The Supreme Court heard arguments challenging Tennessee’s ban on gender-affirming medical care for minors Wednesday. The court’s conservative majority appeared ready to uphold the ban, which says gender-affirming care is “harmful to minors.” That is just one of many falsehoods medical doctors and transgender people say the law contains.
According to a 2020 study, 86% of transgender adolescents reported that they were suicidal, and over half had attempted suicide. Transgender youth are also at high risk of depression and anxiety. Research indicates that gender-affirming treatment reduces these risks.
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Tennessee’s ban, passed in March 2023, seems to ignore this research. Instead, it codifies misinformation about transgender health care into state law.
Most people don’t understand gender-affirming care, said Dr. Susan Lacy, a Memphis gynecologist and one of the plaintiffs in the lawsuit against the state. “People sort of think that somebody wakes up one morning, has a fleeting thought about their gender identity, comes in, gets put on medicine and has surgery. That’s just not what happens.”
For over 20 years, Lacy, who calls herself “the hormone guru,” has given patients testosterone, estrogen and progesterone to mitigate the symptoms of endocrine disorders and menopause.
In 2016, Lacy started using these same hormone treatments for gender-affirming care. By her estimation, she currently sees more transgender patients than any other doctor in Memphis.
While nearly all of Lacy’s patients have been adults, she has also treated a handful of 16- and 17-year-old transgender patients. Despite common misconceptions about gender-affirming care for minors, “we always required parental consent,” she said. “We always required a psychological evaluation as a baseline. We always had a very involved conversation about risk and benefits before starting hormonal management.”
Lacy says Tennessee’s ban on gender-affirming care for minors parrots some of the most pervasive misinformation about the topic. MLK50 looked into the claims the law makes about gender-affirming care, and found that many were misleading or false.
Among other things, the ban implies that gender-affirming care for minors regularly includes surgeries. It does not. It also asserts that “many people” regret receiving gender-affirming medical care — in reality, the overwhelming majority do not.
The language of the ban states, repeatedly, that the gender-affirming care trans children receive is harmful to them and that the ban will “protect the health and welfare” of minors. But Lacy and her patients disagree.
Since Tennessee’s ban has gone into effect, she has been forced to stop treating transgender adolescents. “It’s emotionally difficult for [my teenage patients] to process why something that’s working so well for them is being taken away,” Lacy said. “Even though parents are giving consent, even though we’re seeing excellent results, we’re going to have to withdraw this medication. That’s traumatizing.”
Why do some kids need gender-affirming care?
Most transgender children experience “gender dysphoria,” which the Diagnostic and Statistical Manual of Mental Disorders defines as “marked incongruence between one’s experienced/expressed gender and their assigned gender.”
Helpful terms
- Gender dysphoria: psychological distress, including depression, anxiety, and suicidal ideation, that results from a “marked incongruence between one’s experienced/expressed gender and their assigned gender.”
- Gender-affirming care: Refers to a range of interventions, including those that are social, psychological, or medical in nature, “designed to support and affirm an individual’s gender identity.”
- Gender-affirming medical care: medical interventions, including hormone therapy and surgery, used in gender-affirming care. Gender-affirming medical care varies depending on a patient’s age.
- Puberty blockers: Also known as gonadotropin-releasing hormone analogues, puberty blockers prevent one from producing sex hormones like testosterone and estrogen.
- Hormone replacement therapy: Patients receive sex hormones, such as testosterone and estrogen, so that they develop secondary sex characteristics consistent with their gender identity.
- Conversion therapy: “Programs that claim to change a person’s sexual orientation, gender identity, or gender expression.”
Gender dysphoria is a recognized medical condition. When left untreated, it can cause “depression, anxiety, and an increased risk of suicidality,” said Dr. Marci Bowers, former president of the World Professional Association for Transgender Health, which publishes and standardizes guidelines for the treatment of transgender patients.
Research shows that teenagers are at high risk of these symptoms; most transgender teens have attempted suicide. “The effective treatment of gender dysphoria saves lives,” the American Academy of Pediatrics said in a court brief filed in support of the plaintiffs.
Gender-affirming care is the only research-backed treatment for gender dysphoria. It can encompass non-medical interventions like counseling, changing one’s haircut and voice therapy. For minors, gender-affirming medical care — hormone treatments like puberty blockers and hormone replacement therapy — is only administered to adolescents or children who have started puberty, Bowers said.
Currently, several major medical organizations — including the American Psychiatric Association, the American Academy of Pediatrics, the American Medical Association, and the Endocrine Society — endorse age-appropriate, gender-affirming medical care for minors.
