A new state law puts Arkansas doctors who work with transgender youth in a difficult bind: They must either stop providing what they consider to be life-saving medication to their young patients or risk losing their medical license.
House Bill 1570, now Act 626, the “Save Adolescents From Experimentation (SAFE) Act,” prohibits physicians and other professionals from providing gender-affirming health care to patients under the age of 18. Sponsored by state Rep. Robin Lundstrom (R-Elm Springs), it passed the House on March 10 and the Senate on March 29, both by large majorities. Gov. Asa Hutchinson vetoed the bill on April 5, calling it a “vast government overreach,” but the legislature overrode his veto the next day. It could go into effect as soon as July 28.
The law, which is the first of its kind in the country, will ban Arkansas health care providers from prescribing cross-sex hormones for trans people under 18, including estrogen for patients transitioning from male to female and testosterone for patients transitioning from female to male. The law prohibits doctors from prescribing puberty-blocking drugs as part of a gender-affirming regimen. And, it prevents doctors from referring patients to other providers, though doctors say it is unclear whether that ban would include referrals for counseling and mental health care related to gender dysphoria. (The bill also bans gender reassignment surgeries for minors, but doctors who work with trans youth say such operations aren’t performed on patients under 18 anywhere in Arkansas.)
On May 25, the American Civil Liberties Union filed a lawsuit in federal court seeking to block the measure from taking effect. Holly Dickson, the executive director of the ACLU of Arkansas, said in a press release that the bill would be “devastating to transgender youth and their families, forcing many to uproot their lives and leave the state to access the gender-affirming care they need.”
One provider in particular is in the crosshairs of the new ban: The Gender Spectrum Clinic at Arkansas Children’s Hospital. Dr. Michele Hutchison, a pediatric endocrinologist who helped found the clinic in 2018 and is a plaintiff in the lawsuit, said the “vast majority” of trans children in Arkansas receiving medical care to help affirm their gender identities are doing so at the Gender Spectrum Clinic. After years of building a health care practice that caters to the unique needs of Arkansas’s trans youth, much of Hutchison’s work may soon be deemed illegal.
The clinic’s fate is unclear if the court declines to block the new law, and Arkansas Children’s Hospital has avoided commenting on its future. “While Arkansas Children’s is not party to this litigation, our patients and families continue to seek care and we will continue to provide allowable services,” said Brent Thompson, executive vice president and chief legal officer for the hospital, in an emailed statement.
Hutchison said that if the law goes into effect, some clinic employees could lose their jobs. Hutchison herself would still be employed, she said, because she also works at the Endocrine Clinic and the Diabetes Clinic at Children’s. But, she said, it would be a devastating blow.
“On an emotional level, it would just take the gas right out of me,” she said. “I don’t know how I could keep running. I’d still have a job, I’d still have a paycheck, but I’d be pretty miserable.” Hutchison emphasized that she was speaking as a private citizen and concerned physician, not as a representative of Children’s.
Andrew Bostad, 15, is one patient of the Gender Spectrum Clinic who could lose access to treatment should the law stand. He said the legislation sends a dangerous message to him and his peers.
“Trans teens are [at] very high risk for suicide, so this legislation is just basically telling people like me that they don’t want them to exist,” he said. “They’re not helping anyone with these bills. They’re killing kids.”
Hutchison said that in the three years the Gender Spectrum Clinic has been open, before passage of the bill, two or three patients had attempted suicide. Since early April, she said, staff have been alerted to seven attempted suicides, four by patients of the clinic. (The other three were trans children who were not patients but were treated at the emergency room at Children’s.) Dr. Stephanie Ho, a family medicine physician and a Fellow with Physicians for Reproductive Health at Vector Health and Wellness Clinic in Fayetteville, is one of the few other providers in Arkansas to administer cross-sex hormones to patients under 18. She said one of her patients has also attempted suicide.
Andrew’s mother, Brandi Evans, said Andrew came out as trans when he was 12 years old. She learned about the clinic through a support group for parents of trans children, then got a referral from her son’s primary care provider. Andrew started going to the clinic shortly after he came out and began taking testosterone injections at age 14.
Evans said that when she found out about HB 1570, “to say I was livid would be an understatement.”
“Not only are they taking these kids’ right to have affirming health care away from them, which is detrimental in and of itself, but they’re telling me as a parent that I no longer have control over my child’s medical care,” Evans said.
Willow Breshears, 18, began transitioning when she was 13 years old. She works as a community organizer and founded the Young Transwomen’s Project, which provides resources for Arkansas trans women and girls between the ages of 16 and 28. She said the new law will have a profoundly detrimental impact on trans children.
“Just imagine if you got something that you wanted so bad — something that was so life-changing for you — and then all of a sudden that was taken away,” Breshears said. “How would you feel?”
