Willow Breshears knew she was different for as long as she can remember. Growing up in rural Arkansas, she said she often felt depressed her personal discoveries about herself quashed by social norms and Baptist teachings.
Now 18 and living in Little Rock, the transgender activist recently testified before lawmakers as part of an effort to try to stop the passage of a proposed state law that, among other things, bans doctors from providing gender-affirming care such as including puberty blockers and hormone therapy to youth under 18. She and others protesting the measure were unsuccessful.
The mostly Republican Legislature last week overrode Gov. Asa Hutchinson’s veto to make Arkansas the first state to enact such a law. About 30 states nationwide are mulling similar legislation – a development advocates say endangers the lives of young transgender people, places ideology over science and disrupts the sanctity of the physician-patient relationship by preventing doctors from providing best-practice care.
“The only people who should have that say is that transgender person, their family and their doctors,” Breshears said. “This is not a place for legislators to step into.”
Arkansas’ Save Adolescents From Experimentation (SAFE) Act also prohibits physicians from referring patients to other providers and, in what some call a particularly heinous move, includes no grandfather clause for youth already under treatment.
“That means that if you’re already taking puberty blockers prescribed by a doctor, the state of Arkansas has just gone into your doctor’s office and told them, ‘You cannot prescribe this or do any blood work to monitor your levels,’” said Rodrigo Heng-Lehtinen, deputy executive director of the National Center for Transgender Equality. “This is truly a phenomenal level of government overreach.”
Critics compare lawmakers to bullies picking on a small but vulnerable population, using transgender youth as pawns in a cultural war while placing their emotional and physical wellbeing in jeopardy. Such legislation, they say, plays on fear and misinformation and places doctors in an ethically difficult position of providing best-practice care at the risk of losing their medical license.
It also raises the risk of mental health issues among transgender youth already prone to higher rates of anxiety, depression and suicidal thoughts.
“There’s only so many people taking puberty blockers in Arkansas,” Heng-Lehtinen said. “But every single transgender person is feeling the effect of this attack. It’s the government, pure and simple, saying: You don’t belong. It’s such an antagonistic and heartless message to send.”
Such fears are not unfounded: Arkansas Rep. Deborah Ferguson, a Democrat who spoke out against the bill, said that after the law passed, an Arkansas Children’s Hospital physician testified that several of the approximately four dozen Arkansas youth currently receiving hormonal therapy have tried to commit suicide.
“It is unfortunate that the makeup of our Legislature has changed to the extent that we are weaponizing religion to discriminate against this small minority,” Ferguson said.
Advocates say access to gender-affirming medical care is linked with better mental health, including a lower incidence of suicidal thoughts. Bills denying such care have been condemned by major medical groups around the country, such as the American Academy of Pediatrics and the American Psychiatric Association.
“This legislation throws away decades of medical progress,” said Jack Turban, a fellow in child and adolescent psychiatry at the Stanford University School of Medicine in California, calling it “dangerous and anti-science.”
For Breshears, the Little Rock activist, her gender-affirming care was both “life-changing, and life-saving,” she said. “I started hormones at age 13 and I can say that without that, I might not be here today.”
Breshears came out as gay when she was 12, even as she knew the label didn’t really fit. It wasn’t until after her family moved to Little Rock, where she began attending youth programs at a local LGBT rights organization, that she learned the language that could finally describe who she was.
“I had heard the word ‘transgender’ a couple times before that, but never really in a positive way,” said Breshears, who now leads those same youth programs. “That’s what really helped me flourish. I was a woman, but I never really knew the words to describe that.”
While her declaration splintered her extended family, her mom and grandmother “have been super supportive,” she said.
Breshears scoffs at notions pushed by lawmakers that those under 18 are too young to decide for themselves.
“It’s not something where you just wake up and decide you’re trans,” she said. “Any parent of a trans child is going to tell you they knew from a very young age. The first thing my mom said when I told her was, ‘You don’t know how long I’ve been waiting for you to tell me that.’”
Anti-transgender legislation on the rise
Arkansas’ SAFE Act, while citing the relatively low population of people it describes as having struggled with “distress at identifying with their biological sex,” says gender-affirming treatments prescribed by doctors haven’t been fully proved safe and claims without citation that the majority of individuals come to identify with their birth gender in adulthood, making such care unnecessary.
State Rep. Robin Lundstrum, a Republican who was the bill’s primary sponsor, quoted a Swedish study saying transgender individuals who’d undergone gender reassignment surgery were more likely than the general population to suffer mental health issues and far more likely to commit suicide. But that 2011 study also said such surgeries eased gender dysphoria and improved care afterward.
