Transgender youth in North Carolina face uncertain health care future as lawmakers vote on gender
Aug 20, 2023
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Rowan Bilodeau, 15, spent much of his childhood feeling trapped in the wrong body. He started receiving gender-affirming care at 13 years old to help him transition. This type of care uses a multidisciplinary approach to help people who are transitioning from their assigned gender. It can include social, behavioral, and medical care to help affirm someone’s gender identity when it conflicts with their assigned gender at birth. For Rowan, this meant that he could make a transition to the male gender.
Rowan, originally from Cary, said he felt different and related more to the boys than the girls in his class as early as age 6. When Rowan started puberty at age 9, he became really uncomfortable in his skin as his body began to develop, he said.
Rowan’s journey is a testament to the challenges faced by transgender minors in North Carolina. Despite his early realization of his gender identity, the impending health care restrictions could hinder his path and those of many trans minors like him.
“I’m nervous about these bills passing,” he said.
Starting in August, transgender minors in North Carolina might not get the healthcare support they need for transitioning. North Carolina legislators are scheduled to come back to session on Aug. 7. It’s possible they may vote to override Gov. Cooper’s veto on House Bill 808 during that session. House Bill 808 aims to ban surgical gender transition procedures and puberty blockers for minors. This bill has been on the legislative calendar in July, but was delayed. The earliest possible date for the vote to override the bill is now Aug. 7.
If the veto is overridden the bill would limit gender-affirming care for minors like Rowan, who seek treatment with their families’ consent. Lawmakers supporting the bill claim it’s for the protection of children, but nonprofit organizations argue that it could harm transgender youths by restricting their access to gender-affirming care.
Health care providers argue it is critical for trans minors to start receiving care earlier because of the complications of transitioning later in life. The American Civil Liberties Union of NC sees this legislation as part of a coordinated attack on trans youths in the state and nationwide. Some organizations are also preparing to legally challenge the constitutionality of the legislation if it becomes law, according to the American Civil Liberties Union of NC.
Gender-affirming care is important for minors and can be lifesaving. Studies show that gender-affirming hormone therapy can help develop physical changes that correspond with a person’s gender identity and significantly decrease gender dysphoria, or distress when there is a conflict between the sex assigned at birth and the gender with which an individual identifies.
HB 808 prohibits health care providers from performing surgical gender transition procedures on minors and from prescribing, providing or dispensing puberty-blocking drugs or cross-sex hormones to minors. Health care providers who violate this will have their licenses revoked.
In the past, there have been efforts to restrict gender-affirming care for trans people. In 2016, the General Assembly passed a House bill to ban trans people from using public bathrooms that don’t correspond with their assigned sex on their birth certificate. It was signed by Gov. Pat McCrory. It was then rolled back the following year after Gov. Roy Cooper took office. In 2021, a bill was also proposed in the N.C. Senate to prohibit gender affirming care for those under the age of 21. This bill did not advance, and due to a lack of support, it wasn’t voted on.
The bill allows minors who have gone through a surgical procedure to pursue a private right of action against the medical professional who provided them with care. It also prohibits the use of state funds for surgical gender transition procedures, puberty blockers and hormones.
Any course of treatment that began before Aug. 1 of this year can be continued or completed, so long as a medical professional deems it medically necessary and the parents or guardians consent to it, according to the language in the bill.
North Carolina lawmakers who support the legislation to ban gender-affirming care for minors say they are protecting kids.
HB 808 is among 10 anti-trans bills in North Carolina aiming to impose restrictions on trans people in four categories: health care, sports, education and entertainment. The Senate version of HB 808 is Senate Bill 639. These bills have been introduced in North Carolina during a year when a record number of anti-LGBTQ legislation – 417 bills – was proposed in state legislatures across the country.
Juliana Martinez, an associate professor of gender and sexuality at the American University in Washington, D.C., said the introduction of anti-trans legislation in North Carolina and statehouses across the country is due to the election cycle. The issue is not unique to North Carolina or to the United States, she said.
“Moral panic is highly effective to lead people one way or another during election cycles,” Martinez said. “Gay marriage is no longer a wedge issue with voters, and the abortion issue has become much more complex, so trans issues have emerged as effective, polarizing issues.”
Martinez said this shift in American politics is dangerous.
“It’s a shift that isn’t democratic and it’s not in line with American values,” she said. “It’s shifting toward authoritarian values, under which one single ideological viewpoint gets to make decisions for everyone else.”
