On March 16, Ryl drove from their home near Birmingham for a medical appointment in the Atlanta area—about a four-hour round trip. Ryl, who’s 36 and wears a short, wavy brown shag, identifies as gender-fluid and transmasculine. They started taking testosterone last December but were here for their first visit to a clinic in Decatur called QueerMed. At the appointment, they talked about their progress with Luke Scarborough, a family nurse practitioner. The two went over Ryl’s history, and how their voice will change throughout treatment—Ryl is in the choir at their college. Though they’d been on hormones for only a few months, Ryl said they’d begun to notice subtle shifts. “I feel more settled in my skin, almost like there’s an unrest taken away,” they said. “I’m starting to look in the mirror and see me as me.”
QueerMed specializes in care for gender-expansive patients of all ages, including minors—which has put it in a vulnerable position at a time of rising violence against transgender people as well as the nurses and doctors who care for them. In the past year, providers at Boston Children’s Hospital and the Vanderbilt University Medical Center, among others, have faced campaigns of online harassment, including death threats. Scarborough, a trans man, has taken measures to feel safer: Nearly all of QueerMed’s appointments are virtual, but if a prospective patient needs an in-person visit, he screens them more carefully than he used to. He doesn’t stay late at the office anymore.
As Scarborough saw patients that day, the Georgia House of Representatives was taking a step that will make his job even harder: The body advanced Senate Bill 140, which restricts medical treatment for trans and nonbinary kids. All leading medical and mental health organizations in the U.S., including the American Academy of Pediatrics, the American Medical Association, and the American Psychological Association, support age-appropriate gender-affirming healthcare. Still, under SB 140—part of an unprecedented wave of legislation, being pushed by Republican lawmakers across the country, that’s targeting trans people and their healthcare providers—doctors who provide hormone therapy or gender-affirming surgery to people under the age of 18 could be stripped of their licenses and subject to criminal or civil action. The measure was signed into law by Governor Brian Kemp on March 23.
LGBTQ advocates and medical providers worry that such bills are only the beginning—a beachhead in a sustained assault on trans people in the U.S. In Georgia as elsewhere, young people who undertake hormone therapy do so as part of a sustained regimen, in consultation with a doctor; it typically begins with puberty blockers, a safe and temporary treatment that delays the onset of puberty symptoms, buying adolescents a few years to explore who they are. The Georgia bill carves out exceptions for puberty blockers—but proponents of bills like SB 140 have gestured at further restrictions in the future. In April, Missouri’s Republican state attorney general invoked harms to children while putting into place severe restrictions on care for trans people of all ages—regulations so onerous that Vice said gender-affirming care had been “basically banned” in Missouri.
Medical experts and members of the LGBTQ community worry about what this future could mean for young people especially. According to the Trevor Project—a nonprofit focused on suicide prevention efforts among LGBTQ youth, founded in 1998—more than half of trans and nonbinary kids considered suicide in the past year, and nearly one in five attempted it. Acceptance and gender-affirming care can help reduce the risk of suicide; so can medical attention, with one study showing that teens with access to puberty blockers or gender-affirming hormones were 60 percent less likely to experience moderate to severe depression. The Trevor Project found that receiving hormone therapy was associated with nearly 40 percent lower odds of recent depression and of a past-year suicide attempt in young people.
“Friends have said that, until they started transitioning, they couldn’t even picture getting old,” Ryl said during their visit to the clinic. “Who wants a kid to go through that?”
• • •
Nine-year-old J and his twin brother, M, couldn’t be more different. J is reserved; M is “the mayor of every room he walks into,” said the twins’ father, Peter Isbister. (We’re using first names or pseudonyms for several people in this story, over concerns for safety or privacy.) J is a dancer and plays the double bass and has a dry sense of humor; M is the athlete who wanted to wear his Steph Curry jersey every day to preschool. Guessing at their future careers, Isbister jokes that, if J is a mechanical engineer, M is a life coach.
Another way that M is different: “His government has attacked him,” Isbister says. “That will never not be true now.” M came out to his parents as trans just after his fifth birthday. “He told us he felt like a boy in his heart,” said Robyn, M’s mother. “I had a conversation with him about how women can be strong, women can play sports, women can wear basketball clothes—you can be any kind of girl you want. He’s like, I know. But I’m a boy.”
By the time all states had adjourned their legislative sessions in 2022, 17 bills aimed at transgender and nonbinary children had been passed into law—a record. Since January of this year, the U.S. has seen more than 100 bills being introduced that would prevent trans youth from being able to access healthcare—another record. According to the Trans Legislation Tracker, 2023 is the fourth consecutive record-breaking year for anti-trans legislation, with some bills aiming to restrict healthcare up to age 26.
Such legislation is going beyond healthcare for trans people, who make up about one-half of 1 percent of the U.S. population, into trans and LGBTQ visibility and access to public life more generally: The Human Rights Campaign also reported a record number of bills nationwide restricting access to public bathrooms for trans people; more than 80 bills censoring school curriculum related to LGBTQ people; and 35 bills targeting drag performance specifically. The new restrictions in Georgia come a year after the governor signed a law that allowed a statewide athletic governing body to ban trans high school athletes from playing on teams that reflect their gender identity. (Kansas Republicans recently passed a bill that, critics worry, would allow for the genital inspection of trans teen athletes; a similar measure was also proposed last year in Ohio.)
