Lifesaving or harmful? Trans care debate barrels toward 2024.

When Missouri Attorney General Andrew Bailey issued an emergency order in April to restrict gender-transition treatments in his state, he announced he was acting to protect vulnerable patients – particularly children – from “experimental” medicine, accusing the clinics providing such care of “harming children by ignoring the science.”

To many parents of transgender children in Missouri, however, the real threat they face is not from doctors but politicians. 

“The first thing you learn when you have a trans kid in a red state is that you have to protect them from the government,” says Daniel Bogard, a rabbi in St. Louis who has a transgender son in third grade and runs a summer camp for LGBTQ+ youth from across the Midwest. 

The attorney general’s order has been halted, for now, by the courts. But this week, Republicans in Missouri’s legislature moved to ban all gender-transition treatments for minors, except for those already receiving such treatments. It also passed a bill barring transgender youth from participating on certain sports teams. GOP Gov. Mike Parson has promised to sign both.  

Missouri is second only to Texas in the number of LGBTQ+-related bills introduced this year, part of a wave of states imposing new restrictions on transgender individuals in particular. In GOP-controlled legislatures from Florida to Arkansas to Montana, the ACLU has tracked 474 bills it characterizes as targeting LGBTQ+ rights in 2023 alone. Red states are banning trans athletes from playing on certain teams and placing restrictions on which bathrooms they can use. And at least 16 now ban or restrict medical treatments for transitioning. 

Two decades after Republicans found success at the ballot box by mobilizing against same-sex marriage – only to watch public opinion rapidly move to embrace it in the years that followed – transgender rights are emerging as perhaps the most polarizing culture-war issue of the 2024 campaign. As trans people have moved into the mainstream of popular culture, at a pace that would have seemed remarkable not long ago, conservatives are stoking a social and political backlash, particularly among older voters unfamiliar with a once largely invisible minority. Former President Donald Trump and other GOP candidates are accusing liberals of promoting “radical” ideas about gender identity, and arguing such topics should be off-limits in schools. And many are raising concerns about transition-related medicine, especially for minors, saying it’s unproven and dangerous.

Those on the left, including many families raising transgender children, say conservatives are scapegoating a vulnerable subgroup –estimated in 2022 to number 1.6 million, though the number is fast changing – that still lags far behind gays and lesbians in social acceptance. More than 40% of all trans and nonbinary youth aged 13-24 have “seriously considered” suicide over the past year, according to a recent survey of more than 28,000 LGTBQ+ people. Supporters say the rights of trans individuals are being increasingly infringed upon by legislators for political purposes – and that when it comes to children, it should be up to families and medical providers, not politicians, to make decisions about what many characterize as lifesaving care.

As with so many culture-war debates, polling suggests most Americans hold nuanced, and sometimes contradictory, views. A Washington Post-Kaiser Family Foundation poll taken late last year found strong majorities of Americans support laws prohibiting discrimination against trans people in various arenas from schooling to housing to the workplace. But 57% of adults also said they believe a person’s gender is determined at birth, and 68% would oppose giving trans children between the ages of 10 and 14 access to puberty blockers.

Many Americans are still figuring out their views on transgender policy, says Kasey Suffredini, vice president of advocacy and government affairs at the Trevor Project in Los Angeles, a nonprofit which works on LGBTQ+ youth-suicide prevention.

“The majority of people in this country are fair-minded. They want to do the right thing. And that’s why you see a split between them supporting fair treatment [of trans people] and then having conflicted feelings around sports and other issues,” he says. 

Further complicating the matter is a growing degree of uncertainty, even within the medical community, over how to respond appropriately to a surge in teen gender fluidity. Surveys show that among 13-to-17-year-olds, rates of self-identification as transgender are roughly triple that of adults. The number of youths receiving “gender-affirming care” – namely puberty blockers and hormone treatments – has risen sharply since 2017, with 5,621 new patients under 18 initiating treatment in 2021, according to a Reuters analysis of insurance data, though that is likely an undercount. 

