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David Remnick: In many parts of this country, we're seeing a backlash against LGBTQ people like nothing in recent memory. In Florida, the bill infamously dubbed "Don't Say Gay" tries to prevent teaching about gender and sexual identity for young kids in school. The effect may be much broader than that. The state of Alabama has banned doctors from providing what's known as gender-affirming care to children, making that a felony punishable by up to 10 years in prison. A judge just put on hold parts of that law, but similar measures have been proposed in many states, including Texas.
Rachel Monroe: In Texas's last legislative session, there was an attempt to criminalize gender-affirming care for children, but that effort failed.
David: Rachel Monroe is based in Texas and she reports from around the Southwest.
Rachel: It seemed like that was the end of it for at least the short term, but then the governor and the attorney general of the state issued a legal opinion earlier this year that classified gender-affirming care as child abuse. That has faced a bunch of legal challenges. It's working its way through the courts and it is, at the moment, on hold. The general expectation is that that bill that failed in the last session, the one that criminalized gender-affirming care, we're going to see that come back in the next legislative session and that, this time, there's a much stronger chance that it'll pass.
David: Measures like these in Texas and elsewhere are generally framed as a measure to protect children.
Rachel: I think there's a lot of misinformation going around about what it actually means to get gender-affirming care. There's a lot of focus on the idea that children are getting surgery, irreversible surgeries, which is really not the case. There's a lot of language describing gender-affirming care as mutilation.
I think there's a sense that hormone treatments are something that is provided kind of recklessly and on-demand that all you have to do as a teenager is walk into the doctor's office and ask for some hormones. The next thing you know, you're getting treatment from the providers that I've talked to and the patients that I've talked to. This care often proceeds quite slowly and often much more slowly than the patients themselves would prefer, but there's a real sense that caution is a priority.
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David: Rachel, can you define simply what gender-affirming care refers to? Because I think people's familiarity with this varies a lot.
Rachel: Sure, so gender-affirming care is a term that is used to refer to any kind of care that affirms a patient's gender identity. That can be all sorts of things, including using a trans girl's preferred name and preferred pronouns. Usually, when we're talking about it in a legal context, what's being talked about there is the medical aspect of gender-affirming care.
On that side of things, the first step in a medical protocol is usually medications known as puberty blockers. These are essentially medicines that put puberty on pause and gives patients and families the chance to buy some time and to discuss how they want to proceed what's best for them, what's best for the child, what's best for the family. The step after that would probably be hormonal treatments. That's estrogen for trans girls and testosterone for trans boys.
David: Rachel, you've been talking with some of these families for months. What are you hearing?
Rachel: There's a lot of fear and a lot of frustration and a lot of uncertainty, which I think is really tough on these families that are trying to figure out the best way forward with their kids, not knowing what the legal status of their medical treatments is or is going to be a year from now, two years from now. I've been talking to one family in particular. They're a family of four in Galveston. I first started talking to them pretty soon after the governor and attorney general's order came down when they were worried that their child wasn't going to be able to receive medical care anymore. She's 13. She's trans. She's socially transitioned for a few years now. I talked with her mother again just recently.
Have you kind of gamed out with your family, best-case scenario, worst-case scenario, short-term, long-term like, "This is what we might have to do"? Can you walk me through some of that thinking?
Mother: Yes, absolutely, we have. Initially, we discussed that we would absolutely find care out of state. We navigated that and, at this point, have a relationship and a backup relationship in place, two different states, depending on what happens in those states. It's just still unbelievable to me that we have to discuss that plan and then where we would go if we had to temporarily relocate, how that would look. My husband and I both work and we have another child in high school. That would be a challenge. We would absolutely do everything we can to keep our child safe.
Rachel: What would you want people who don't live in Texas to understand about what your life is like now? What do you think they might not understand or might not know that would be good for them to know?
