Health experts: Gender-affirming care saves lives

The scientific consensus is clear when it comes to gender-affirming care: it reduces suicidality and promotes well-being for transgender people. 

Even when it comes to patients under the age of 18, all major medical organizations back evidence-based gender-affirming care like therapy and medication that temporarily stops puberty. That includes the American Medical Association, the American Academy of Child and Adolescent Psychiatry, the American Psychological Association, the American Psychiatric Association, the American Academy of Pediatrics and the Endocrine Society, among others. 

At the same time, conservative lawmakers across the country and in Wyoming have promoted bills that limit options for transgender people and their doctors. 

WyoFile used a scientific lens to analyze several pieces of legislation — bills that restrict what teachers can talk about, what gender-affirming care can be provided to trans youth, which kids can participate in school sports and whether Medicaid expansion could benefit those who seek out gender-affirming care. 

Don’t say gay

Senate File 117 – Parental rights in education would ban teachers from talking about sexual orientation and gender identity in kindergarten through third-grade classrooms in a manner the state board of education deems “not age appropriate or developmentally appropriate.”

It’s similar to so-called “don’t say gay” legislation passed in Florida. 

“I wanted to focus on the youngest children. The children that we would hope that the parents would be fully involved with,” the bill’s sponsor Sen. Dan Dockstader (R-Afton) said in a hearing. 

When asked about what happens when kids ask about these topics, though, Dockstader said, “K through 3? That’s a very early age. Let’s proceed cautiously.”

Kids as young as 3 first start becoming aware of gender constructs and placing themselves into a construct, according to University of Minnesota professor Jenifer McGuire.

“Sometimes kids are able to articulate that at [that] early age,” she said in a media briefing in September.

Recent polling has shown that the debate and passage of this kind of legislation has a negative impact on trans kids’ mental health. 

Despite anti-trans rhetoric, though, there are multiple organizations devoted to supporting LGBTQ people struggling in Wyoming.

Steps like letting kids use a different name than what was given at birth had positive impacts on mental health, reducing suicidality and anxiety. 

The trans community has the highest rate of suicide attempts, according to peer-reviewed research and findings from a national survey in 2015. About 40% of respondents said they had attempted suicide in their lifetime — almost nine times the national rate. More than a third of those attempts happened by age 13. 

That survey was re-opened in 2022, and updated results are expected this year. 

Centers for Disease Control and Prevention data from 2020 revealed that Wyoming had the nation’s highest suicide rate. 

About 94% of children who “socially transition,” or start presenting themselves publicly as a trans person, retain that identity over five years, according to research published last summer.

Senate File 117 has passed the Senate and now heads to the House. 

Criminalizing care

Senate File 111 – Child abuse-change of sex creates a felony child abuse charge for providing “any procedure, drug, other agent or combination thereof that is administered to intentionally or knowingly change the sex of the child.”

That includes administering puberty blockers, hormone therapy and surgeries, though many medical professionals noted that there are no sex reassignment surgeries being done in Wyoming. 

Senate File 111 has exemptions, including for babies born with an ambiguous sex or who develop both sets of sex organs. However, it does not exempt psychological conditions because, “if you allow this kind of sex change as a result of those, you’d create a loophole that would just be impossible,” said Sen. Charles Scott (R-Casper), sponsor of the bill. 

“Studies find poorer mental health and twice as many suicidal thoughts and attempts among youth not yet receiving gender-affirming care when compared to youth who are receiving care,” according to a compilation of research published by the Society for Research in Child Development. “Counseling and psychological support also contribute to improved mental health for [transgender and gender-diverse] youth; however, they can not replace the benefit of medical care, when indicated, for TGD youth’s well-being.”

Opponents of SF 111 argue that lawmakers don’t understand trans healthcare needs. 

New data published in the New England Journal of Medicine last month shows positive outcomes from providing gender-affirming medications to teens. 

An editorial in the same journal said the research adds to evidence that gender-affirming hormone treatments can help mental health, while withholding them can hurt kids. It also noted that while overall mental health metrics improved, some individuals didn’t benefit. Two of the 314 participants died by suicide. It also called for more research into the effects on teens’ bones and brains while puberty is on pause.

