Bills Like South Dakota’s Are Based On Myths About Trans Health Care. Here Are The Facts.

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On Jan. 29, South Dakota lawmakers passed a bill that would make it a crime for medical professionals to provide gender-affirming care to transgender youth. The bill, HB 1057, and similar bills in other states, have faced fierce backlash from medical professionals, trans people, and advocates, who say the bill is built on myths and misconceptions about transgender health care. Dr. Daphna Stroumsa, a physician and lecturer with the University of Michigan and one of four physicians Bustle spoke to, says bills like HB 1057 "promote transphobia, promote ignorance, and promote violence towards transgender people."

HB 1057 and similar bills in Texas, Georgia, Kentucky, Florida, South Carolina, and Missouri purport to "protect" transgender kids, citing potential adverse health effects from surgeries or hormones. But physicians, trans people, and the parents of trans children tell Bustle that much of the language in bills like HB 1057 flies in the face of the medical guidance on trans care.

Advocates and experts say it's crucial that people are informed about the myths surrounding trans health care — and the truth behind them. Here are seven common myths about trans health care, debunked by experts and trans people.

1. Myth: Trans youth are being forced into making medical decisions they don't understand, or they're not given other options.

Derek Gaskill, 27, tells Bustle his experience was "quite the opposite" of being "forced" into anything. When he started his transition in 2010, at age 17, "people were trying to force me not to make decisions." At the time, he was required to be in therapy for about one to two years before he could see a doctor about medical intervention. "There was a lot of gatekeeping in order to discourage me from making any decisions at all," he says. Once Gaskill was able to see a doctor, he says she was "very adamant about me having autonomy." His doctor, a trans woman herself, was clear about what the process of transition would be like, why she needed letters from a therapist, and why she would then make her own evaluation.

Dr. Stephen M. Rosenthal, co-founder and medical director of the UCSF Child and Adolescent Gender Center (CAGC), tells Bustle that the care medical professionals provide to trans youth follows evidence-based standards of care like the Endocrine Society's Clinical Practice Guideline, which he co-authored, and the WPATH Standards of Care. The guidelines recommend an approach that involves mental health professionals, social workers, and physicians.

"It's really up to the medical team to figure out what is the safest way to provide the care that would be deemed in the best interest of the patient," he says. Medical intervention is "only one" of myriad options presented to a patient, including social transition, where they present in accordance with their gender identity and use a chosen name, or they might just need affirmation. "Each person would be evaluated on their own," he adds.

2. Myth: Children are receiving hormone replacement therapy or gender-affirming surgeries.

Susan Williams, founder and executive director of the Transformation Project, an organization that supports trans youth and their families in South Dakota, tells Bustle that people think you can just go to a doctor's office and "be like, 'yeah, I'm trans and give me my hormones,'" but that doesn't happen.

"For kids prior to puberty, there are no medical interventions," Dr. Joshua Safer, executive director of the Mount Sinai Center for Transgender Medicine and Surgery, tells Bustle. Medical guidance recommends waiting until gender expansive or transgender adolescents reach a certain stage of puberty before starting GnRH agonists, also called puberty blockers, which are reversible.

Safer says kids are encouraged to wear whatever clothing or hairstyle they want to wear and identify themselves in the way they want — all changes that are completely reversible. "We want to be supportive of kids living how they want to live," he says. "There's no commitment."

The Endocrine Society guidelines recommend waiting until adolescents are 16 years old to add gender-affirming hormones, and waiting until the patient is no longer a minor in their country to have gender-affirming surgery.

3. Myth: Puberty blockers are irreversible.

Williams, whose son is trans, says that people often lump puberty blockers and hormone replacement therapy into the same category, but they're completely different. "Putting someone on a puberty blocker is not a life-altering decision," she says.

Puberty blockers are "super active versions" of gonadotropin-releasing hormones, which occur naturally in the human body, Rosenthal says. Gonadotropins are hormones made in the pituitary gland that stimulate the testes or the ovaries to make either testosterone or estrogen, respectively. GnRH "turns on" part of the pituitary gland to start puberty.

The super active form, known as the GnRH agonist, given in the form of an implant or an injection, is so strong that it ends up having the opposite effect — it shuts down that part of the pituitary and stops puberty. When you take the medication away, puberty begins again, which is why physicians say puberty blockers simply put puberty "on pause." The medication "is thought to be 100% reversible," Rosenthal says. Children who start puberty earlier than they should also receive this medication.

Dr. Jamie Conniff, a family physician in Duluth, Minnesota, tells Bustle that trans adolescents want to pause puberty often because developing sex characteristics like breasts could traumatize them or cause other serious mental health issues down the road. "It's a way of postponing that development so that they have more time to decide what's right for them and for their bodies," he says.

