Gender-Affirming Care is a Basic Human Right. Why this Bill Strips Bodily Autonomy

Trans People Are Who They Say They Are

by Stefan Simanovich, LCSW

Alabama's most recent legislature is highlighted and bolded:

Relating to public health; to prohibit the performance of a medical procedure or the prescription of medication, upon or to a minor child, that is intended to

alter the minor child's gender or delay puberty;

The intention of medical interventions are to facilitate health and wellbeing as preventative care, not to change someone’s gender or to delay puberty.

You cannot alter or change someone’s core gender. Gender is simply knowing who you are, present at birth, it is embodied over the lifetime through being “attuned to", or seen, secure, safe, soothed in an authentic way of being as related to one’s body and sense of self.

Trans people are not a threat, people feel threatened by trans people. To criminalize someone is to deem them punishable by the law, with the idea that someone causes harm to others or is a threat to society. Despite how corrupt the legal system is in dehumanizing people, providing medical interventions that enhance health and wellbeing should not be “punishable” and does not cause harm to others. All People are worthy of basic human rights and access to high-quality healthcare that increases life expectancy based on each individual’s needs. Under our constitutional rights, healthcare that is trauma informed, holistic, and dignifying does not warrant being criminalized. Policies like these should be criminalized.

(1) The sex of a person is the biological state of being female or male, based on sex organs, chromosomes, and, endogenous hormone profiles, and is genetically encoded into a, person at the moment of conception, and it cannot be changed.

The “sex” one is assigned at birth does not indicate the same genetic make up, gender, and sense of self as other people who also assigned that same sex, or “born” with specific sex characteristics and anatomy. We know that there is so much variation of genetic expressions and ways of being among people that are assigned the same sex at birth. Biological sex does not equal someone’s gender identity, gender expression, or gender presentation. Men, women, trans people, genderfluid people, non-binary people, all have variations of experiences related to their bodies. No one has the same experience and relates to their body the same way. That’s a human experience.

(2) Some individuals, including minors, may experience discordance between their sex and their internal sense of identity, and individuals who experience severe psychological distress as a result of this discordance may be diagnosed with gender dysphoria.

Discordance means “lack of agreement”, so I’ll use that meaning since an alternate meaning was not specified. How does someone’s “sex” disagree with someone’s internal sense of self? "Dysphoria" is used in healthcare to enforce the idea of a “psychological illness”, a “lack of agreement between sex and their internal sense of identity”.

We know through neurobiology and the impact of our experiences on the brain, that one’s sense of self is shaped by how we are perceived, treated, and how our experiences shape us. “Identity” is not just “of the mind”. One’s core gender identity is embodied, meaning of the body and mind by feeling attuned to by others and seeing ourselves in the world. At Transforward, based on lived, trans experiences that center health, this is an integrative, human, neurobiological perspective that is evidence based.

“Gender dysphoria” as a concept and diagnosis has fueled these explicit transphobic policies. The ideology of “Gender dysphoria” is inherently transphobic because it enforces a “mind and body” disconnect, insisting only two genders associated with two body types (“male and female”) exist, using language that aims to “rid” biological sex characteristics, assuming biological sex is connected to one’s gender, and enforces “distress” as coming from within; a pathological source of distress. The distress of trans people stems from lack of bodily autonomy. Furthermore distress is linked to the lack of access to sound healthcare that humanizes the trans experience as a legitimate human existence worthy of basic human rights. Also, the diagnosis and definition completely eradicates androgynous and non-binary identities and actually blocks people from receiving healthcare they need by insisting on rigid requirements for procedures.

The DSM uses “gender as social elements and norms” saying it’s just outside and social, then at the same time says it is biological by enforcing medical interventions. It does not make sense and perpetuates confusion. Another paradoxical impact of the diagnosis itself.

(3) The cause of the individual's impression of discordance between sex and identity is unknown, and the diagnosis is based exclusively on the individual's self-report of feelings and beliefs.

There is not a “discordance between sex and identity”. This is a false interpretation of the trans experience and transgender health. The diagnosis they are referring to is “Gender dysphoria.” This is a diagnosis that has been used to make sense of the distress for trans people and to expand access to gender-affirming medical healthcare by ensuring insurance coverage. Unfortunately, this diagnosis has perpetuated harm by assuming that one’s gender identity is intrinsically attached to one’s biological sex, that there are two sexes associated with two genders, and that one must experience “distress” because of one’s anatomy and sex characteristics to be worthy of healthcare interventions that facilitate healthy gender development. This rhetoric has enforced erroneous beliefs of gender, mental health, and the human experience that are not embedded in accurate science on gender that include all experiences of gender identities and expressions.

