What is gender-affirming care, and does it save lives?

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Adults who are transgender and/or nonbinary understand the struggles of gender dysphoria firsthand, and parents are seeing what it does to their children.

With Ohio’s new law that bans transgender minors from undergoing gender-affirming medical care set to go into effect soon, these adults are advocating to maintain the medical practice that they say is lifesaving for transgender or nonbinary youth.

“If gender-affirming care is banned ― even if it’s just until you’re 18, even if it’s just severely restricted ― that’s going to cause a lot of suicides,” said Chester Stander, a young adult who is transgender. He started hormone replacement therapy at 16.

“I’m not entirely sure that I would still be here if I had to wait to 18,” Stander said.

When vetoing the proposed ban on gender-affirming care for minors, Gov. Mike DeWine said such care saves lives. In overriding DeWine’s veto and putting House Bill 68 into law, Ohio lawmakers argued the care shouldn’t be offered to minors.

“I would say that the adverse effects of the treatments probably are just as adverse as not being on them, in my opinion,” said state Rep. Rodney Creech, R-West Alexandria. “I think gender-affirming care for youth is not a good decision. There’s a lot of decisions that need to be made in the future and they’re blocking themselves in the corner at an early age.”

Credit: Rodney Creech

Credit: Rodney Creech

The Democrat likely to face Creech in the November election — she faces a write-in candidate in March — is Bobbie Arnold, an openly transgender woman who is involved in PFLAG Dayton.

Arnold transitioned in her 30s, and she said it was like a weight being lifted off her shoulders.

“Gender-affirming care, without a doubt, is lifesaving,” Arnold said. “To feel at home in your own body after so many years, it is indescribable.”

What exactly is gender-affirming care, which is at the center of this debate?

The Dayton Daily News talked to medical experts, adults who are transgender, and parents of children who could be affected by the ban to look at what gender-affirming care is, how it can be used to treat conditions like gender dysphoria, and why families are worried for what the future holds for their kids.

What is gender-affirming care?

Gender-affirming care can include a range of medical interventions designed to support and affirm an individual’s gender identity, including hormonal treatment or surgery, according to the World Health Organization. Some transgender people seek medical or surgical transition, others do not.

“It’s nothing experimental. It’s nothing like wildly inappropriate. It’s actually been going on across different cultures around the world for thousands of years,” said Dr. Teagan Vaughn, director of gender-affirming care at Equitas Health.

Gender-affirming care can include medications such as hormone therapy, like testosterone or estrogen, Vaughn said.

Gender-affirming surgeries for adults can impact people’s genitals, reproductive organs, and different areas like breast or chest tissue, the face or other parts of the body, she said.

0.0003% of Ohio minors

Gender dysphoria is the distress felt when one’s identity is of a different gender than their sex assigned at birth.

There are approximately 2.6 million children in Ohio. Around a third of the individuals diagnosed with gender dysphoria begin medical treatment under the age of 18. This is 0.0003% of the population of minors in Ohio, according to Ohio children’s hospitals.

Over the last 10 years, Ohio’s children’s hospitals served approximately 3,300 individuals whose first appointment at a gender clinic took place when they were under the age of 18, said Nick Lashutka, president and CEO of the Ohio Children’s Hospital Association.

The average age at their first appointment was 16 years old. Of those 3,300 individuals, 7% were prescribed a puberty blocker, and 35% were prescribed hormones, according to Lashutka.

“This means that of the patients under the age of 18 who come to our clinics for treatment, 65% are never prescribed medication prohibited by Sub. HB 68,” Lashutka said.

While few minors are prescribed this medication, it is still lifesaving and crucial in the instances where it is used, he said.

“It is a dangerous precedent for government to dictate when medication is appropriate in pediatrics,” Lashutka said.

Health providers follow team approach

Dayton Children’s Hospital declined an interview on this topic, directing this news outlet to the statement from the Ohio Children’s Hospital Association. Some individuals interviewed on this topic received gender-affirming medical care at Dayton Children’s, while others were referred to Cincinnati Children’s Transgender Health Center.

Children’s hospitals across the state list steps on how they approach gender-affirming care, including statements their transgender health centers follow national and international professional guidelines.

“All service lines within our hospitals follow standards of care to ensure quality, safe, and effective care,” Lashutka said.

Children’s hospitals answer questions from families, such as how do families know if their child’s transgender identity is “real” and not a “phase?”

The answer: If the child is insistent, consistent, and persistent, Cincinnati Children’s Transgender Health Center says, with experiencing their sense of being male or female as different from their sex assigned at birth.

Multidisciplinary teams work with families to create plans when it comes to transitioning at school and discussions around treatment like puberty blockers and hormone replacement therapy. Not all children with transgender and/or gender diverse identities will seek medical treatments.

To start puberty blockers, a child needs to have started puberty but not gone too far, Cincinnati Children’s says. The medical team discusses the risks and benefits of treatment, asking families to sign consent forms.

