State bills seek to place limits on transgender care, ‘punish’ physicians

Pediatricians in some states are facing battles in their ability to care for transgender and gender-diverse (TGD) patients, as legislators propose bills that aim to limit treatment — often based on misinformation — and would even punish physicians who deliver care.

A recent bill in South Dakota would have criminalized medical providers who prescribe puberty blockers, hormone treatment or gender-confirmation surgeries on minors. Pediatricians could have been fined up to $2,000 and jailed for one year for providing such care to youths under age 16 years. The bill passed in the House but was defeated in the Senate on Feb. 11.

That outcome is providing encouragement to those opposed to similar bills under consideration in at least 13 states. While language in the bills varies, all seek to make forms of transgender care illegal.

South Dakota Chapter speaks out

AAP South Dakota Chapter President Michelle Schimelpfenig, D.O., M.P.H., FAAP, and chapter officers marshalled more than 20 pediatricians and pediatric residents to advocate against their state’s current bill on transgender issues. Coincidentally, the chapter planned its first advocacy day at the capital when the bill originally was presented to a House health committee.

Dr. Schimelpfenig testified against the bill — her first such experience — along with Alaa Al Nofal, M.D., a pediatric endocrinologist from Sioux Falls, S.D.

The bill’s defeat is a significant victory both in the state as well as for AAP efforts across the country. The experience also convinced Dr. Schimelpfenig of the importance of pediatrician involvement in legislation.

“I don’t think you go into pediatrics thinking that ‘someday I’m going to testify at our state capital,’” she said. “But I truly feel it’s part of the job when we care for children and want to advocate for children.”

A major reason Dr. Schimelpfenig opposed the bill was because she said it “criminalized” medicine, with physicians facing fines and jail time if they defied the law.

“… Physicians want to take care of their patients. They don’t want the government in their clinic or hospital telling them what they can and can’t do,” she said.

In the end, Dr. Schimelpfenig found the most impactful testimony came from families and children who are living with transgender issues.

Advocates decry misused terms

Gender care terms sometimes are misused, and support for legislation is built around misunderstandings, said Jason Rafferty, M.D., M.P.H., Ed.M., FAAP, lead author of the AAP policy statement Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents, http://bit.ly/2HeJbxv. Examples include the terms gender affirmation — or gender-affirmed care — and the “watch and wait” approach.

Gender affirmation is about supporting families and creating a safe space for children to explore who they are, Dr. Rafferty noted. “It’s not blindly following what a child wants.” There is an assumption that treatment progresses right to medical interventions early on, even before they might be indicated. In reality, gender affirmation can be very different for different people.

“There is a lot of focus on that one decision of whether to start hormone treatment, but affirmative gender care is more about supporting the family than any one decision — it’s the whole process,” said Dr. Rafferty, who also is a psychiatrist.

In addition, there is no expectation or goal that a child will end up transgender or identify as transgender. The goal of affirmative care, he said, is that children feel affirmed and secure in their own identity, whatever that identity may be.

Another misconception involves the watch and wait approach — not intervening because the issue “might go away.”

“I think it comes down to what ‘wait’ means,” Dr. Rafferty said. “For some approaches, waiting means waiting to see if, without any support, the child becomes dysphoric enough that it proves they’re transgender. That is not part of the affirmative care model because it brings a lot of stress, discomfort and dysphoria to the child.”

The approach deprives the family of support and education.

AAP policy reflects standard  

The Academy opposes stigmatization and marginalization of transgender youths, who have higher rates of depression, anxiety, substance use, self-harm and suicidality, and frequently face harassment and victimization.

The 2018 policy recommends that youths who identify as TGD have access to comprehensive, gender-affirming and developmentally appropriate health care. It asserts that variations in gender identity and expression are normal aspects of human diversity.

A lot of decision-making goes into gender care and supporting identity formation, Dr. Rafferty said. “You look at (these state) policies that are trying to regulate that process. It takes away from the value of the patient-family-provider connection that is so important to navigating individual care.”

The American Academy of Pediatrics stands by pediatricians who are delivering care to transgender youth, said AAP CEO/Executive Vice President Mark Del Monte, J.D.

“We share their alarm at legislative efforts aimed at undermining their expertise and compromising care for this vulnerable population of patients,” Del Monte said. “Our policy is clear, our chapters are engaged and our pediatrician members are leading the way. We will continue to support their work and advocate for policies that allow them to continue to provide gender-affirming, developmentally appropriate care to their patients.”