Mother: You're dealing with a child. That feels uncomfortable as just about every moment of their day and how unhappy and uncomfortable they are, and to try to think about being a parent of that child and see that child hurt emotionally and not understand why people are talking about them and are focused on them, and that they're just doing their best in our experience to survive the day. I would just hope that we would take a step back and give these families a chance to work with their medical providers.
Rachel: For your family, what would an interruption and care mean? What kind of impact would that have on you and your daughter?
Mother: I would say, right now and even in the last several months, if we were to stop care, I would be afraid that our child wouldn't survive. I would absolutely. There's no question that she's not safe to herself.
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David: Now, Rachel, you also wanted to talk with doctors in Texas who provide this kind of care and you couldn't find a doctor who would speak on the record, right?
Rachel: Yes, I think, for doctors, there's a real strong sense that coming forward and being vocal about these issues is just risky for them and their practice and, ultimately, their patients. Even in states where these kind of anti-trans political issues aren't gaining traction, specialists are still really wary of attracting attention. I was ultimately able to find somebody outside of Texas who was willing to go on the record. Her name is Gina Sequeira and she's the co-director of the Gender Clinic at Seattle Children's. One thing that's interesting about her practice is that she also sees patients who come in from Idaho, which is a place where lawmakers have recently tried to ban gender-affirming medical care.
Gina Sequeira: One bill that really came close to home for us was proposed and unfortunately passed through the House, HB 675. What that bill said was that for myself as a medical provider to continue to provide the gender-affirming medications that I currently provide to patients in Idaho, I would have been at risk for receiving felony charges for continuing to provide this care. Even more concerningly, this bill had language in it that would criminalize family members for driving a patient across state lines.
Rachel: You mentioned that there had been some protests. Can you talk about them a little bit more specifically like who was protesting? In what way?
Gina: Yes, for sure. It's unclear to me who exactly they are or what kind of the intent of these protests was outside of making it very clear that they did not agree with the fact that we were providing gender-affirming care. Fortunately, both of the days that the protests took place were not actually Gender Clinic days. We did not actually have patients that were coming into our clinic, have to walk by the protesters themselves that day. I do think just trying to wrap my head around the fact that that's a conversation that I would need to have with a 10-year-old or an 11-year-old is really horrifying.
Rachel: It's hard for me not to think about some of the reporting that I did. I guess it was last fall at the Jackson women's health clinic, which is a clinic in Mississippi. It's the center of the abortion case that the Supreme Court is seeing right now. I just remember talking to them about the protestors there who are very long-standing and very aggressive and who've come up with these tricks to call the clinic to figure out what days the clinic is seeing patients so they can target their protests. It's hard not to-
Gina: -make that parallel.
Rachel: -make that parallel and see how that--
Gina: I've definitely made that parallel as well. I think, honestly, some of the online threats to sue me, threats to come to the clinic, I think I really started to say, "Who can I reach out to, to try to help me figure out how to navigate this?" It was those colleagues who had experience as abortion providers that I think really have that expertise and know-how to navigate some of those pieces. Sadly, I think there's going to be a lot that we as gender care providers, especially gender care providers for kids, need to learn to protect ourselves and protect our patients and their families.
Rachel: I was just speaking with a physician in Texas who treats trans kids before I got on the phone with you. They were really anguished about feeling like they couldn't really come forward. They feel like they have this incredible amount of experience. As a provider, they know the science and the research. They could be a really strong voice in this conversation. They're who we should be hearing from.
They felt like if they spoke out, they would be subject to harassment that the clinic that they work for might be subject to harassment, and that, ultimately, the harm to their patients wasn't worth it, and so they were staying quiet. You're, I think, one of only a handful of providers that I've seen speak publicly under your name talking about these things. I'm wondering, was that a decision for you and how you came to decide it was the right thing to do?
Gina: Yes, I needed to know that that is, I think, the norm today. I'm on meetings with other gender clinic leaders from across the country. The vast majority don't feel like that they would be supported either by their institutions, by their clinics in speaking publicly and going on the record. I think some of it is fear over losing their jobs. Fear over what additional publicity in their state would look like for their patients and families, I think, is a huge one. I think many of them are really struggling with being silent. I think it is so important. I think, really, my decision to come forward and speak out and go on the record was a really hard one.