Patients, their families and the treatment team all need to agree that puberty blockers are the appropriate next step, Cincinnati Children’s says. Cincinnati Children’s, along with other children’s hospital systems in the state, generally require patients see a therapist prior to starting treatment.

“The foundation of our clinics is to support families and youth with their mental health needs, and each patient undergoes a rigorous mental health assessment to determine if this care is appropriate for them,” said Lashutka.

Puberty blockers

Children’s hospitals in Ohio do not perform surgeries on minors for the condition of gender dysphoria, said Lashutka.

Vaughn agreed that for youth, there’s not a lot of surgical intervention

“Most often, we see things like puberty blockers that really just pause puberty from happening,” she said.

Puberty itself can lead to irreversible changes, as well as be detrimental to a minor’s mental health if they go through the bodily changes associated with a different gender than that of their identity, she said.

By using puberty blockers, it is giving the person more time to understand their identity.

The effects of puberty blockers are almost completely reversible, according to Cincinnati Children’s.

“Puberty blockers have very little long-term effects on youth who use them,” Vaughn said.

Gender-affirming hormones

Hormones like testosterone or estrogen are used to help a patient’s body align more with their identity. If their sex assigned at birth was female, but their gender identity is male, testosterone may be prescribed to promote growth of facial hair, increase muscle mass, and stop periods.

Republican lawmakers opposed to gender-affirming care cite concerns with the potential health consequences of such treatments, such as fertility when it comes to hormone treatments.

Hormones are not prescribed haphazardly, children’s health systems say. Some of the effects of hormones are reversible, some are not. Risks are discussed with families, along with options on preserving fertility.

To start gender-affirming hormones through health centers like Cincinnati Children’s Transgender Health Center, a young person needs to have either gone through puberty or have been on puberty blockers for several years.

Additionally, the patient will need a letter from their therapist and baseline blood work. The patient’s care team will help determine the appropriate type and timing of treatment based in part on physical examination and blood work.

Patients, their families, and the treatment team all need to agree that this is the appropriate next step if the patient is under 18 years old, Cincinnati Children’s says.

Other children’s hospitals in the state, like Akron Children’s Hospital, outline the path a patient’s health journey may take when seeking out gender-affirming care. Multidisciplinary teams can include doctors, therapists, endocrinologists, and social workers.

Satisfaction rates after care

Health experts say this process is meant to avoid someone making a decision they later regret.

Morgan Keller testified before the Ohio Senate on behalf of H.B. 68. She said she was dealing with trauma and other mental health issues and “put on life-altering cross-sex hormones with minimal questioning or treatment of my underlying issues.”

She started taking testosterone at 21, and at 22 received surgery with a letter of recommendation from a therapist, she said. The treatment did more harm than good, she testified.

“I needed the practitioners that I trusted to help me make peace with my body, not affirm my delusion that hormones and a cosmetic mastectomy might make me feel better. I needed them to just say no,” she told lawmakers.

“I couldn’t give informed consent at 21, so why are we pretending that children can do that?”

Keller has not said where she received care. She did not respond to interview requests from the Dayton Daily News.

The U.S. Transgender Survey, the largest survey of transgender people across the U.S., found this outcome is more the exception than the norm.

While 2% of respondents said they were “a lot less satisfied” with life since transitioning, 79% reported that they were “a lot more satisfied.”

Parent: Removing access is ‘cruel’

More minors are seeking out gender care, but experts say this is likely due to minors having the language to describe their feelings and the resources to educate themselves.

“There’s not only an education awareness, but also a cultural awareness,” said Richelle Frabotta, LGBTQ+ health initiatives project manager at Public Health - Dayton and Montgomery County.

Transgender adults and parents of gender-diverse adult children interviewed by the Dayton Daily News said they did not have the language to describe the gender dysphoria they felt as minors, leading them to transition in their adulthood.

Credit: Avery Kreemer

Credit: Avery Kreemer

“I don’t think there’s any more transgender identified youth than there ever have been. I think the phenomenon that people might be referring to is the fact that we now have an awareness,” Frabotta said.

Many of the transgender adults interviewed by this newspaper have experienced suicidal ideation, they said. If they’d thought about suicide, they were still in a desperate position when they sought gender-affirming care.

Many parents of transgender and/or nonbinary children ― whether their children are still minors or are now young adults ― told the Dayton Daily News their children experienced suicidal ideation and struggled with their mental health.

“These laws are going to end up being something that is going to cause a rise in transgender youth suicide,” said Sarah Nolan, a Kentucky resident who had been traveling to Ohio to get access to gender-affirming care for her son.

Now, their family will have to travel further for care as the “grandfather” or legacy clause of H.B. 68 doesn’t provide exceptions for out-of-state patients who received gender-affirming care in Ohio.

“I’ve seen the gender dysphoria and how it hurts him,” Nolan said about her son. “Taking away access to things that are going to help transgender children is cruel, and it should be illegal to do that. This is their right to health care and the government is just saying no, it’s not. And the government needs a stop overstepping.”

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