Rhetoric and the data: The fight over gender-affirming care in Idaho
Last month, as the Idaho House debated whether or not to charge doctors with a felony if they prescribe cross-sex hormones or puberty blockers, or perform sex-reassignment surgery – something that isn’t done in the state – two narratives appeared: one of a deliberative and lengthy process with several safeguards protecting patients, and another claiming the complete opposite.
“I had the opportunity to spend the day with a young woman who actually underwent puberty blockers and hormone treatment,” said Rep. Julianne Young (R-Blackfoot).
Young previously pushed a bill banning transgender people from changing the sex listed on their birth certificates over the advice of the former state attorney general. A federal judge declared her law unconstitutional and cost taxpayers more than $300,000 in legal fees.
“Her experience was not the standard of care that we’ve heard described to us today,” Young said.
Battle over gender-affirming care for minors goes nationwide
That young woman she’s talking about, Chloe Cole, has spoken in states across the country, including a stop in Idaho last month, supporting bans on gender-affirming care for minors.
As of earlier this month, seven states have passed similar bans, including Arkansas, Alabama, Florida, Mississippi, South Dakota, Tennessee and Utah.
Cole said she began puberty at eight or nine years old and had to deal with comments from other kids and adults that made her uncomfortable.
She told a crowd in a capitol hearing room that her friends and family would tell her about the hardships of being a woman – menstruation, menopause and others.
“I would often hear things from other girls, phrases like, ‘Why did God make me into a girl? Why couldn’t I just live life so much easier as a man?’ And I started to feel the same way,” she said.
Cole, who’s from California, eventually found an online community that got her thinking about the possibility of transitioning. After telling her therapist and her family she wanted to be a boy, she saw multiple endocrinologists.
“The first one who I was referred to actually refused to put me on blockers and testosterone because he said I was too young.”
Her parents wanted her to wait until she was 18, but Cole said doctors pressured them into signing off on the treatment, saying their daughter could commit suicide without it.
Cole said she eventually began taking puberty blockers six months after her diagnosis of gender dysphoria.
A month later, at 13 years old, she was on testosterone. At 15, she underwent a double mastectomy. Just a few months after that, she said she realized she made a mistake.
“I thought that I would live life easier as a boy, that I was destined to be. But I learned the hard way that this was not the case.”
Data shows regret is rare
Cases like Cole’s do happen.
A survey conducted by the National Center for Transgender Equality in 2015 spoke to nearly 28,000 trans people.
Eight percent reported de-transitioning at some point in their lives, though the majority of those reported doing so because of social and economic pressures. Only 0.4% of those surveyed de-transitioned because they realized they had made the wrong decision.
Dianne Piggot was part of that 8% for a time.
“I essentially convinced myself over time that I was not trans enough,” Piggot said.
She tried to transition while living in Seattle years ago, but she couldn’t find a job that paid well enough to let her stay there. She moved back to Boise where she purged all of her women’s clothes.
Piggot’s trans friends back home were suffering as social outcasts, she said. So, she tried to repress her gender dysphoria in the hopes it would just go away.
“Funny story. It didn't.”
Now, as a licensed professional counselor, Piggot helps LGBTQ clients navigate their mental health, including gender dysphoria.
Children must meet at least six of eight criteria in the latest guidelines issued by the American Psychiatric Association to be diagnosed with gender dysphoria.
Those include insisting they’re another gender, a strong dislike of their sexual anatomy and a strong preference for cross-gender roles.
“Sadly, there is no way to draw some blood and put it on a slide and say, ‘Look right there, there is ‘transgenderness,’” Piggot said.
She said she’s occasionally had to turn away clients who don’t check those boxes, including one who she counseled for about 15 sessions.
“The majority of the criteria were not there, and so I had a talk with them and I had a talk with the parents and said, you know, I don't think so.”
That tracks with what Dr. Marvin Alviso has seen in his own experience.
“In my seven, eight years of practice and with over at least 300 patients, I think those are just very little,” Alviso said.
He specializes in LGBTQ care as a family physician at Full Circle Health in Boise.
He said Cole’s story raised a number of red flags for him. While he doesn’t require a referral from a counselor to treat a transgender patient, Alviso said it helps.
