Is it ‘so easy’ for minors to get gender-affirming health care, as Kansas lawmakers say?

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For the second year in a row, Kansas lawmakers are attempting to pass a bill that would ban transgender minors from receiving gender-affirming health care — if they can get the votes to override Gov. Laura Kelly’s veto.

The bill, backed by the Kansas GOP, contains even more restrictions than last year’s version. It bans any state employee from promoting a transgender child’s medical or social transition. Activists warn the vaguely worded section could prohibit people like public school teachers or social workers from allowing a child to dress in a way that affirms their gender identity or use their preferred pronouns.

The bill also threatens the medical licenses of providers who offer gender-affirming care to minors. If the veto override succeeds, SB 223 could become law within a week. New care would likely halt immediately, while minors already on hormone therapy medication would have until the end of 2024 to find care in another state.

The Republican-led Legislature has said repeatedly that the bill aims to protect children from making “irreversible decisions” they claim minors are unable to understand. Some have argued that treatments like hormone replacement therapy are “too easy” to obtain.

But what types of gender-affirming health care are minors actually seeking, and how easy is it to access such treatments? Here’s a closer look at lawmakers’ claims and what trans health care actually looks like for minors in Kansas.

What is gender-affirming health care?

Let’s start with the basics. Most people are assigned a sex of either “male” or “female” at birth based on their external genitalia. But that assignment at infancy may not match up with their gender identity later in life, according to the American Psychological Association.

Some people, even young children, have a gender identity that doesn’t match their sex assigned at birth. Those people are generally considered members of the transgender community.

Gender-affirming health care is a combination of services including mental and physical health care that help people better align with their gender identity, according to the American Association of Medical Colleges.

While this care is commonly discussed in the context of the LGBTQ+ community, cisgender people whose gender matches their sex assigned at birth can also receive gender-affirming health care. For example, a cisgender man may seek treatment for erectile dysfunction in order to better align his physical characteristics with his gender identity.

Gender-affirming health care can involve a variety of services, writes the U.S. Department of Health and Human Services’ Office of Population Affairs. These include talk therapy, puberty-blocking medication, hormone replacement therapy, social and emotional support, body hair electrolysis, speech therapy, cosmetic procedures and surgeries.

What types of gender-affirming care do minors receive?

Transgender minors typically receive minimally invasive social and mental health-oriented gender affirming care, according to Columbia University. These include using a new name and pronouns, joining social groups aligned with their gender identity and receiving support from a therapist.

“The process of transitioning for a child looks like using a different name, a different dress, a different haircut,” said Ari Hawk, an outpatient therapist in Junction City.

Even these social measures, which involve no medical intervention at all, would come under fire if Kansas legislators’ veto override attempt succeeds.

Hawk added that in some cases, minors are prescribed puberty-blocking medication to delay a gender-disorienting puberty.

Puberty blockers are fully reversible and commonly used on cisgender children as well, according to the Pediatric Endocrine Society. The medication blocks the release of hormones that cause the bodily changes associated with puberty.

“Pubertal suppression, also considered fully reversible, allows for a ‘pause’ on puberty and for further development of gender identity,” Columbia University experts Kareen M. Matouk and Melina Wald wrote in 2022.

Some transgender adolescents also seek out hormone replacement therapy, or HRT, in order to better align their bodies with their gender identity. For example, estrogen therapy can stimulate breast growth, while testosterone can help stimulate masculinizing body hair.

Gender-affirming surgeries, especially those that alter external genitalia, are typically only performed on adults.

Is gender-affirming health care safe and reliable?

Rep. John Eplee, an Atchison Republican who is a physician, has called gender-affirming care a “relatively new medical endeavor” that is “somewhat of a trend.” But other medical professionals disagree.

“Gender-affirming care is medically-necessary, evidence-based care that improves the physical and mental health of transgender and gender-diverse people,” said Dr. Michael Suk, a board member of the American Medical Association, in a 2021 statement.

Gender-affirming health care is also supported as a safe and evidence-based best practice by the American Academy of Pediatrics, the Association of American Medical Colleges, the American Psychiatric Association, the American College of Obstetricians and Gynecologists, the American Association of Clinical Endocrinology and many others.

Nevertheless, Eplee has expressed support for this year’s bill — despite opposing the version last year that didn’t place restrictions on nonmedical social transition.

What are the requirements for accessing gender-affirming care?

Some Kansas Republicans have claimed that HRT is “too easy” for minors to obtain.

“These physicians have gotten to the places where it’s so easy to do this,” Eplee said during a floor debate last month. “I think it’s become too easy.”

Rep. Brenda Landwehr, a Wichita Republican who chairs the committee the bill was originally heard in, agreed with Eplee. She claimed that patients are not evaluated enough before receiving hormone replacement therapy.

“I think if a lot of people really, really cared, they would ask that a person wanting to do this went through two or three different opinions before they did it,” Landwehr said in a floor debate last month. “I do believe that there’s individuals out there that as soon as they hear doubts that a child professes, they jump on it and encourage it.”

But medical and mental health care providers say the process of obtaining hormones can take years to complete and require the approval of multiple medical professionals.

Kara Nishimuta, a practicing clinical psychologist at the University of Kansas Health System, said the process involves multiple mental health and physical evaluations consistent with other kinds of surgery.

“It does take quite a while,” they said. “Having to navigate those kinds of care and having to coordinate all these different appointments, that’s difficult. People have to have a certain level of persistence to get these treatments.”

Most minors need to acquire two referral letters from mental health providers in order to receive a prescription for hormone replacement therapy.

The letters of recommendation require the licensed mental health care worker to sign off with their license number, staking their career on the fact that their patient understands all potential health outcomes — temporary or permanent — that may come with taking hormones. Patients are also required to undergo labs to create baseline data for their hormones.

Mental health providers often have lengthy discussions with their patients before writing a letter of recommendation, according to Hawk, the Junction City therapist. Due to these restrictions, it is very rare for minors to receive hormones at all.

Even if they get approval, it can take anywhere from a few weeks to several months before a patient is able to begin treatment because of limited appointment availability.

“This is not the kind of scenario where doctors are just writing these prescriptions because people express vague interest in it,” Hawk said.

What will happen if Kansas legislators override the governor’s veto?

Kansas lawmakers reconvened Thursday for the Legislature’s wrap-up session and are expected to attempt an override of Gov. Laura Kelly’s veto of the bill in the coming days.

If the override is successful, it would prohibit state employees like public school teachers, social workers and other providers from affirming transgender minors’ identities in any of the ways described above.

“A state employee whose official duties include the care of children shall not, while engaged in those official duties, provide or promote the use of social transitioning, medication, or surgery as a treatment for a child whose perceived gender or perceived sex is inconsistent with such child’s sex,” the bill reads.

If passed, Kansas’ bill could also impact access to gender-affirming health care for minors throughout the Midwest. The Gender Affirming Medicine clinic at The University of Kansas Health System serves patients in Kansas, Missouri, Nebraska, Oklahoma, Arkansas, Alabama and Tennessee.

A state law passed last year in Missouri also banned medical professionals from providing gender-affirming health care to minors, although this law did not include restrictions to social transition.

The Star’s Jonathan Shorman contributed reporting to this piece.

Do you have more questions about Kansas’ proposed ban on gender-affirming health care for minors? Ask the Service Journalism team at kcq@kcstar.com.