DR. Gina Sequeira saw the demonstrators for the first time last September on a clear and bright morning. A co-director of Seattle Children’s Gender Clinic who provides gender-affirming care to young people, Sequeira had confronted ignorance about her medical specialty in the past. But nothing had prepared her to see people outside her office, waving signs and handing out flyers warning of the “dangers” of the work she does.
“That was really, really hard for us as a clinic,” she says. “And I think it was really hard for the hospital’s patients and families who witnessed it.” Just a month later, protesters showed up again.
Hers wasn’t the only clinic having a hard time in 2021. The LGBTQ advocacy group Human Rights Campaign has calculated that, last year, conservative lawmakers introduced over 130 anti-trans bills into state legislatures—including 35 that explicitly limited the ability of trans and gender-expansive youth to access gender-affirming care, a term that refers to holistic psychological and medical care that affirms a person’s gender identity. The ACLU had tracked 17 similar bills this year as of February 11.
Only a small group of pediatricians provide such care in the U.S., and, in this political context, those who do are often finding themselves at the receiving end of growing harassment—even as research confirms the potentially life-saving nature of the work they do. Demonstrators have organized protests like the ones at Sequeira’s clinic at other sites across the country; in Ohio, billboards have been rented spreading disinformation about affirming care—including one near a children’s hospital. TIME has heard from pediatricians that they’ve been threatened by mail and impersonated online, as well as being concerned for their safety. These harassment campaigns can have a negative impact on young people’s ability to get crucial medical care.
Sequeira was sent an unmarked, anonymous letter in her mail about one month prior to September’s protest. This gave Sequeira pause. She’d worried about the risk of anthrax, she tells TIME; of someone trying to hurt her. She finally opened the envelope. The envelope contained posters that decried gender-affirming children’s care. “No child is born in the wrong body!” one read. “Who profits from this crime?”
“I was taken aback, and really kind of fearful,” Sequeira recalls. She’d seen colleagues who provided abortion receive similar abuse. However, she didn’t think her work would be as controversial. “It really made me wonder what the future of our work looks like,” she says. “Is that the path we’re going down?”
At a protest at Austin’s Texas State Capitol on May 4, 2021, medical professionals voiced their opposition to legislation banning gender-affirming medical treatment.
Erich Schlegel—Human Rights Campaign/AP
Gender-affirming care can support youth experiencing gender dysphoria, which is often described as the discomfort or distress that might occur when a person’s gender identity is inconsistent with the sex they were assigned at birth, per the Mayo Clinic. In gender-affirming care models, according to the American Academy of Pediatrics (AAP), “pediatric providers offer developmentally appropriate care that is oriented toward understanding and appreciating the youth’s gender experience.” That includes conveying the message that variations in gender identity and expression are a normal aspect of human diversity, and that, if a mental health issue does exist, it “most often stems from stigma and negative experiences rather than being intrinsic to the child.”
Gender dysphoria in young children can be managed with non-medical behavioral and social interventions. This can include changing a child’s name or pronouns to reflect their gender identity.
Continue reading: Studies show that gender-affirming hormone therapy for LGBTQ youth can save lives.
After puberty has begun, a child experiencing gender dysphoria may also begin receiving gonadotropin-releasing hormone (GnRH) analogues—known by the term “puberty blockers.” They are “simply a pause button,” says Ladinsky, to stop the continued development of a puberty incongruent with a child’s gender identity. These blockers, Ladinsky says, can be reversed at this time. Puberty blockers can help “reduce distress that may occur with the development of secondary sexual characteristics” and reduce the need for surgery in the future by holding off physical changes like an Adams apple or breast growth, according to the AAP.
Some adolescents may start taking hormones that are gender-affirming as they age, like testosterone and estradiol. Although there are a few differences in opinion about when a young person should begin hormone treatment, many teens have found the intervention to be pivotal in their dysphoria management. It is rare for a person under 18 to undergo any type of surgical intervention, but some may decide to pursue “top surgery”—reconstructive surgery to change the appearance of one’s chest—while they are still teenagers.
A growing body of research shows that affirming models of care can lead to young people experiencing fewer mental health problems. Like all medical care decisions, they are complex and driven by the conversations that take place between young people, their families, and their doctors. Trans and gender expansive children cannot receive affirming medical treatment without their parent’s or guardian’s consent in the U.S. healthcare system.
Much of the critique surrounding gender affirming care stems from the perception that young children receive unsupervised, irreversible, rushed treatments. Best-selling authors and right-wing commentators as well conservative social media stars have used such words to describe the moral panic growing in recent years. According to the UCLA Williams Institute, 45,100 trans teenagers could lose their health care care if every bill that was being considered at the time would restrict or ban gender affirming care. Arkansas also banned pediatricians’ ability to provide gender-affirming and referral services. The law has been blocked by a federal court. The Texas Governor. Greg Abbott said that providing affirming treatment to teenagers is the same as child abuse.