Supporters point to studies that show positive outcomes for youth who receive such treatments, and the American Academy of Pediatrics and other medical associations continue to support them. Many also argue that the risks of denying treatment are far greater. Critics, on the other hand, note studies have also shown that gender dysphoria in childhood – or the feeling of being in a wrong-gendered body – often recedes over time, suggesting advantages to a wait-and-see approach. And several European countries are now recommending more caution in treating minors.

This clinical debate exploded into the open in Missouri in February after Jamie Reed, a former case worker at the Transgender Clinic at the St Louis Children’s Hospital, alleged multiple cases of malpractice by doctors who provided transition care to minors. The attorney general’s office launched a probe, while Washington University, which owns the hospital, announced its own internal investigation. In April, the university said it had found no evidence to substantiate the allegations.

That same month, Attorney General Bailey, who was appointed by Governor Parson, issued his emergency order, which put Missouri on par with Texas, where Republicans have used executive orders to shut down transgender clinics and ordered child welfare workers to report families who access care.

While the clinical and ethical debate over youth-transition medicine is complex, most medical professionals don’t favor bans on minors receiving transgender care and fear for these young people’s mental health if care ends. They say Republican lawmakers have reduced an issue with many shades of gray to a black-and-white choice in which support for transitions for minors equates to child abuse, to the frustration of many families of trans children navigating difficult and highly personal medical decisions.

Jennifer Harris Dault, a Mennonite pastor in St. Louis with a transgender daughter, says she wishes questions about treatment could be taken out of the political arena entirely. “Every time that our kids need medicine or need medical intervention, it is scary. But we listen to the benefits and the risks … and then we make the best decision that we have in front of us with the help of our care teams,” she says. 

For now, she and other families are fighting what feels like an “exhausting” battle – on an issue that has grown markedly more divisive in just a few short years.

Rapid political escalation

Midway through a speech to supporters in Davenport, Iowa, in March, Donald Trump said as president he would cut federal funding to “any school that’s pushing critical race theory, transgender insanity.” The crowd inside the theater, which had grown quiet during a long stemwinder about farm subsidies, erupted in sustained cheers. 

“Look at the hand you get for that,” Mr. Trump said admiringly, once he could be heard again. “Bigger than ‘We’re going to be energy independent.’” He then vowed to keep trans women out of sports and called a transgender swimmer a “monster.” 

But when Mr. Trump first ran for the GOP nomination back in 2016, he evinced a far more hands-off approach to transgender issues. 

That year, North Carolina became the first state to prohibit trans people from using their preferred bathroom, igniting a political firestorm that led to boycotts. Supporters of the North Carolina bill had argued that it was necessary to protect privacy and safety in schools and other public spaces. Researchers, however, say trans people are far more likely to be victims of public assault than perpetrators. 

Asked about the issue at the time, Mr. Trump said there had been “very few problems” with trans people using public bathrooms and advised North Carolina to “leave it the way it is.” Texas Sen. Ted Cruz, who was also running for the GOP nomination, attacked Mr. Trump for bowing to a politically correct ideology that would, as he put it, allow “grown men” in a bathroom with little girls.

The following year, North Carolina largely repealed its bathroom law after the NBA and NCAA moved its All Star and championship games out of state in protest. But the backlash on the right had begun. And as the politics evolved, Mr. Trump’s stance evolved as well.

In 2017, the then-president called for a blanket ban on transgender people serving in the military, bucking his own Defense Department, which wanted to retain and recruit transgender soldiers. A modified version of the ban that took effect in 2019 was reversed by President Joe Biden in his first full week in office in 2021. 

Since then, other states have taken up transgender bathroom access. In April, Republicans in Kansas overrode a veto from Democratic Gov. Laura Kelly of a sweeping bill restricting trans people’s use of bathrooms in jails, prisons, and athletic facilities, as well as schools.

