Gender affirming care for youth is banned in Iowa, North Dakota and South Dakota. It’s banned in more than 20 other states around the country, too, after a flurry of legislation over the last two years.
Then, there’s Minnesota, which has gone in the opposite direction, passing a bill last year that made the state a “trans refuge.”
“We’re this island in the middle of states who are banning and restricting access,” says Dr. Kelsey Leonardsmith, director of youth gender care at Family Tree Clinic in Minneapolis. She says it's hard to provide this care in the political spotlight.
“You have two choices, you can get scared and say, ‘I don't know if we can do that,’” she says. “Or you can take a deep breath and say, we know the work we do. We've looked at the research. We've been doing this for a long time now, and we are doing good work — our patients cry tears of joy in this building.”
Providers like Family Tree and others NPR spoke to say they’re adapting as quickly as they can to serve an influx of out-of-states patients.
Instead of freezing from fear, says Leonardsmith, “the other thing you can do is you can say, ‘We're going to do it, we're going to do it more, and we're going to teach everyone else how to do it, too.’”
That attitude is how Family Tree came to run the Midwest Trans Health Education Network. So far, they’ve trained about 50 health care providers from all over the region, including in rural areas. Over eight virtual sessions, they prepare members of each cohort to be able to take care of trans patients.
That goes beyond the relevant medical education, into some of the bureaucracy.
“A lot of it is: ‘Here, these are all of the patient handouts, the intake forms, the letter templates for when you have to fight with an insurance company,’” Leonardsmith explains. She co-leads the initiative with project manager Dylan Flunker.
The trans patients coming in from around the region are now heading to Minnesota are creating challenges, clinic staff says.
Last year, “just for our small clinic, we saw over 200 people from out-of-state,” says Family Tree executive director Annie Van Avery.
Children’s Minnesota has also seen an influx, with a 30% increase in calls to its gender health program and the hospital has hired more clinicians to help. One Minneapolis pediatrician told NPR he personally treats 15 trans patients who travel in from out-of-state.
The bans have meant financial hits for both patients and providers. For patients, traveling out-of-state for care can mean fewer follow ups, plus travel costs for things like gas and hotel rooms, and time off of work. For hospitals and clinics, patients’ health insurance often doesn’t reimburse out-of-state doctors.
Family Tree uses a sliding scale and doesn’t turn patients away who can’t pay, Van Avery says. “We're doing a service — at this point — for other states, and we want to be able to continue that access, but it's such a huge financial burden and challenge,” she says.
Across town, Dr. Kade Goepferd, a pediatrician who runs the gender health program at Children’s Minnesota, says a lot of their patients’ families have ended up moving to the state, rather than travel in periodically for appointments.
“They're now Minnesotans,” Goepferd says. “Knowing that they were going to [move], they called and got themselves on our waiting list ahead of time.” Even after hiring more clinical staff, the wait for the program is still about a year long.
For families with young kids, like 5-year-olds who are already strongly expressing a transgender or nonbinary identity, it is possible to wait many months until an appointment because gender-affirming care at that age is just talking.
“We have some families who will call us with their kids that young to find out, ‘How do I talk to grandparents? Should they pick out their clothes? What if they are asking to be called a different name — how do we handle that?’ So they're just looking for support,” Goepferd says.
Timing becomes much more important as patients get older. Trans teenagers and their families may decide to use puberty blocking medications or cross-sex hormones or both. (Surgery is very rare for minors.)
These are the types of interventions that some lawmakers object to, despite the fact that major U.S. medical organizations, including the American Medical Association and the American Academy of Pediatrics, support access.
When lawmakers in Iowa, Minnesota’s neighbor to the south, debated that state’s ban last March, the bill’s sponsor, Republican Rep. Steven Holt explained why he thought the ban was needed. “Our children deserve the time to grow into themselves, to find themselves, to go through phases, without medical interventions that are unproven in their efficacy,” he said.
Goepferd emphasizes that the gender health program is not like a tunnel that you walk into as a boy and walk out as a girl — or vice versa. Every patient is different and there’s room for that diversity.
“The agenda is set by the kids and the families, not by us,” they explain. “They may or may not end up using any medications, they may or may not socially transition, they may or may not shift their identity over time — my only goal is helping them thrive.”
They say that the care is slow and thoughtful and multidisciplinary. “We work with our rehab team in speech pathology; we work with our psychiatry team, with medication management. We have nursing care that helps families navigate appointments and resources and things like that.”
With all the political attention on transgender kids right now, Goepferd has also spent a lot of time recently at the Minnesota state house, as laws affecting their patients have come up. “Sometimes it takes someone who's a pediatrician to get up on the stand and correct disinformation,” they say. “I had some disingenuous questions from legislators, but I also had some very genuine questions from legislators who were just trying to understand.”
That very public work has had a personal cost. Goepferd says they have received death threats. But they don’t plan to stop.
“If I can't get accurate information out there and if I can't help create the culture change that trans kids need, the medical care that I'm providing is just not going to make a difference,” Goepferd says.
After all, they say, most of what affects a child’s wellbeing happens outside the doctor’s office.
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