Expectation management and family-conscious care
Though debate around health care for trans youth has focused on hormone therapy and puberty-blocking drugs, Hutchison said the Gender Spectrum Clinic does far more than simply provide medications. The clinic is “holistic,” she said, “in the sense that we can’t work with just the child: It has to involve the entire family.”
“A lot of what we do is expectation management, both for the parents and for the kids,” Hutchison said. “A lot of these teenagers come hoping that they’re going to get their cross-sex hormones on the very first visit, and that’s not going to happen.”
Before a patient visits the Gender Spectrum Clinic for the first time, the clinic’s social worker will interview the patient by phone, Hutchison said, primarily to gauge whether the child is “actively suicidal” and needs to be connected with appropriate mental health resources. The interview also helps the clinic better understand the child’s family environment.
“For example, maybe mom is accepting and affirming, but dad is not. Well, we need to know that ahead of time,” Hutchison said. “Is this child living with their grandmother, but mom has custodial rights?”
Hutchison said part of the clinic’s role is to help families with the often difficult task of adjusting to a child’s transition.
“The best way that I’ve tried to reach out to some parents who are struggling … is to say, ‘Imagine if you woke up in someone else’s body. … And nobody saw you. Nobody recognized you. Your wife doesn’t recognize you, your boss doesn’t recognize you, people on the street don’t recognize you, or they see you as somebody else. How terrifying would that be?’” she said.
“All these kids want is to be seen as who they are,” she said. “And they have to live that every single day.”
Brandi Evans said Hutchison is a “very hands-on” doctor who wants her patients and their families to “understand the entire process.”
“She wants everyone involved to know what her expectations are [and] what our expectations should be,” Evans said. “We shouldn’t have these grandiose expectations of, ‘He’s gonna take one [testosterone] shot, his voice is going to drop and he’s going to grow a full beard.’ ”
In addition to the social worker, the team at the clinic includes nurses, a gynecologist and other doctors, a psychologist, a chaplain and an attorney. Hutchison said the attorney may help with a variety of legal matters, from name changes to parental custody issues to situations in which a child’s school refuses to let them use the appropriate bathroom.
Other medical providers say the expert guidance provided by the Gender Spectrum Clinic is a vital resource. Dr. Natalie Burr, a pediatrician with the Little Rock Pediatric Clinic, said she refers her transgender patients to Hutchison and her team, rather than prescribing them medication herself. Being prohibited from doing so, she said, “really ties my hands.”
“To me, this is just in opposition to the Hippocratic Oath that I take,” she said. “I really and truly never imagined that it would be illegal for me to refer a patient to care that is evidence-based.”
In her four years of practice at the Little Rock Pediatric Clinic, Burr said, she has learned that trans children “are still kids [who] need to be supported just like any other kid.”
“[Trans children] still might get strep throat like a lot of the other kids do. They have those common childhood concerns that you see, just as they have their unique concerns,” Burr said. “Acceptance and respect for who they are as people goes a long way. I may not be the one prescribing gender-affirming medications, but just using a correct pronoun or name means so much to them.”
‘Like switching on a light’
Proponents of the new law claim it is intended to protect kids. When presenting the bill on the floor of the state House of Representatives in March, Rep. Lundstrum said minors shouldn’t be able to receive hormone treatment, even with parental consent.
“Some of them may choose to be transgender when they’re older,” Lundstrum said. “That’s okay, that’s their choice. But when they’re under 18, they need to grow up first. That’s a big decision. There’s no going back.” (Lundstrum did not respond to repeated requests for comment for this story.)
But the Gender Spectrum Clinic extensively vets patients before beginning medication, Hutchison said. The clinic requires patients to be 14 years old before they begin cross-sex hormones. Hutchison said the clinic also requires that a patient see a therapist for at least six months before they’re considered for hormones.
According to Hutchison, around 50 patients at the Gender Spectrum Clinic are taking cross-sex hormones and would be forced to stop (or go out of state for care) if the new law goes into effect. She said 40 more patients are “in the pipeline” to begin hormones within the next year, and around 30 patients are waiting to be seen at the clinic.
The clinic also sees a number of patients who are too young to begin cross-sex hormones, as well as patients with mental or emotional issues that must be addressed before starting treatment. For example, Hutchison said she recently learned that a patient who was preparing to begin hormones has an eating disorder, so the clinic will work on helping the patient address that problem before starting hormones.
Patients’ mental and emotional health often improve further once hormone treatments begin. After Andrew began puberty and before he started taking testosterone injections, Evans said, her son was a “closed off, very angry, depressed child.”
