There were 25 bills introduced in a single year to restrict access to gender-affirming care for trans children. Trans is an umbrella term for people whose gender identity does not match the gender assigned to them at birth, and GA care includes medical, surgical, mental health, and non-medical care intended to affirm trans people. The Alabama law would make it a felony to prescribe gender-affirming puberty blockers and hormones to people under the age of 19 if the bill were to become law. Depending on how many become law, over 58,000 trans youth could lose access to GA care.

There is a claim that GA care is experimental. The main justification for outlawing such care is this false claim. The Save Adolescents from Experimentation (SAFE) Act is the same name as Arkansas, Louisiana, and Ohio bills that make false scientific claims about biology, sex, and reproductive health. These bills are reminiscent of the strategy that antivaxxers have used to demonize COVID-19 vaccines in which they portray them as "experimental" and therefore dangerous, even to the point of making false claims that these vaccines violate the Nuremberg Code.

There are bills in Ohio, Arkansas, and Louisiana that are basically copy-and-pasted from each other, and all of them state that the use of GA hormones in "biological females" is incorrect. There isn't much evidence for these claims. People who are on gender-affirming testosterone have been found to have a lower risk of breast cancer and endometrial cancer than people who are not on testosterone. The science used in these bills to justify outlawing GA care is bad.

The bills mention it.

The risks of gender transition procedures far outweigh any benefit at this stage of clinical study on these procedures.

The assertion is not true. There are 52 studies that show improvement in the well-being of trans people following GA medical and/or surgical interventions, four studies that show mixed or null findings, and zero studies that show harm from GA interventions. Studies show that gender-affirming care can benefit candidates.

The demonization of surgical procedures used for gender reassignment is one of the main themes in these bills. The Kansas bill would outlaw gender reassignment surgeries for trans people under the age of 18 and the Idaho bill would exempt those with differences in sex development or who are intersex from the ban. Making genitals look normal is important to Kansas legislators. Intersex surgeries are not necessary while gender-affirming surgeries are. GA bottom surgery is rare before patients are of legal age to give informed consent.

Alabama's Senate Bill184 and House Bill266 ignore these facts.

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.

GA medical and surgical care is vastly different from gender affirming. The latter description implies that doctors bully children into transitioning and push their parents to allow GA care. It's time to criminalize health care for those who are already marginalized. Intersex patients who are under the age of 18 are not usually carried out on for genital surgery for gender reassigning.

Alabama's bill also claims.

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.

Their parents don't know what's going on? Everyone should be banned from using GnRH agonists, hormone therapy, and surgical procedures. The quality of the arguments being made in support of the bills is amazing.

Experimental medicine

The argument that GA care is experimental is still being used to argue against giving care to minor. The LGBTQ program director for Media Matters for America noted.

The new right wing angle of attack is that NO trans people should have access to hormone replacement therapy because it’s “experimental.” Trans people have literally taken cross-sex hormones since at least 1918. Governor DeSantis’ move is illegal, dangerous and based on lies.

What distinguishes a medical or surgical intervention from a standard of care? An experimental treatment is an intervention or regimen that has shown some promise as a cure or ameliorative for a disease but is still being evaluated for efficacy, safety, and acceptability. Experimental medical care and surgical procedures are not considered an acceptable standard of care for the treatment of the condition for which they are being evaluated and are still undergoing clinical trials to assess them for efficacy and safety. Some will be found in the trials to be safe and effective, while most won't and won't be abandoned.

I will argue that gender-affirming medicine is not experimental, no matter how often it is described as such in the bills introduced in Alabama, Arizona, Kansas, Louisiana, Missouri, Oklahoma, and Ohio. There are examples of medicine that are still considered experimental. I will break down the tenants of safety and acceptability after that.

There are a lot of areas that use experimental medicine. Gene therapy trials can be used to treat cancer. Medicine experiments are needed to advance the study of treatments. The term "experimental" seems to be used to dismiss GA care in contrast to the term "experimental". The use is meant to promote the view that the safety and efficacy of GA care is so much in doubt that it can't be used and requires more clinical trials to evaluate its efficacy and safety before it can be recommended. GA care is labeled "experimental" because it is also dangerous, which leads to more claims that clinical trials of GA care are unethical. The bills seem to be conflating experimental medicine with discredited treatments in a way that most people outside of medicine will not know the difference.

