Imagine that you’re a parent, and your kid has a health concern — any health concern. You do your research, look into doctors, and find the best specialist for your kid. You make an appointment, and when the doctor walks in, they tell you, “I know how to make your child healthy, safe, successful, and thriving, but I can’t do it.”
Dr. Kristin Rager has been playing that scenario out in her head for more than a year. She’s a pediatrician and adolescent-medicine specialist who focuses on care for trans kids — teaching families about their options when a child first starts questioning their gender, prescribing puberty blockers to protect kids from the trauma of going through a puberty that doesn’t correspond with their gender, and eventually, maybe, prescribing gender-affirming hormones. It is care that’s supported by the American Medical Association, the American Academy of Pediatrics, and the American Psychological Association. But in Tennessee, where her practice is, lawmakers have spent the past year trying to make it impossible for her to do her job.
When she talks about it, she warns me that she might cry, but her voice never breaks — she’s just angry. “It makes me sick to think of having to do that,” she says. “Physicians, we all have to take this oath that we’re not going to do any harm. For a patient to come to me, and to have to tell them that I can’t help them? It’s the definition of harm.”
The proposed Tennessee legislation is just one of at least 25 bills in 21 states around the country introducing draconian limitations on gender-affirming medical care for trans youth. In South Carolina, one bill would make it a felony to provide affirming medical care to minors, punishable by 20 years in prison. Bills in Texas, Kansas, and New Hampshire would legally make supplying puberty blockers and hormones to minors child abuse. A bill in Oklahoma would make it a felony to prescribe puberty blockers to a trans person before they’re 21 — a good decade after they’re meant to be prescribed.
Earlier this month, Arkansas became the first to instate one of these bills when its legislature overrode the governor’s veto of the “Save Adolescents from Experimentation” Act, which makes all affirming care illegal under the age of 18. Advocates expect that other states are not far behind.
“The common thread between all of these bills is cruelty,” says Dr. Rager. Most of them have names like the “Vulnerable Child Protection Act” and purport to protect kids, but really they are depriving them of life-saving care. Trans minors have one of the highest rates of suicide of any demographic. But studies show that pubertal suppression for transgender young people brings that risk down dramatically, so that it is on par with their cisgender peers, Dr. Rager says.
In a year that’s already hit record-breaking highs in the introduction of anti-trans legislation — 117 bills and counting, up from 66 last year — these medical-care bans are a new spin on an old tactic to amp the culture wars and try to galvanize the conservative base. They’ve tried to use trans lives as a wedge issue before — the 2016 election season was dominated by conservatives fear mongering about “biological men” in girls’ bathrooms — but their new tack almost exclusively targets trans kids, and the medical bans are a new low.
“They’re taking these vulnerable children and using them as red meat for their base,” says Ivy Hill, the community health program director for the Campaign for Southern Equality. “It’s an attack on science, an attack on medical providers, and it’s all at the expense of trans kids.”
Like most “wedge issues,” these bills were manufactured in back rooms and think tanks and conservative convention halls. The first trans medical ban was introduced by Fred Deutsch, a state senator from North Dakota, in 2020, after he attended an event co-hosted by the Heritage Foundation, a far-right conservative think tank, and the Alliance Defending Freedom, one of the largest anti-LGBTQ organizations in the nation, and one of the more extreme. ADF supports the recriminalizaton of homosexuality and the sterilization of trans people, and is classified as a hate group by the Southern Poverty Law Center.
Panelists at the event called gender-affirming care “child abuse,” “malpractice,” and “uncontrolled experiments,” citing the American College of Pediatrics to support their claims — an anti-LGBTQ hate group with several hundred members that’s been cleverly named to be mistaken for the apolitical, 70,000-strong American Academy of Pediatrics.
In an interview with NPR, Deutsch said that after the event, he took to the internet and was “overwhelmed” by the stories of children who’d decided to “detransition.” (Data is limited, but the largest-scale survey found that 0.4 percent of people who transition choose to “detransition” after realizing that it wasn’t the right decision.) “I googled ‘transgender medicine South Dakota’ and found a handful of doctors, not many, that do the procedures,” Deutsch, a chiropractor, told the New York Times. “And that’s the genesis of the concept of this bill.” With the help of Alliance Defending Freedom, he said, he drafted it, introduced it in South Dakota, and sent it to other conservative states so that they may follow.
At the same time, Deutsch’s bill dovetailed with the work of the American Principles Project, a national conservative think tank that campaigns against abortion, same sex marriage, and trans rights. Heading into the 2020 election, APP’s executive director Terry Schilling told the Times that APP was faced with a challenge: Conservative groups that campaigned against social issues like abortion and LGBTQ rights had been shying away from electoral politics in the past few years. APP’s polling showed that the anti-trans “bathroom bills” had failed to be the wedge issue that they’d hoped in 2016, and they were losing political ground. APP was determined to turn that around. “What we’re doing is trying to show Republicans that they could win on these issues,” Shilling said.
They pivoted to a new strategy, first testing it out in the 2019 Kentucky governor’s race — a “pilot program” for the 2020 election. Rather than focusing on the purported threat of “biological men in bathrooms,” they turned to trans kids in school sports. It makes the case stronger, APP founder Frank Cannon told the Times, because it focused on “the idea that you are taking something away from people” — that their daughters could be losing their spot on the team, their wins, their scholarships, to someone assigned male at birth.
“This is an old playbook,” says Alphonso David, president of the Human Rights Campaign. Conservatives have consistently played on fears of lost opportunities and vulnerable children: After integration, conservatives stoked fears that black people would usurp white athletes; in the 1970s, Miami’s “Save Our Children” campaign effectively changed public opinion on gay people by casting them as a moral threat to kids. Just take out “gay” or “people of color” and replace it with “trans,” David says, “and it’s the same arguments they’re using now.”
