Transgender kids in the South face multiple obstacles to affirming care

Maria Clark
The American South

Editor's Note: Alabama's SB 10 also known as the Vulnerable Child Compassion and Protection Act , which would have restricted affirming care for transgender or gender non-conforming people under 19, failed to come to a vote on Monday (May 17) terminating the legislation. The story has been updated to reflect this.

Elise, a physicians’ assistant in Birmingham, Alabama knew from a previous experience with a young patient how challenging it can be for transgender teens in the South to access gender-affirming care. More than a year later, her family came face to face with that challenge, when her 13-year-old son Kevin revealed that he was transgender. 

Already armed with research, Elise knew where to find a doctor who could help. In his early adolescence, Kevin now receives medical care at a critical juncture, something that has been the target of intense public debate across the U.S. this year. 

Alabama is among seven states in the South that proposed bills criminalizing a healthcare provider’s ability to serve transgender patients under the age of consent, according to the Human Rights Campaign. It’s a relatively small population. Only about 0.7% of teens ages 13 to 17 in the U.S. identify as transgender, according to data from the Williams Institute at the UCLA School of Law.

In Alabama, the Vulnerable Child Compassion and Protection Act (SB 10) applied to transgender or gender non-conforming people under 19. However, the bill failed to come to a vote on the house floor on May 17, the final day of the legislative session in Alabama.

Protesters rally in support of transgender rights outside the Alabama State House in Montgomery on March 30.

Arkansas is the first and only state this year to pass a law barring doctors from treating trans youth including those with gender dysphoria, the term used by the American Psychiatric Association to describe feelings of discomfort and distress caused when a person’s gender identity doesn’t align with the sex assigned to them at birth. Despite strong opposition from business groups, doctors, and the LGBTQ community, the law passed in April.

The ACLU of Arkansas said in a statement shortly after that it was going to fight it in court. The debate has stirred so much opposition that similar bills have died early in committee in other states such as Louisiana and Mississippi. 

Earlier this month, the Biden administration restored protections for the transgender community under the Affordable Care Act, reversing a Trump-era policy that allowed sexual discrimination against transgender patients in healthcare settings. The former rule defined “sex” to mean gender assigned at birth, which excluded transgender people from being protected by the law.

Health and Human Services secretary Xavier Becerra said in the May 10 announcement that discrimination leads people to forgo medical care, “everyone-—including LGBTQ— should be able to access healthcare, free from discrimination or interference, period.”

LGBTQ advocates said that the Arkansas law and similar bills will likely be contested and fought in court. Regardless of the trajectory of these laws, the public debates have impacted families with transgender children and sewn confusion about what gender-affirming care means, they said. 

“These bills help perpetuate the misunderstanding of what kind of care young transgender people receive,” said Asaf Orr, the director of the Transgender Youth Project, with the National Center for Lesbian Rights. “It creates this idea that they will be rejected by providers even though it is a standard of care.” 

Orr said it’s also forcing doctors who already treat a vulnerable population, to make contingency plans for if and when that becomes restricted in their state. 

Medical services already sparse

In the South, gender-affirming medical care is already sparse. This includes a variety of medical services that help a person align their body to their gender identity, including puberty blockers to stop the development of secondary sexual characteristics in younger teens, hormone therapy, and counseling. 

In Alabama, teenagers as young as 14 can consent to see a mental health counselor without parental permission. The goal, however, is to eventually get the parents involved, said Katie Reese, the director of counseling and support groups at the Magic City Wellness Center in Birmingham. 

Reese, who also facilitates a support group for families and transgender kids and teenagers said, counseling can be a lifeline for young people who don’t have support at home.

“If a young person is connected with an affirming therapist about how they are feeling and what gender dysphoria is like, they can also get plugged into a slew of life-saving resources that will help decrease their anxiety, depression, and lower the risk of self-harm,” she said. 

Amid the debate on gender-affirming care for minors, Dr. Morissa Ladinsky has seen an alarming uptick in the number of trans-identifying young people coming to the emergency room for psychiatric evaluation or exhibiting suicidal ideation. 

More:Doctor: Alabama lawmakers want to punish me for treating transgender youth

Ladinsky co-leads the Youth Multidisciplinary Gender Team at the University of Alabama-Birmingham. She is one of three providers working with transgender adolescent and pediatric patients at the unit. They serve patients from across the state as well as neighboring Mississippi where services are also limited.

