Legal fight over Texas law banning transgender health care for youth centers on whether treatments help or hurt

Laura’s son holds his Pride flag at Discovery Green in downtown Houston on Sunday, June 25, 2023.
LGBTQ+ Texans and some doctors are suing the state over a new law that seeks to ban puberty blockers and hormone therapy for transgender kids. Credit: Annie Mulligan for The Texas Tribune

At the heart of the legal fight over Texas’ new ban on puberty blockers and hormone therapy for transgender children is an ongoing debate about whether those treatments help or hurt youth with gender dysphoria.

During a two-day hearing over an attempt to block the law from taking effect Sept. 1, medical experts testified that such gender-affirming treatments are safe. The state attorney general’s office called on its own scientific professionals, who cast doubts on the existing research.

Families of trans youth and medical professionals are suing Texas, asserting that state lawmakers discriminated against trans youth in crafting the prohibition and that the law violates the rights of parents to choose medically approved care for their children.

The new law does not ban any particular treatments or medical care outright. They are prohibited only for the purpose of gender transitioning.

“Make no mistake, our doctors are not being targeted for the type of care they provide. They are not being targeted for the quality of their care. They’re being targeted because of the community they are providing care for,” Alex Sheldon, executive director of GLMA, an association of LGBTQ+ health professionals that is one of the plaintiffs, told reporters outside the courthouse on Wednesday.

The state rejected the claim of discrimination. In her opening statement, Assistant Attorney General Heather Dyer rejected the plaintiffs’ claim that Senate Bill 14 discriminates based on sex because, she said, people with gender dysphoria are not a protected class.

“SB 14 was designed to protect minors from scientifically unsound treatments,” Dyer said.

The new law would ban transgender youth from taking puberty blockers, receiving hormone therapies and having transition-related surgery, the latter of which is rarely performed on minors. Such medical interventions are used to treat gender dysphoria, a medical term for the distress someone experiences when their gender identity doesn’t match their body. The plaintiffs assert that the new law violates their parental rights and interferes with their ability to practice medicine.

Legal groups including the American Civil Liberties Union of Texas, Lambda Legal and the Transgender Law Center requested that Travis County District Court Judge Maria Cantú Hexsel issue an injunction against the law.

Doctors defend gender-affirming care

Dr. Johanna Olson-Kennedy, a doctor who treats adolescents and has been providing gender-affirming care for 17 years, said the body of medical research demonstrates these treatments have a high success rate in improving mental health outcomes of trans youth. But in her clinical work, the evidence is more obvious.

“Recently, I had one of my patients tell me, ‘If you had not allowed me, and helped shepherd me through these interventions, I don’t think I would be here,’” said Olson-Kennedy, the medical director of the Center for Transyouth Health and Development at Children’s Hospital Los Angeles.

She added that hundreds of her patients have expressed the same sentiment in her nearly two decades treating roughly 1,100 young patients.

A central argument of lawmakers supporting SB 14 during the legislative session was that puberty blockers and hormone therapies put young patients at risk for fertility loss and a reduction of bone density. Defense attorneys for the state repeated these claims.

The medical experts called on by the plaintiffs rejected those claims Tuesday, arguing that the scientific literature supports the use of hormones or puberty blockers as a means to improve the mental health of transgender youth and reduces the dysphoria these young people feel.

“I would not consider estrogen or testosterone the end of the story for fertility,” said Dr. Daniel Shumer, a pediatric endocrinologist at the C.S. Mott Children’s Hospital in Ann Arbor.

Pediatric endocrinology is the field of medicine that specializes in transgender adolescent health care.

Representing the state, Assistant Attorney General Johnathan Stone asked Shumer about the number of his patients who stopped receiving gender-affirming treatment. A group of people who refer to themselves as detransitioners have been vocal opponents of gender-affirming care for youth in legislative hearings throughout the country. During this year’s regular Texas legislative session, Republican lawmakers called on several people who had detransitioned to testify in support of SB 14.

Shumer said of his roughly 400 patients, 10 had stopped taking puberty blockers, a reversible treatment that delays the onset of puberty, and two had stopped taking hormones.

Olson-Kennedy noted that there are a variety of reasons people detransition — including a lack of acceptance of their new identity or a loss of health care access — but overall, the number of people who do take this step is very small.

Dr. Aron Janssen, a psychiatrist at the Ann & Robert H. Lurie Children’s Hospital of Chicago, testified to the evidence that psychotherapy alone cannot alleviate gender dysphoria, asserting that puberty blockers or hormone therapy is medically necessary. By restricting access to these treatments, young patients will have worse outcomes, Janssen said.

“There’s an intense improvement we see amongst these kids,” Janssen said of his clinical experience.

