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Forced Outing and Gender-Affirming Care

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Content warning: this article discusses transphobia, self-harm, childhood abuse, and suicide.

During my last several years as a teacher, I gave my high school English classes a survey on the first day of school which asked them many questions that helped me understand who they were as learners. This helped me to begin humanizing them in my own mind and to remind me that each was coming with an individual universe of stories, academic needs, and interests. Some questions were about stories that were important to them, some were about music. I also asked them optional questions about what they wanted to be called, and which pronouns they would like for me to use in class.

To most students, these last few questions were probably not important or noteworthy. To a few, they were a rare example of the educational system treating them as people instead of as a collection of test scores, grades, and assignments. I know many teachers who did the same; to us, this was best practice.

It could also be considered “gender-affirming care.”

H. 4634


The South Carolina House Medical, Military, Public and Municipal Affairs Committee spent most of its first subcommittee meeting of the new session hearing testimony against H. 4624 (which passed the House the following week).

H. 4624 bans most gender-affirming care for minors and prohibits state funding of gender-affirming care for adults up to 26 years of age. It also requires school staff to report students who are transgender or questioning to their parents and does not include exceptions for situations that might put children in danger.

When I provided public comment against the bill during that first subcommittee meeting, along with sixty-six others who spoke against the bill, Rep. Thomas Beach (Anderson)  had a follow-up question for me. He prefaced his question with, “I’m assuming that teachers, uh, come from all walks of life and backgrounds. This is, you would say, a hot potato—this issue,” he continued, “and I’ve been reached out by from [sic] other educators, and their concern is they don’t want to get in the middle of all this. They just want to stick to math and science, and things of that nature.” (This, incidentally, is a great example of a common anti-public-school argument: that teachers doing anything but “teaching the facts”—regurgitating state-approved talking points—are going beyond the scope of their jobs.)

But the legislation itself inserts educators into the issue of whether the state, rather than individuals and medical experts, should determine which kinds of medical care their children and adults receive. 

Unfortunately, transgender people have been made into political “hot potatoes” by politicians, and people who professionally serve and care for children have been thrust into the middle of a conflict between these politicians and the LGBTQ+ community. For example, according to ProPublica,

In South Carolina, after it became clear last December that MUSC was halting transition-related care for all minors, conservative lawmakers celebrated their victory. “I went after the Medical Center of South Carolina with 19 other of my door-kicking, rock-ribbed, and South Carolina’s most Conservative legislator friends,” Republican state Rep. Thomas Beach wrote in a Facebook post. “It feels good to be a gangster.”

That doesn’t particularly sound like someone who is interested in working with professionals to help transgender youth, as much as someone who is interested in the way villainizing those professionals (and transgender people) might make him look tough or cool to certain voters.

More than ever, LGBTQ+ students need educators to understand the complexities involved, and to be able to see past the heightened political rhetoric of election season (every legislator in South Carolina is up for election this year) to the human children sitting in our classrooms.




Gender-affirming care

While H. 4624 uses the term “gender transition,” some medical associations have consciously moved away from framing gender-affirming care as transition, using the term “affirming” to acknowledge the fact that for many people, a disconnect between what the world tells them their gender may be, and what they feel on the inside, begins very early in life. For many people, the process of affirming their gender is about removing this disconnect, affirming what they feel was there all along.

According to the American Academy of Pediatrics, “In a gender-affirmative care model (GACM), pediatric providers offer developmentally appropriate care that is oriented toward understanding and appreciating the youth’s gender experience” (emphasis mine).  And as healthcare providers in the committee meeting repeatedly testified, that does not include, for children, the kinds of “transition” surgeries the proponents of the bill repeatedly targeted.

As the blog Erin in the Morning recently pointed out, in an article about the hearing, the body of scientific literature heavily supports gender-affirming care and debunks essentially all of the arguments made by those promoting the ban during the hearing. For example, researchers at Cornell University wrote:

We conducted a systematic literature review of all peer-reviewed articles published in English between 1991 and June 2017 that assess the effect of gender transition on transgender well-being. We identified 55 studies that consist of primary research on this topic, of which 51 (93%) found that gender transition improves the overall well-being of transgender people, while 4 (7%) report mixed or null findings. We found no studies concluding that gender transition causes overall harm.

For educators, gender-affirming practices, like calling students by the names they ask to be called, need not be a “hot potato” any more than calling students by preferred names or nicknames has been in the past. The committee hearing testimony on the bill had no problems addressing anyone who signed up to speak—including many individuals who were transgender or gender nonconforming—with the names and pronouns they requested; why would we create a different standard for children, who are required to attend school?