“His brain this whole time is saying ‘I’m a boy, I’m a boy,’ but he’s getting this flood of estrogen that makes him [feel] ‘no, this isn’t right, I don’t like it,’ so it just really shut him down,” Evans said. “He just wanted to stay in his room. He didn’t want to talk to anybody; he was just mad at the world.”
Evans said that Andrew would literally faint every time he started his menstrual cycle. She took him to see neurologists and gynecologists to determine why he was losing consciousness every time he got his period. But once Andrew came out as trans, she said, “the passing out made sense, because this wasn’t supposed to be happening.”
Andrew has now been taking testosterone for almost two years. Evans said that a couple of months after he began treatment, “I started to see [my] happy-go-lucky kid come back.”
“He was talking to us, he wanted to go out and do things, he wanted to hang out with friends again,” Evans said. “All of the things [that make you say], ‘Right there, that’s the kid I remember.’”
Andrew said his testosterone injections have helped him “pass,” or be perceived as his affirmed gender.
“Changes really started a couple months in,” he said. “My voice started to drop, my skin got oilier, [I got] body hair everywhere. I used to not pass at all, previously to starting testosterone, and now I pass all of the time. It’s pretty liberating.”
Andrew said the new friendships he’s made during his transition have been an important part of the process.
“I’m not friends with the same people I was friends with when I first started testosterone,” he said. “But meeting new people who are more supportive and more like me is probably the best thing that has happened.”
Ho, the Fayetteville doctor, said she sees about a dozen minor trans patients, nine of whom are taking cross-sex hormones.
The change in behavior and emotional well-being for trans youth after beginning cross-sex hormones can be profound, she said. “It’s like switching on a light,” Ho said.
Hutchison said the new law makes inaccurate claims about the risks of puberty blockers. HB 1570 states that doctors are prescribing puberty blockers “despite the lack of any long-term longitudinal studies evaluating the risks and benefits of using these drugs,” but Hutchison said such medications have been routinely used in pediatric practices for the last 40 years. Puberty blockers are regularly prescribed to children who are not trans but are experiencing early puberty, she said, and the effects are “completely reversible.”
For example, a pediatrician may prescribe a puberty-blocking drug to a young girl who has begun to go into puberty and is poised to start menstruation at the age of five, Hutchison said.
She said that within one week at the Endocrine Clinic at Arkansas Children’s Hospital, she saw four children taking puberty blockers and diagnosed a fifth patient with early puberty, who will soon start taking the drugs. She added that the Endocrine Clinic follows between 150 to 200 patients with early puberty.
For trans youth, puberty blockers serve a different purpose. For a child with gender dysphoria, puberty can be a jarring experience, as their body changes in ways that don’t feel aligned with their gender identity. Taking puberty blockers can, according to Burr, provide a young trans patient with “time to work through their gender identity.”
If a patient stops taking a puberty blocker and does not start taking a cross-sex hormone afterwards, that patient will go through puberty in accordance with the sex they were assigned at birth.
Hutchison said the Gender Spectrum Clinic currently has only two or three patients taking puberty blockers. Most patients are already well into puberty by the time they’re seen at the clinic, she said. Hutchison also said puberty blockers are “prohibitively expensive” — costing around $20,000 per year out of pocket — and the use of such medication for gender-affirming purposes is usually not covered by insurance. Even when a young child in the Endocrine Clinic is prescribed puberty blockers, “we really have to prove that the child is in early puberty for the insurance to pay for it,” Hutchison added.
(Ho said she does not prescribe puberty blockers for her trans patients and refers families who are interested in the medication to the Gender Spectrum Clinic.)
“In terms of numbers, epidemiologically, the [puberty blockers] prohibition doesn’t affect a large number of children,” Hutchison said. “But, it has a dramatic effect on those individual children.”
The new law also prohibits “genital and nongenital” gender reassignment surgery for minors, but Hutchison said genital gender reassignment surgery is not performed on any patients under the age of 18 in the state of Arkansas. Hutchison said she would support legislation that prohibited genital reassignment surgery on minors.
Should HB 1570 go into effect, Hutchison predicted the prohibition on doctors referring young people to other providers for gender-affirming care would cause a great deal of confusion. Though the law would not prohibit psychological counseling for minor trans patients, Hutchison said pediatricians have been left confused about whether referring a minor patient to a therapist might be considered a “gender transition procedure.”
“What’s the difference between a referral versus just giving somebody information? That’s one of the things that I have asked for some guidance on,” Hutchison said.
According to Burr and Hutchison, trans youth experience high rates of anxiety and depression because of the cultural stigma associated with being gender nonconforming and the emotional pain of experiencing gender dysphoria. Evans said the new law will further this stigma and have devastating consequences.
“This isn’t just costing health care providers. This isn’t just costing affirming care. This is costing lives,” Evans said. “These kids are losing hope.”