The efficacy and safety of GA care need to be considered.

Efficacy of gender-affirming medicine

GA surgery and medical therapy have been endorsed by the World Professional Association for Trans Health, which is considered to be the leader in promoting evidence based trans health care. Since the 1990s, scientific studies and publications have documented the effectiveness of GnRHa in delaying puberty. Studies show that trans children who are supported in their gender identity by their families have lower rates of depression than cis children. According to studies, access to gender-affirming care has improved body satisfaction and self-esteem, which is protective against poorer mental health and supports healthy relationships with parents and peers. Trans youth who are affirmed in their gender identity by their family have better health outcomes. Social and medical gender affirming is related to mental health problems.

Safety of gender-affirming medicine

When puberty blockers are used as part of GA treatment for pubescent trans youth, they seem to be considered "experimental" and "dangerous". The use of off-label drugs is compared to the use of experimental drugs. The FDA does not approve off-label drug use for certain indications. The FDA doesn't have the power to limit how health care providers prescribe drugs once they're on the market.

The off-label use of puberty blockers in youth is not a treatment. Since the 1960s, GnRH analogs have been the gold standard treatment for children with central precocious puberty. puberty blockers have an excellent track record when used incis children. Once puberty hits, puberty blockers are used to stop permanent changes. The effects of blockers are not permanent.

Standard of care and gender-affirming medicine

One thing that almost all standard of care treatments have in common is that they are recommended and endorsed by major professional societies after evaluation of existing evidence in the peer-reviewed medical literature. An appeal to authority is not a logical fallacy if the authority is legitimate. I like to think of an appeal to expert consensus as a shorthand for referring to the evidence base. General expert consensus statements from such medical societies always include lengthy discussions of the evidence, including strengths and weaknesses, upon which consensus recommendations are based.

WPATH has published standards of care for trans health care since 1979 and GA care is endorsed by every major medical association. The standard of care for trans patients is currently the standard of care for adults. Better quality research has consistently concluded that access to GA care can be life-saving and improves mental health outcomes. Trans youths thrive in supportive environments. An affirmative approach is supported by the research base.

The American Medical Association passed a resolution in 2008 in support of health insurance coverage for gender dysphoria.

Health experts in GID, including WPATH, have rejected the myth that such treatments are “cosmetic” or “experimental” and have recognized that these treatments can provide safe and effective treatment for a serious health condition.

The Department of Health and Human Services has issued new guidance to clarify the topic of non-discrimination related to gender identity, as states.

Specifically, the guidance states that categorically refusing treatment based on gender identity is prohibited discrimination under Section 1557. The guidance also states that Section 1557’s prohibition against sex-based discrimination is likely violated if a provider reports parents seeking medically necessary gender affirming care for their child to state authorities, if the provider or facility is receiving federal funding. The guidance further states that restricting a provider from providing gender affirming care may violate Section 1557.

It is a misrepresentation of what a standard of care is in medicine and of what constitutes "experimental" medical interventions to argue that GA care is "experimental" That is not the case. The standard of care is called GA care. To cite examples, the evidence base supporting the current standards of care for various cancers, diabetes, hypertension, and the like is not as certain or settled as it is for. GA care is not experimental because the standard of care will likely change in the future as new evidence accumulates.

It's important for physicians to stay on top of the latest information because standards of care and clinical guidelines change frequently. New standards of care replace older ones as new evidence is accumulated. If new standards of care were not based on evidence, doctors would still be using bloodletting for almost everything and patients with toxic heavy metals would be treated with concoctions.

Uncertainty in medicine

Medicine is described as a science of uncertainty and an art of probability.

