By Rachel Crumpler
Atlas, a 15-year-old transgender boy living in Moore County, wants to have his body align with who he feels he truly is before leaving for college.
However, he’s now forced to come to terms with knowing that won’t be his reality.
Atlas’ access to gender-affirming health care in North Carolina was withdrawn on Aug. 16 when Republican lawmakers in the General Assembly overrode Democratic Gov. Roy Cooper’s veto of House Bill 808 — a law prohibiting medical professionals from providing puberty-blocking drugs, hormone therapy and gender-transition surgeries to transgender youth under age 18.
“I don’t want to be waiting for my body to catch up,” said Atlas, who requested that NC Health News only use his first name for privacy and safety concerns.
But that’s exactly what he will now have to do — live with his body not aligning with his gender identity for years longer than he planned since the General Assembly vote disrupted his goal to start testosterone.
“A form of treatment for our child has been taken away,” said Julie, his mom, expressing outrage that lawmakers would put her in this position by interfering with parents’ decisions.
Although Atlas said starting testosterone was his first choice, at this point, he said his plan is to pursue gender-affirming voice and top surgery when he is 18, rather than work through the logistical challenges of out-of-state care and expenses — tasks he said just feel daunting.
“It feels dehumanizing, like things that should be personal decisions — medical decisions that doctors say are good — are being taken away from me,” Atlas said.
For Atlas and other transgender youth younger than 18 in North Carolina, the state’s ban on gender-affirming care is thwarting personal medical choices and undercutting medical advice and expertise. Advocates say the law is forcing delays in needed and desired health care and imposing burdens on those seeking care out of state.
Less than three months after many transgender youth lost access to gender-affirming medical treatments, North Carolina families, medical providers and LGBTQ+ advocacy groups are seeing turmoil caused by the state ban. And they’re taking action to challenge House Bill 808.
The family of a transgender 9-year-old boy from Durham, a family physician providing gender-affirming care at UNC and national LGBTQ+ advocacy groups are suing state health officials to block implementation of the gender-affirming care restrictions.
The federal lawsuit filed Oct. 11 by Lambda Legal and the National Health Law Program alleges that North Carolina’s new law is unconstitutional. The lawsuit argues that the law discriminates on the basis of sex and transgender status and infringes on parents’ rights to make medical decisions for their children.
“This case is brought because of the importance of ensuring continued access to this care for transgender youth in North Carolina — that’s our first and foremost goal,” Omar Gonzalez-Pagan, counsel and health care strategist at Lambda Legal, said during a news conference announcing the lawsuit on Oct. 11.
Gender-affirming care for transgender adults and minors is considered medically necessary and often lifesaving by major medical organizations, such as the American Academy of Pediatrics, the Endocrine Society and the American Medical Association. Furthermore, more than 660 health care professionals across North Carolina signed an open letter opposing the state’s legislation restricting gender-affirming care.
Across the country, 22 states with mostly Republican-led legislatures have passed laws prohibiting gender-affirming care for transgender youth in the last two years — despite objections by medical professionals. Many of the laws are facing legal challenges.
A recent Arkansas ruling offers a glimpse about how North Carolina’s case could play out, Gonzalez-Pagan said. In June, a federal judge struck down Arkansas’ ban on gender-affirming care for minors as unconstitutional — the first ruling in the country to overturn such restrictions. Court injunctions in several other states are ensuring continued access to care while the legal process unfolds.
That’s what lawyers are asking to happen in North Carolina.
Riley Smith, the physician plaintiff in the case who is suing on behalf of his patients, said at the Oct. 11 news conference that lawmakers do not understand what taking away gender-affirming care for this population means — the toll it inflicts by denying transgender youth the opportunity to live as their authentic selves.
“I could recite statistics on rates of violence, harassment, depression or suicide,” Smith said. “But this work is not about numbers. It’s about people.
“It’s about the 15-year-old living in a conservative town who drove two hours to his appointments and by starting testosterone gained the confidence he needed to finish high school and go to college with a full scholarship,” he said. “It’s about the 16-year-old who was so dysphoric about her body that she had to turn the lights off just to take the shower but who started taking estrogen and has now grown into a self-assured young woman who can now focus on regular teenager things like her friends, her schoolwork and her extracurriculars. These are the stories and the real lives of my patients.”
Before the ban on gender-affirming care took effect, Jennifer Abbott, a family physician in Asheville who has provided gender-affirming care for 16 years, saw about four new teenagers a month who were seeking to start puberty blockers or hormones.
The need is still there, but she said she can no longer serve these patients. It’s distressing, Abbott said. She has spent years building the skills and knowledge to provide the evidence-based health care to help teens with gender dysphoria who are struggling.
Not every young person with gender dysphoria — a condition in which there is a conflict between the sex assigned at birth and the gender someone identifies with — needs gender-affirming health care, Abbott explained. Sometimes, a child being affirmed by their choice of pronouns or the clothes they want to wear is enough to relieve gender dysphoria, she said.
But for youth in which gender dysphoria is taking a toll on their mental health and other facets of their lives, gender-affirming medical intervention can be the answer.
“I’ve seen teens come in on three and four mental health meds,” Abbott said. “They’ve been hospitalized. Their family has tried every single thing to try to alleviate their child’s suffering. And really what they need is to be on gender-affirming hormone therapy. And when that happens, everything clicks. They are thriving in school. They are participating in activities. They are able to get off of some of their mental health meds — or all of them.”
Alex Street, a 16-year-old transgender teen in Moore County, said starting gender-affirming hormones was a critical step to have her body align with who she knows she’s always been on the inside.
“Trying to become who I need to be without gender-affirming care always felt like I was swimming upstream — like impossible,” Street told NC Health News.