An uncertain future
The ACLU lawsuit argues the new Arkansas law abridges the constitutional rights of doctors, patients and their parents in several ways. The plaintiffs contend the law discriminates against transgender people, violating the equal protection clause of the 14th Amendment. The plaintiffs also claim it violates the rights of parents to make decisions concerning the care of their children, as guaranteed by the 14th Amendment’s due process clause. And, the plaintiffs contend the new law violates the First Amendment’s guarantee of freedom of speech by prohibiting doctors from making referrals and preventing patients and their families from hearing those recommendations.
Even if the court declines to block the law, much remains uncertain about how it will be implemented. For example, the law says any health care provider who refers a minor trans patient for “gender transition procedures” would be “subject to discipline by the appropriate licensing entity or disciplinary review board.” But Hutchison said she and other doctors are unclear as to how they would be sanctioned if they violated the law.
The Arkansas Medical Practices Act states that physicians who are found guilty of “unprofessional conduct” — the definition of which ranges from conviction of a felony to committing an “ethical violation” as determined by the Arkansas State Medical Board — may have their medical license revoked or suspended, be issued a reprimand, be placed on probation, or have to pay a fine of up to $1,000 per violation.
The medical board, which is responsible for licensing and disciplining physicians, may need to establish rules to enforce the law and flesh out its details. Meg Mirivel, a spokeswoman for the state Department of Health, said the medical board is still determining whether and how they would craft new rules to implement the legislation.
Regardless of what the courts decide, advocates for transgender youth said they will continue to speak out against the ban on gender-affirming care.
“[Arkansas legislators] are politicians. They’re not medical doctors,” Ho said. “There have been medical doctors all over the state and all over this country who have adamantly opposed [this] ban.”
“It’s incredibly rewarding to take care of these kids, and I can’t imagine why anybody would want to take away their care or to bully them,” Ho said.
Should the law take effect, Hutchison suspects some patients will find their medications on the black market and take them without the oversight of a physician.
That could be dangerous, she warned. The Gender Spectrum Clinic conducts a blood test before any patient begins cross-sex hormones to check liver function, cholesterol levels, blood counts and other metrics. Hutchison then monitors her patients’ body functions throughout their hormone therapy.
“The fear is that if a child were to have an unexpected event and nobody was there to catch it, you could then go on to develop liver disease or a stroke,” Hutchison said. “The [other] concern is that if you have a child who’s taking a higher dose than they should … that’s going to give them problems, and nobody is there to regulate it or give advice.”
Nonetheless, she said, “it would be very naive to think that these incredibly resourceful and intelligent children are simply going to stop taking their medication because the legislature tells them to.”
”Keep in mind that this is not kids sneaking around to buy illicit drugs,” Hutchison added. “These are kids whose parents have already agreed with the therapy and support it, so this is a situation where the parents are going to go find a way for them to get their testosterone or estrogen.”
Evans said she’s spoken with other parents of trans children about what their options will be if the law goes into effect. They’ve discussed going across state lines to access gender-affirming care, or even reaching out internationally, as telehealth options have expanded during the pandemic. They would also have to find an out-of-state pharmacy to mail them any medications, as in-state pharmacies would be prohibited from filling the prescriptions.
“There would be the expense of traveling, the expense of prescription costs out of state, and we would have to pay the doctors’ offices out-of-pocket because his in-state insurance won’t pay for it,” Evans said. “It just would be a tremendous financial burden on everybody that is in this position.”
Other families may leave Arkansas altogether. Hutchison said the families of at least twenty of her patients have called to ask which state they should move to in order to access care, and two families have already moved.
“[Parents are] saying they’re leaving because they don’t want to live somewhere where their child is not accepted,” Hutchison said. “It’s a lot more basic than just getting medication: It’s this feeling of, ‘I’m not wanted here, my child’s not wanted here, so we’re going to go somewhere where my child can feel wanted, accepted and loved.’”
“[These] kids feel like they’re being erased; that’s a word that keeps coming up,” Hutchison said. “The patients feel as if society is trying to erase them, trying to make it as if they don’t even exist. As an adult, I think that would be a tragic situation to have to encounter … So imagine being a teenager and feeling that way.”
Evans said she wants to emphasize that Andrew, who is a sophomore at Bauxite High School, is, above all else, a typical teenage boy.
“While he is a trans person, that is just a label or a box they want to put my child in,” Evans said. “He has friends, he plays in the band, he does theater, he makes good grades. Outside of being transgender, [he] is a typical teenage boy who just wants to live his life.”
This story is courtesy of the Arkansas Nonprofit News Network, an independent, nonpartisan news project dedicated to producing journalism that matters to Arkansans.