Pictured: An exterior view of Columbus Regional Hospital’s sign directing patients to the emergency entrance. The Republic file photo
Pictured: An exterior view of Columbus Regional Hospital’s sign directing patients to the emergency entrance. The Republic file photo
 
Columbus Regional Health officials have raised concerns that a proposal to ban gender-affirming care for children in Indiana could lead to an increase in mental health challenges and have other negative impacts for local transgender youth who will be denied care they need.

Indiana Republicans advanced a bill last week prohibiting transgender youth under 18 from receiving puberty blockers, hormone therapy and surgeries to treat gender dysphoria, treatments that doctors and major medical groups say are evidence-based, medically necessary and sometimes even lifesaving.

The proposed ban, Senate Bill 480, is pending before Gov. Eric Holcomb and has received strong support from state lawmakers who represent areas of Bartholomew County, including Sen. Greg Walker, R-Columbus, who is a co-author of the bill, and Rep. Ryan Lauer, R-Columbus, who authored a bill with similar language this session. Lauer has characterized the treatments as “appalling” and akin to “experimenting on children,” views that doctors and medical groups dispute. Walker has said he supports the bill because he wants to “understand better” any long-term effects of gender-affirming hormone therapy.

While CRH does not offer puberty blockers, hormone therapy or gender-reassignment surgeries to minors who have been diagnosed with gender dysphoria, officials said the hospital system provides unrelated care to transgender youth who would be dealing with the consequences of being denied care they need should the bill become law.

CRH refers many of those patients to the Gender Health Program at Riley Hospital for Children in Indianapolis. However, officials said they recognize that they may no longer be able to refer patients there if the ban is enacted into law and may consider the possibility of referring some patients out of state.

“As those patients are negatively impacted by a lack of access to care they need, we definitely anticipate that they may have more needs from us, and certainly, we’ll continue to provide that care as needed,” Dr. Rachel Reed, CRH vice president and associate chief medical officer, said. “…What we would anticipate, based on the services that we already provide, would be an increased need in mental health care.”

Transgender and non-binary youth have alarmingly high rates of depression, anxiety and suicidal behavior compared to their peers, experts say.

More than half of transgender and non-binary youth in the U.S. reported seriously considering suicide in the previous year, including nearly one in five who reported attempting suicide, according to a 2022 survey of nearly 34,000 LGBTQ by the Trevor Project, a non-profit organization dedicated to LGBTQ+ youth suicide prevention.

By comparison, one in three cisgender youth — meaning those whose gender identity matches their sex assigned at birth — considered suicide in the previous year, including nearly one in 10 who attempted it.

The survey also states that transgender youth are more likely to experience symptoms of depression and anxiety.

Experts say transgender youth are not inherently more prone to suicide risk or mental health challenges because of their gender identity, but rather because of social stigma and discrimination.

Wave of anti-LGBTQ bills

Gender-affirming care has been thrust into the spotlight in recent months as state lawmakers in Indiana advanced SB 480 and other proposals targeting transgender youth.

The proposed ban comes amid a wave of anti-LGBTQ legislation filed by Republican lawmakers across the U.S. At least nine states have enacted laws restricting or banning some forms of gender-affirming healthcare for minors: Alabama, Arkansas, Arizona, Georgia, Iowa, Mississippi, Tennessee, Utah and South Dakota.

In total, an estimated 156,500 transgender youth in 32 states have lost access to gender-affirming care or are at risk of losing access due to legislation filed this year, according to figures released this week by the Williams Institute at the UCLA School of Law.

There are an estimated 4,100 teenagers ages 13 to 17 in Indiana who identify as transgender, or about 0.91% of the population of that age group, according to the Williams Institute.

That would suggest that there could be an estimated 50 teenagers ages 13 to 17 in Bartholomew County who identify as transgender, based on 2020 population estimates for that age group from the National Center for Juvenile Justice.

Dr. Samantha Loza, a pediatrician at Columbus Pediatrics, said she has a handful of patients who identify as transgender. However, Loza said her practice does not offer the treatments mentioned in the bill and would generally refer patients to other providers.

“We feel pretty firmly that this really feels like yet another blatant intrusion into the patient-physician relationship,” Reed said. “It’s another effort to sort of undermine the integrity of that relationship, which, honestly, is at the core of American healthcare. It’s frustrating to continue to see this happen, especially (as) it’s currently being done under the guise of protecting children from experimental procedures.”

“I have seen no evidence to date that gender-affirming care is experimental or dangerous in any way to the people who are receiving it,” Reed added. “Overall, the data is quite clear that it is beneficial. It is medically necessary. …Given, overall, this sort of lack of evidence that this gender-affirming care is dangerous or harmful, to us, it begs the question of is there another motive behind the introduction of these bills? …We’d like to understand that better from the people who are introducing this legislation.”

Increasing depression, anxiety

Experts say the bill is already having “clear negative impacts” on transgender youth in Indiana and their families — even though the proposal has not yet become law.

Because gender-affirming care has been shown to greatly improve the mental health and well-being of transgender and gender-diverse youth, there is “no question” that restricting access to these treatments will result in increased rates of depression, anxiety, substance use and suicidality among these youth, said Richard Brandon-Friedman, an assistant professor at the Indiana University School of Social Work who studies, among other things, the impact of gender-affirming care on the well-being of youths and their families.

Brandon-Friedman, who also is a clinical social worker at the Gender Health Clinic at Riley Hospital for Children at IU Health, said that some transgender youth he has been helping for over a year are now “in a worse mental health state then they were previously just because of the fear of this law.”