For years, Street described her gender dysphoria as “crippling.”
She was distressed by her body — the development of broad shoulders, a square jaw, dark body hair. She developed an eating disorder. She attempted suicide.
After an extensive process of therapy, meetings with medical professionals, discussion of risks and undergoing tests, Street took her first dose of estrogen in March.
“The second I took it, I felt satiated,” she said.
For the first time, she says she felt content — at peace in her body.
She couldn’t have waited much longer for gender-affirming health care, potentially a few more months, she said, but certainly not to age 18. She said she would have committed suicide.
Erica Street, her mom, knows starting estrogen was the right call. She’s seen her child’s confidence and happiness blossom.
“It’s always been, like, what can we do to keep my child alive?” Erica Street said.
Rhett Brown, a family physician in Charlotte who has provided gender-affirming health care since 2010, worries about transgender youth who have fallen into a care gap in North Carolina, no longer able to access gender-affirming treatments in the state.
He said transgender youth will suffer without access to appropriate treatment in North Carolina. The population is already vulnerable to higher rates of depression and suicidality, he said, and denying gender-affirming care to those who need it will make mental health outcomes even worse.
“It’s going to result in a significant amount of pain, and it’s going to result in unneeded death,” Brown said.
Noah Granade, a transgender psychotherapist practicing in Charlotte, who works with many transgender adolescents, agrees. His clients are voicing new concerns and anxieties about their safety and futures as a result of the legislation and two other recently enacted North Carolina laws that restrict the rights of transgender youth in sports and schools.
“One thing that often helps younger folks is having a sense of hope, having a sense of something to move forward to — that one day I might be able to feel this congruence in my body,” Granade said. “Now that being pushed way farther out or completely taken away creates a sense of hopelessness in addition to those layers socially, where not only do you not get access to the care you need, but you’re also being told that it’s bad and wrong to even want that care. That is a really dangerous cycle to be in.”
Granade said many families with transgender youth have put in a lot of work to understand their child’s identity, including how gender-affirming medical care may be needed to find congruence with their bodies. They’ve come to a place of acceptance and are ready to move forward with gender-affirming care now or in the months and years ahead.
He says it’s “whiplash” for that care to no longer be an option in North Carolina, upending planned medical journeys.
The effects of the state’s gender-affirming care ban are not limited to only those who can no longer receive health care, Granade added. Transgender adults and youth who have benefited from gender-affirming care are repeatedly verbalizing intense concern and distress for peers who may now be forced to go without the care that they personally know has the power to be lifesaving, he said.
Alex Street said she’s also grappling with the additional uncertainty and fear of what lawmakers could decide to restrict next. She’s anxious that her gender-affirming care could be jerked away.
“I do not know what they can or cannot control,” Alex Street said. “I do not know what my level of safety is.”
Every month when Alex’s hormone prescription is ready, Erica Street said her daughter insists they pick them up immediately because she fears they could be cut off.
Her concerns aren’t completely unfounded. Abbott, a physician who continues to legally provide hormones to patients she started seeing before Aug. 1, recently had a pharmacist call her practice insisting that testosterone could not be provided to an older teen and refused to fill the prescription.
Abbott said this is an example of over-interpretation of the law that affects youth who can still receive care within the scope of the law.
Navigating out-of-state care
Due to North Carolina’s law, transgender youth are now forced to delay starting gender-affirming care until age 18 or pursue the care out of state.
It’s a complicated access landscape since most Southern states have now passed legislation preventing medical professionals from providing gender-affirming health care to transgender youth. The Campaign for Southern Equality estimates that about 90 percent of transgender youth in the South live in a state where this type of care is banned.
The rapidly shifting landscape of access prompted the Campaign for Southern Equality to launch the Southern Trans Youth Emergency Project earlier this year to help transgender youth continue to access care out of state by providing families with direct support finding providers and offering grants to cover some expenses.
Project manager Carolyn Jones said North Carolinians quickly started seeking help navigating care across state lines after the state’s law took effect.
For example, Jones said, a family in North Carolina was left in a tough spot after an appointment scheduled at Duke’s Child and Adolescent Gender Care Clinic for their 12-year-old child to start puberty blockers did not come soon enough. Because the care was not ready to be initiated before Aug. 1, the family had to pivot away from the medical providers they had an established relationship with to travel to Virginia to receive care that had been years in the making.
Every family’s plan is different, Jones said, but South Carolina and Virginia — two nearby states without bans — are frequently places where North Carolinians can pursue care, though that’s not always the answer.
“Some families traveling to Seattle for one reason or another makes more sense than traveling to Virginia,” Jones said. “Maybe they have family over there. Maybe they have a really young kid and just want to establish something really consistent within a state that they could guarantee will be safe for that care for the time being.”
Jones said her work is constantly cobbling together a network of regional providers who will take on patients in these circumstances. It’s a job that’s gotten harder due to an increasingly restrictive environment and providers stepping back from advertising their services or providing the care altogether due to being targeted by protestors and news coverage.
But Jones emphasized that bans on gender-affirming health care, like bans on abortion, are not stopping people from receiving the medical care, just forcing people to get it in a more complicated, onerous way.
“Families are still moving mountains to get their child the care that they need,” Jones said. “It’s very inspiring to see what families have done and continue to do to make sure that their child gets what they need in the face of legislative horror, for lack of a better term.”
Medical providers and families with transgender youth say it shouldn’t be this difficult — that the evidence-based care should be available in their home state.
“The legislature has not walked a mile in our shoes,” Erica Street said. “They have not lived in our house. They have not experienced dysphoria. So how dare they make a decision they know nothing about? Trust doctors. Trust parents. Let us work together for the benefit of our kids.”