Fight or Flight: Transgender Care Bans Leave Families and Doctors Scrambling

Laws in 20 states have left the fate of clinics in doubt and families with transgender children searching for medical care across state lines.

July 6, 2023

David and Wendy Batchelder hate the thought of putting their spacious house in West Des Moines, Iowa, on the market, disrupting the routines of their six children or giving up the Lutheran church that they have attended for roughly a decade.

But two new laws have left them debating whether to leave Iowa.

A ban on a medication that pauses puberty taken by their transgender son, Brecker, was signed into law by the state’s governor in March. The same month, teachers informed Brecker, 12, that he could no longer use the male restrooms and locker room at his middle school after another law was approved in the Republican-led Statehouse.

“It’s like trying to cross a bridge but the boards just fall out,” said Brecker, who recently finished seventh grade and began receiving puberty blockers in December, a year after coming out as transgender. “So you’re hanging on those two ropes, inching yourself across, not knowing whether the ropes are going to snap or break.”

In 20 states, bans or restrictions on transition-related medical care for transgender youths are upending the lives of families and medical providers.

In places where the care is outlawed, doctors have hastily shut down practices in recent months, leaving patients in the lurch. Clinics in states where it is still permitted are newly contending with a crush of out-of-state patients seeking treatments that include puberty blockers and hormone therapy. Wait lists for initial appointments can exceed a year.

More than 93,000 youths in the states that have passed bans identify as transgender, according to an analysis of federal data by the Williams Institute at the UCLA School of Law, though other data suggests that only a small number receive puberty blockers or hormones. The number of teenagers who identify as transgender has been rapidly rising over recent years.

Some families — there is no way to be sure of the numbers — already are moving or searching for homes in states where the care is still permitted. Other families are awaiting the outcome of court challenges to the new laws in states like Florida, Kentucky and Nebraska before deciding next steps. Still others say they are wrestling with what to do.

“We need to leave,” Ms. Batchelder, 39, an executive at a tech company, recalled telling her husband this spring. “I grew up in the state, but this is not the Iowa I know.”

The field of gender transition care for minors is relatively new, and prominent clinicians have disagreed on issues such as the ideal timing and diagnostic criteria for these treatments as demand has soared. These debates have recently led several European countries with nationalized health care systems to review the evidence and limit which children can receive gender-related medications. In June, England’s health agency ruled that children could only receive puberty blocking drugs as part of clinical research trials.

“Our position is we cannot see this as just a rights issue,” said Thomas Linden, director of Sweden’s National Board of Health and Welfare in an interview last year after the country’s health service announced it would limit hormone treatments for minors while more research is conducted. “We have to see patient safety and precision in the judgment.”

In the United States, the debate has instead largely taken place in statehouses, becoming among the most highly charged political issues of the last year. Republican-led legislatures began in 2021 passing bills banning access to gender transition care for minors. They argue that children lack the maturity to consent to treatments, some of which are irreversible, that they may later regret. Many Republican lawmakers have taken this further, calling the treatments mutilation.

Officials in some states have made it a felony to provide transition-related treatment for minors and have raised the prospect that parents could be investigated for child abuse. Other measures are more limited, exempting from bans, for instance, patients who were already receiving treatment.

There is broad agreement among major medical associations in the United States, including the American Academy of Pediatrics, that this form of health care can be beneficial for many patients and that legislative bans are a dangerous intrusion into complex decisions best left to doctors, patients and their families.

In the Batchelders’ home state of Iowa, Gov. Kim Reynolds, a Republican, told reporters in March that she had met with families with transgender children before signing that state’s laws affecting transgender youths. “This is an extremely uncomfortable position for me to be in,” she said. Still, she called the new laws prudent measures. “We need to pause, we need to understand what these emerging therapies actually may potentially do to our kids,” the governor said.

In the medical world, the flurry of legislation is reshaping the landscape for treatment. Some doctors say they fear young physicians may now be dissuaded from training in this specialty in much of the country.

“I feel like I’m in an impossible situation,” said Dr. Ximena Lopez, a pediatric endocrinologist who founded a clinic in Dallas for transgender youth but has watched patients leave Texas as state lawmakers moved to ban transition care for minors.

Reluctantly, she said, she is moving to California this summer to work at a new clinic where the treatment is allowed. “I either have to do something illegal or I’m a negligent physician,” Dr. Lopez said.

Health care professionals in states where treatment is still permitted have limited capacity to carry out the kind of research that could improve this field of medicine, said Dr. Angela Kade Goepferd, medical director of the gender health program at Children’s Minnesota.

“We’re all feeling overwhelmed,” Dr. Goepferd said. “If you’re a gender-affirming care provider in the United States right now, it is hard and you’re under distress.”