I was growing so frustrated seeing the narrative around this, around gender-affirming care provision for youth so full of misinformation and so full of just blatant falsehoods that I couldn't in good conscience, I don't think, continue to stay quiet. I don't know. I think it felt really important to me to have regular people see someone's face that is another regular person. Someone that they could see and put a face to and like myself being visible would help normalize this care in some way that I'm not a radical person. I'm a pediatrician and I am really passionate about caring for kids and I want kids to be well.
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David: That's Gina Sequeira, who's co-director of the Gender Clinic at Seattle Children's Hospital. She's speaking with our reporter, Rachel Monroe, and we'll continue in just a moment. This is The New Yorker Radio Hour.
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David: This is The New Yorker Radio Hour. I'm David Remnick. We're talking today about the attempt in several states to ban doctors from providing gender-affirming medical care for trans children. Now, that's already happened in Alabama and it's been proposed in Texas and elsewhere. What the Texas ban would mean is not entirely clear. It's being fought out in the courts, but the governor and the attorney general issued an opinion that calls the use of hormones and other medical treatment a form of child abuse. Rachel Monroe has been reporting on this story for The New Yorker. Let's continue with her conversation with a pediatrician, Gina Sequeira, who co-directs the Gender Clinic at Seattle Children's Hospital.
Rachel: When you decided to specialize in this field, did you have any idea that this level of political and social backlash would be part of your working life?
Gina: I could have never imagined that this day like today that we would be talking about families fleeing states in our country to be able to continue to get this care for their kids, that we would be in a position where we see nearly 250 anti-LGBTQ bills in one legislative session. Never in a million years would I have guessed that this would be our reality.
Rachel: I can't imagine a lot of people going into pediatrics or pediatric endocrinology or think that they're going to be on the front lines of a political battle.
Gina: Yes, I don't know. I also want to acknowledge. I don't know that-- [sighs] I think I'm not naive as someone who grew up in Texas, did a good bit of my medical training and undergrad in med school in the south in New Orleans. I think I was aware of what it was like to be a queer person in the south, but I think never did I think that this care would be politicized in the way that I have seen it over these last couple of years.
Rachel: When did you start to notice things changing or ramping up?
Gina: I think I had, especially on the political side of things, really distinctly remember one of my colleagues in Pittsburgh, where I did my adolescent medicine fellowship, come to me and say, "Hey, did you hear about this bill?" That was just proposed in Ohio. I want to say, this is probably 2019. I remember thinking like, "There's no way this could make it out of committee. This is so fringe." Even then, we had data suggest the positive impact on mental health. Now, we have so much more.
We have the American Academy of Pediatrics and every other reputable medical organization standing in support of this care. It is mind-boggling to me that this has happened really over three years. It feels like it goes through one state and then it pops up somewhere else in the next state. Almost like whack-a-mole like you put all of this effort into advocating against it in this state and then it just pops up somewhere else. I think it's definitely taking a toll.
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Rachel: You mentioned that Idaho bill earlier that the state considered this bill that would've opened up providers like you to felony charges for providing gender-affirming care and would've criminalized taking children across state lines as you just said. That bill, as I understand, it was killed by Republicans in the state who objected to it on privacy grounds, arguing that it interfered with parental rights and was some form of governmental overreach. I'm just curious what you made of that.
Gina: [sighs] Oh, that's a good question. I think, honestly, I was so grateful that it was squashed and that we had a little bit more time to prepare for the next time. [sighs] I don't even know that I had a chance to wrap my head around like beyond feeling just this sense of relief that we were going to be able to continue to provide care for our kids in Idaho.
Rachel: Are you hearing from families in Alabama, in Texas, in places farther afield from that region that you primarily work in?
