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    • Some providers are dropping gender-affirming care for kids even in cases where it's legal

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    ST. LOUIS -

    As Republican-led states have rushed to ban gender-affirming for minors, some families with transgender children found a bit of solace: At least they lived in states that would allow those already receiving puberty blockers or hormone therapy to continue.

    But in some places, including Missouri and North Dakota, the care has abruptly been halted because medical providers are wary of harsh liability provisions in those same laws -- one of multiple reasons that advocates say care has become harder to access even where it remains legal.

    "It was a completely crushing blow," said Becky Hormuth, whose 16-year-old son was receiving treatment from the Washington University Gender Center at St. Louis Children's Hospital until it stopped the care for minors this month. Hormuth cried. Her son cried, too.

    "There was some anger there, not towards the doctors, not toward Wash U. Our anger is towards the politicians," she said. "They don't see our children. They say the health care is harmful. They don't know how much it helps my child."

    Since last year, conservative lawmakers and governors have prioritized restricting access to transgender care under the name of protecting children. At least 22 states have now enacted laws restricting or banning gender-affirming medical care for transgender minors. Most of the bans face legal challenges and enforcement on some of them has been put on hold by courts.

    All the laws ban gender-affirming surgery for minors, although it is rare, with fewer than 3,700 performed in the U.S. on patients ages 12 to 18 from 2016 through 2019, according to a study published last month. It's not clear how many of those patients were 18 when they received the surgeries.

    There's more variation, though, in how states handle puberty-blockers and hormone treatments under the new bans. Georgia's law does not ban starting puberty blockers for minors. The others do. Some states, including North Carolina and Utah, allow young people who already are getting either kind of treatment to continue, as does Georgia with hormones. Others require the treatments to be phased out over time.

    These treatments are accepted by major medical groups as evidence-based care that transgender people should be able to access.

    James Thurow said the treatment at the Washington University center changed everything for his stepson, a 17-year-old junior at a suburban St. Louis high school who is earning As and Bs instead of his past Cs, has a girlfriend and a close group of friends.

    "His depression, his anxiety had pretty much dissipated because he was receiving the gender-affirming care," Thurow said. "He's doing the best he's ever done at school. His teachers were blown away at how quickly his grades shot up."

    For its part, the centre said in a statement that it was "disheartened" to have to stop the care. Its decision followed a similar one from University of Missouri Health Care, where the treatment for minors stopped Aug. 28, the same day the law took effect.

    Both blamed a section of the law that increased the liability for providers. Under it, patients can sue for injury from the treatment until they turn 36, or even longer if the harm continues past then. The law gives the health care provider the burden of proving that the harm was not the result of hormones or puberty-blocking drugs. And the minimum damages awarded in such cases would be US$500,000.

    Neither state Sen. Mike Moon, the Republican who was the prime sponsor of the Missouri ban, state Sen. Justin Brown nor state Rep. Dale Wright, whose committees advanced the measure, responded immediately to questions left Thursday by voicemail, email or phone message about the law's intent.

    In North Dakota, the law allows treatment to continue for minors who were receiving care before the law took effect in April. But it does not allow a doctor to switch the patient to a different gender dysphoria-related medication. And it allows patients to sue over injuries from treatment until they turn 48.

    Providers there have simply stopped gender-affirming care, said Brittany Stewart, a lawyer at Gender Justice, which is suing over the ban in the state. "To protect themselves from criminal liability, they've just decided to not even risk it because that vague law doesn't give them enough detail to understand exactly what they can and cannot do," Stewart said.

    Jasmine Beach-Ferrara, the executive director of the Campaign for Southern Equality, said it's not just liability clauses that have caused providers to stop treatment.

    Across the South, where most states have adopted bans on gender-affirming care for minors, she said she's heard of psychologists who wrongly believe the ban applies to them and pharmacists who stop filling orders for hormones for minors, even in places where the laws are on hold because of court orders.

    "It's hard to overstate the level of kind of chaos and stress and confusion it's causing on the ground," she said, "particularly ... for people who live in more rural communities or places where even before a law went into effect, it still took quite a bit of effort to get this care."

    Her organization is providing grants and navigation services to help children get treatment in states where it's legal and available. That system is similar to networks that are helping women in states where abortion is not banned get care.

    But there's one key difference: gender-affirming care is ongoing.

    For 12-year-old Tate Dolney in Fargo, North Dakota, continuing care means travelling to neighbouring Minnesota for medical appointments. "It's not right and it's not fair," his mother, Devon Dolney, said at a news conference this month, "that our own state government is making us feel like we have to choose between the health and well-being of our child and our home."

    Hormuth's son is on the waiting list for a clinic in Chicago, at least a five-hour drive away, but is looking at other options, too. Hormuth, a teacher, has asked also her principal to write a recommendation in case the family decides to move to another state.

    "Should we have to leave?" she asked. "No one should have to have a plan to move out of state just because their kid needs to get the health care they need."

    In the meantime, the family did what many have: saving leftover testosterone from vials. They have enough doses stockpiled to last a year.

    ------

    Mulvihill reported from Cherry Hill, New Jersey. Associated Press writer Jack Dura contributed from Bismarck, North Dakota.

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