‘Hopeless’: Idaho trans teens seeking to transition cope without gender-affirming care

Inside a Boise clinic in April, Dr. Marvin Alviso was meeting with a transgender patient who had been on puberty blockers for a year. The Boise teen was ready and “giddy” to start taking testosterone, Alviso said, as part of the next step in his transition. It’s also a step in the slate of practices recommended in gender-affirming medicine.

Alviso was about to prescribe his patient the hormone when he received a message from a nurse to come see her. He left the patient’s room, and the nurse told him the news: The U.S. Supreme Court just allowed Idaho’s gender-affirming care ban for minors to take effect.

“My jaw just dropped,” Alviso told the Idaho Statesman by phone.

The family medicine physician returned to the patient’s room and told him and his guardian that the treatment he sought was now illegal in Idaho. Alviso could no longer prescribe it to him.

“My patient’s face just went blank,” he said. “It was heartbreaking to see that. I felt very helpless.”

The Idaho law, which was allowed to take effect in April, bans a spectrum of medical interventions that doctors around the country use for transgender patients. Many of those patients experience gender dysphoria, which is acute distress felt because of an incongruity between the sex a person was assigned at birth and their gender identity.

In the weeks after the Supreme Court’s ruling, its effect has upended the practices of family physicians around the state who provide gender-affirming care recommended by U.S. medical associations.

The Williams Institute, an LGBTQ+ law center at the University of California Los Angeles, estimated that there are about 1,000 transgender minors in Idaho, and 1,500 trans people between the ages of 18 and 24. Dr. Ashley Davis, who has been administering gender-affirming care in Boise since 2005, guessed that there may be as many as 100 to 200 transgender youth receiving medical treatment.

Davis said the state’s ban will likely make the depression and anxiety transgender teenagers experience worse, and that the law amounts to another effort to “pretend they don’t exist.”

“Now they may be afraid to reach out to their pediatrician or family doctor and ask for help for fear that they or us will get in trouble,” said Davis, a family medicine doctor. She said the effects of the ban will be worse for poorer Idahoans, who cannot afford to fly to Seattle or another city out of state for treatment.

For medical transitions, doctors can prescribe a range of medications to alter the appearance of their patients or give them feminizing or masculinizing traits. That can include puberty blockers, which slow the effects of puberty, or hormone replacement therapies, which have feminizing or masculinizing effects. Physicians have said surgeries, such as “top surgery” or breast removal, are very rarely sought by adolescents.

The new state law, called the “Vulnerable Child Protection Act,” bans any of these treatments or procedures for people under 18 if they’re seeking to transition to another gender.

While opponents of gender-affirming care point to instances when people choose to detransition, around 1% of transgender patients regret transitioning, according to a 2021 review of several studies reported by the Associated Press. Davis said the rate of regret is much higher for people who receive knee replacement surgery.

Davis said she prescribed hormones to a teenager three weeks before the ban went into effect and wondered what would happen if they tried to get the prescription filled afterward.

“It was valid three weeks ago. Am I a felon retroactively? Or is the pharmacist?” she said. “We were doing just fine for a good 15 years without any outcry from the government saying we’re harming people.”

Boise student grapples with ban

Liliana Rauer is a 17-year-old student at Boise High, where she participates in Science Bowl, a national academic challenge. On her team, which competes against other students to answer multiple choice questions, she specializes in math and physics. At school, Rauer tutors other students in math and also likes to write in her spare time.

Rauer is also transgender, and one of the dozens of transgender teens in Idaho affected by the Supreme Court’s decision last month.

Rauer told the Statesman in an interview that ever since she was in third or fourth grade, she has felt uncomfortable in the sex she was assigned at birth.

“It just felt gross and kind of icky whenever I thought about that as who I was,” she said.

In elementary and middle school, she didn’t know what those feelings meant. But as she grew older, she learned what it was to be transgender and began to discuss with friends the questions they also had about their identities.

“That really helped me come to terms with who I was, because I really struggled and had a lot of imposed self-transphobia,” she said. She sees a therapist regularly.

When she was 15, Rauer began to socially transition, which is when a person makes life changes to feel more comfortable – such as selecting a different name, using different pronouns, and dressing in ways that align with their gender expression. On a warm day in April, Rauer wore faded skinny jeans, lilac boots with black laces and an unbuttoned collared shirt, under which she wore a T-shirt that read, “Trans rights are human rights.”

Rauer has not yet begun to medically transition, but she hopes to soon. She had a consultation with a doctor scheduled eight days after the Supreme Court ordered such medical interventions cease in the state.