APP’s candidate didn’t win the governor’s race, but their polling found that he did pick up nearly 13,000 new votes. And that was proof enough that it could work in the Trump campaign. When APP took the strategy national, they kept the “trans kids” angle, but expanded it, debuting three ads in Michigan about trans student athletes, and two that accused Joe Biden of endorsing “gender change treatments in minors.” It may not have turned the election for Trump, but the campaign stuck, and state-level politicians have jumped on the wedge issue for 2021.
The pivot to medical bans is especially harmful, advocates say, because while the emotional and psychological impact of the sports bans can still be sweeping, trans student athletes are a small part of the population. Bans on trans medical care, on the other hand, could tangibly change the lives of the vast majority of trans youth in their state.
And state legislatures are now inundated with them. Advocates say they’re seeing a coordinated attack from the Heritage Foundation, the Alliance Defending Freedom, and Family Policy Alliance, which banded together this year to form the “Promise to America’s Children.” The group has been providing model anti-trans legislation to lawmakers around the country. Legislators need only fill out a form to request it. (A spokesperson for the Promise coalition, Autumn Leva, said that “like many other national policy and legal organizations, we regularly advise state lawmakers on legislative issues,” but declined to specify which types of bills, or which states they’d advised.)
None of this legislation is addressing a real issue facing their constituents. The medical community has explicit guidelines for the care of trans adolescents. In every state in the country, minors need parental consent to receive any affirming medical care. And medical guidelines dictate that doctors provide care in very specific stages. Despite conservative fear mongering of hormonal treatments and genital surgery on 11-year-olds, Dr. Rager says, before puberty, “the recommended treatment is really just for the parents to love and support their kid. There’s nothing medically to be done.”
As children start to go into puberty, though, puberty blockers are a safe and completely reversible way to push the pause button on those changes, Dr. Rager says. “You are putting puberty on hold while you figure things out. That could mean that the family figures out that they do support their child, and they’re ready to proceed with gender-affirming hormones. Or it could be that the child figures out that they actually are OK with going through their birth puberty. That doesn’t happen often, but it leaves room for the fact that children are developing, and learning as they go.” And if they do decide to move forward with gender-affirming hormones, doctors recommend that they start when they’re still a teenager.
The American Academy of Pediatrics explicitly supports this standard of care. Last month, as the volume of trans medical-care bans came to a head, the Academy released a statement in direct opposition to the bans, saying that the “legislation would allow policymakers rather than pediatricians to determine the best course of care for our patients…Politics has no place here.”
But politics has moved in, and for trans kids and their families, they’re presented with a choice: They can uproot their lives and try to move to a state that’s safer, or they can stay and fight. “It’s such an undue burden to put on a family,” says Dr. Rager, who says she has several patients who plan to move if the Tennessee bill passes.
Most people don’t have the means to move, so their only choice is to fight. In South Carolina, Eli Bundy, a 16-year-old high school junior who is trans and nonbinary (and uses they/them pronouns), has already testified once in front of the state legislature. The hearing was in the middle of the school day, so they had to skip class to remind lawmakers that 40 percent of trans students attempt suicide at some point in their lives, and when anti-trans bills are introduced, those numbers go up.
It’s fallen to trans kids themselves, advocates say, to publicly out themselves in communities that are largely unsafe, and spend their time and energy convincing lawmakers of their humanity. “I’m a trans teenager. So my goal is that you have to look me in the face, and still say, ‘Yeah, we’re gonna hurt trans kids,’ ” says Bundy. “It’s much easier to demonize someone or make them the villain when you don’t see their face.”
Bundy’s been campaigning against their state’s anti-LGBTQ laws since they were 15. “I’m someone that likes to have things to do, rather than sitting and being afraid of things,” they say. But on a recent call with one of their state representatives, they looked around at their peers, and saw the absurdity of it. “There were kids on there that were younger than me, some that were older than me. And I remembered that this should not be how it is,” they say. “These folks should not have to spend their time after school — when they probably have homework to do — to talk to a legislature that is actively trying to hurt them.”
For the ones who fight, it’s a long road ahead. But most advocates are confident that these bills can be halted in the courts. “This targets health care for a discrete minority — trans youth are being treated differently. And that is [an] equal protection issue,” says Holly Dickson, the executive director of the ACLU of Arkansas, where they’re preparing to challenge the ban that was passed earlier this month. It also violates a right to privacy, she says, “both for the youth that are affected by this ban, as well as the parents’ right to control the upbringing of their children.” And for any health care facility that receives federal funds, these bans would explicitly put them at odds with the equal-protection clause of the Affordable Care Act.
“But we’ve got to have plaintiffs who are willing to speak up,” says Ivy Hill from the Campaign for Southern Equality. Taking these bills to court once again puts the onus on trans kids, who will have to endure the Trump-packed judicial system. “We’re gonna fight like hell to beat it,” says Hill. “But it’s a very real threat, and I’m very concerned about what happens if it does pass.”
When I ask Bundy what they’d like people outside of South Carolina to know about their experience, they talk about Inauguration Day. Donald Trump came into office when they were 12, and they were so excited when Joe Biden was elected — they even worked on the campaign. “It felt like, ‘Great job, team! We did it,’ ” they say. But by the start of the year, the conservative backlash had rolled in. As a trans kid in post-Trump America, they say, “I really definitely do not feel safer.” But they’re worried that the rest of the country still feels that relief. That they don’t see how scary it still is for people like them. “Complacency is really dangerous,” Bundy says. “I think sometimes it can feel more distant — that it’s happening somewhere else. But for us, you know, this is it. Like, this is where we live, this is where my friends live, this is where my school is, and so this is a law that hurts the people that I love and it hurts me and it is a big deal.”