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This past legislative session, Montana Medical Association CEO Jean Branscum knew her group would be quite busy educating lawmakers on the intricacies of care that transgender children receive. Lawmakers were advancing legislation that would have limited doctors’ ability to provide gender-affirming care to children and teens. “(There was) a gap in regards to knowledge of what they were really talking about, and what the reality was in regards to individuals who have gender dysphoria, so we knew there was a great need for education,” Branscum said. “And we thought we could be the best group to come in and provide evidence and science-based conversation with the legislators on what otherwise is a very polarizing topic.” H.B. 113 would have banned gender-affirming care for transgender youth in the state. Dr. Lauren Wilson, a pediatric hospitalist and vice president of the Montana Chapter of the American Academy of Pediatrics, testified for the first time and had informal meetings with lawmakers to educate them about who their patients are and around the standards of care. “Kids start forming their gender identity at a young age—age 3 or 4—and some of them know at that point that they’re transgender, and there’s absolutely no medical care that involved at that point in time; we just tell parents to meet kids where they are and support them and to not push them in any particular direction,” Wilson said. “And only at the start of puberty is there even a question of starting medications of some kind. We were thrilled that enough legislators were able to see past the inaccurate talking points and decide not to pass these bills into law.”
National debate Legislation has been introduced in nearly 30 states this year that would in some way restrict the care delivered to transgender youth. “Children should be free from either parental, peer or cultural pressure to deal with their gender confusion by starting down a one-way road to lifelong medical intervention,” Montana Republican Rep. John Fuller said in a committee meeting back in February. As bills like those in Montana have been introduced, medical associations and health systems across the country have arguably been a key part of why several of the bills never made it out of committees, failed, or at the very least, faced major criticism from the medical community. “Those attempts to intrude into the practice of medicine on behalf of government are inappropriate,” said Dr. Jesse Ehrenfeld, a member of the American Medical Association board who works on LGBTQ healthcare issues. “We have great, long-standing partnerships with our state societies through our advocacy resource center to try to make sure that we can provide appropriate support to their activities that are synergistic with ours.” The Montana Medical Association at the last moment before the H.B. 427 vote delivered a letter from the AMA to the desks of every senator stating why these types of legislation were a bad idea. Eight Republicans ended up voting against it. Branscum said her groups is guided in part by AMA policy, and from physicians on the ground. During every session, a group of doctors decide on which bills to support and advocate against. But it can be walking a tightrope with so many priorities. “We’re going to be working with these legislators in the session and this is just one bill, one transaction that we’re going to have with that legislator, and we’re going to need their votes one way or the other on other pieces of legislation that are equally important to us,” Branscum said. “The question is, how much can they go with you on the bills that are most important to you?” The Tennessee Chapter of the American Academy of Pediatrics was also successful in keeping a bill from passing that would have made it a crime for doctors to provide gender-affirming care for transgender youth, even though the care does not fall under standard care—prescribing puberty blockers and other hormones to minors who haven’t hit puberty. The Legislature, however, was successful in passing a bill that makes the standard of care law. “It was a discussion of, ‘Why do you have to put what we’re doing into code?’ I do all kinds of other medical practices with other patient populations, because I’m an endocrinologist, and that’s not being put into code,” said Dr. Cassandra Brady, a member of the Tennessee Chapter of American Academy of Pediatrics. “There a lot of panic and fear from our families and our patients of, ‘What do we do if we can’t get this care?’ And I think there was a lot of confusion on what that bill actually meant,” Brady said. “Our number one strategy is ensuring that our patients know that they can still come to us without fear; that we can still do what we have always done.”
Health systems step in In addition to backup from medical societies, state and local associations also in some cases had the backing of their respective health systems. “I had the support of Vanderbilt in this, so whenever I testified, our government affairs group here really helped me by reading my testimony and, would also communicate with legislators as well because they have a relationship with them,” said Brady, assistant professor of pediatrics at Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville. She added that she gathered stories from other medical providers throughout the state who see transgender youth to share with lawmakers. In North Carolina, lawmakers sought to change the definition of youth in need of this care to 21 and under, instead of 18. The bill would have fined doctors $1,000 every time gender-affirming care was delivered to people in that age group. It failed to pass. “At Atrium, we definitely reached out to them (government affairs team) early, and they were on it and ready,” said Dr. Shamieka Dixon, division chief of adolescent medicine and medical director of Atrium Health Levine Children’s and the Center for Gender Health in Charlotte, N.C. “Eventually, that bill got killed before it was pushed forward. The Atrium (Health) leadership group, they were on top of it.” Other medical societies weren’t as successful, like in Arkansas where a law now bars gender-affirming care for transgender youth and allows private insurers to enact exclusions for this care to plan members of any age. That, however, was halted after a federal judged issued a temporary injunction in a lawsuit brought by the American Civil Liberties Union. These actions aren’t the first time statehouses have tried to legislate medical care provided to transgender people. Kellan Baker, executive director of the Whitman-Walker Institute, said restrictions to the care of transgender youth might be the result of a growing acknowledgment in the medical community that this care is medically necessary. “In the 1990s, as the transgender civil rights movement became more visible, there started to be a backlash, similar to what we’re seeing right now with provision of care to trans young people, but it was against the provision of care to trans adults,” Baker said. “There was actually a new wave of explicit exclusions that were written into a lot of private insurance plans that had not had them before, and written into state Medicaid law.” And indeed, in the past five to 10 years, many more health systems have opened programs for gender diverse and transgender people, including youth, as insurance coverage insurance coverage opened up post-Affordable Care Act. In 2017, the first medical fellowship for gender-affirming surgeries was launched at Mount Sinai Health System in New York. Recently, the AMA announced funding for an LGBTQ fellowship program at the University of Wisconsin School of Medicine and Public Health. “I expect that there’ll be more and more like this to come in the future,” Ehrenfeld said. “There’s tremendous demand for competent physicians and healthcare teams that can provide services to LGBTQ patients that is just not being met. As we think about policies that support coverage, access and inclusion—as well as our work to support the development of the healthcare workforce today and tomorrow—all those things are pieces of the puzzle.”
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