The existence of “Gender dysphoria” as a diagnosis has actually caused more barriers for trans people in accessing healthcare and well-being. The diagnosis as it exists is not exclusively based on an individual’s self-reporting. If it were, gender-affirming interventions would actually be more accessible. This is the yet another paradox to the diagnosis of “Gender dysphoria”.

As a healthcare provider, I know that in my practice and by state law and Social Work ethics, one must perform evaluations, intakes, questionnaires, among other requirements to meet regulations of a proper Psychiatric Evaluation. No diagnosis is just given by self-reporting. There is an in depth process involving several hours of getting to know a client through bio-psycho-social assessment and clinical interview. Any healthcare provider should be offended by this assumption asserted by a state law.

(4) This internal sense of discordance is not permanent or fixed, but to the contrary, numerous studies have shown that a substantial majority of children who experience discordance between their sex and identity will outgrow the discordance once they go through puberty and will eventually have an identity that aligns with their sex.

There is not an “internal sense of lack of agreement between one’s sex and identity.” This statement does not make sense from a neurobiological standpoint; the way gender and sexuality operate as related to the body and human development. The self is constantly evolving over the lifetime. Gender is a core part of self that is present from birth. You just know who you are. Gender is of the heart-brain, heart-gut, these are interconnected parts of the mind-body, not separate or correlated. The body is not wrong, the body knows what it needs. Youth is about growth, learning, and development. Gender is not just an “identity” of the “psyche.” Gender is felt from birth, and is embodied through conscious awareness. Biological sex is not black and white and so rigid to "male" and "female". I believe trans people are born trans just as each individual is born with an interconnected web of genes, body types, anatomy, organs, spirit, mind, soul, and all elements of what it means to be human. I think we must stop compartmentalizing the complexity of the human body in healthcare.

(5) As a result, taking a wait-and-see approach to children who reveal signs of gender nonconformity results in a large majority of those children resolving to an identity congruent with their sex by late adolescence.

These approaches are not “wait and see”, they are interventions of preventative healthcare. In order to prevent distress for a young person exploring and understanding a core identity in a world that rigidly only acknowledges two genders with two body types, associated with strict gender norms and expectations, these interventions are lifesaving and sometimes necessary.

(6) Some in the medical community are aggressively pushing for interventions on minors that medically alter the child's hormonal balance and remove healthy external and internal sex organs when the child expresses a desire to appear as a sex different from his or her own.

The medical community is actually not pushing for trauma-informed, trans-affirming healthcare, and as emphasized in this article. I argue the healthcare community unfortunately has perpetuated harm. Trans people have not found healing and embodied in healthcare facilities. This has come through acceptance, community, and a sense of ownership of one's body and life. Interventions that are trauma-informed, trans affirming, and trans embracing actually saves lives. These intervention are holistic, integrative, and provide space to consider all the elements of one’s life, body, and gender identity.

(7) This course of treatment for minors commonly begins with encouraging and assisting the child to socially transition to dressing and presenting as the opposite sex. In the case of prepubertal children, as puberty begins, doctors then administer long-acting GnRH agonists (puberty blockers) that suppress the pubertal development of the child. This use of puberty blockers for gender nonconforming children is experimental and not FDA-approved.

No one can present as the “opposite sex” because gender expression and presentation is not the same as one’s reproductive organs, sex characteristics, and chromosomes. It is unethical for any healthcare provider to “encourage or assist'' an individual with any medical intervention if client-centered and follows ethicals guidelines.

We all know there are many things that the FDA approves that are unhealthy and not evidence based.

Many puberty blockers are indeed FDA approved. In fact, the puberty blocker Lupron has been used safely since 1993 to combat precocious puberty in children. Many trans people use blockers, both youth and adults. At Transforward, not a single client has experienced long term, unhealthy effects of blockers. In fact, many young people actually do not use blockers, and instead wait until appropriate age to begin hormone replacement therapy if that is true for them. When young people are given a safe space to explore decisions for their life and their body, young people make the decision that is best for them. I have had young people who actually start hormones and make the decision to stop because it is just “not their truth” or because they feel complete, whole, and embodied. Young people are chronically devalued in our society and dismissed, when in fact adolescence is one of the most precious times in our human life development where young people should be the most. honored and given space to be what is authentic to them.

(8) After puberty blockade, the child is later administered "cross-sex" hormonal treatments that induce the development of secondary sex characteristics of the other sex, such as causing the development of breasts and wider hips in male children taking estrogen and greater muscle mass, bone density, body hair, and a deeper voice in female children taking testosterone. Some children are administered these hormones independent of any prior pubertal blockade.

This assumes that: 1) there are only two genders associated with two biological sexes 2) that trans people do not exist because there are only two genders and two perceived body types.