For trans and gender-nonconforming people, in the South especially, access to healthcare is already limited and labyrinthine. Most providers require a letter from a therapist—sometimes more than one—to verify that a patient has gender dysphoria, and some require up to 12 months of mental health treatment prior to hormone therapy, even for adults. “There are so many barriers to healthcare,” Scarborough said during Ryl’s visit. Ryl chose QueerMed because it operates on an informed-consent model—meaning clinicians equip patients with the information they need and trust them to make their own decisions, without a therapist’s sign-off. (“Informed consent” is the standard for medical care, generally, so in a sense trans care is just catching up; whether to operate on such a model is left to individual clinics.) Still, in order to be prescribed testosterone, a schedule III drug, Ryl had to be seen in person. The next-closest informed-consent clinic, where they’d received their first prescription for HRT, was in Nashville.
Dr. Izzy Lowell, who grew up in the Northeast, moved to Atlanta in 2013 to work at the Family Medicine Department of Emory University. Seeing the dearth of options for trans people, she founded Emory’s Transgender Clinic in 2015 and, in 2017, left to start QueerMed, the first telemedicine clinic in the country to exclusively serve trans and nonbinary patients. Today, the clinic has seven employees and 3,500 patients, about 600 of them under the age of 18. In several of the states it serves—including Mississippi, Kentucky, and the Carolinas—QueerMed is either the only provider of trans care for minors or one of very few. The majority of young people its practitioners see live in Georgia.
QueerMed’s process for treating minors is controlled, closely monitored, and “heavily considered,” Lowell said: Starting on puberty blockers and advancing to transitioning with hormones takes years. “The big secret is that it’s not complicated. It’s not even that significant in terms of treatments,” she continued. “What it looks like is a regular kid growing up. It’s someone getting to be their regular self. They get to be a kid and then they get to go through puberty like everybody else. It’s just allowing someone to grow up as they are.”
M, Peter and Robyn’s son, is now a patient at QueerMed, and the family, alongside their doctors, will consider puberty blockers or hormones when it’s medically appropriate; otherwise, M is just a typical 9-year-old. Three years ago, Peter Isbister started a local chapter of TransParent, a national nonprofit whose mission is to “empower our children to live authentically.” But right after M came out, his parents told me, they spent several nights crying together. They weren’t mourning the loss of their daughter—they were fearful for their son’s future. “His life is going to be hard. His life may be scary, and his life may be dangerous,” Peter said. “You feel the weight of trying to protect your kid, knowing you now have this even more intense and challenging parental job of protection. But you can’t completely protect your kid: Your kid is going to be a trans grown-up at some point.”
As more and more states in the Southeast have restricted care for kids, treating patients has become more difficult for Lowell and her staff: “The last couple of months, there’s been a shift in how much more under attack trans youth are.” There’s the political climate; there are also the logistics of working across states with increasingly punishing, and constantly changing, legal regimes related to trans care. “My lawyers can’t even tell me exactly what is going on now and will be in the near future in many states in the South that we cover,” Lowell said. But she considers leaving hostile states a form of patient abandonment, violating her ethical obligations.
For now, she’s encouraging those who need care to see a doctor soon. SB 140 won’t go into effect until July 1, and existing patients will be allowed to continue therapy under the new law. “It’s important for people to know that they can still get full access to care,” Lowell said. “We will be seeing patients until midnight on June 30 if we need to.” Young people who want to begin hormone therapy after July 1 will have to drive to a state where it’s legal. That could mean simply having a telemedicine visit with Lowell from, say, a parking lot just over the state line in South Carolina, where she holds a medical license, and where HRT has not been banned—yet.
The ACLU of Georgia is expected to sue the state over the bill. But Isbister has little hope the law will change before his son needs hormones: “I don’t want to tell my kid: ‘You have to go out of state with me because there are people in Georgia who passed a hateful law targeted at you,’ but we’ll do it. But are all the states around us gonna fall?” The law—like abortion restrictions also on the rise around the country—will have disproportionate impacts on lower-income people, who may not have the time or the resources to travel out of state or permanently relocate to receive medically necessary care.
“There are a lot of more complicated grown-up arguments about the impact of the denial of healthcare or the impact on the economy of the state and all that,” Isbister added. “But, as a parent, I just feel like, ‘Why are you being so mean to my kid?’”
Meanwhile, Republicans have questioned whether legislation like SB 140 is severe enough: Before the bill was signed into law, one of its cosponsors wondered whether even 18-year-olds should be allowed access to surgery. Representative Marjorie Taylor Greene, along with far-right groups and advocates for conservative Christian causes, are pushing to eliminate access to puberty blockers and narrow the law’s current exemption for medically necessary surgeries. (I reached out to Carden Summers, the state senator who authored SB 140, to ask if he foresees further legislation along these lines; his office didn’t respond.)
During their appointment at QueerMed, Ryl mentioned meeting a young trans person at a recent rally. With her parents and her pastor keeping an eye on her, the child—maybe 8 years old—was running around, holding a pool noodle to her forehead that had pink and blue streamers attached. “Seeing her surrounded by a supportive family, supportive community, part of me is like, what would it have been like if I had that growing up and had been able to know who I was sooner—instead of figuring it out later, after years of stuff just not being quite right?” Ryl said. They heard someone ask the girl if she was a trans unicorn. No, she replied. I’m a trans narwhal.
This article appears in our June 2023 issue.