What is gender dysphoria? Answering your questions on Ohio care for trans youth

In recent months, a wave of proposed state laws has placed Ohio at the center of a national debate on LGBTQ+ rights.

Among them is a bill approved by the Ohio House on June 21 that could severely limit access to medical treatment for transgender or questioning minors.

House Bill 68 would ban therapists from diagnosing or treating minors with gender dysphoria without parental consent, and would prohibit the use of puberty blockers and hormone therapy for minors. The bill does not include an exception for minors who have already started treatment, meaning they would have to leave the state to seek health care.

Some Ohio Republicans have raised concerns that gender-related health care is dangerous, and that youth cannot consent to “permanent medical procedures.”

"These medical interventions are not evidence-based, but simply experiments on Ohio’s youth ... Our only concern is for the physical safety and mental health of children that are incapable of providing informed consent," said Rep. Gary Click, R-Vickery, the primary sponsor of House Bill 68, who also serves as a pastor. "There is no place for ideology or activism in this debate."

Opponents and health care providers say the bill threatens some forms of treatment that are often considered medically necessary for transgender youth. Some say that parts of the act demonstrate a misunderstanding of what treatment options actually look like for minors.

As the bill moves to the Senate, The Dispatch spoke with local health experts to answer questions about gender-affirming health care.

What is gender dysphoria?

Gender dysphoria is a medical condition that people experience when their sex assigned at birth does not align with their gender identity — their psychological sense of their gender. Transgender people often experience medically diagnosed gender dysphoria.

Gender-affirming care is an umbrella term used by some medical professionals for many types of health care that can help recognize people’s gender identities. This can include therapy and other mental health services, the use of medication treatments, or surgery.

What are puberty blockers?

Puberty blockers are one of the most common forms of health care for minors who are questioning their gender, according to Teagan Vaughn, senior director of gender-affirming care for Equitas Health.

“These are really pause buttons that work anywhere from a month to three months, and then they wear off, and that child's natural puberty kind of takes over again,” Vaughn said.

Studies show that there are no known irreversible impacts of puberty blockers.

What is hormone therapy?

Hormone therapy is usually an option for individuals who have diagnosed gender dysphoria and are ready to begin transitioning. Transgender women are typically prescribed estrogen, while transgender men are typically prescribed testosterone.

These treatments aim to spur the development of male secondary sex characteristics in trans men, or female secondary sex characteristics in trans women. This can help to “augment the aligned gender” of the patient, Vaughn said.

Changes undergone during hormone therapy are typically more permanent. According to the World Professional Association of Transgender Health, reproductive issues — including infertility — are a major risk of hormone therapy that must be discussed with all patients. Other risks, which Vaughn said are often minimal, do persist and should be considered before starting treatment.

For this reason, Vaughn said most patients start with puberty blockers and may begin hormone therapy later in their adolescence, depending on decisions made by the patient, their family and their medical care team.

Legislators on both sides of the aisle have also acknowledged that there is little research on the long-term impacts of hormone therapy, increasing the potential risks for adolescents undergoing such treatment.

If House Bill 68 is passed, it will become impossible for Ohio youth to legally access hormone therapy or puberty blockers, forcing current patients to either detransition or seek medical care in other states.

How easy is it right now to get a prescription for puberty blockers or hormone therapy?

According to Nick Lashutka, president of the Ohio Children's Hospital Association, children’s hospitals across the state have a “rigorous multidisciplinary team” that works with patients and families who report experiencing gender dysphoria.

“It is deeply rooted in mental health,” Lashutka said. “There's a rigorous evaluation that occurs before any type of medical treatment is recommended to the family to consider.”

Dr. Mark McLoney, a board member of the Ohio Academy of Family Physicians, said that "one of the biggest misconceptions that people are pushing with (House Bill 68) is that a kid can walk into a doctor's office, say they're transgender, get started on hormone blockers and hormones, and the next week they’re scheduled for surgery. That just does not happen that fast.”