“Perhaps as a parent, one feels that if it keeps my child alive for one day then it’s worth doing, and that’s certainly understandable,” ​​Mike Leman with the Catholic Dioceses said in support of SF 111. “But real science isn’t supposed to make assumptions. Or promises. It’s supposed to help us be informed, fully informed.”

Leman cited a study from the Society for Evidence-Based Gender Medicine questioning Dutch research about gender-affirming care being positive for kids. SEGM, which claims over 100 members, is not recognized by the international medical community.

“There are a lot of unofficial, fringe and radical organizations posing deceptively as legitimate healthcare professional societies and claiming, falsely, that gender-affirming medical care causes harm,” said Dr. Alex S. Keuroghlian, an associate professor of psychiatry at Harvard Medical School who also directs programs at Massachusetts General Hospital and the Fenway Institute.

Alternately, the Endocrine Society — which claims around 18,000 members — supports gender-affirming care for minors.

“For the 2017 transgender medical care guidelines, 266 articles were specifically referenced in the document. Then, recommendations were made using a grading system that was informed by the quality of the studies,” according to Dr. Joshua Safer, executive director of the Center for Transgender Medicine and Surgery at Mount Sinai Health System, a professor of medicine and co-author of the Endocrine Society guidelines.

Those recommendations were made available to all of the society’s members and revised to create the final document, Safer added via email. 

Asked about the critics, Safer stated the small number of people who “routinely criticize” transgender guidelines aren’t active in the field and haven’t led research in the topic.

“Also, they have not criticized Endocrine Society guidelines on other topics even when the other guidelines followed the same process and had similar quality data,” he stated. 

WyoFile reached out to bill sponsor Scott via email and phone to ask about any research he used to back his claims, but he didn’t provide a comment by press time. 

“You get into a lot of details, get lost in the weeds of medical treatment. So I’ve tried to make [this bill] simple,” he said when presenting the bill. 

Meanwhile, Sen. Fred Baldwin (R-Kemmerer) stated that he voted “no” on the bill because he’s uncomfortable with non-experts at the Legislature making decisions on what could be life-or-death situations.

“I think we need to let doctors be doctors and not criminalize people,” he said. 

Senate File 111 passed out of a Senate committee 3-2, but hasn’t yet been read on the floor. 

Team sports

States around the country have been discussing whether and where trans teens fit into high school sports. 

The Wyoming High School Activities Association has a policy for transgender athletes that states “all students should be considered for the opportunity to participate in Wyoming High School Activities Association activities in a manner that is consistent with their gender identity, irrespective of the gender listed on a student’s records.”

That policy and its appeals process is working, according to the association. 

Even so, it has faced challenges from those who believe it contains discriminatory restrictions and those who don’t think it’s restrictive enough.

Senate File 133 – Student eligibility in interscholastic sports would ban anyone who was born with male sex organs from competing with girls in an interscholastic athletic activity.

Biology gives trans women an advantage, the bill’s sponsor Rep. Wendy Schuler (R-Evanston) said. “And it doesn’t go away, [with] hormonal treatments that some of them may be taking.” 

Research has shown a swift drop in testosterone and hemoglobin levels once a trans woman starts gender-affirming hormone treatment. Those levels have direct effects on athletic performance.

That same research found trans women’s overall strength still lingered above levels of cisgender women, adding “strength may be well preserved in transwomen during the first 3 years of hormone therapy.”

Another study on trans members of the U.S. Air Force found that after two years of using feminizing hormone therapy “the push-up and sit-up differences disappeared [between trans women and cis women] but transwomen were still 12% faster.”

There are calls for significantly more research based on specific sports.

Joanna Harper has authored a few studies on trans athletes, including the one that looked at hemoglobin and strength levels. Harper, a trans runner herself, told Outsports that she believes trans women should still be allowed in sports because they face their own physical drawbacks, like having a larger frame with a now-decreased muscle mass.

That said, in recent writings about trans athlete history and science, she talked about a possible middle ground. 

“The differences between those who advocate for the exclusion of trans women from women’s sports and … those who advocate for the unconditional inclusion of trans women in female sport are seemingly unsolvable,” she wrote. “If one were to consider that both sex and gender matter when determining who is male and who is female, however, one might make headway. Perhaps there is also justification for some middle ground between total exclusion and unconditional inclusion.”

That’s similar to what Wyoming Equality Director Sara Burlingame said Wyoming’s high school sports policy already does.