“Female children” do not take testosterone and “male children” do not take estrogen. This is conflating gender with biological sex and sex characteristics. This is not the same thing or trans people would not exist. Every individual has their gender-affirming self-image that is authentic to them and their body. This is not always the traditional understanding of what it means and looks like to be a woman or man. Men, women, and people look like many different things and has various body types.

Countless evidence, research, life experience, and narratives show us time and time again that the embodiment of gender, which includes sound medical interventions that are gender affirming, facilitates health, well-being, community, and ultimately increases life expectancy. This is evidenced based at Transforward across background, identity, and age. Actually, the embodiment of gender increases health, well being, and an internal sense of harmony, decreasing symptoms (distress).

(9) The final phase of treatment is for the individual to undergo cosmetic and other surgical procedures, often to create an appearance similar to that of the opposite sex. These surgical procedures may include a mastectomy to

remove a female adolescent's breasts and "bottom surgery" that

removes a minor's health reproductive organs and creates an artificial form aiming to approximate the appearance of the genitals of the opposite sex.

Actually, most trans people do not undergo surgery, and no trans people undergo “cosmetic” surgery related to gender affirming procedures because all surgery that is pursued is necessary according to each individual’s needs. It is a myth that all or most trans people need and seek surgical interventions. 1) because people experience different relationships with their body, gender expression, and gender identity 2) due to the inaccessibility and barriers to high quality medical healthcare that is trans embracing and affirming, enforced by insurance payers strict regulations for gender affirming procedures that are often denied as “unnecessary” (unworthy, invalid). Many trans people experience healthcare trauma, a lack of bodily autonomy, safety, and trust in healthcare facilities and in interactions with healthcare providers that prevents seeking care.

(10) For minors who are placed on puberty blockers that inhibit their bodies from experiencing the natural process of sexual development, the overwhelming majority will continue down a path toward cross-sex hormones and cosmetic

surgery.

Many who continue on hormone replacement therapy do so because trans-affirming healthcare, that includes bodily autonomy, safety, attunement, and space to explore an authentic part of self always increases socio-emotional health. Sometimes, this includes hormones that are necessary in creating harmony between a young person’s internal and external world.

(11) This unproven, poorly studied series of interventions results in numerous harmful effects for minors, as well as risks of effects simply unknown due to the new and experimental nature of these interventions.

Many studies explore the use of puberty blockers in pre-adolescents, most notably a thirty year Dutch study led by Amsterdam Center of Expertise on Gender Dysphoria and most recently in 2019 a ten year study by Johanna Olson-Kennedy, Amsterdam Center of Expertise on Gender Dysphoria, MD, Yee-Ming Chan, MD, PhD and Stephen Rosenthal, MD which both conclude that, “transgender individuals who underwent hormonal gender transition at younger ages assimilated more easily into their “new gender” roles because of greater concordance between their physical appearance and gender” (Olson-Kennedy et.al).

Additionally, both studies observed that individuals undergoing an unwanted endogenous puberty experience, faired far worse than their counterparts who utilized “blockers”. In fact, distress in academic, emotional functioning and familial relationships were noted by researchers in the case of transgender youth who were unable to prevent an unwanted puberty. Failure to intervene early led to mortality in these groups who were denied trans-affirming care. These deaths were due to substance abuse, suicide and homelessness which were psychosocial effects. This study led Dutch clinicians to seek early interventions and the results were unsurprising. Those receiving early trans affirming care fared far better than their counterparts. Results showed a decrease in emotional and behavioral problems. The research overwhelmingly points to one conclusion; failing to provide trans people life-saving early intervention has catastrophic results. Denying the existence of these studies is blatant transphobia. We know that these trans-affirming interventions save lives, yet live in a country so hellbent on willful ignorance that they will allow trans people to die before they attempt to understand them and offer them adequate care.

(12) Among the known harms from puberty blockers is diminished bone density; the full effect of puberty blockers on brain development and cognition are yet unknown, though reason for concern is now present. There is no research on the

long-term risks to minors of persistent exposure to puberty blockers. With the administration of cross-sex hormones comes increased risks of cardiovascular disease, thromboembolic stroke, asthma, COPD, and cancer.

Again, hormone replacement therapy as a necessary intervention for trans youth and adults according to each individual’s need improves socio-emotional health. Distress for trans youth comes from inherently not belonging in a largely transphobic society, which looks like fear of being judged, feeling like there is something wrong with them, and fear of being misunderstood, misperceived, and unsafe in an authentic way of being in one’s gender. Distress is a trauma response. Pain, discomfort, and suffering come with life. That is a human experience. Distress is avoidable. Gender and the trans experience is not inherently distressing. Like any medical procedure, there are always risks. These are risks that people take to save their life and for their well-being. Assuming that trans people would pursue medical interventions blindly, impulsively, simply by "being out of their minds" further displays the insidious ways transphobia has inserted itself into our political discourse. Many trans youth report wanting certain procedures for “years” of their lives. Why do we think trans youth are so distressed? Because they are denied access to life itself: bodily autonomy, safety, happiness, and sense of belonging.

