Gov. Greg Abbott told state health agencies in Texas on Tuesday that medical treatments provided to transgender adolescents, widely considered to be the standard of care in medicine, should be classified as “child abuse” under existing state law.
His statements, made in a letter to the Texas Department of Family and Protective Services, followed an opinion Friday by Attorney General Ken Paxton that said providing medical treatments like puberty-suppressing drugs and hormones to transgender teenagers should be investigated as child abuse.
Abbott specified that the reporting requirements applied to “all licensed professionals who have direct contact with children who may be subject to such abuse, including doctors, nurses, and teachers, and provides criminal penalties for failure to report such child abuse.”
It is still unclear how and whether the orders, which do not change Texas law, would be enforced. While the state’s child welfare agency has said that it will investigate such claims, some county and district attorneys have stated that they will not enforce the opinion.
“This is a complete misrepresentation of the definition of abuse in the family code,” said Christian Menefee, the Harris County attorney. Menefee said that any such investigations in Harris County, the state’s most populous county, will not be prosecuted. “We don’t believe that allowing someone to take puberty suppressants constitutes abuse,” he said.
Abbott’s effort to criminalize medical care for transgender youth is a new front in a broadening political drive to deny treatments that help align the adolescents’ bodies with their gender identities and that have been endorsed by major medical groups. Twenty-one states introduced such bills last year, according to the Williams Institute at the UCLA School of Law.
Arkansas passed a law making it illegal for clinicians to offer puberty blockers and hormones to adolescents and banning insurers from covering care. But the law was temporarily blocked by a federal judge in July after the American Civil Liberties Union sued on behalf of four families and two doctors.
Several such bills were also introduced in Texas. None passed. Facing political pressure, the University of Texas Southwestern Medical Center and Children’s Medical Center Dallas closed the state’s only multidisciplinary clinic for transgender youth in November.
The letter from the Texas governor comes as early voting has begun in primary elections across the state. Election Day is March 1. Abbott and Paxton, both Republicans, face challengers who have questioned whether they have been sufficiently conservative. Paxton, a two-term incumbent who has been indicted on securities fraud charges, is seen as particularly vulnerable. Political strategists say he is unlikely to receive more than 50% of the vote and is heading for a runoff.
Professional medical groups and transgender health experts have overwhelmingly condemned legal attempts to limit “gender-affirming” care and contend that they would greatly harm transgender young people.
“Gender-affirming care for transgender youth is essential and can be lifesaving,” Adm. Rachel Levine, assistant secretary for health for the Department of Health and Human Services and the Biden administration’s highest-ranking pediatrician, said in an emailed statement. “Our nation’s leading pediatricians support evidence-based, gender-affirming care for transgender young people.”
A growing number of transgender adolescents have sought medical treatments in recent years. Transgender teenagers are at high risk for attempting suicide, according to the Centers for Disease Control and Prevention. Preliminary research has suggested that adolescents who receive such medical treatments have improved mental health. Long-term studies are ongoing.
Marissa Gonzales, a spokesperson for the Texas Department of Family and Protective Services, said that there were no pending investigations of child abuse involving the procedures described, but that the agency would investigate cases that were reported.
Whether children can be taken from their parents for allowing them to receive such medical care will ultimately be at the discretion of the courts.
“At this moment, it’s unclear what child protective services, prosecutors and judges are going to do with this nonbinding opinion from the attorney general,” Kate Murphy, senior policy associate for child protection at Texans Care for Children, a nonprofit children’s policy group, said in an emailed statement. “What is clear is that politicians should not be tearing apart loving families — and sending their kids into the foster care system — when parents provide recommended medical care that they believe is in the best interest of their child.”
If local attorneys do not pursue cases, the state attorney general’s office could do it, Menefee, the Harris County attorney, said, adding that the position taken by the governor and the attorney general could have a chilling effect. “It’s designed to make parents scared,” he said. “It’s designed to make doctors scared for even facilitating gender-affirming health care.”
Some treatments used in gender-related care carry medical risks. Puberty-blocking drugs, which suppress the production of testosterone and estrogen, can weaken bone development, though evidence suggests it recovers once puberty starts. If blockers are used at an early stage of puberty and a teenager pursues hormone therapy, the drug regimens can lead to fertility loss. The standards of care for transgender health therefore recommend that patients and their families be counseled on how to preserve fertility by delaying the use of blockers if having children is important to them.
The standards also recommend that doctors and families wait until the teenager has reached the age of majority, which is 18 in Texas, before pursuing irreversible genital surgeries.
Some political groups who oppose gender-related treatments for young people say the stakes are simply too high.
“Minors are prohibited from purchasing paint, cigarettes, alcohol, or even getting a tattoo,” said Jonathan Covey, director of policy for the group Texas Values. “We cannot allow minors or their parents to make life-altering decisions on body-mutilating procedures and irreversible hormonal treatments.”
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Experts who work with transgender patients, like Dr. Alex Keuroghlian, a clinical psychiatrist at Fenway Health in Boston and the director of the Psychiatry Gender Identity Program at Massachusetts General Hospital, say decisions about treatments for young people should be weighed only by a patient, their parents and their physicians. Keuroghlian denounced Abbott’s letter: “It’s legislating in a manner that is entirely divorced from medical evidence, consensus and mainstream practice.”
Though some doctors have debated how much time should be spent on psychological assessments for adolescents before starting treatment, medical groups broadly agree that puberty suppression and hormones benefit transgender teens.
Erica Anderson, a clinical psychologist and the former president of the United States Professional Association of Transgender Health, has pushed for more assessment for such teenagers before initiating medical treatments. She said that blocking gender-affirming care and forcing teenagers to go through the physical changes of puberty for a gender they don’t identify with was “inhumane.”
“For legislators or politicians to weigh in on an area of medicine for which they have no background is preposterous,” Anderson said. “People in Texas should be outraged.”
Adri Pérez, a policy and advocacy strategist at the ACLU of Texas who uses gender-neutral pronouns, called the governor and attorney general’s stance politically motivated and said it could prevent young trans people from getting the medical care they urgently need.
“Gender-affirming care saved my life,” they said in a statement. “Trans kids today deserve the same opportunity by receiving the highest standard of care.”
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