Social conservatives have also focused on transgender women competing in sports, an issue that plays well on right-wing media but that also wins sympathy from some Democrats and independents. Supporters of bans say female athletes should not be forced to face opponents who may have physical advantages from being born male, and at least 21 GOP-run states have passed bans on trans student athletes competing as their preferred gender, with little protest from the NCAA and other sports federations with anti-discrimination codes. 

In April, the Biden administration issued new rules that were seen as a compromise of sorts – prohibiting schools and athletic associations from issuing blanket bans on transgender athletes, but also allowing them to make case-by-case decisions about imposing restrictions when questions of fair competition arise.

An evolving field 

But by far the thorniest and most fiercely fought issue of 2023 is gender-transition treatment for young people, a once-rare intervention that is now offered at more than 100 specialist transgender clinics across the country, including the St. Louis center that is under investigation. Minors who are diagnosed with gender dysphoria can choose, with parental consent, to use puberty blockers and hormone injections to transition. 

Others opt for continued counseling and decline medical treatments, often while going public with their new gender identity, known as “social transitioning.” Genital and breast surgery on minors, a popular talking point on the right, remain exceedingly rare, and some transgender clinics won’t offer referrals. 

Critics say the medical treatment of gender dysphoria has expanded rapidly without sufficient guardrails and that the long-term risks of medical transitioning, including on things like fertility, bone density, and even brain development, aren’t fully understood. A related concern is that some adolescents, whose evolving relationship to their bodies has always been shaped by peers and popular culture, may essentially be led by external forces toward a medical intervention with lifetime effects they could later regret. 

In recent years, France, Sweden, and other European countries have tightened their rules on gender care, citing the uncertainty over medical side effects and potential overuse. Others continue to use similar protocols as U.S. specialists in treating minors, while collecting more data on patients who transition.  

This evolving area of medicine has run headlong into the entrenched political polarization in the U.S., pitting social and religious conservatives, mostly on the right, against progressives who align with the LGBTQ+ community. Within the latter group, raising doubts about prescribing transition medicines, even in scientific journals, is often cast as undermining not just the rights but the humanity of trans people. Concerns about broader repercussions on trans people’s mental health and position in society – which activists say are already being impacted – has worked to further stymie debate on the left.

“The way that we’re living now is really dangerous for us and our children,” says Lazarus Jameson, a chaplain in St. Louis who serves trans adults. “I’m a trans person, visibly trans. My community members are trans people. The level of harassment at our jobs has been super increased. People are feeling unsafe.” 

Greg Razer, a gay Democratic state senator from Kansas City, says lawmakers seeking political victories need to keep in mind the young people whose lives might be impacted. “These are actual kids – and they’re hurting. Whether you think they’re right or wrong, they’re hurting. Don’t say something that’s going to push them over the edge,” he says. 

Those on the left see the recent rise in trans identification as a positive reflection of a more-accepting society, which they fear is now being undermined. On the right, however, that rise is often framed as a social contagion or even manifestation of mental illness that should be gently corrected, not accommodated. Critics point to studies that show a relatively high percentage of those seeking gender-transition care also have other diagnoses, ranging from depression and anxiety to autism.

Republicans say they’re propelled by genuine concerns, not politics. Brad Hudson, who represents a rural district in southwest Missouri, filed the state House bill banning gender-transition care. A pastor who was first elected in 2018, he took on the issue because he had met families who didn’t know how to deal with gender dysphoria. “These kids really do need help. And these parents need help, too,” he says. 

In an interview in his office on the second floor of the Capitol, Representative Hudson says he believes “many, many children” with gender dysphoria can learn to embrace their bodily sex, with the right supports in place.

Asked why lawmakers were spending so much time on an issue that affects relatively few Missourians – the attorney general’s office has put the number of trans adults and children at 12,400 out of more than six million state residents – he said that trans-identifying teens who take medication now might regret it later on when they can’t have biological children. (Some trans teens harvest eggs or bank sperm before starting hormone treatments.) 

