A trial to determine the constitutionality of the nation’s first ban on gender-affirming care for transgender youth began Monday with two expert witnesses and two nasty surprises.
A fire alarm went off at the Little Rock Federal Courthouse around 10:20 a.m., sending the entire courtroom full of lawyers, security guards, reporters, trans youth, their families and friends. supporters in three floors and outside to wait for the fire trucks. The green light came quickly.
The biggest disruption had come a little earlier when U.S. District Judge James Moody kicked things off by announcing that everyone, supposed to last two weeks, should be crammed into one. Moody’s schedule is packed, he said, so if the trial isn’t finished by Friday, he’ll have to drop it until December.
Arkansas state attorneys are planning to fly in their witnesses next week and will have to find another option; Plaintiffs’ attorneys, many of whom are from out of town, have set a punitive hearing schedule from 8 a.m. to 8 p.m. through the weekend if necessary to get it all done in one piece.
Despite the bewildered start, the lawyers for the four transgender youths, their families and the two doctors who constitute the plaintiffs in Brandt et al versus Rutledge et al presented two of their expert witnesses on Monday: a Californian psychiatrist with 30 years of experience studying and treating people with gender dysphoria and a pediatric endocrinologist from Duke Child and Adolescent Gender Care Clinic which uses puberty blockers and hormones to treat young people in hopes of better aligning their bodies with their gender identity.
The airy courtroom with its vaulted white ceiling and creaking wooden benches was nearly full on Monday. Plaintiffs Amanda Dennis; Sabrina, Lacey and Aaron Jennen; and Dylan and Joanna Brandt lined the benches behind attorneys for an ACLU football team. The defense team bench was thinner, with four attorneys from Rutledge’s office.
Dr. Dan KarasicTestimony for the plaintiffs lasted most of the day. He explained some of the basics, defining gender dysphoria as “distress related to the incongruity between gender identity and sex assignment at birth”, and explaining the stages that children, adolescents and their families must follow up before young people with gender dysphoria can start puberty blockers and/or hormones commonly used to treat them.
Leslie Cooper, one of the American Civil Liberties Union attorneys representing plaintiffs in the case, enlisted Karasic in efforts to preemptively debunk some of the arguments she expected from state attorneys working to enforce the law. prohibition of gender-affirming medical treatment for trans youth. Bill 626 of 2021 would not only close the Arkansas Children’s Hospital Gender Spectrum Clinic and prevent Arkansas doctors from prescribing hormones and puberty blockers to transgender youth, but would also make it a crime for doctors in Arkansas to even refer their young patients to other caregivers for these treatments.
The state will argue that gender dysphoria is a self-diagnosed condition because it’s based on what patients report, Cooper said, and asked Karasic if that was indeed the case. All psychiatric diagnoses derive at least in part from patients’ own reports, and gender dysphoria is no different, he said. But other symptoms evident to their family and social circle may include withdrawal from school and social life, high levels of depression and anxiety, and suicidal thoughts.
Cooper also asked Karasic to explain the rise in the number of patients treated with gender-affirming care in recent years. He attributes the larger numbers not to social contagion or social media influence, but to the willingness of insurance companies to cover the costs of these treatments and to the increased number of trained clinicians available to patients. administer.
Karasic testified that gender identity is not something one can voluntarily change. Documenting efforts to treat gender dysphoria by trying to align patients’ gender identity with the sex they were assigned at birth has shown no success, Karasic said. But these efforts have provided evidence of harm to patients, including increased feelings of shame, lowered self-esteem, increased risk of suicide, and feelings of failure when tricked into believing someone ‘Impossible change is possible,’ said Karasic.
Working with the World Professional Association for Transgender Health (WPATH) over the years, Karasic has helped set standards of care for transgender youth. He spoke of the evolving knowledge and experience in this rapidly changing field. Karasic explained that no medical intervention is recommended for children with gender dysphoria until puberty. WPATH supports puberty blockers and gender-affirming hormone therapies like testosterone and estrogen for transgender teens, and sometimes supports breast tissue removal in emotionally mature teens. Other surgeries such as vaginoplasty and phalloplasty to surgically create a vagina or penis are not part of the accepted treatment regimen for adolescents, he said.