She said many anti-trans bills being introduced in legislatures across the country are sustained by disinformation.
HB 808 was sponsored by Reps. John A. Torbett, R-Gaston, Hugh Blackwell, R-Burke, Mark Pless, R-Haywood, Ken Fontenot, R-Nash, Dean Arp, R-Union, Celeste C. Cairns, R-Carteret, Neal Jackson, R-Moore, Jake Johnson, R-Henderson, Donnie Loftis, R-Gaston, Jeffrey C. McNeely, R-Iredell, Bill Ward, R-Camden and David Willis, R-Union.
On the House floor, Rep. Fontenot said he blames “social contagion” for the rise in the trans teen population. He also compared gender transitioning to “medical experimentation.”
Carolina Public Press reached out to all the bill sponsors for comment, but they either didn’t respond or weren’t available.
“The state has an interest in protecting our children from long-term harm, and that’s what this bill is all about. We have laws to protect children,” Sen. Joyce Krawiec, R-Forsyth, said on the Senate floor in June. Krawiec is the sponsor of one of the anti-trans bills, Senate Bill 631. CPP reached out to Krawiec for comment, but she was not available.
“I think that their idea of protecting children is harming them,” Rowan said, “and if you are denying care to these kids, that’s just further reinforcing the idea that they have, that something is wrong with them.”
Rowan testified in the legislature against SB 631 before the focus of the bill was changed from fairness in women’s sports to prohibiting the use of public health care facilities and funds for gender-affirming care for minors, and he was the only person able to speak in opposition to this bill.
Rowan and his mother, Margaret Bilodeau, also testified against HB 808 in June. Margaret spoke at an Equality NC and Campaign for Southern Equality rally outside the General Assembly before HB 808 was being heard on the Senate floor, she said.
Republicans have a supermajority in the General Assembly and can override the governor’s veto, resulting in HB 808 becoming law. If the bill becomes law, North Carolina will join 19 other states in restricting access to gender-affirming care.
Since Rowan started receiving gender-affirming care two years ago, he and his family have seen a major difference in his health and outlook on life.
“In 2019, if you asked him what he wanted to do with his future, he would basically say that he doesn’t see himself in the future,” said Margaret, Rowan’s mother. “Him being himself, it makes a huge difference.”
She said she thinks it would have benefited Rowan to start puberty blockers from a younger age, an option that will be banned for trans minors under HB 808 if the bill becomes law.
“Looking back, I really wish he could have had the blockers, and in the climate we are in right now, it makes it a lot less of an option for people,” Margaret said. “It’s a wonderful tool that can put a pause, so a child doesn’t have to go through the stress of puberty and having this body that is not theirs.”
Restrictions on minors receiving gender-affirming care, such as puberty blockers, can lead to dire consequences, according to health care providers.
“I’m just seeing a lot of anxiety, fear and just dealing with the unknowns of am I going to be able to continue care, or am I going to get my child the care they need?” said Natalie Frazier, a clinician supervisor and the gender-affirming program director for Planned Parenthood South Atlantic.
Frazier said that families she’s met recently are feeling pressured into making decisions about their children’s transitions.
“I think that’s an ironic outcome of this bill, when the politicians are saying that they’re trying to protect kids and don’t want people making rash decisions,” she said. “But they’re backing people into a corner by saying you have to start by this date or you’re not going to be able to access this care.
The bill does not only ban hormone therapy but also puberty blockers, and that is really going to harm patients significantly, said Izzy Lowell, a family medicine physician and the founder of QueerMed, a medical clinic that offers gender-affirming care for transgender and nonbinary communities in 25 states.
QueerMed has been working to help establish care for patients from North Carolina before Aug. 1 to help them continue care, Lowell said. But continuing puberty blockers long term can be harmful, she said.
“If you had somebody on puberty blockers for five to seven years, they would actually develop osteoporosis as a teenager, and their bone density may not recover even after they come off these treatments,” Lowell said. “They’d be at risk for pathologic fractures lifelong.”
Research by The Trevor Project, a suicide prevention organization for LGBTQ youths, shows that receiving gender-affirming care has been proven to reduce thoughts of suicide and attempts in transgender individuals. Transgender and nonbinary individuals experience mental health challenges at higher rates and experience anxiety and depression 10 times the rate of those who are cisgender, or those who identify as their assigned gender at birth.
Eighty-six percent of transgender and nonbinary youths, aged 13-24, say that the recent political debates around anti-trans legislation have negatively affected their mental health, according to The Trevor Project’s national poll.