Many transgender youths in the state are “panicking” over the bill, Brandon-Friedman said. Most gender clinics in Indiana have wait lists, and transgender youth who have been waiting for weeks or months are “suddenly being told, ‘Actually, we might have to cancel that appointment because we might not be able to provide that care anymore.’” Some parents have also been calling providers, in tears, asking, “‘Do I have to pick up the rest of my family and move (to another state) because this is the care that my child needs?’” Brandon-Friedman said.

“I’m already seeing spikes in the depression, the anxiety, (among transgender youth)” Brandon-Friedman said. “Some of the clinicians I work with have said that they’ve had more suicidal concerns and having to report that to caregivers in the last couple weeks than they’ve had in months. Even without the law passing, the impact is already there.”

What is gender-affirming care?

Gender-affirming care is a supportive form of evidence-based healthcare that encompasses a range of services that may include medical, surgical, mental health and non-medical interventions for transgender and nonbinary people, according to the U.S. Department of Health and Human Services.

The American Academy of Pediatrics recommends that doctors provide access to comprehensive gender-affirming care to youth with gender dysphoria, a condition that describes a sense of distress or discomfort that occurs in some people whose gender identity differs from the sex they were assigned at birth.

The AAP also “strongly opposes” any legislation that would limit access to these services.

And they’re not alone. Leading health care organizations in the United States — including the American Medical Association, Endocrine Society, American Psychiatric Association, American Psychological Association, World Professional Association for Transgender Health, among many others — agree that is clinically appropriate for transgender youth.

Local health officials said it is “exceptionally rare” for minors anywhere in the U.S. to undergo gender-affirming genital surgery.

“We don’t reach the surgical point with minors,” Loza said. “…None of the clinics I have ever gone through will do this before 18 without another medical reason. So, I know that there’s a lot of fear there, but it’s not something, at least through pediatrics, that we recommend before legal adulthood.”

How youth transition

While not every transgender youth wants to undergo gender-affirming treatments, those who do generally are under the care of a multi-disciplinary team of healthcare and mental health professional that often includes endocrinologist, urologists, pediatricians, psychologists, social workers, among others.

Pediatricians who are treating children who identify as transgender often will initially focus on what is called a social transition, Loza said.

Social transitions entail using the child’s preferred pronouns and/or wearing clothes associated with the gender they identify with. In some cases, this also includes a legal transition, which may involve changing the child’s legal name and gender on documents.

“For children, we always start there,” Loza said. “You would never jump into anything else without starting there and basically watching for essentially the opposite of gender dysphoria, which would be a gender euphoria, or just immediate relief of any negative experiences or symptoms they’ve been having.”

After transgender children start puberty, doctors may recommend treatments that will pause puberty, also known as “puberty blockers,” Loza said.

These treatments, which are completely reversible, seek to prevent unwanted physical changes to the children’s bodies and give youth and their families more time to decide what their next steps are.

The medications, also known as gonadotropin-releasing hormone agonists, have been approved by the U.S. Food and Drug Administration to treat abnormal early onset of puberty in children. They also are used to treat prostate cancer and other conditions in adults, according to the National Cancer Institute.

“It’s basically just preventing gender dysphoria as much as we can until these patients are getting to the point that … we’ve shown that affirming their gender is beneficial to them (and) until they get old enough to consider other options,” Loza said.

Once transgender teenagers reach the later years of adolescence, physicians may offer hormone treatments — testosterone for transgender boys and estrogen for transgender girls.

These treatments help youth align their physical appearance with the gender that they identify with, Loza said.

Because hormone treatments are partly irreversible, the Endocrine Society recommends them only after a multi-disciplinary team of medical and mental health professionals has confirmed the preexistence of gender dysphoria and that the adolescent has the capacity to give informed consent, adding that “most adolescents have this capacity at age 16.”

The Endocrine Society is a medical organization in the field of endocrinology that includes more than 18,000 investigators and clinicians around the world.

“This is not something that’s offered until after puberty,” Loza said. “…If it is going to be done in minors, it’s not until about 16 and not until we’ve already gone through a social transition phase, maybe even puberty blockers and shown pretty overwhelming evidence for each specific patient that they’re going to be what we call a ‘persistor,’ which is when a transgender child would persist as transgender in adulthood.”

“It’s definitely not taken lightly,” Loza added. “It’s something that has been agreed upon for a while in discussion with the parents and the child if, again, minors are even getting it to begin with.”

What’s next?

Currently, it is unclear whether Holcomb will sign the bill into law. So far, the governor’s office has declined to say what his views on the proposal are. “If the governor releases a statement, it would be when he signs it or vetoes it,” Erin Murphy, Holcomb’s press secretary, told The Republic this week.

Last year, Holcomb vetoed a bill that banned K-12 students who were born male but identify as female from participating in a sport or an athletic team that is designated for women or girls. But the General Assembly, including Lauer, voted to override the governor’s veto.

Walker said at the time that he thought the sports ban was unconstitutional and voted against the overriding the governor’s veto, as well as against the proposal when it came before the Senate.

Lauer campaigned on overriding the governor’s veto in the 2022 Republican primary, stating in an advertisement that he “voted to protect the integrity of girls’ sports in our state” and that he “will proudly override the governor’s veto.”

Last week, Kentucky Republicans voted to override their governor’s veto of a similar ban on gender-affirming care. It is unclear if Indiana Republicans would attempt to do the same should Holcomb veto the bill.

Even if the proposed ban on gender- affirming care becomes law in Indiana, it is almost certain to face legal challenges. Federal judges have blocked enforcement of similar laws in Alabama and Arkansas. The American Civil Liberties Union of Indiana said last week that it is prepared to “defend the rights of transgender youth in court” if the ban becomes law.
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