Under questioning by Cooper, Karasic said doctors who follow accepted standards for treating young people with gender dysphoria work methodically and diligently, using an informed consent process to ensure patients and parents understand not only the effects of treatments, but also the limits of knowledge in the field. field.
While ethical concerns limit the clinical studies that can be performed on young transgender people, Karasic said that over her 30-year career, “most patients see improvement with gender-affirming care.” He said he had worked with thousands of transgender patients and none of his patients who opted for surgical transitions had ever reverted to their sex assigned at birth.
“I was impressed with the extent of improvement people can achieve with gender-affirming care,” he said.
Michael Cantrell, Arkansas’ deputy solicitor general and state attorney who questioned Karasic, struggled to convince Judge Moody to accept studies he hoped to admit into evidence, including association reports in Finland and Sweden and a 102-page section of the DSM. -V. Were they even admissible? A long volley of legalese between the judge and lawyers on both sides suggested not. “We’re wasting a lot of time going around in circles,” Moody told Cantrell before guiding him to his next points. But Cantrell successfully noted that medical groups in Sweden and Finland seem to place more emphasis on psychotherapy than their peers in the United States. And Cantrell argued that Scandinavians seem more cautious about providing gender-affirming medical care to young people.
Cantrell also pointed to older studies that found children with gender dysphoria were likely to be cured of the disease by the onset of puberty. These studies focused primarily on effeminate boys whose families sought treatment out of fear that their sons were gay, Karasic said. Although the boys’ behavior did not fit traditional gender roles, they did not necessarily suffer from gender dysphoria, he said.
In the afternoon, the ACLU lawyer ChaseStrangio interrogates Dr. Deanna Adkins, Duke’s pediatric endocrinologist who has shared his experience and expertise treating hundreds of children and adolescents. The goal of endocrine treatments is to eliminate dysphoria by aligning bodies to gender identity, and they are not started until she and her team assess the mental health of families and children, took medical histories and performed physical exams, she said.
Adkins said she does not rush patients or refer them to a certain treatment, and not all patients receive the same treatments.
Adkins said she uses a “relearning technique,” asking patients and their families to explain their understanding of treatments and risks to her, to make sure they fully understand.
Adkins explained the role of puberty blockers as placeholders for teens who experience anxiety about the onset of puberty changing their bodies in unwanted ways, but said she also uses the same treatment for children. with precocious puberty that begins much too early, sometimes as young as age 2 or 3. Once hormone blockers are stopped, these patients’ bodies return to puberty without a hitch, she said.
Adkins also talked about using hormones for conditions other than gender dysphoria. She prescribes testosterone or estrogen to children with delayed puberty or impaired development caused by childhood cancer treatments, she said. She acknowledged that a combination of puberty blockers and cross-sex hormones can affect fertility. She noted that weight gain is a side effect of some hormone treatments and that estrogen can cause a decrease in libido, while testosterone can have the opposite effect. The risks of side effects from hormone treatments are the same for all patients who take them, whether they’re prescribed for gender dysphoria or another condition, she noted.
Timing is an important part of these treatments, with results depending on which treatments are started and when. But Adkins said the most important benefit of one of the treatments she uses is suicide prevention. The doctor said she lost a patient to suicide before the patient started hormone therapy. She rejected the idea that teenagers with gender dysphoria should forgo medical intervention until they turn 18. It’s too late, she said. “The risks are real.
Arkansas State Deputy Solicitor General Dylan Jacobs asked Adkins about patients who started puberty blockers and/or hormones but dropped out of treatments.
(Note: Jacobs’ questioning continued, but I snuck out at this point. It was 6:45 p.m.! Reporters from the Arkansas Advocate and Arkansas Democrat-Gazette were still there and working hard, so check their stories to fill in any missing pieces.)
The trial was scheduled to continue Tuesday at the Little Rock federal courthouse at 9 a.m.