Gina: Yes, absolutely. We've had many calls from families in Texas and definitely have multiple patients who were receiving gender-affirming care in Texas who are relocating to Washington to establish care with us without a doubt. I think this is something that is going to continue as we have more and more states proposing legislation like this or having their politicians enact policy in the way they have in Texas that we are just going to continue to see more and more kids and families.
Rachel: From the families that I've spoken with in Texas, it seems like there's a real patchwork effect happening now where you have-- Some physicians are ceasing to provide this kind of care entirely. Some are providing it, but only to preexisting patients. Everybody's wondering what's going to happen in the next legislative session. Just a lot of things that are up in the air. I guess I'm just wondering, what kind of impact is that having and are you seeing that playing out in the people that you're caring for and what does it do to care and to those people's lives?
Gina: I think there's maybe two parts to that answer. I think one is very clearly that interrupting gender-affirming care, whether that's puberty blockers or gender-affirming hormones for a young person, I don't think-- [sighs] It is incredibly harmful. We know that transgender-diverse youth have experienced higher rates of depression and anxiety and suicidality. I think I am very scared that young people are being forced to discontinue care as is happening today in Alabama. I'm really fearful for the impact that will have on mental health.
Rachel: I think all the time about this mom I was interviewing who talks about her daughter. She was like, "We just want her to get to 25." That's the thing driving all of our choices, which is just really wild. Now, as you mentioned, all the major medical associations have a clear position supporting gender-affirming care for trans kids. There have been a number of studies showing that this care is correlated with positive mental health outcomes. Is it also fair to say that using puberty blockers in conjunction with hormones is still relatively new in a youth population?
Gina: I think using puberty blockers in conjunction with hormones, I think that's a fair statement. However, I think just talking about puberty blockers specifically that I think have been so much the focus of the attacks from legislators in Texas especially are the same medications that are used in patients with precocious puberty or early puberty. These medications have been shown to be incredibly safe in that population for 30-plus years. You're right to say that there are some differences in the way we approach like if a young person were to initiate puberty blockers and then go on to gender-affirming hormones. I think puberty blockers by themselves, I think there is a relatively robust evidence base in youth themselves.
Rachel: On the right, I think the relative newness of this form of treatment gets used as an argument that it just shouldn't be offered at all, that it's too risky, too many unknowns. Is there any truth to that at all?
Gina: I don't think so. I think, as a pediatrician, there's a whole lot of the care that we provide in pediatrics that hasn't been robustly studied. It's not okay for us. It's not ethical for us to withhold care from a patient when we have evidence to suggest that it actually has a positive impact on mental health. I think that's one narrative that I feel like I hear frequently, especially in the lay media that we don't have randomized control trials.
We're not going to have randomized control trials because it's not ethical. What we can do is follow large cohorts of kids and understand the impact of care like the impact care is having on them. There's a lot of nuance that is necessary, I think, as it relates to providing this care to youth and to their families. I think it's been really hard to see it be a pawn in politics right now.
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Rachel: I guess just to close, as you said earlier, it seems like a lot of this intensity and this politicization and these laws have come up very suddenly. I'm just wondering what you think is the path forward. Where are we going to go from here?
Gina: [sighs] To see things go from really what felt like 0 to 60 in the last three years is really scary, especially in light of what's happening with the Supreme Court. I think it is possible that that is the direction this goes. I think that on one hand. Then I think, on the other hand, I see this incredibly resilient group of young people that I have the absolute privilege of taking care of every day and see them despite feeling incredibly anxious about what they're seeing politically. I also see them mobilizing with one another and fighting against this kind of rhetoric and this hate, but I have to be honest that I'm nervous about what the next couple of years looks like.
David: Gina Sequeira is a pediatrician and co-director of the Gender Clinic at Seattle Children's Hospital. We heard earlier in the segment from a mother in Galveston who asked to remain anonymous. Rachel Monroe writes our column Letter From the Southwest, which you can find at newyorker.com.
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