After years spent struggling with who she was, she said she had begun to love and accept herself but now is cut off from the changes she wants to undergo. She said she found out about the order via a mass email from the ACLU of Idaho.

“I felt really kind of hopeless,” she said of learning the news. Rauer also helps run two LGBTQ+-focused support groups – one at Boise High and another for teenagers across the Treasure Valley, called the Sexuality and Gender Alliance. She said her high school group has had a meeting since the Supreme Court decision; the mood was “somber.”

“A lot of people didn’t really know what they were going to do,” she said. Rauer plans to seek gender-affirming care out of state — an expensive proposition that will require her to travel regularly to obtain the medications.

“The thing I most want these legislators to know is that we’re just people,” she said. Rauer said that last year, when the proposed ban was debated at the Statehouse, she sent an email to every lawmaker offering to talk to them on the phone or meet for brunch to discuss what it means to be transgender. Only one Republican, Twin Falls Sen. Linda Hartgen, got back to her.

In February, Rauer missed an AP Calculus exam to testify before a House committee at the Legislature, where she called a bill to ban teachers from using students’ preferred pronouns without parental consent “a denial of basic human respect.” That bill became law.

She told the Statesman she realizes some people do not understand transgender people but emphasized that major medical associations have confirmed people like her need the transition-related treatments for their mental health and well-being.

The junior works at Zoo Boise in the summers. Her favorite animal there is Paji, a sloth bear. She said she plans to finish high school in Idaho but wants to go to college and study theoretical physics out of state.

“I want to go to college in a state where I don’t have to feel like my rights are constantly under attack,” she said.

Quinn Carter, a transgender senior at Sage International School in Boise, turned 18 in December and narrowly missed being affected by the ban. He has been on testosterone for nearly two years and told the Statesman that choosing to undergo gender-affirming care is wrongly characterized as a “spur-of-the-moment” decision. Before Carter began the treatment, which lowered the pitch of his voice, he said he often chose not to speak and was “forced” into silence to avoid the sound of his own voice.

“I thought about it every day for like two years,” he said. “I just was carrying so much anxiety for how people viewed me and how I viewed myself, and when I was able to finally start it, I didn’t even realize how much I needed it.”

Though some trans adolescents have begun receiving medical intervention, not all do. Dr. Sara Swoboda, a pediatrician at St. Luke’s Health System, told the Statesman that the majority of her transgender patients don’t receive medical interventions. Of the 15-20 trans patients she has now, only one has been taking gender-affirming medication, she said, though Swoboda doesn’t prescribe it herself.

Julia Sharkey, a teacher who is the advisor for the Gay Straight Alliance at Kuna High, said trans students don’t understand why they’re being targeted. They joke about how they must be dangerous if legislators are passing laws that only go after a handful of students.

When students don’t have access to gender-affirming care, their mental health deteriorates, Sharkey said.

“They can’t focus on school,” she told the Statesman. “They can’t focus on learning when they are so ill at home in their own bodies.”

Idaho Republicans push to limit trans rights

Idaho Republican leaders have been at the forefront of anti-trans legislation around the country, which has expanded in recent years, from prohibitions on transgender people competing in sports to bans on gender-affirming medical care.

As the first state to bar trans students from participating in sports in 2020, Idaho has since expanded its limitations to trans medical care and the accommodations trans people ask for in the public sphere. Around a dozen laws in recent years have outsized effects on the thousands of trans people in Idaho.

Last year, the Idaho Legislature passed the law banning gender-affirming care for trans youth with overwhelming support in the House after receiving emails from hundreds of people and hearing testimony from dozens. Several trans people testified against the bill and spoke about their experiences growing up trans. Others said the bill was a form of government overreach and that parents should be able to make their own decisions on what’s best for their families. Doctors warned about the mental health impacts.

Still, others said they believed the care could be detrimental for youth and that kids need more time to figure out who they are.

The Legislature last year also passed a law that barred trans youth from using bathrooms that corresponded to their gender identity.

Many of these laws have been caught up in the legal system as trans youth and their families challenge them.

At least five laws passed this year have consequences for trans people, including the law that bans teachers from using a student’s preferred pronouns without parental consent. Another law banned Medicaid and state health insurance funds from being used for gender-affirming care; a third defines “gender” as synonymous with “sex” in state code. A fourth forbids state funding from being used for “inclusive” programming at universities. Yet another law affirms therapists’ ability to refuse to counsel clients whose “goals, outcomes or behaviors” they object to.

