Bioethics Forum Essay

Child Abuse in Texas

Medical care that is widely considered beneficial for transgender teenagers has been identified as  child abuse in Texas. The state attorney general issued a decision that gender-affirming medical treatments such as puberty-suppressing hormones fall under the definition of child abuse in Texas state law. A directive by the Texas governor, temporarily blocked last week, would require doctors, nurses, teachers, and other “licensed professionals who have direct contact with children” to report parents who have sought such treatments for their child and “provides criminal penalties for failure to report such child abuse.”

Texas isn’t alone.  Last year, 34 states introduced 147 anti-transgender bills. A bill in Idaho would make providing   gender-affirming care a felony punishable by life in prison. Alabama is advancing legislation that would make it a crime for clinicians to prescribe puberty blockers, hormones, or recommend surgery for gender affirmation. Arkansas passed a ban on gender-confirming treatment that is now temporarily blocked by a judge. This trend should be on the radar for bioethicists. It is harmful for children and families, poses ethical conflict for clinicians, and is a potential human rights violation.

The benefits of gender-affirming care are well-supported by research. Transgender youth experience significantly higher rates of depression, anxiety, and suicidal ideation and attempts when they do not receive it. Marginalization and discrimination  worsen mental health outcomes for this population. Gender-affirming care, and even the simple act of using preferred names and pronouns, can significantly improve mental health outcomes for transgender youth. The benefits of gender-affirming care are life-saving, particularly when done in specialized gender health clinics.

These clinics help children and families navigate questions about the persistence of gender identity, appropriate types of support, and the process of social affirmation. Some children may benefit from medications that temporarily block puberty. Gender-affirming care can help reduce the negative consequences of gender dysphoria, like self-harm and suicide, and assist in ensuring confidence in their identity.

Leading medical, mental health, and public health organizations support understanding gender-diverse youth and providing gender-affirming medical and other care as the standard of care, including the American Academy of Pediatrics, American Psychological Association, Centers for Disease Control and Prevention, Society for Adolescent Health and Medicine, and the American  Medical Association. Major nursing organizations—the American Nurses Association and the American Academy of Nursing— have made statements that young people’s access to inclusive, safe, and competent health care is a human rights issue.

Despite the overwhelming evidence of the benefits of gender-affirming care, politicians use it as a lightning rod to spread misinformation and fear. Misinformation and fear should not shape policy, especially when  policy comes with harm and ethical violations. The Texas directive is not about protecting children. It lacks  grounding in medical or behavioral health research. It is not ethically defensible. There is no professional analysis that concludes that appropriate gender-affirming care is child abuse. In fact, quite the opposite. There is a strong argument that refusing to use affirming language and denying access to beneficial health care cause harm and could be classified as abusive.

Physicians, nurses, and other clinicians have an obligation to advance health. The Texas directive and similar laws being considered in other states interfere with this obligation by denying people the right to good medical care. Clinicians would be acting unethically by complying with  these laws. They play on the fears of those who don’t understand the condition of transgender youth. And they place clinicians in the tough spot of having to weigh doing the right thing against the risk of losing their license and being charged with a crime. This is, of course, exactly the playbook that fear-mongering authoritarian regimes have long used to get one segment of the population to fear another. They rely on moral silence by making it difficult not to comply. But clinicians and other mandated reporters must not comply. Moral courage is required.

Moral silence in the face of hierarchies of governmental power being wielded negatively against its own citizens is what perpetuates injustice. In order to address the injustice created by directives against gender-affirming care, we offer five areas of guidance:

• Clinicians  should consider themselves in violation of professional ethics if forced to comply with directives defining gender-affirming medical care as child abuse.
• Institutions (hospitals, unions, etc.) and professional organizations should support their members by providing unequivocal guidance on what clinicians ought to do, as well as provide legal support if possible or needed. Clinicians’ moral courage must not be met with institutions’ moral silence.
• Legal scholars should analyze the legality and constitutionality of anti-transgender policies. (The judge who temporarily halted the Texas directive said that it was unconstitutional.)
• Legislators should bring forward bills protecting transgender youth and their access to good and appropriate medical care.
• Bioethicists must analyze the ethicality of anti-transgender policies, and advocate for children, parents, and clinicians. Bioethicists must also affirm that questions around benefit and harm in medical treatment are clinical and ethical issues, and that government should only be involved in assuring a right to access appropriate care.

Ian D. Wolfe, PhD, RN, HEC-C, (@iandwolfe) is the senior clinical ethicist at Children’s Minnesota and a member for the ethics advisory board for the American Nurses Association Center for Ethics and Human Rights. Angela Kade Goepferd, MD, (@DrGoepferd) is the chief education officer, chief of staff, and medical director of gender health at Children’s Minnesota.