And while many of us-- including those who often object to gender-affirming care-- are rightly concerned about child mental health, the medical consensus is that gender-affirming care can address many mental health issues. According to one 2022 study published by the Journal of the American Medical Association, “receipt of gender-affirming care, including puberty blockers and gender-affirming hormones, was associated with 60% lower odds of moderate or severe depression and 73% lower odds of suicidality over a 12-month follow-up.

 

Misinformation

But opponents of gender-affirming care have consistently misrepresented what that kind of care is and have used legislative language to tie together a witch hunt against transgender people and a witch hunt against teachers.

H. 4624, for example, bans what sponsor Rep. John McCravy III (Greenwood) derisively termed “so-called gender transition procedures” during the hearing. He claimed that he had read a number of studies on the supposed dangers of gender-affirming care, but was not able to cite any when asked by another member of the committee.

In fact, it’s likely that much of this information came from the sole person, out of 58 speakers, to testify in favor of the bill during that hearing: Matt Sharp, senior legal counsel at the Arizona anti-LGBTQ+ group Alliance Defending Freedom (ADF), which has been labeled a hate group by the Southern Poverty Law Center. The group has been connected to legislation targeting trans athletes, attempting to criminalize same-gender marriage, and a host of other anti-LGBTQ+ efforts.

Committee members Rep. Heath Sessions and Rep. Fawn Pedalino focused their questioning of Sharp on easily-debunked conspiracy theories about transgender regret and outsized claims about the supposed harms of gender-affirming therapies that are supported by physicians and medical organizations.

Sharp, like McCravy, shared several pieces of misinformation about transgender “regret” and health issues, which are, again, easily debunked by reviewing medical research. For example, Sharp relied heavily on the “Swedish study” to make his argument. But that study, in full context, does not support what he claimed; rather, its authors even suggested that declining mortality and morbidity for people undergoing gender-affirming care might be explained “"by improved health care for transsexual [sic] persons during 1990s, along with altered societal attitudes towards persons with different gender expressions."

McCravy’s argument for the legislation rested centrally on a debunked argument about high rates of regret in people who have pursued gender-affirming care. For support, he repeatedly and vaguely alluded to a controversial 2021 60 Minutes episode as a source. In fact, research has suggested that as few as 1% of people who “transition” regret doing so, and that “detransitioning” rarely happens.

If McCravy actually watched the 60 Minutes episode, he knows that it began with host Lesley Stahl saying that bills like McCravy’s are “part of a new culture war”; she later stated that, as of 2021, “at least six major medical associations have weighed in against these bills, including the American Academy of Pediatrics”. Later, Stahl also pointed out that “the vast majority of transgender youth and adults are satisfied with their transitions”.

But what McCravy and others have glommed onto in that segment is a series of examples of people who have later “detransitioned” or expressed regret about seeking gender-affirming care, even though those people are not statistically representative of the vast majority of people who have sought gender-affirming care.  They have used these to falsely claim that gender-affirming care is harmful for most people, and that it leads to high levels of “regret” later in life.

But even the “de-transitioner” with the most screen time in the 60 Minutes segment said she worried about people using her story against transgender people, and advocated for more mental healthcare, rather than a ban on gender-affirming care.  And the healthcare experts interviewed during the piece supported such care, as well; their concern was in making sure that guidance was consistent and consistently followed. Every medical expert who testified during the committee hearing said that South Carolina healthcare providers are consistently following clear guidance from professional organizations, and that minors are not receiving permanent surgical interventions, and the proponents of the bill provided no evidence to rebut this claim.

If McCravy were interested in helping LGBTQ+ children and adults instead of overtly villainizing many of them, he might have a different take-away from the 60 Minutes segment, which does attempt to address the relative difficulty of obtaining good medical care around issues like gender dysphoria.

This was an issue that came up again and again during the hearing, as pediatricians, parents of transgender children, and transgender individuals described a system with very few providers and many obstacles to care, though McCravy only stuck around to hear about half of that testimony.

If McCravy cared about transgender children, he might instead support making it easier, not harder, for transgender people in South Carolina to get good care, and easier, not harder, for medical providers and experts to work to continue to improve and follow guidance and science-based regulations around gender-affirming care, rather than pushing legislation that many testified would scare providers away from providing this kind of care at all.

As many healthcare workers testified during the hearing, South Carolina’s disturbing rates of infant mortality, firearm mortality, and other grim health statistics provide plenty of obvious priorities for the legislature, and yet here we were on the first day of session, watching the medical subcommittee target and spread misinformation about a group which makes up about 0.6% of the U.S. population, and which has already suffered disproportionately bad health outcomes, while doing nothing to address these pressing health issues.

No one who testified called for educators to provide or promote medical interventions; only proponents on the committee suggested that school employees were somehow qualified to identify and report students who may be experiencing gender dysphoria or other feelings related to their gender identity.