4. Myth: Hormones or puberty blockers are equivalent to "chemical castration."

HB 1057's sponsor, Rep. Fred Deutsch, said in a statement the bill is meant to protect children from "chemical castration" and other harm. But Conniff tells Bustle that "chemical castration" isn't a term used in the medical community.

Rosenthal says many people think, incorrectly, that by allowing a young person to socially transition or use a puberty blocker "you're committing them to this life of sterilization, but that's ridiculous." He notes that all trans people go through a thorough evaluation before receiving any medical intervention. And, second, he says that research shows that someone's gender identity when physical puberty began "was highly predictive of their adult gender identity."

If people proceed with gender-affirming hormones and then surgery later on, they will become infertile. Though Rosenthal says loss of fertility could be considered an adverse effect, doctors are often weighing that risk against the harms of not treating gender dysphoria. Going through puberty would also lead to irreversible side effects, he notes. It's a complex, difficult conversation that he says physicians have to work out with each patient.

5. Misconception: Puberty blockers cause bone damage.

Limited research has shown that puberty blockers can have long-term effects on bone density. But Conniff says the risk of decreased bone density from puberty blocker use is minor.

The Endocrine Society's 2017 guideline, its latest, notes that there are "compelling reasons" to take someone off of puberty blockers before they're 16. This makes these bone concerns far less likely, says Rosenthal. Physicians also prescribe puberty blockers to kids and adults for other medical problems often.

Rosenthal says the field of transgender medicine, being relatively new, is suffering from a lack of evidence in general. Physicians also have concerns about the impact of puberty blockers on brain development, which Rosenthal says needs to be better studied. He's working on one of the first long-term observational studies of transgender youth, with more than 400 kids, along with three other centers.

Many of Conniff's patients choose to use puberty blockers despite risks "because they feel like their mental health depends on them moving forward." In fact, a new study published Jan. 23 in the journal Pediatrics found that transgender youth who have access to puberty blockers had a significantly lower risk of suicidal ideation and mental health problems.

In Gaskill's case, he chose to move forward with treatment in 2010, despite the limited research on long-term health effects, because he felt like he had no other choice. "Those two years of not being able to access hormones were really, really terrible," he says. "It was the saddest I've ever been. The only reason it wasn't overwhelming was because there was hope that I would be able to access hormones."

6. Myth: There's a high "desistance" rate in adolescents.

Proponents of bills that restrict trans people's access to medical care often note that the limited available studies show that young people who say they're trans before puberty "change their minds," or "desist." But Rosenthal says those studies used mixed groups of kids, including, for example, gay children, who may be understood as gender expansive before puberty and then come to identify as cis. Researchers have also spoken out about the "desistance" myth, noting that the studies purposefully included kids who didn't meet the criteria for being transgender, Think Progress reported. These studies also only included a small number of transgender kids, or classified kids who didn't complete the study as ones who "desisted."

If there were truly that high a rate of desistance, Rosenthal says physicians wouldn't introduce any kind of medical intervention that had potential adverse affects.

Stroumsa, the University of Michigan lecturer, who specializes in OB-GYN care for trans patients, says every medical intervention they perform has risks, benefits, and side effects that patients are not always happy with. That's why medical decisions are made with a physician's guidance. "We make a shared decision with [the patient] understanding what they're taking on," they say. "We make decisions when we think that the benefit is greater than the risk. The focus should be on how massive the benefit can be for trans people getting the care they need."

Stroumsa also notes that the 2015 U.S. Transgender Survey found that the majority of people who started hormones and then stopped, or regretted having started hormones, felt that way "not because they felt like it was the wrong decision for them, but because of peer pressure, family pressure, social pressure, fear of discrimination, actual discrimination," they say.

7. Myth: Bills like HB 1057 won't do any harm if trans adolescents aren't receiving surgery or hormones until 16 anyway.

Even if trans teens won't need surgery or hormones until they're 16, Gillian Branstetter, a spokesperson for the nonprofit National Women's Law Center, tells Bustle that HB 1057 sets a dangerous precedent of inserting the government into personal, private medical decisions. Bills like HB 1057 "are part of a frightening trend at the state level of rejecting the health care of marginalized people in the name of scoring political points as well as rejecting science."

Stroumsa says the biggest barrier trans people face to their health, lives, and safety is transphobia. They pointed to the epidemic of violence against transgender women of color, but also the discrimination in housing, employment, and in the military that trans people face.

"Bills like this promote transphobia, promote ignorance, and promote direct violence, physical violence, and structural violence toward transgender people," they say. "All of these things have direct and indirect effects on people's lives and their health."