In conservative media especially, online disinformation has been spreading about transgender people. Media Matters’ Nov. 9 report found 77% of top trans-related Facebook posts from Oct. 2020 to Sept. 2021 came from right-leaning sites, and nearly three-quarters of all interactions with posts on trans issues.
“There’s nothing grassroots about this at all,” argues Imara Jones, journalist and founder of TransLash Media, whose podcast the Anti-Trans Hate Machine has documented the rapid rise of anti-trans legislation in recent years. “This is a highly organized movement that is targeting trans people and trans rights.”’
Jones traces the proliferation of anti-trans bills to an umbrella organization of over 60 right-wing groups called Promise to America’s Children, which lists on its website “leading national partners” including Family Policy Alliance (the lobbying arm of longtime anti-LGBTQ group Focus on the Family), Alliance Defending Freedom (which the Southern Poverty Law Center has defined as an anti-LGBTQ hate group), and conservative think tank The Heritage Foundation. Jones adds that Family Research Council, an anti-LGBTQ organization has promoted anti-transbills.
Promise to America’s Children’s website includes model legislation for policymakers titled the “Protecting Children from Experimentation Act,” which aims to criminalize gender-affirming treatment for young people. Although a version of this bill was presented in Congress 2021, it didn’t advance.
These bans have been condemned by leading medical organisations. “[We] strongly oppose any effort to criminalize or penalize physicians for providing necessary care for their patients,” read a April 2021 joint press statement from AAP, the American Academy of Family Physicians, the American College of Physicians, the American College of Obstetricians and Gynecologists, the American Osteopathic Association, and the American Psychiatric Association. “Physicians must be able to practice medicine that is informed by their years of medical education, training, experience, and the available evidence, freely and without threat of punishment.”
Continue reading: In 2021, Anti-Trans Violence and Rhetoric reached record highs across America
Gender-affirming pediatricians have been the focus of this attention beyond legislative. As disinformation and fearmongering about trans youth has surged, TIME has spoken with numerous providers who say they’ve witnessed a rise in harassment in the past two years—whether via in-person protests, online threats and cyberbullying, menacing mail, attempts to cut their research’s funding or even their medical licenses. TIME also spoke with other gender-affirming pediatricians, who refused to speak out due to fears of violence against their family and children.
“This is shocking, shocking, shocking,” says Dr. Robert Garofalo, the head of adolescent and young adult medicine at Lurie Children’s Hospital of Chicago. “No one is prepared for this, and pediatric institutions aren’t prepared for it.”
At a Montgomery rally, opponents to several anti-transgender laws are present to raise awareness about the new legislation in Alabama.
Julie Bennett—Getty Images
According to research done by Health Liberation Now, a trans-run advocacy site that studies the political impact of trans health and researches gender-affirming pediatricians, December 2020 was the first time there was a protest. However, by February 2021, the anti-trans group had already announced their plans to demonstrate in Los Angeles, Chicago, Philadelphia, Dallas, Hartford, Connecticut, and Ontario, Canada. Protests began to become more common in the fall and summer of 2021. Some anti-trans groups have begun using an online interactive map that tracks the location of clinics providing gender-affirming care, per HLN’s research. Other forms of harassment stay online, but pediatricians say they are similarly frightening—and have been going on since even before the first documented in-person protest.
When Susan, a pediatric endocrinologist, got the call from her hospital’s administrative assistant in the fall of 2020, it felt like she’d been punched. (TIME is withholding Susan’s identity and that of one other provider out of concerns for their safety.) A patient’s family had contacted the hospital, the assistant said, flagging that they’d seen posts online from an account that was purporting to be Susan, but didn’t sound like her. Susan rushed to her computer, and sure enough, there was her picture and her name on a Facebook profile, apparently posting about how she regretted her treatment of transgender kids—a feeling that couldn’t be further from the truth. She found a similar fake account on YouTube pretending to be her, expressing “remorse” for her actions.
Susan tells TIME that at least three other Gender-Proofing Pediatricians were also impersonated. Their posts were made to look as if they were in conversation with each other, agreeing about the “harm” they’d done to kids.
“I don’t think I ever went into medicine thinking something like this could happen,” Susan says. “We’re always just trying to care for kids.”
The situation has worsened. Her clinic was threatened with protests in the spring 2021. Protests occurred in 2021’s fall. “It really made us evaluate our safety systems for our patients, families, and staff,” she says. Susan says that she’s repeatedly been threatened with being reported to her state’s medical licensing board—though her care is not in violation of any policies—and adds that she knows gender-affirming mental-health clinicians who have faced similar harassment.
Leigh, a pediatric endocrinologist in the southeast, says people have tweeted at her asking her how she sleeps at night, arguing she is violating God’s plan.