Forced Outing

Perhaps most crucially for educators, bills like H. 4624 require what critics have called “forced outing”; this is the part of the bill Beach was addressing with his hypothetical question to me about who should “share information” about children “if” the bill passes (which he treated as an inevitability).


“Forced outing” can be defined as sharing information, or requiring others to share information, about an individual’s gender identity, sexual orientation, or other identity-related feelings and preferences, without that individual’s consent. Arguments for forced outing are often based on the idea that parents have a right to know literally everything about their children, or that students have no right to privacy at school.

But while many students are “out” in schools, others may feel unsafe being out to everyone at school, or to anyone at school, or to people outside of the school.

In a nutshell, if H. 4624 (full text here) passes, school staff will be required under law to do something they are not trained or qualified to do: report their hunches and guesses as to whether a student might be struggling with gender dysphoria to all parents and guardians, even for students who request—and have the right to receive—confidentiality, regardless of what the outcome of outing that student might be. (According to the ACLU, lawmakers across the country are aware that students have a right to confidentiality, and have been careful in wording legislation to try to find loopholes in these rights; Virginia, for example, has seen very similar wording in at least one of its anti-trans bills.)

As several current and former teachers and school counselors testified during the hearing, this is a dangerous and unethical position in which to place students and school staff.

Even in states like North Carolina, where, according to the Associated Press, forced outing legislation includes exceptions from information-sharing requirements when abuse might result, advocates, students, and parents are conflicted about requiring teachers to potentially remove the one safe space where kids may be able to be themselves.

The South Carolina bill contains no such exception, and proponents on the committee did little to address these concerns during the hearing. 

Research published by the National Institute of Health shows that LGBTQ+ youth in general suffer greater rates of childhood physical and sexual abuse than their peers, and that transgender/ gender-nonconforming youth suffer higher rates than others in the LGBTQ+ community. Transgender students are at higher risk for being forced to leave home if outed. Many who share feelings of gender dysphoria or questioning with school staff may have very good reasons for not wanting that information to go home.

While the more extreme proponents of laws banning gender-affirming care for children have wrongly labeled this kind of care as “child abuse,” there is a real danger that by removing that care, children will be subjected to more actual abuse.

While there is room for healthy debate about how best to help transgender students, we know through rigorous scientific research that a small but significant minority of children do not feel at home in the gender society has selected for them, and that some of these children are objectively suffering. We know transgender children are at greater risk for childhood abuse, relationship abuse, self-harm, depression, anxiety, and suicide. We know this. It is not a feeling or a guess; it is a substantiated fact. We don’t have to have easy answers for the broad moral and philosophical questions involving “gender” to know that in the short-term, kids need our help. A wealth of research shows that gender-affirming care and/or support from family, friends, and people at school, are associated with better outcomes for transgender children.

And in the real world, most victims of childhood abuse unfortunately suffer it at home, or at the hands of trusted adults. Sharing information with parents is generally best practice for educators, but telling their parents everything all the time may not be the best way to protect and help all kids. After all, according to the most recent (2000) data from the Bureau of Justice Statistics, “almost half (49%) of the offenders [which were reported to law enforcement] of victims under age 6 were family members, compared with 42% of the offenders who sexually assaulted youth ages 6 through 11, and 24% of offenders who sexually assaulted juveniles ages 12 through 17”. To argue that all parents are trustworthy simply because they are parents is an obvious fallacy.

What do we do when we know children are hurting? 

Of course, we should do whatever we can to help them. And while some educators will inevitably be uncomfortable with or even resistant to the medical consensus that gender is not binary, it’s not okay to do things we know will lead to more children being harmed. The research and experts are telling us that gender-affirming care does not generally harm children, and that removing it generally does.

The American Medical Association’s formal statement on gender-affirming care (most recently modified last year) opposes “laws and policies that criminalize, prohibit or otherwise impede the provision of evidence-based, gender-affirming care, including laws and policies that penalize parents and guardians who support minors seeking and/or receiving gender-affirming care”.

Sadly, while it remains politically popular to claim proposed policies are geared at “protecting children,” children remain an underserved constituency. They can’t vote, they don’t have paid lobbyists, and they don’t have buying power.

Educators, parents, and sincere advocates for children must stand up for children and young adults in the face of attacks by those who would use them as political pawns. Affirming a child’s gender should not be seen as a political act and should not be conflated with a partisan goal; it is simply best practice, based on our best available scientific and medical knowledge. It is a way to keep schools humane, and to address part of a frightening trend in childhood self-harm and suicide.

CEWL will be hosting a livestream with neuroendocrinologist and Stanford University professor Robert Sapolsky on April 11, 2024, at 7PM. Professor Sapolsky will be addressing research on the neurobiology of transgender people during the conversation. The link for the livestream is https://fb.me/e/c75hYKniE. April 11 at 7PM.

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