There are mental health dangers for trans minors who don’t receive gender-affirming care and go through puberty, according to Lowell, who said her patients’ mental health has suffered significantly due to restricted access to gender-affirming care.
“If they survive to adulthood, then they have suffered all the consequences of going through the wrong puberty and living in the wrong body for that time,” she said, and “so their mental health is typically worse.”
If HB 808 passes, trans minors may not have other options in North Carolina if they are only able to continue the course of treatment, instead of starting cross-sex hormones to continue their transition, according to Lowell.
“Those already on puberty blockers in North Carolina would not be able to transition to hormone therapy at age 12 or 13, as they should, and would have to continue puberty blockers until they turn 18,” she said. “They’d be on this medicine for potentially eight to nine years, or, for example, they’d go through female puberty, and so both options are terrible.”
If trans patients go through female puberty, they’ll develop wider hips and breasts and would need chest surgery, according to Lowell, and if they go through male puberty, they might be very tall, have broad shoulders, have a deep voice and have hair growth all over their body.
“Some of these changes are permanent and can never be undone,” she said. The restrictions in the bill inhibit a proper transition, Lowell said.
“I wouldn’t put my child through either of those things – being on puberty blockers too long or dropping puberty blockers without hormone treatment,” she said. “I would find a way to get out of state; there’s no other option.”
In North Carolina, the proposed ban on gender-affirming care for minors has been met with public opposition through protests and demonstrations held in different parts of the state. Groups and individuals have mobilized and held rallies across the state, for example in Asheville, Greensboro and Raleigh.
While Rowan has the family support to ensure he receives the care he needs, not everyone does, he said, and he’s concerned about the long-term consequences for trans minors who aren’t able to receive care in the state once HB 808 becomes law.
“If your kid is transgender, they’re always going to be transgender, there’s nothing you can do that will make them not be transgender,” he said. “The only thing that this will do is make them feel unsafe, unsupported and like something is wrong with them.”
Allison Scott, the director of impact and innovation at Campaign for Southern Equality, said North Carolina lawmakers are using LGBTQ people and especially trans and nonbinary kids as a “political football,” with no regard to the consequences of how such laws hurt children.
“As a trans woman myself, and a fifth-generation North Carolina native, this is just infuriating to me to see our publicly elected officials specifically targeting children,” Scott said.
Scott said when she was transitioning, her parents were not supportive, and medical care at that stage would’ve been practically impossible. She said she is familiar with the struggles of trans kids.
“For me to see kids who are coming out at a time where it is actually possible to find the right care and to have that taken away from them, it worries me deeply,” she said. “We don’t need to go backwards in our state.”
“We know the sponsors of these bills, we know that it’s the conservative majority in North Carolina that is putting forth the bills and voting in favor of them,” Scott said. “It’s the conservative majorities in other states that are doing the same.”
Rowan said he believes that lawmakers working to ban gender affirming care for minors have a very limited understanding of the process.
He said before he started hormones, he and his family had to read pages of side effects, and he and his parents had to give consent. “Even though I’m a minor, my consent mattered,” Rowan said.
Rowan’s mother, Margaret, emphasized that this is a private medical decision for children and their families and that lawmakers should not be involved in it.
“We don’t need to bring legislators into the doctor’s office every time we go there to make a medical decision,” she said.
Across the country, laws on gender affirming care are being challenged in courts for constitutionality, on the basis that they violate the equal protection and due process clauses of the 14th Amendment. In states like Arkansas, the ban has been challenged successfully.
“It’s a coordinated attack on trans youth, statewide and nationally, to essentially legislate trans youth away,” said Ivy Johnson, a staff attorney at the American Civil Liberties Union of NC.
“It’s unconstitutional, gender-based discrimination,” said Johnson. “This is the new frontier of civil rights litigation, particularly for the LGBTQ+ community, and especially trans youth.” The American Civil Liberties Union of NC has a position on this issue and believes this bill is unconstitutional, she said.
“The purpose of a private right of action, to sue civilly, is likely to intimidate health care professionals from doing their jobs and providing care for the children for fear of being sued down the line,” said Johnson.
She also said the state funds are vital for public health care facilities, such as the UNC health care system, that provide gender-affirming care, which could be prohibited under HB 808.
