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Every weekday, pediatricians see patients at Gender Pathway Services of Children’s Mercy Hospital in Kansas City and the Transgender Center of the St. Louis Children’s Hospital. For the young patients, an appointment can mark a turning point in their lives.
Transgender children visit the clinics at the onset of puberty to receive puberty blockers. These reversible medications, also prescribed to young cisgender children who begin puberty before their peers, postpone the onset of sexual maturation as long as patients take them.
For some children, this pause allows more time to decide whether they want to pursue medical gender transition. And it gives their parents time to become more comfortable with their child’s gender. Once a family is ready, a team of pediatricians moves forward with hormone replacement therapy for teenagers.
But this therapy — the prescription of hormones like testosterone and estrogen to transgender people in order to develop secondary sex characteristics like facial hair or breasts — is under threat in the Missouri legislature.
Missouri bill would require pediatricians to violate standards of care
Senate Bill 843, proposed by Sen. Mike Moon, a Republican from Ash Grove in southwest Missouri, would outlaw gender-affirming hormone replacement therapy and surgical procedures for minors. A medical practitioner who prescribes or administers these treatments would have their medical license revoked.
For Dr. Sarah Garwood, a pediatrician at the Transgender Center in St. Louis, passage of the law would mean her license could be revoked by the state of Missouri, even though she is adhering to the guidelines of the American Academy of Pediatrics (AAP).
“Bills like this basically ask us to practice medicine in violation of professional standards of care,” Garwood said. “That’s an incredibly uncomfortable and difficult place to be as a medical provider. Do we risk losing our license, or do we do what is medically accurate and evidence-based and ethical?”
Two other bills in the 2022 Missouri legislative session impact transgender people. Senate Bill 781 would prohibit women of transgender experience from competing on a women’s athletic team, and House Bill 2086 would prohibit changing the sex marker on a birth certificate.
At least 15 other states have similar bills that would restrict transition-related health care for minors, compared to 20 states in 2021. Only one bill, in Arkansas, has passed so far. A federal judge blocked the law from going into effect after a legal challenge from the American Civil Liberties Union.
Though data for the total number of patients receiving these treatments in Missouri is not available, Children’s Mercy Hospital’s Gender Pathway Services in Kansas City saw about 150–200 new patients in 2021.
Democratic Sen. Greg Razer, who represents Kansas City, said that, on a societal level, these bills tell transgender children they’re not welcome in Missouri.
“If the government is doing this, does everyone think that I’m wrong? And then do you internalize that wrongness? Does there come a point where you think, ‘Missouri is my home, but my home doesn’t want me?’” Razer said. “To young people out there, as a state senator, I want you in Missouri. We want you here.”
Hormone therapy for transgender youth is widely endorsed as safe and effective
Garwood said the AAP, a national organization of 67,000 pediatricians, endorsed the use of hormone replacement therapy as a safe treatment after rigorous clinical studies. Gender-affirming surgeries are rarely deemed appropriate for minors, and most surgeons will not perform gender-affirming procedures on minors.
Numerous studies demonstrate the high risk of suicide among transgender children, particularly those without affirming families, with the rate of suicidal thoughts just over 50%. This rate increases if the child is forced through conversion treatment, a heavily criticized practice that attempts to “cure” homosexuality or transgender identity as an illness, rather than accept an LGBTQ child’s identity.
Garwood said the AAP recognizes puberty blockers and hormone replacement therapy as two of the most effective ways to prevent death by suicide among transgender youth, along with family and societal acceptance.
Anthony Rothert, director of integrated advocacy at the ACLU of Missouri, said bills like the one in Missouri are dangerous for young people.
He said Moon’s bill “is telling them they don’t belong, and that there’s something wrong with them. It’s not an exaggeration to say that this will literally cause the loss of life.”
Opponents of hormone therapy contend the medical practice is experimental. But Garwood said gender-affirming treatments are thoroughly researched and a standard practice of care for transgender children.
She said the treatments are always administered by a team of medical professionals, including pediatricians, endocrinologists and child psychiatrists who specialize in gender development.
Advocates say it is highly unusual for a state government to revoke medical licenses, which are issued in Missouri by the state Board of Registration for the Healing Arts. The board declined an interview with The Beacon, saying it does not comment on legislation.
“I’m hopeful that the medical community will see the encroachment into licensing in the medical practice by politicians to be a threat to all forms of medical care,” Rothert said.
Transgender youth are usually aware of their gender by the start of puberty
Merrique Jenson is the founder and executive director of Transformations Youth Group, a nonprofit in the Midwest that supports transgender youth and their parents, with a focus on young women of color of transgender experience.
“There are a lot of harmful effects that happen emotionally and mentally when we tell people to stop and just wait,” she said. “They’re watching things happen to their body that they can’t control, and now we’re saying, ‘Hey, you’re going to have to spend decades fixing that damage.’”
Jenson said most transgender children are aware of their gender before they start puberty. Her point is backed up by the same medical literature cited by Garwood.
In a 2020 study, 3.5% of participants in a survey of 214 youths with gender dysphoria discontinued reversible puberty blockers and chose not to start hormone treatment. In a 2011 study that researched hormone therapy specifically, none of the 70 transgender youth participants withdrew from hormone treatment.
Garwood said that, in her experience as a provider, once kids reach the point where they stop taking puberty blockers and switch to hormone replacement therapy, fewer than 1% revert to the gender assigned at birth. When they do, it’s often because of a lack of family acceptance or fear for personal safety.
Advocates emphasize the importance of other barriers to health care
Jenson said she regards bills such as the one in Missouri as another way for politicians to regulate the bodies of transgender people — particularly women of transgender experience. In doing so, they decide who qualifies as an authentic woman.
That said, she emphasized that it’s important not to let these bills distract from other barriers to health care for trans people and women of trans experience.
“I don’t want to completely say that this bill is a problem, when in fact, Missouri’s health care systems are the problem and Kansas’s health care systems are the problem,” Jenson said. “There’s a much larger system at play. Senator Moon is a single individual operator. It’s a greater issue of systemic violence towards trans people.”
Before any transgender child receives transition care, Jenson said, they need affirming parents, stable housing, financial security, health insurance and other necessities that are not always present for Black children, children of color or lower-income children.
“It’s been a critique I have presented to many of the health systems in Kansas City,” she said. “They are doing great work…but they know that work is still completely racially biased, and is not actually reaching everyone.”