While Arkansas’ is the first of its kind to become law, the Human Rights Campaign says nearly 60 such bills have been introduced nationwide in the last two years despite no evidence of any youth receiving inappropriate care.
Thirty of those bills, the group said, would likewise deny gender-affirming care and medical services to transgender youth. They’re part of a larger tally of nearly 200 anti-LGBTQ bills that the organization says are being considered in state legislatures around the country.
At the same time, 29 states are debating bills that would prohibit transgender girls and women from girls’ and women’s sports, even as trans athletes and their advocates say groups that support such bans use harmful, traditional definitions of gender.
Such legislation has been on the rise in the last two years, despite surveys showing that most Americans support transgender rights overall, including the right of transgender youth to participate on sports teams that feel most comfortable to them, and that a majority of parents would support their teen’s request to transition to another gender.
In a statement, CEO Kevin Jennings of LGBT civil rights organization Lambda Legal, said such measures “are rooted in animus and ignorance about what it means to be transgender. They disregard medical science, standards of treatment for transgender youth and basic human dignity.”
Lambda Legal, along with the American Civil Liberties Union, has already promised legal challenges against the Arkansas law.
“These states are truly heading in the wrong direction and straight to the courts,” said Avatara Smith-Carrington, of Lambda Legal’s south central regional office. “These bills are explicit attempts at erasing trans youth from public life.”
Clair Farley, executive director of San Francisco’s Office of Transgender Initiatives, said the escalation of such bills is a result of Trump administration rhetoric and rollbacks of transgender protections in housing, health care, employment and public accommodations.
Farley, whose upbringing as a trans youth in Montana inspired her to pursue advocacy work, said that such bills are even being discussed is upsetting for youth already fearful society won’t accept them for who they are.
“Growing up is hard enough for anyone and can be particularly difficult for transgender youth, especially those living in conservative and rural environments,” Farley said.
Sam Brinton, vice president of advocacy and public affairs for The Trevor Project, a national LGBTQ suicide prevention organization, said recent survey results, to be published next month, found that 90% of LGBTQ youth said current politics had negatively affected their wellbeing.
“If your state legislator is debating whether you should exist or have rights, you can imagine that that is basically destroying your sense of self,” Brinton said.
Transgender youth face higher levels of anxiety and depression, especially if they lack family support or experience bullying at school and mistreatment from teachers and officials. In The Trevor Project’s 2020 survey on mental health of LGBTQ youth, more than half of transgender and gender-nonconforming respondents said they had seriously considered suicide.
“Being transgender in and of itself does not lead to these risks,” said Paula Neira, board secretary for GLMA: Health Professionals Advancing LGBTQ Equality and clinical director for the Johns Hopkins Center for Transgender Health. “What increases it is how you are treated and whether you are able to receive care.”
Denying gender-affirming care to these youth is a form of discrimination, advocates say, that will only increase the stigma they likely already feel in society.
Hannah Willard, vice president of government affairs for Freedom For All Americans, a national LGBTQ advocacy organization, said the human cost of these bills “cannot be overstated. This is causing unparalleled levels of despair and heartbreak, and it sends a terrible message to kids that they are broken and damaged and don’t deserve access to the care we all deserve.”
In a statement issued by the Human Rights Campaign, Arkansas State manager Eric Reece called the Arkansas law “a cruel and shameful way for legislators to score political points by targeting transgender youth, who are simply trying to navigate their adolescence.”
Parents of trans youth fear harm of removing gender-affirming care
For parents, the possibility of seeing their children’s support systems ripped apart is devastating. Among the states considering similar bills is Alabama, where parents Christa and Jeff White worry about the effect passage could have on their 12-year-old transgender daughter, a middle-schooler they chose not to name to protect her privacy.
“The idea that this could put my daughter in danger is not OK with me,” said Christa White, a stay-at-home mom and women’s rights activist. “This is potentially devastating, not just to our child, but to all transgender children undergoing these treatments. Children will die.”
The family, including two older teenage sons, lives in northern Alabama, near Huntsville. In addition to seeing a pediatric endocrinologist who prescribes hormone blockers, they said, their daughter also receives regular counseling.
“We’re covering all angles to try to do what’s best for her,” Christa said.
Her path began unremarkably, they said, and at first, they figured she was “just being a kid,” Christa said. “Nothing extreme. She was dressing gender neutral, and she liked strong female leads in movies.”
Then came a series of conversations that progressed as their daughter became exposed to terminology her parents used with LGBT friends.
“She always prompted the conversations,” Christa said. “I’d just say, you let me know and we’ll talk about it. And finally, it clicked. She knew what she was before, but she didn’t know the wording. And she blossomed. There was no looking back. It was just, like, ‘This is me.’”