“This prohibition of the use of state funds is likely to fold entire practices of gender-affirming care for minors, and lots of children will not have a way to pay for care,” she said. For minors on Medicaid, for example, their insurance won’t cover whatever gender-affirming care they’re receiving from their physician, and the costs would be exorbitant, she said.
HB 808 is set to be voted on Aug. 7, and lawmakers are expected to override the governor’s veto. The law does not go into effect until lawmakers vote to override it, according to Johnson.
“If someone started a course of treatment after Aug. 1, I don’t think they would fall into the exception of getting to continue that course of treatment,” Johnson said.
The state should not have a role in personal health care decisions, and the ACLU hopes that the bill will be challenged in the courts, according to Johnson.
Currently, preparations are ongoing to challenge these laws, and people and organizations are looking into it in North Carolina, according to Johnson.
“All eyes are on the bill and trying to think of ways it could be challenged, if it becomes law,” she said. “Currently, all the signs point to the veto being overridden.”
The ACLU NC is tracking the progress of these bills, and its policy director, Liz Barber, has been at the legislature for all the debates on HB 808 and other anti-trans legislation, according to Johnson.
The Campaign for Southern Equality is partnering with all of the state-level groups working on similar issues, according to Scott.
“Everyone is preparing, but nobody has anything ready yet because the bill has not been voted in,” Scott said. “But everybody is, I think, gearing up for a very long, protracted fight.”
The ACLU NC is also working in partnership with nonprofit organizations like Equality NC and Campaign for Southern Equality to strategize against anti-trans bills, Johnson said.
If the bill, once it becomes law, is successfully challenged, trans minors, like Rowan, can continue to seek the gender-affirming care they need to safely transition from their assigned genders.
Rowan is also closely following anti-trans bills, especially HB 808, he said. He is interested in psychology, sociology and social work and wants to be an advocate for trans minors.
“I’m honestly kind of teary, because I know how depressed he was and how much of a difference affirming him has made,” said Margaret. “Hearing him have plans and be excited is an example of how accepting him and him being himself makes a huge difference.”
Rowan considers himself fortunate because his quality of life improved with the strong emotional support from his family and friends and receiving gender-affirming care to help him transition, he said.
“I shared my story, because I think it’s important for all sorts of people to hear a perspective that maybe they haven’t heard before,” Rowan said. “People my age and younger who don’t have the support or the ability to speak out, have someone that is speaking for them, and I think that’s really important.”
Neighboring states, such as South Carolina and Virginia, don’t have bans on gender-affirming care yet, and both QueerMed and Planned Parenthood South Atlantic can help patients arrange for care out of state.
“We’re having people in other states that have bans travel out of state,” Lowell said. “We saw a patient when they were on a layover at Logan Airport in Boston while they were traveling, and so we are getting as creative as we can, but we’re not going to stop providing this care.”
Lowell said QueerMed is working with 30 grant funding programs from advocacy groups to help people cover travel expenses.
“Our primary option will be having families go to our health centers in other states,” Frazier said. Planned Parenthood South Atlantic has help centers in surrounding states where patients can seek care, according to Frazier.
Gender-affirming care for minors remains a contentious and politically polarized issue in North Carolina. HB 808, which bans gender affirming care for minors, was vetoed by Gov. Roy Cooper and will be voted on in the legislature on Aug. 7. If the veto is overridden by the Republican-majority legislature, it will become law.
The outcome of this vote will have an impact on the lives of trans minors and their families. Healthcare providers say access to gender-affirming care is critical and can be life-saving for trans minors. Nonprofit organizations in the state view the ban on gender-affirming care for minors as unconstitutional and may challenge it in the courts, if it becomes law.
For out of state access to gender-affirming care:
Other local organizations and resources for support:
Correction: In an earlier version of this article we misstated some details about House Bill 2 (HB2). HB2 was passed in 2016 and signed by Gov. Pat McCrory. After Gov. Roy Cooper took office, HB2 was repealed in 2017.
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by Mehr Sher, Carolina Public Press August 1, 2023
Mehr Sher is the staff democracy reporter at Carolina Public Press. Contact her at [email protected].Rowan BilodeauPat McCroryJuliana MartinezJohn A. TorbettHugh BlackwellMark PlessKen FontenotDean ArpCeleste C. CairnsNeal JacksonJake JohnsonDonnie LoftisJeffrey C. McNeelyBill WardDavid WillisJoyce KrawiecMargaret BilodeauNatalie FrazierIzzy LowellAllison ScottIvy JohnsonLiz BarberCorrection: