The federal trial challenging Arkansas’ ban on gender-affirming medical care for transgender minors began Monday with testimony from medical professionals with years of experience treating people, including minors, with gender dysphoria.
Act 626 of 2021, or the Save Adolescents From Experimentation (SAFE) Act, was the first of its kind in the U.S. The law banned physicians from providing “gender transition” treatments like puberty blockers and sex reassignment surgeries to minors. Several transgender minors, their families and two doctors filed suit against the law shortly after it was passed, and the American Civil Liberties Union is representing them.
Not all transgender individuals seek surgeries to change their anatomy, said Dr. Dan Karasic, a psychiatrist based in San Francisco.
Karasic said he has seen firsthand that people of all ages with gender dysphoria, or distress due to the incongruence of gender identity and biological sex, experience a “dramatic relief” of anxiety, depression, suicidal ideation and other mental health struggles after receiving gender-affirming care.
He disputed the defense’s claim that medical professionals and organizations that support healthcare for transgender minors are ideologically motivated.
“To essentially label almost all people who are actually providing care for trans people as ideologues, to me, just seems silly or meaningless,” Karasic said.
U.S. District Judge James Moody is hearing the case in a bench trial that will last the rest of this week. Moody placed an injunction on Act 626 in July 2021 that was upheld in August by a three-judge panel of the 8th U.S. Circuit Court of Appeals.
Similar laws restricting access to gender-affirming care in three other states — Alabama, Arizona and Texas — also are on hold after judges blocked enforcement.
A Kaiser Family Foundation analysis of the legal landscape published in June noted that in addition to the four states that have adopted similar bans on gender-affirming care for youth, 15 others were considering 25 pieces of legislation with similar aims.
A lack or loss of access to gender-affirming care leads to a resurgence of the mental health struggles that a transgender patient faced before receiving treatment, said both Karasic and Dr. Deanna Adkins, a pediatric endocrinologist from Durham, N.C.
The doctors answered questions from both sides’ attorneys about the prescription and effects of puberty blockers, or hormones that pause or delay puberty in adolescents, and a variety of gender-affirming hormones that can be prescribed as treatment for gender dysphoria.
Karasic and Adkins said it’s considered best practice to fully inform minor patients and their parents about gender-affirming medical treatment so they can all give informed consent. They said adolescents typically have the “cognitive maturity” to understand the decisions they are making.
The same hormones that are used for gender-affirming care — estrogen, progesterone and the administration or suppression of testosterone — are also used in other medical treatments for cisgender patients, Adkins said.
The defense, including Attorney General Leslie Rutledge, has said that minors who transition may “outgrow” their stated gender identity or come to regret transitioning. Karasic said he has not seen this from any of his patients over about 30 years. He also said he has seen patients’ mental health struggles return if their treatments stopped for any reason, including loss of health insurance.
The defense has also claimed minors identify as transgender due to “social contagion” based on their friendships and media consumption. This is a misunderstanding, Karasic said.
“As they grow to have an awareness of being transgender or having gender dysphoria, they seek out peers that might share their experiences and seek out media to gain more information and social support,” he said.
Referrals for gender-affirming services, both hormonal and surgical, rapidly increased in the 2010s. Karasic said this was a result of gender-affirming care being covered by health insurance.
He said he would not typically recommend genital surgeries for transgender minors, and Adkins said she has never referred minors for genital surgeries but has for gender-affirming mastectomies in transgender minors assigned female at birth.
“When my patients come back from their top surgery, they’re all over the moon,” she said. “They are very happy to have their body align with their gender identity. They are often coming off their antidepressants and their anti-anxiety medications because their anxiety and depression have improved so much. It allows them to focus on the future.”
Adkins sees gender identity as fixed in almost all cases, and said she learns about a minor’s gender identity from their parents, mental health providers and directly from the patient.
“I weigh a person’s own statements fairly heavily, and I also take into account all the perspectives, because when you’re working with children, you have to include everyone in the conversation to really get the full picture,” she said.