According to the Trevor Project, an organization that advocates for LGBTQ+ rights and conducts a survey on the mental health of young people, trans teens who attended schools with policies supportive of gender transitions had lower rates of attempting suicide.

The Washington, D.C.-based Human Rights Campaign, another LGBTQ+ advocacy group, as of April found 38% of transgender youth — over 100,000 people ages 13-17 — live in states that have passed laws banning gender-affirming care. In some of those states, the laws are caught up in the legal system and are not in effect.

“That is a huge population of young people who are being negatively impacted by these pieces of legislation,” said Brandon Wolf, a spokesperson at the Human Rights Campaign. “We’re talking about families losing the freedom to go to their kids’ doctor and get advice on what best-practice, medically necessary care their child should receive. We’re talking about families sometimes who are forced to leave their homes to travel out of state to get care.”

Wolf called it a state of crisis for LGBTQ+ youth and their families and said right-wing politicians have chosen their political careers over the well-being of kids.

The push for state laws that combat the burgeoning visibility of trans people comes largely from legislators who have publicly cast doubt on the sincerity of the growing number of transgender Americans. Some professed they believe “transgenderism,” as it is often referred to on the right, is an affront to the accepted social order.

“We have different worldviews, and I can be respectful of yours,” Rep. Bruce Skaug, R-Nampa, told a testifier at the February hearing where Rauer testified. “I’m having a hard time. When somebody comes to me, if a man born as a man wants to be called by a woman’s name, I’ll do that. But I will not call him a woman, because it’s not the truth. Help me deal with that.”

Rep. Julianne Young, R-Blackfoot, repeatedly rebutted testimony about the benefits of gender-affirming care in hearings this year by saying that “you can never create the healthy sexual function of the opposite sex.”

Republican Attorney General Raúl Labrador has defended the state’s ban and pushed to escalate the lawsuit over gender-affirming care to the Supreme Court, which led to the court’s April decision to allow the law to take effect while lower courts grapple with the case’s merits in the coming months.

Labrador has said he has seen “firsthand” the “devastating” consequences of transgender treatments, and that care should be “rooted in biological reality.”

“Denying the basic truth that boys and girls are biologically different hurts our kids,” he said in a previous statement.

Labrador’s spokesperson, Dan Estes, did not respond to inquiries from the Statesman requesting an interview or to written questions about the effects of the law.

Gov. Brad Little said once minors become adults, they have the freedom to choose what kind of care they receive, but he agreed with the Legislature that the state must “protect juveniles.” He said the “jury’s still out” on the impacts of gender-affirming care, referring to European countries that have recently moved to limit hormone treatments for minors after a review in England. The doctor who conducted the review said the care was based on “shaky foundations.”

“I’m not being critical of the medical community,” Little told the Statesman, “but it is not resolved science in the health industry worldwide.”

For teens who will lose access to the gender-affirming care they were receiving, Little said: “We want to be sympathetic,” but the state also wants to make sure there are no “unintended consequences.”

Davis, who has helped hundreds of transgender patients transition, called Idaho’s laws “evil.”

She said her transgender patients, including minors, have generally been thinking about their gender and the prospect of transitioning for years before they see a doctor. Davis said she thinks transgender people “risk everything when they are finally true to themselves. They’re willing to risk all their relationships, all their jobs, because they can’t hide another day as their assigned gender.”

She said the satisfaction of her transgender patients is the “highest of anything I do in medicine.”

“I am over the moon helping these people, because they are so excited,” she said. “They’re just giddy when they finally come in and say, ‘I’m ready to start my transition, I’ve been thinking about this for 10 years.’ ”

Transgender youth in Idaho can still receive mental health counseling for their struggles, and Davis, Alviso and Swoboda recommended that teens still make appointments with their doctors to talk about their options.

“They are still welcome in every practice, in any family medicine clinic,” Alviso said, pointing out that it is important for youth to seek help if they experience depression or anxiety. Transgender and gender-nonconforming youth are much more likely to experience mental health issues than cisgender youth, according to one 2018 study. About one-third of LGBTQ+ young people also said they had poor mental health at least most of the time because of policies and legislation targeting the community, according to the U.S. National Survey from the Trevor Project.

“We will acknowledge gender dysphoria; we just can’t really act on it,” Alviso said.

Alviso added that it can be helpful for a medical provider to affirm a young person is “not making up” their gender identity.

But for many, he said it is just a bandaid. Without treatment, the gender dysphoria will escalate, Alviso said: “My hands are tied.”