Jeff White, a software engineer, said while they’ve lost a few friends and family members along the way, he and his wife feel lucky their daughter’s path was not as challenging as it could have been.
“Her confidence has really grown,” he said. “And her relationships with her friends as well. Her whole life experience has been changed.”
She’s a happy, regular kid, into Star Wars, anime, video games and long phone chats with her friends.
That’s why the thought that her gender-affirming care could be ripped away is so upsetting.
“We don’t want to go backwards,” Jeff said. “We’ve seen the positive effect that transitioning has had in her life. We don’t need the government coming in and deciding for us what innate qualities of a person are acceptable. We want her to be free to be herself.”
While they haven’t yet discussed the legislation with their daughter in major detail “because we don’t want to scare her,” he said, she knows something is up.
“We don’t know what our plan is,” Christa White said. “We’re going to fight it in some way. If we’re allowed to go out of state, we will. We will do all we are able to do to help her down this path.”
For doctors treating transgender youth, Arkansas law creates ‘an impossible situation’
Advocates note that decisions about such care are made only after a methodical series of discussions between the patient, parents and physicians.
“It really is very careful and thoughtful and deliberate,” said Lee Savio Beers, president of the American Academy of Pediatrics. “There’s often a misconception that it’s something people rush into. But it takes place over a long time and the path for one patient may be different than for another, and it heavily involves the family.”
When a child’s identity doesn’t match thegender assigned at birth, it can be agonizing, especially as the changes of puberty begin to set in. Treatments such as hormone therapy, said Arkansas Rep. Ferguson, give youth a chance to pause development while they come to terms with who they are.
Jack Turban, the Stanford School of Medicine fellow, said he’d seen patients “so distressed by their chests developing that they bind their chests tightly despite medical issues like trouble breathing and skin infections,” he said. “Some kids will even have rib fractures.”
Legislation that bans doctors from providing gender-affirming care will put them “in an impossible position,” Beers said. “We take an oath that we’re going to provide the best possible care, and bills like this tell us you can’t provide that care. We’re being forced to have to decide.”
One after-effect of the law, she said, may be that if doctors can no longer make referrals, patients will seek help on their own, even if it’s out of state. Without guidance, they could end up with lower quality or substandard care.
“This completely violates the physician-patient relationship,” Beers said. “It’s an incredibly dangerous precedent.”
Arkansas pediatrician Susan Averitt, who runs a private practice north of Fayetteville, Arkansas, said she and her colleagues find the law frustrating.
“We feel like it’s legislating what we can discuss with our patients in our clinics and the way we provide care,” Averitt said. “Our role is to help guide them and either provide care ourselves or refer them to specialty care, and this limits my ability to provide good guidance and care within my own office.”
Such decisions, she said, “are being made by people who don’t have medical training and don’t understand the science and medicine taking place,” Averitt said. “But for some reason, they feel like they’re protecting children. It’s based on fear and misinformation. We don’t do surgeries on patients under 18, so they’re not receiving experimental treatment – just support, and in some cases, hormonal care.”
If the law stands, the hospital clinic to which she would normally refer patients, set up to meet the needs of transgender youth, would likely cease to exist. It breaks her heart, she said, to think about how it will disrupt the relationships that doctors have built with young transgender patients, and she worries those youths will suffer mental health issues and suicidal ideation as a result.
“They will feel like society doesn’t accept them,” she said.
Brinton, of The Trevor Project, said the law will make trans youth less likely to come out as such or to talk to someone about their experience, even as research shows that having an understanding adult in a youth’s life reduces suicidal ideation by 40%.
And Willard, of Freedom For All Americans, said the law will only exacerbate the pandemic-related economic problems that Arkansas already faces, making it hard to recruit and retain medical talent, especially in the state’s rural areas.
“Doctors are not going to want to relocate to a state that threatens to revoke their license for just doing their jobs,” Willard said. “There will be a massive medical fallout.”
Advocates hope science and time will be on their side, noting the generational divides in terms of how the public views transgender issues.
Heng-Lehtinen of the National Center for Transgender Equality, said that as Americans become more aware of trans individuals in their communities, attitudes will come around.
While that might sound Pollyannaish, he said, the same thing happened with same-sex marriage equality.
“More and more trans people are coming out at a younger age,” he said. “That’s why younger generations are more supportive. They see their friends. They see that trans people are in their neighborhoods and schools. That does fill me with hope that at the end of the day people will see that we’re on the right side, but there’s a lot of urgency to do that as fast as possible so that we save lives.”