latest health care restriction for trans youth is a dangerous precedent with an uncertain future. While much of the attention around gender-affirming care was aimed at children, bills limiting this type of care for adults have also gained traction in the Texas Legislature.

“I can compare this with living in a medical dictatorship, in which you are told what treatment you can and can’t do,” Lopez said. “But it’s not based on reason. It’s based on whatever the person in power is saying is best.”