An increase in socio-emotional health is attributed to a decrease in suicidality, self-harming behaviors, depression, social anxiety, dissociation, numbness, isolation, restlessness, irritability; while an increase in emotional expression, peace of mind, physical health, self-worth, confidence, and sense of hope can be observed.

(13) Puberty blockers prevent gonadal maturation and thus render patients taking these drugs infertile. Introducing cross-sex hormones to children with immature gonads as a direct result of pubertal blockade is expected to cause irreversible sterility. Sterilization is also permanent for those who undergo surgery to remove reproductive organs, and such persons are likely to suffer through a lifetime of complications from the surgery, infections, and other difficulties requiring yet more medical intervention.

A person’s choice of whether or not to have biological children is their individual right to bodily autonomy (this includes minors). Minors can give birth to children legally throughout our country. In fact, legislature in many states makes it illegal for these minors to do otherwise. Many youth and minors are required to have children unwillingly if they do not have access to reproductive rights, like the right to an abortion. Minors and trans youth deserve reproductive rights and the ability to choose if, when, and how one would like to have children. Gender variance, as it relates to medical decisions regarding one’s body and gender identity, is a connected yet separate discussion.

(14) Several studies demonstrate that hormonal and surgical interventions often do not resolve the underlying psychological issues affecting the individual. For example, individuals who undergo cross-sex cosmetic surgical procedures have been found to suffer from elevated mortality rates higher than the general population. They experience significantly higher rates of substance abuse, depression, and psychiatric hospitalizations.

The distress for trans youth is due to policies like these that elevate a lack of safety, causing an increase in emotional distress due to the terror of never being able to embody (be “of one’s body, creating connection between one’s body, self, and others) an authentic way of being in one’s core gender. This includes a lack of access to gender-affirming medical care that is necessary and healthy for many trans/non-binary youth.

(15) Minors, and often their parents, are unable to comprehend and fully appreciate the risk and life implications, including permanent sterility, that result from the use of puberty blockers, cross-sex hormones, and surgical procedures.

This is because there is enormous confusion about gender and the trans experience as the current models throughout society and healthcare talk about gender in a manner that does not make sense on neurobiological and human levels. We now know so much more about how the brain, body, and our external world shape our socio-emotional development, including one’s sense of gender identity. I believe we must stop emphasizing a "brain/body disconnect". There is not a separation or disconnect between biological sex and gender identity experienced by anyone. The body, sexuality, and gender identity or one's sense of self, are interconnected, not correlated; evolving over the lifetime as authentic to each individual.

Confusion has been exacerbated by diagnoses like “Gender dysphoria” and the pathologizing of a natural human experience as mentioned before.

(16) For these reasons, the decision to pursue a course of hormonal and surgical interventions to address a discordance between the individual's sex and sense of identity should not be presented to or determined for minors who are incapable of comprehending the negative implications and life-course difficulties attending to these interventions.

The reality is that this bill is detrimental to not only our country, but every single person because of the traumatizing ripple effects for all of us.

Bills such as this prohibit the removal of "healthy tissue" inadvertently prohibit cis women from undergoing preemptive mastectomies in the case of having a strong gene for breast cancer. Additionally, this bill makes it illegal to augment the body through plastic surgery if the body parts involved are healthy. The rigidity of this law will unexpectedly impact those who think it doesn't concern them at all. This is why many are calling for the bill to be followed to the letter so that cis people will recognize how this bill effects them and perhaps infer how deeply this bill will hurt the trans community.

So many people know trans people, have trans family members and friends, and are coming out as trans, non-binary, genderfluid. Many more people are related to and know trans people, and many parents are fighting for their kids to live and be in their authentic self of self. I witness it everyday and honor the parents/caregivers who embrace their children no matter what gender identity or expression by giving them bodily autonomy and safety. That is life saving.

We are all impacted by rigid standards, beliefs, and assumptions we hold on gender associated to biological sex. Cisgender, straight people are also victims of these inflexible systems of gender and sexuality heavily based on the physical body, held hostage to expectations of what a man or woman should be like, look like, feel like, think like; or how one should express their emotions based on gender, who one should socialize with, what someone "should do" with their career, time, energy, body; what one should wear. Gender and how we are perceived impacts everything we do because it's so engrained in our society. I believe that trans people have a lot to teach us as a society if we would only listen, which includes reaching out and listening to trans youth.

Young people would not experience such heightened distress related to being trans if we lived in a world where trans people belonged. This means being integrated into our society through policies, practices, and mindsets that acknowledge the trans experience and gender variance based on body type as a normal human experience that is worthy of bodily autonomy: existing.

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