This reality is not reflected in Tennessee’s ban, which falsely states that gender-affirming care “is not consistent with professional medical standards.”
It also asserts gender dysphoria “can be resolved by less invasive approaches.” While those approaches are left unspecified, “the alternative treatments to gender-affirming care that the state suggests often resemble conversion therapy, which is widely discredited,” Bowers said. “Conversion therapy,” which attempts to change someone’s sexual orientation or gender identity, is currently illegal in much of the United States.
Similarly, the ban claims that “many individuals have expressed regret” after receiving gender-affirming care as children. The regret rate for gender-affirming care is extremely low — “lower than for knee replacements or breast augmentation,” Bowers said.
What does gender-affirming care look like for teens?
For adolescents, gender-affirming medical care typically includes puberty blockers or hormone therapy — not surgery, Bowers said. She added that these treatments are not administered to children before puberty.
The first step in this process is “always a psychosocial assessment conducted by a mental health professional skilled in pediatrics,” said Bowers. “This evaluation looks at the child’s living situation, family dynamics, school environment and overall well-being.”
According to the Cleveland Clinic, puberty blockers were originally developed to treat “precocious puberty,” or puberty that begins at an abnormally early age. They are administered to children during puberty and temporarily stop puberty from progressing. Puberty resumes when treatment ends. They have been prescribed to children since the 1980s. In gender-affirming care, puberty blockers are used to prevent the development of permanent secondary sex characteristics.
Children typically use puberty blockers for a year or two, said Bowers. If they continue to experience gender dysphoria after this point, they might begin hormone therapy. Generally, hormone replacement therapy is only administered to older teens. When used in gender-affirming care, hormone therapy allows patients to develop secondary sex characteristics in line with their gender identity.
Legislators sometimes imply that puberty blockers and hormone therapy create permanent changes; Sen.Jack Johnson, who introduced the ban in the state Senate, wrote in a 2023-op-ed that hormone treatments were “irreversible.” This is misleading. The effects of puberty blockers are fully reversible. Most effects of hormone therapy are also reversible.
“Puberty blockers are really like a pause button,” said Regina Lambert Hillman, a professor at The University of Memphis’ Law School specializing in LGBTQ+ law and individual rights. They give adolescents time to think about long-term treatment options, she said. Children who take puberty blockers are “not making a permanent decision.”
Gender-affirming medical care for teens almost never includes surgery. The World Professional Association for Transgender Health does not recommend gender-affirming genital surgeries for minors.
Is gender-affirming care experimental?
Tennessee’s ban makes several misleading claims about the risks associated with gender-affirming medical care, including that gender-affirming medical care can leave children “irreversibly sterile” and at risk of “disease and illness.” While this care does have side effects — like most medical treatments — they are generally treatable, Bowers said.
Both puberty blockers and hormone replacement therapy can reduce bone density and compromise fertility. However, bone density can be preserved with weight training and vitamin supplementation. Bowers added that there have also been “significant advances in fertility preservation.” Doctors discuss these risks with teens and their parents before treatment begins.
The ban claims that there isn’t sufficient research on the long-term impacts of gender-affirming medical care, which it calls “experimental.”
In reality, the long-term health impacts of these treatments are known because both puberty blockers and hormone therapy have been used for a variety of medical conditions for decades. “The state doesn’t have a problem with those medical uses,” said Hillman. “They only have a problem with those medical uses if they’re used for transgender children.”
There is also substantial evidence that shows gender-affirming care is effective at treating gender dysphoria in adults, said Bowers. “While evidence for adolescents is more limited due to the relatively recent use of puberty blockers [for gender-affirming care], preliminary data are promising.”
Clinicians treat patients for conditions that require more research all the time, Lacy said. For example, oncologists continue to treat patients even as more research continues to be done on cancer. “We should always be doing ongoing research and gathering more information,” she said. “But just because more research can be gathered doesn’t mean that you can’t treat patients.”
As it stands, Tennessee’s ban prevents more research on gender-affirming care from being conducted. It’s also scaring adult patients, who worry that the ban for minors is a sign of things to come.
“I get calls like, ‘Can I get a year’s worth of medicine? What do I need to do? Do I need to move out of the state?’” Lacy said. “There’s a lot of fear and worry about what is coming down the pipe.”
Rebecca Cadenhead is the youth life and justice reporter for MLK50: Justice Through Journalism. She is also a corps member with Report for America, a national service program that places journalists in local newsrooms. Email her rebecca.cadenhead@mlk50.com.
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