Mr. Hudson emphasized that his bill only applied to minors. As a pastor, though, he said he would also counsel an adult in his community not to try to change their gender. “I would try to lovingly and thoughtfully explain to them why that would be a huge mistake. And I would try to help them embrace the way that God made them.”  

Rallies at the capitol

During the spring legislative session, supporters and opponents of Missouri’s transgender bills held rallies on different days at the Capitol under its vividly painted dome. Those opposed greatly outnumbered the supporters. 

Catherine Dreher was among the supporters. Her child came out as a transgender woman last year, two weeks before turning 18. “He said, ‘Yeah, I’m trans. I’d be happier as a female.’ But he couldn’t answer why,” she says.

Their relationship is now estranged, though she says she still sends regular emails. “I put things in the subject line, like, ‘I love you and I always will,’” she says. 

Ms. Dreher believes that her child, whom she homeschooled, has been misled by online friends and will someday regret the decision to transition. “I pray when the day comes that he realizes this is not, you know – that he made a mistake. That he knows it’s okay to say that he regrets it, and knows that he’s always welcome back home,” she says. 

Among those rallying against the bills was Stephanie W., a wellness coach from St. Louis whose trans daughter began medically transitioning in her first year in high school. It was her first political rally, not something she ever imagined herself doing. 

“I don’t like confrontation, but I will no longer just agree to disagree with someone. This is not a political issue. This is an issue of human rights, the health and well-being of another person,” she says. 

Stephanie, who asked not to use her full name for her family’s privacy, says her daughter, who was recorded as male at birth, always preferred girls as friends. In middle school, that child began to struggle with depression and bullying. “We went from having a happy kid that was creative and pretty well-adjusted to where I was checking on her every night because I was afraid,” she says. 

After two years of seeing a therapist, Stephanie’s daughter was diagnosed with gender dysphoria. Like many families in the area, she ended up at the Washington University Transgender Center, where her daughter was treated first for depression before eventually starting hormone treatment. “She’s now three years into transition. She is the happiest I’ve seen her in a very long time. And this saved her life,” she says. 

Partisan and generational divide

Since 2017, at least 50 politicians who identify as trans have been elected to local and state offices in the U.S. They include Zooey Zephyr, a Democratic lawmaker in Montana who was barred last month from the House floor after telling Republicans they would have “blood on [their] hands” for ending youth transition care. 

Four days later, GOP Gov. Greg Gianforte signed the medical-transition ban into law, making Montana one of the latest states to deny treatment to minors. Civil rights groups said they would sue to stop its implementation on Oct. 1. 

Analysts say as Republicans increasingly seek to impose restrictions on trans people, they run the risk of overreaching politically, giving Democrats an opening to label the GOP position as mean-spirited and extreme. Indeed, it’s not hard to envision the issue following a similar trajectory as the same-sex marriage battle, in which short-term political victories for one side might be masking or even facilitating a longer-term shift in the other direction.

But the issue has also opened fissures in the Democratic coalition, including among feminists who worry about women’s rights being compromised in the name of transgender equality and who say legitimate debate is too often shut down with charges of transphobia. 

In a 2022 poll, Pew found a wide partisan and generational divide on transgender issues. Among Democrats under 30, 72% said a person can be a man or a woman regardless of their sex recorded at birth; in older age groups that percentage fell to 60% or less. Among Republicans and those who lean Republican of all ages, though, only 13% said a person’s gender could be different than their sex at birth. And 66% said society had gone too far in accepting trans people.

“This is a wedge issue,” says Annise Parker, a former Democratic mayor of Houston and president of the LGBTQ+ Victory Fund which supports candidates for office from that community. Even within her coalition, not everyone is fully on board, Ms. Parker admits. “We do lose some right-leaning gay candidates who will not support this issue,” she says. 

Over time, the stark generational divide behind the trans culture wars may well dictate where the issue is heading. “All the cool kids in high school are queer now,” Ms. Parker says, half-joking.

But for now, she adds, that generational split only adds to the political foment: “It taps into a deep well of unease among parents.”