“I am here to take care of my patients and make sure that they live longer, better, healthier lives,” she says. “And to have someone suggest something otherwise is just devastating to me.” Late at night, she’s sometimes filled with a sense of dread over where this rise in harassment could be leading. “We’ve had active shooters in the hospital where I practice for years,” she says. Was it possible that one of the shooters would come looking for her private clinic or her house? “That is one of my biggest fears.”
Continue reading: America’s Foster Care System Is a Dangerous Place for Trans Teens. Now They’re Fighting for Change
Garofalo, of Lurie Children’s Hospital, says that at least three of his colleagues in more conservative states reached out in 2021 asking for advice on how to deal with the harassment they were facing. They’ve told him “horror stories,” he says, including instances of receiving death threats.
Dr. Brandon Hill, the former President and CEO of Planned Parenthood Great Plains, which operates in Kansas, Missouri, Oklahoma, and Arkansas, says he’s been contacted by children’s hospital administrators in major cities across the country asking what trainings he gives abortion providers to prepare them for intense backlash and harassment. “This stuff isn’t new. These anti-trans-care people have used the same tactics for years. [target abortion providers],” Hill explains. “[But] I don’t think we ever thought of this being something where protesters would be outside of adolescent health centers. Ever.”
In response, many gender-affirming pediatricians have banded together to be each other’s support systems. “There are definitely colleagues who have to worry more about safety than others,” says Garofalo. “We check in on each other.” They hold wellness events and share experiences.
“We’re trying to advocate and be united together,” Susan adds. “But I can see the potential for burnout.”
Dr. Sequeira provides young women with gender-affirming services on January 28.
Jovelle Tamayo at TIME
The stakes couldn’t be higher. Published in the Journal of Adolescent Health The use of Gender-affirming Hormone Therapy (GAHT) was found to be significantly associated with lower rates of suicide attempt, depression and suicidal ideastion among transgender or nonbinary young people. The Trevor Project LGBTQ suicide prevention organization conducted the study. It also revealed that GAHT had nearly 40 percent lower chances of young transgender and nonbinary youths attempting suicide in the last year. Half of transgender youth and others who were surveyed stated that they did not receive GAHT, but would like to.
Many health providers worry that intimidation techniques could reduce the options for youth who are transgender, gender fluid, or other people with complex needs. These young adults face numerous barriers including stigmatization, lack of family support, high cost, long travel times, and difficult access to care.
“We don’t need another [hurdle],” says Sequeira. “We don’t need kids to have to walk through a gauntlet of protesters to get care.”
Dr. Janet Cathey, a gender-affirming provider who treats adults and adolescents at the Planned Parenthood in Little Rock, Ark., also worries that primary care doctors considering offering gender-affirming care might choose otherwise because they don’t want to risk wading into controversial territory. She says providers might be nervous about treating trans teens in states like Arkansas where it was banned temporarily for 2021.
Sequeira conducted a study over the last year that found many pediatricians were concerned about providing gender-affirming healthcare. “Which is a shame, because we so desperately need more providers in this area,” Sequeira says. A lack of available doctors doesn’t mean young people will stop needing affirmative care, adds Susan. It is possible that they will seek care underground without supervision from a doctor. This could prove dangerous.
This exodus hasn’t occurred for abortion providers despite years of deadly attacks including bombings, arson and threats of death. David S. Cohen is a Drexel University professor and author of Living in the Crosshairs – The Untold Stories Of Anti-Abortion Terrorism. Cohen states that there have been many cases where abortion clinics were forced to close as a result of regulatory and financial constraints. If anti-trans legislation continues to grow, it could also happen to providers of gender-affirming care, regardless of whether doctors decide to quit the field.
“The impact of this harassment is broad. It has a negative impact on clinical care. It can also impact research. It even affects philanthropic support, which for a lot of programs has been critical,” says Garofalo, who adds that there has already been “tremendous amount of efforts to defund” his research on gender-affirming care with the National Institute of Health.
Continue reading: Andraya Yearwood, a Star of Hulu’s New Changing the Game Documentary, Talks Life as a Trans Athlete
In November, the Children’s Medical Center Dallas and UT Southwestern Medical Center in Texas dissolved their six-year-old program that offered gender-affirming care to young people. The two medical centers stated that the best way to protect patients’ privacy was to disband the program in a statement sent to LGBTQNation. Following organized protests targeting hospital board members that argued the care was child abuse, according to the Texas Tribune. It was the first of its kind in Pennsylvania.
“That’s the part that really breaks my heart about all this,” says Sequeira. “There’s a lot that’s really challenging about being an adolescent, and especially an adolescent who is finding ways to affirm their gender.”
“It just makes me so fearful to see the increasing number of protests and discrimination happening to us as providers,” she continues, “Knowing that, I can only imagine what’s happening in communities, for many, many kids.”
—With reporting by Julia Zorthian
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