First, he makes sure the patient and both parents understand the risks and the side effects of these medications can have.
After a couple of years, puberty blockers can decrease a patient’s bone density. So, Alviso said they monitor that with testing. He admits there’s no long-term data on its extended use, but puberty blockers are largely reversible.
He also checks out the patient’s medical history that might be causing their distress.
“Is there something mental health-wise that needs to be addressed first? Or is there any medical condition that needs to be addressed first?” Alviso said.
"I've had a lot of thoughts of am I doing this for attention or am I doing this because I've seen other people do it and it seems fun or whatever. And then I remember just how much it hurt before any sort of medical treatment."Calvin Udall, a 19-year-old trans man in Boise
Sometimes, he has denied treatment because of underlying conditions.
He also stresses that he won’t put a patient on puberty blockers or hormones unless both parents agree to the plan. Alviso tells me about one transgender girl he treated who had to delay care because of those circumstances.
“It was a traumatic experience because she was there, the mom was there and the dad was there and they just stormed out,’ he said. “I respected that dad’s decision because he still has to make that decision for the kid.”
That girl eventually did get treatment months later after her father consented.
Alviso said he typically starts patients on puberty blockers when they’re around 15 – a regimen far more conservative than Cole’s treatment and one he says is more typical. He then waits at least a year before starting hormones, if the patient and their parents choose that route, which can have more permanent side effects.
“At this point, the thing that you would really hone in is the ability for the kid to reproduce in the future because that becomes greatly affected,” he said.
A long road before treatment
Calvin Udall, a 19-year-old transgender man studying at Boise State, began taking testosterone when he was a teenager after feeling for a long time he was born in the wrong body.
“It was this sort of deep seeded discomfort, like someone was referring to me as someone else – like someone calling me the wrong name almost, but, you know, deeper than that of course,” Udall said.
He was struggling with depression and self-harm over these feelings. That 2015 survey found 40% of trans people reported attempting suicide compared to low single digits for all Americans, according to federal data.
When he was in junior high, Udall took steps to try to feel normal.
“I cut all my hair off, started wearing jeans and hoodies all the time and that was around the time we left the [LDS] Church so I didn’t have to wear dresses anymore and I just started to realize how comfortable I was.”
After a while, Udall asked his parents to start a testosterone regimen.
“It took a couple conversations between all three of us to make sure that everyone was on the same page, was aware of the same potential complications and understood what the outcomes were going to be,” he said. “I think especially since I was a minor it wasn't my call to make.”
Udall also had to undergo a psychiatric evaluation and his parents were interviewed to ensure there wasn’t any coercion.
After a lengthy process, he began testosterone injections. It took several weeks before he noticed much of a difference.
“I remember getting really excited about noticing that my leg hair was getting darker and my older brother was like, ‘You want this?’ I was like, ‘Yeah, like, it's extremely affirming.’”
Years later, when he was an adult, Udall chose to get a double mastectomy and a hysterectomy.
Only a quarter of those who participated in the 2015 survey chose to undergo some type of transition-related surgery. Many don’t want to or aren’t sure they want to.
Udall said he is happy with his decision.
“I've had a lot of thoughts of am I doing this for attention or am I doing this because I've seen other people do it and it seems fun or whatever. And then I remember just how much it hurt before any sort of medical treatment,” he said.
Multiple studies published show this spectrum of care is beneficial – especially for those who start it while teenagers. All major medical associations in the U.S. with hundreds of thousands of members support gender-affirming care to treat gender dysphoria.
Legislation banning these treatments for minors in Idaho is currently awaiting a committee hearing in the state senate. A similar proposal didn’t get a hearing there last year and died when lawmakers adjourned.
I asked Aviso if he would leave the state to practice elsewhere should it become law.
“I would not desert these patients,” he said. “I think that all the more that providers should stay here and fight for these kids.”
Doctors would have to be creative in treating patients, he said, potentially referring them out of state.
One outcome he’s certain of, though, is such a move would heighten depression and anxiety for trans kids and could lead to more youth suicides.
If you or someone you know is having thoughts of suicide, please call or text 988 to reach the Idaho Suicide Prevention Hotline.
Follow James Dawson on Twitter @RadioDawson for more local news.
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