Timelines for treatment regimens vary from patient to patient, Vaughn said. Most treatment centers will ensure patients have attended therapy and have received a clinical diagnosis of gender dysphoria before prescribing puberty blockers, Vaughn said, noting that hormone therapy is typically not prescribed until later in adolescence.

Liam Strausbaugh, practice associate at the National Association of Social Workers Ohio Chapter, said most Ohio medical professionals screen minors questioning their gender for comorbidities such as depression or anxiety before issuing a diagnosis.

House Bill 68, if approved by the Ohio Senate and signed into law by Gov. Mike DeWine, would require parental consent for all therapy options or medical treatments, though Strausbaugh said laws that require parental consent are already in place.

The bill could also require mental health professionals to screen all patients for ADHD and autism before considering a diagnosis of gender dysphoria. While Strausbaugh said professionals typically refer patients they believe may have ADHD or autism for these tests, he added that screening every patient for these disorders can be "lengthy and expensive," which could increase wait times for minors seeking treatment.

If House Bill 68 goes into effect, health care providers would still be able to offer counseling for gender-related conditions.

Are Ohio doctors performing surgery on transgender minors?

The consensus among experts The Dispatch spoke with is that gender reassignment surgery is not being performed on minors in Ohio or anywhere else.

Some of the discussion about House Bill 68 has revolved around some politicians’ concerns about the dangers of gender reassignment surgery. The bill includes a provision to ban gender reassignment surgery for minors.

“There are no surgeons who are doing genital surgeries on children at all, anywhere in the United States,” Vaughn said.

The analysis of the bill cited a rise in recent referrals for children to have genital and nongenital reassignment surgeries as a concern for lawmakers.

In its 2022 standards of care, the World Professional Association for Transgender Health (WPATH) recommended that adolescents should only be considered for gender reassignment surgery once they have reached Tanner Stage 2 of puberty, which usually occurs around ages 9 to 11. This is a younger baseline than was used in previous WPATH standards of care, and drew some criticism last year. Other WPATH criteria for adolescent surgery include sustained evidence of gender dysphoria and more tha 12 months of hormone therapy.

Most health care providers, including Ohio State University's Wexner Medical Center, follow the WPATH standards of care. Currently, the University Hospitals system in Cleveland requires patients to be 18 before considering gender reassignment surgery. Planned Parenthood of Greater Ohio also requires patients to be 18 before starting hormone therapy.

How high is the 'regret rate' for gender-related treatment?

Some proponents of House Bill 68 have raised concerns that many patients, especially those who are treated for gender dysphoria as minors, may regret undergoing treatment. If passed, the bill will assert on behalf of the Ohio General Assembly that most minors who identify as transgender will outgrow it in adulthood.

In the debate surrounding the bill, different stakeholders have cited different numbers on how many transgender youths transition back to their gender assigned at birth later in life.

Lashutka said that, while some minors do decide to detransition later in life, this represents a minority of patients. The Associated Press reported in March that a recent review of studies found that about 1% of adults and adolescents who transitioned ended up detransitioning later in life. A 2022 study by the American Academy of Pediatrics found that 2.5% of youth had detransitioned five years after their initial social transition.

Rep. Click and other sources maintain that between 85 and 95% of people who experience gender dysphoria in adolescence come to naturally identify with their sex assigned at birth by adulthood.

Some sources have claimed that numbers above 80% are "myths" and stem from a series of faulty studies.

Vaughn said Equitas Health sees an extremely low regret rate for gender-related treatment.

Mental health treatment is also key to ensuring that patients and their families are certain about diagnoses of gender dysphoria before undergoing treatment, McLoney said. While therapists can help minors seek treatment for gender dysphoria, they can also simply offer support to anyone questioning their gender without seeking a diagnosis, he said.

“That's where behavioral psychology and everything continues to grow because that's really where we need help with these kids, you know, to help them decide, is this really the best change for you,” McLoney said.

lcarey@dispatch.com

This article originally appeared on The Columbus Dispatch: How will House Bill 68 limit health care for Ohio transgender youth?