While resources are few, there is a strong network of providers working in neighboring states who can help treat her patients if she is unable to continue her work in Alabama, she said. 

Ladinsky said she has tried to assure her patients and their families that they will be able to continue their medical care even if it means seeing a provider in another state.

But assurances can only go so far.

“These are kids who have already faced the challenges of living in a part of the country where they are made to feel guilt and shame for who they are. I worry about my patients, but the kids I worry the most about are the ones I don’t know yet,” she said. 

Queermed telehealth

To reduce the patchwork availability of gender-affirming care, QueerMed, a telehealth clinic that provides hormone therapy and counseling for transgender patients of all ages, expanded to cover 11 states (including nine Southern states).

Dr. Izzy Lowell, the founder of Queer Med, is working with legal teams in every state that has filed a bill targeting healthcare access for young transgender people. The clinic is also reaching out to their patients in these states to ensure they have their medication and contingency plans in place to continue care should their states follow Arkansas.

Izzy Lowell is a family medicine physician whose clinic, QueerMed, specializes in transgender medicine.

If they have transportation, this could mean driving to a neighboring state where Lowell is licensed to visit with their doctor via video. It could mean hours of driving, for what amounts to a 15-minute appointment so Lowell can refill their prescription. 

“It’s a huge disruption,” Lowell said. “To say this type of care is life-saving is not an understatement. It has been well documented that access to affirming care dramatically reduces the risk of harmful behavior and helps them carry on a normal life.” 

A 2019 study commissioned by the Trevor Project found that transgender and non-binary people experienced depression and anxiety at a rate 10 times higher than cisgender people (people who identify by the sex assigned to them at birth). Consistent access to gender-affirming medical care, coupled with familial and social support, reduced those rates significantly, according to the study. 

But even with the expansion of care through clinics like QueerMed, access is limited.

Dylan Waguespack, an advocate with Louisiana Trans Advocates, goes as far as describing what’s available as a “healthcare desert for trans southerners.”

More:Why the gender-affirming care debate for minors in Louisiana is a concern for the rest of the Gulf South

Waguespack was among hundreds of Louisianians who opposed a bill criminalizing gender-affirming care for minors in April. The law would have impacted people across the Gulf Coast, he said. 

“People get on buses and ride five hours because the providers (in New Orleans) are accessible in a way that isn’t available in their own community," he said. "The impact goes far beyond one state, especially when we’re talking about the pediatric and adolescent care that is targeted in these bills; there’s almost zero access.”

Patients travel more than 100 miles to see Dr. Michael Hennigan, an endocrinologist in Destin, Florida. Many are from southern Alabama, where he is also licensed to practice and range in age from 14 to their late 60s. Hennigan, who began working with transgender patients nearly 30 years ago, said even today there are few endocrinologists that are willing to work with the trans community. 

“Some are very well educated on this topic but fear the public perception. Others, not so much,” Hennigan said.

Legal issues limit care

Public debates around healthcare access could further limit doctors considering treating these patients.

“Doctors aren’t lawyers. When you have multiple states debating this issue at the same time, it could put a freeze on physicians venturing into this out of fear running into legal issues,” he said.

It’s still unclear if the Alabama bill will be signed into law. The state’s legislative session ends May 17. If it does, advocates have said they will fight it in court. 

In the months since transgender care has been in the national conversation, Kevin became an advocate, his dad, Paul said. 

Most days, he wears a Trans-Rights T-shirt. 

He’s actively sharing information about the law with his peers.

And at school, he joined the gay/straight alliance. 

While Elise and Paul are proud, they also worry about the future. They are considering leaving Alabama, a place that has been home for generations. 

Sometimes, Paul thinks about kids who show up to the family meetings they attend at the Magic City Acceptance Center in Birmingham without their parents. Kids who can’t really talk to their parents about what they’re going through.

“That’s what I worry about, " he said. "What happens to these kids if they feel like they have no support coming from anywhere."

Maria Clark is a general assignment reporter with The American South. Story ideas, tips, questions? Email her at mclark@gannett.com or follow her on Twitter @MariaPClark1. Sign up for The American South newsletter. Follow us on Instagram, Facebook and Twitter.