The defense

The state disputed the efficacy of puberty blockers and hormone therapy based on the amount and quality of research. Other witnesses for the state argued transgender people can not change their sex and that young people cannot comprehend the long-term implications of these treatments.

The state’s first witness on Tuesday was evolutionary biologist Colin Wright, who has a Ph.D. in evolutionary biology and ecology from the University of California Santa Barbara. Wright testified that humans can only be “observed and recorded” as either the male or female sex. While individuals can modify their secondary sex characteristics, like body hair and breast development, Wright said people cannot change their sex.

Lawyers for the plaintiffs noted that Wright was not an expert in gender dysphoria and had not published original research on the topic of biological sex. Wright, who is vocal on his social media platforms about his opposition to gender-affirming care for minors, was asked if he thought transgender individuals were delusional. Of the idea that people can change their sex from what was assigned at birth, he said, “that specific belief is a delusional belief.”​

Dr. Michael Laidlaw, an endocrinologist affiliated with the Sutter Roseville Medical Center in California, said Wednesday that the risks of using puberty blockers and hormone therapy outweighed the benefits. He said reviews of the existing research on these treatments indicate there is limited evidence to show the benefits of using puberty blockers on minors.

Katrina Taylor, an Austin-based therapist designated as an expert witness in psychotherapy, offered starkly different testimony about the origin of gender dysphoria in children.

“When there is gender dysphoria, I see it as a symptom of the family,” said Taylor, the state’s expert witness on psychotherapy. “There’s something going on in that family system that is awry, that is going wrong.”

The state focused attention on the concept of “informed consent” — the agreement to provide care between a health care professional and their patient — and whether minors could agree to receive puberty blockers, hormone therapies and surgery.

Dr. Clifford Hopewell, a North Texas neuropsychologist and former Texas Psychological Association president, said an adolescent’s reasoning was limited based on their brain development and therefore couldn’t appreciate the risks of some gender-affirming care treatments.

“They don’t know what puberty blockers are,” Hopewell said. “An adolescent doesn’t understand that.”

Texans testify

Wednesday was the second day of Nathan Noe’s new school year, but instead of spending the morning at high school, he was in the Travis County Civil and Family Courthouse testifying on how SB 14 would cut him off from life-changing medical treatments. For two years, Noe — who is using a pseudonym as a plaintiff for the lawsuit — has been taking testosterone, which he said dramatically shifted his life for the better.

“I was able to go about my life as a teenage boy, like I wanted to,” Noe said, smiling on the stand.

Parents of trans youth like Noe testified about the impact SB 14 would have on their families. Another parent, identified by the pseudonym Mary Moe, said she and her daughter have moved out of the state in the wake of SB 14.

“I would like to return to Texas, but Texas has become very ugly to me and my family,” Moe said.

Texas health care workers, also named as plaintiffs in the lawsuit, spoke to SB 14’s impacts on their practice. Dr. David Paul, a pediatric endocrinologist who works at Texas Children’s Hospital in Houston, said SB 14 would strip him of the ability to provide the standard of care for his transgender patients.

“They are probably the most positive outcomes of all the patients I see,” Paul said of patients who receive gender-affirming care. If his patients couldn’t access this type of care, Paul said he worries their physical and mental health will deteriorate. He added he has already lost one of his patients to suicide.

To attest to the regret some people experience after receiving gender-affirming care, the state called on Soren Aldaco, a woman who took testosterone when she identified as transgender boy and received top surgery when she was 19.

Aldaco testified that her mental health did not improve after taking hormones and was forced to deal with a number of complications from receiving chest reconstruction surgery. She has since filed a lawsuit against her medical providers for failing to follow their duty of care.

Texas’ new law will still allow transgender people 18 or older to receive chest reconstruction surgery. It will also allow cisgender girls under 18 to have breast augmentation surgery.

Texas lawmakers’ efforts to restrict gender-affirming care in Texas followed nearly identical campaigns from other Republican-led state legislatures. Across the country, 19 other states have passed similar legislation. Prohibiting doctors from providing gender-affirming care to trans youth is widely popular among Republican voters — over 85% of registered GOP voters in Texas supported these restrictions to some degree, according to an April poll by the Texas Politics Project.

But the wave of new legislation invited a series of lawsuits across the country seeking to block the laws from going into effect. Those suits have largely proved successful in federal courts.

In June, a federal judge ruled that Arkansas’ ban on gender-affirming care for minors is unconstitutional because it violates the due-process and equal-protection rights of transgender children and their families. Federal judges in Florida, Kentucky and Tennessee have also blocked those states’ laws from going into effect. An appeals court intervened to allow Tennessee to implement its ban, and the Kentucky federal judge lifted the injunction he issued, allowing the law to go into effect.

This lawsuit is filed in state court and claims SB 14 violates parental-right protections laid out in the Texas Constitution.

Disclosure: The ACLU of Texas has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.

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