Opponents of trans care often point to the lack of randomized control trials of gender affirmation, ignoring that such trials would be unethical and near impossible. It is possible to show whether a treatment is better than a placebo. It's unethical to carry out an RCT in which one group of trans youth is randomized to GA treatment and the other to placebo because there would not be clinical equipoise between the groups. An example can be given. If puberty blockers can stop distressing characteristics of an unwanted puberty from developing, withholding them from a control group would likely intensify distress. Randomizing and double-blinding an RCT in which the group receiving GA interventions will always feel the effects of treatment is a question. The placebo group will not show the changes that are caused by gender-affirming hormones. There is no need for an RCT to show the efficacy of gender affirming therapy.

RCTs are difficult to carry out in small populations. The Symposium on Evidence Based Medicine was published.

Small trials are methodologically challenging: the smaller a trial, the larger the treatment effect necessary for the results to be significant, so that it is easy to miss small effects that may be clinically, but not statistically, significant. Trials that show no statistically significant benefit are less likely to be published, and so less likely to make their way into systematic reviews and thus into the accepted evidence base. Other reasons why small studies that target disadvantaged populations are unlikely to be performed concern the funding of research and the comparative nature of many studies.

Although RCTs are considered the gold standard of medical evidence, they are not always right.

To work with instead of on trans people is one of the changes upcoming research is evolving to make. There is a need for larger-scale studies that have questions about gender identity, recruitment in rural areas as well as metropolitan, the inclusion of intersectional minorities, and analysis of the specific factors that predict rejecting family behaviors. The gaps in our knowledge about who benefits most from GA care does not make GA care "experimental", even if we do not know which groups benefit most from different approaches. Due to issues such as systemic racism, people who are historically minoritized have been excluded or underrepresented in studies on hypertension, aspirin use, diabetes, and cancer screening. Current hypertension guidelines, heart disease treatment and diabetes treatment are notexperimental.

A closer look at some of the bills outlawing GA care

Trans Formations provides actionable information on harmful anti-trans legislation. Some examples are provided.

The provision of gender-affirming care to children under the age of 18 is a Class C felony in Alabama and can lead to up to 10 years in prison. A federal judge has stopped Alabama from implementing the legislation. The law requires schools to tell parents if their child reveals to a school official that they might be trans, but this provision is blocked by the courts.

Texas Gov. Abbott and Attorney General Paxton want to criminalize families who help their trans children receive age-appropriate gender-affirming care. The investigations have been halted. The claims underlying the reasoning of the Texas bill were examined by the Yale Law School and the Yale School of Medicine and found to be flawed.

The Florida Board of Medicine is being recommended by the governor to ban gender-affirming care for children and all Medicaid recipients. The two-pronged tactic ensures quick action. A law was signed last year prohibiting trans girls from playing on college sports teams. He declared a cis gender woman the "rightful winner" in the NCAA's first division swimming championship won by Lia Thomas, and in March he signed the "Don't Say Gay" bill, which protects the rights of parents.

On June 2, Florida State surgeon general and secretary of the Florida Dept of Health Joseph Ladapo sent a letter to the Florida Board of Medicine suggesting against surgical and pharmaceutical interventions for trans adolescents. Ladapo has created controversy with his anti-mask stance, opposition to vaccine mandates, promotion of quack COVID treatments, and an emergency rule that discriminates against black farmers applying for medical marijuana licensure. Florida is the first state to recommend against the COVID vaccine for healthy children. Three studies concluded that vaccines are safe.

Ladapo wrote to the medical board recently.

As State Surgeon General, I recommended against certain pharmaceutical, non-pharmaceutical, and surgical treatments for gender dysphoria. The recommendations are based on a lack of conclusive evidence and the high risk for long-term, irreversible harms from these treatments…The current standards set by numerous professional organizations appear to follow a preferred political ideology instead of the highest level of generally accepted medical science. Florida must do more to protect children from politics-based medicine. Otherwise, children and adolescents in our state will continue to face a substantial risk of long-term harm.

Ladapo sources guidance released on April 20 by the Florida Dept of Health, which directly contradict federal guidance by the HHS and has already been refuted by more than 300 Florida health care professionals, as well as the report of an investigation conducted by the Agency for Health Care Administration, which was released on

The report summary, titled "Let Kids Be Kids*", has been condemned by WPATH and USPATH, which had previously discredited research cited in the April 20th guidance.

*writer’s note: unless they’re trans.