“What our policy has done has struck a balance,” she said in a committee hearing. “And that’s a balance that says: ‘the answer isn’t always, the answer also isn’t never.’”

Research is also clear that playing sports promotes physical and mental health. Those activities can also play a role in kids feeling accepted and supported during tumultuous teen years.

LGBTQ youth are already half as likely to participate in sports than their peers, according to a national secondary school survey. Part of the identified reasons are concerns over safety or not feeling welcome. 

However, SF 133 sponsor Schuler was clear that she is more concerned about cisgender female athletes’ needs than providing equality for trans athletes.

“Regardless of how anyone tries to frame the question of the transgender athlete and their potential lost opportunity and their mental well-being, what we really need to do is keep the biological females at the forefront of the equation,” she said in a committee hearing. “Because this is their lane, it’s their playing field, it’s their safety, it’s their welfare that should be uppermost. And also their mental well-being.”

This bill was crafted after Utah’s legislation, which is now tied up in court. 

Senate File 133 passed out of the Senate Education Committee 4-1.

Amendment to Medicaid expansion

Wyoming is one of 11 states that haven’t expanded Medicaid under the Affordable Care Act to cover people who fall into a gap of making too much to qualify for traditional Medicaid but can’t afford more expensive, private insurance. 

Those who oppose expansion have said they don’t want to depend any more on the federal government. 

House Bill 80 – Medical treatment opportunity act-Medicaid reform would expand Medicaid, but in committee, an amendment was added that restricts potential care for trans residents. 

This came after Rep. John Bear (R-Gillette) had a short discussion during a committee hearing with JJ Chen, an inpatient psychiatrist with Cheyenne Regional Medical Center who has also worked with Healthy Wyoming and the Wyoming Medical Society.

Bear pressed Chen about whether expanding Medicaid could include funding for services that include surgical and medication-based services for transgender people. 

“As a psychiatrist, my duty first and foremost is to take care of the patient,” Chen responded. “I do see a lot of times where folks who do have the diagnosis … for gender dysphoria, they are at greatest risk of having completion of suicide, having attempts of suicide.”

Bear added an amendment so that no money that comes in from expansion could be used for puberty-blocking drugs, “chemical drugs” or surgeries to treat gender dysphoria. That amendment passed 5-4.

Sometimes politics have been forced to bend to medical necessity, though. 

Idaho leaders fought to keep an inmate from receiving gender-affirming surgeries. A trans woman, Adree Edmo, had such severe gender dysphoria while in a men’s prison that she had tried to castrate herself multiple times, risking her life. 

Ultimately, the 9th Circuit Court of Appeals ruled that the prison’s then-insurance provider would have to cover the surgeries. Not doing so, it found, violated the 8th Amendment to the Constitution: cruel and unusual punishment. 

Now free, Edmo was the first inmate in the U.S. to get court-ordered gender reassignment surgery. 

Many Wyoming lawmakers have stated that being transgender is a phase teens go through, but experts point to a clear difference between confusion and those formally diagnosed with life-threatening gender dysphoria. 

Testifying in support of the bill criminalizing gender-affirming care for minors, Bear also stated that an increase in trans teens is “a fad.”

Bear did not respond to requests for evidence or experts backing his position. 

“There have been transgender and gender-diverse people throughout all of history,” Keuroghlian with Harvard said in response to Bear’s comment. “At different points in history and different societies and different civilizations, more or less room has been made for transgender and gender-diverse people.

“It’s the naturally occurring gender diversity that’s always existed among humans, and we can be in denial about it, or we can accept human nature and diversity,” he added.

In his acute inpatient psychiatric unit in Cheyenne, Chen works with adult patients who have severe suicidal ideation and have either attempted to take their own lives or have a plan to. That includes patients with gender dysphoria who plan to seek gender-affirming care.

“This is one of the demographics, one of the patient populations I have the most tender loving care for,” he said. “The opportunities for them to have their own support systems are quite limited [in Wyoming].”

He wants those struggling in Wyoming to understand something, though: “At the end of the day, I think providers, parents, teachers — we’re not going to stop loving and taking care of folks who need the right care. I took a Hippocratic oath and I’m first going to do no harm.”

If you or someone you know is having suicidal thoughts, you can call or text The National Suicide Prevention Lifeline at 988.

Reporting contributed by Tennessee Watson.