The bans, which passed in states including Idaho, South Dakota and Missouri, left families with transgender children sorting through options.

Some wasted no time leaving conservative states. They cited health care restrictions but also, they said, a broader sense of hostility toward L.G.B.T.Q. people, as book bans, restrictions on drag performances and limits on public restrooms were approved.

Others are, at least for the moment, planning to stay put, but travel out of state for health care while monitoring legal challenges.

Families say decisions about relocating have become agonizing: There are other relatives to think about, careers and finances to consider, and concern about what departures from conservative states would mean for other families of transgender youths who cannot move.

Amber Brewer, born and raised in Texas, said she worries about her 17-year-old son who has grown up near Dallas. Under the state’s new law, his doctors will be required to wean him off his testosterone medications starting in September. But with nine children, seven of whom are adopted, starting over somewhere else feels impossible. Her son is on a wait list to see doctors in San Diego.

“How am I supposed to move? I can’t even afford to get out of here,” Ms. Brewer said. “Otherwise we would pack and leave now.”

In rural Fort Dodge, Iowa, Sarah SmallCarter’s family is leaning toward moving away so that her 10-year-old, Odin, can grow up in a state where transgender people have more rights.

Odin, who came out as a transgender girl during the summer of 2021, when she was between first and second grade, was scheduled to start treatment at a clinic in Des Moines the day before Iowa’s law passed; doctors told the family they needed to seek care out of state, Ms. SmallCarter said.

The prospect of leaving their town of 25,000, where Ms. SmallCarter says neighbors help one another and where housing is relatively affordable, seems unavoidable, but also troubling in an increasingly polarized nation, she said.

“We’re intentionally consolidating into two different sects of the country and that’s very scary,” she said.

For the Batchelder family in West Des Moines, Brecker’s transition began in the summer of 2021 after he told his parents that he was bisexual.

“How can mom and I best support you?” Mr. Batchelder, 40, recalled asking.

That fall, Brecker, who had long hair, asked for a trim cut and began wearing more collared shirts and athletic shorts. Then, shortly after Christmas, Brecker came to his parents with additional news: He was a transgender boy, he told them. A few days before, Brecker had asked classmates and teachers to use male pronouns and a new name — Brecker.

Brecker’s four grandparents — all of whom live nearby — were supportive.

Brecker said that his early days of transitioning brought tremendous relief: “Honestly, like I was just floating on a cloud.”

In March of 2022, Brecker told his parents he wanted to get puberty blockers, a medication that halts bodily changes including the development of breasts and menstruation. He had been menstruating for a little over a year and growing breasts. The Batchelders said that they had never heard of puberty blockers, and spent several weeks studying the medical literature and consulting with professionals.

“We felt like, between his therapist recommendation, his pediatrician, his specialists and our own research, that this was the right choice for him,” Ms. Batchelder said.

Getting treatment required waiting seven months for an appointment and driving to a specialized clinic in Iowa City during a snowstorm last December. Brecker said getting a period tormented him and he was thrilled when it stopped.

Soon, as Iowa lawmakers began debating the transgender bills, his mood darkened. The political debate reverberated among classmates.

As the national debate over transgender rights intensified early this year, Brecker became deeply distressed, his parents said. In February, after disclosing he was having thoughts of self harm, his parents took him to an emergency mental health clinic. Fretting about the future, he began sleeping in his parents’ bedroom.

For now, Brecker and his parents have decided to stay in Iowa and travel out of state for medical appointments.

Mr. Batchelder, who went to law school and has been a stay-at-home father since 2020, said the fight over transgender rights motivated him to become more active in politics, and even to contemplate running for office. As an undergraduate, he served as the chair of his college Republicans organization, but said he has viewed himself as a political independent formost of his adult life.

As the laws were being debated, Mr. Batchelder delivered an impassioned speech under the rotunda in the Capitol in Des Moines, protesting what he saw as an egregious infringement of parental rights. “I will stay and fight for you,” he told fellow demonstrators. “But I need you to stay and fight.”

Ms. Batchelder is less optimistic about the family’s ability to change Iowa. During the debate, some supporters of the ban cited their religious beliefs, which Ms. Batchelder, who leans heavily on her Christian faith, said she saw as a distortion of scripture.

“I come back to what the Bible tells us to do, it tells us to love people above all else,” she said. “None of this is love.”

Leaving Iowa would mean moving away from the children’s grandparents. It would disrupt the routines and friendships of Brecker and his five younger siblings. And the Batchelders say they worry about what next year’s state legislative session might bring.

“If they move into criminalizing this care or punishing parents, we’re out,” Mr. Batchelder said.

Audio produced by Adrienne Hurst.