In a wave of anti-LGBTQ legislation, 19 U.S. states have so far banned at least some gender-affirming health care for minors — care that is evidence-based and backed by major medical and professional organizations. The state of Texas could soon add to that tally, as lawmakers last week passed a bill that Gov. Greg Abbott has promised to sign when it hits his desk.
State bans on gender-affirming care tend to share similar guidelines and language, prohibiting clinicians from prescribing hormones or puberty blockers to those under 18. The proposed Texas ban also includes a requirement that has been mentioned in every media coverage article: who is already taking gender-affirming drugs when the ban goes into effect “must wean off the prescription drug over a period of time and d ‘in a way that is safe and medically appropriate and that minimizes the risk of complications’.
But experts say it’s impossible to get trans children off drugs in a “safe and medically appropriate” way.
“There is no appropriate way to do this because it is a medically necessary treatment,” said Alex Keuroghlian, associate professor of psychiatry at Harvard Medical School and director of education and training programs. at the Fenway Institute, which focuses on LGBTQ health research and policy. “The premise is flawed.”
Five other states include a similar stipulation to “systematically reduce” gender-affirming care for patients who are already receiving it when the laws go into effect. But experts aren’t sure what that might look like in practice.
“In some ways, withdrawal doesn’t exist,” said Meredithe McNamara, a physician specializing in adolescent medicine and an assistant professor at Yale School of Medicine.
Puberty blockers, which delay the physical changes of puberty by telling the body not to make sex hormones, are generally not drugs that people gradually reduce their intake of. When a child takes them because they started puberty too soon, in what is called precocious puberty, they simply stop getting the medicine when it’s time for their body to start this process over again.
“These people have no idea what they’re legislating,” McNamara said. Last year, she and her colleagues who specialize in pediatrics and adolescent psychiatry co-authored a report on the biased science used in early anti-trans measures in Texas and Alabama.
Although the Texas ban recommends withdrawal as a method to avoid complications, there are no known complications from stopping gender-affirming drugs all at once. The most serious consequences, for adolescents’ mental health and well-being, will occur no matter how slowly they come off the drug.
Experts fear that as the bans go into effect, the United States will see a surge in mental health crises among trans youth. Young trans people are already much more likely to consider suicide than their cisgender peers. Gradually reducing the hormones young people take may delay or stagger these attacks, experts say, but it won’t address the fundamental impact of denial of care.
“You can hurt someone at any rate, but you still hurt them,” Keuroghlian said.
Clinicians trying to provide care under these prohibitions can still try to find a way to wean off the dosage of these drugs, with the goal of delaying unwanted physical changes for patients as long as possible while they try to arrange care in another state or via telehealth. But with no standard protocol on how to reduce dosage, it’s unclear if this tactic will work and how it will affect patients.
Some states have specific deadlines, months after a ban takes effect, by which time patients must have completely stopped taking the medication. Experts say these deadlines are arbitrary.
“It feels like they’re asking us to experiment on our patients, which is funny because that’s exactly what they’re accusing us of,” McNamara said.
Although there is no institutional research on how to slowly withdraw needed care, there may be community knowledge about how best to reduce drug dosage to reduce harm, especially among clinicians who work with non-binary patients who have “a more non-linear relationship with hormones,” said Diana Tordoff, postdoctoral researcher on the PRIDE study from Stanford University School of Medicine. “But again, the main difference is what is initiated by the patient and desired by the patient.”
There is no research yet on how these prohibitions affect trans youth or how clinicians can successfully wean care. And Tordoff isn’t necessarily interested in initiating that search herself.
“I’ve really stopped trying to do reactionary research where people who aren’t invested in the well-being of trans people inform the research questions I ask,” Tordoff said.
She believes it is important to document the experiences of trans youth under these bans to honor them. At the same time, Tordoff said, “no research will come out of this that will significantly advance our science or add to what we already know about the benefits of being able to access gender-affirming care or the disadvantages of not to be able to access them.” His own research has already found that delays in accessing this care lead to poor mental health outcomes, including depression and suicidal thoughts.
McNamara compares the bans, many of which will come into effect this summer and later this year, to a tsunami that can be seen from afar rushing towards the shore – with one key difference.
“Tsunamis can’t be stopped,” she said, “but they are.”
If you or someone you know is considering suicide, contact the 988 Suicide & Crisis Lifeline: call or text 988 or chat with 988lifeline.org. For TTY users: Use your preferred relay service or dial 711 then 988.
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