Transgender Texans and doctors say Republican lawmakers misconstrue what science says about puberty blockers and hormone therapy

People hold up a transgender flag at an event held by Equality Texas at the Capitol in Austin in 2021. (Sergio Flores For The Texas Tribune, Sergio Flores For The Texas Tribune)

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Several Republican Texas lawmakers are clashing with medical groups over whether puberty blockers and hormone therapies help or hurt transgender kids. Those conflicting positions come as some legislators push bills that would limit — or completely block — queer youth from accessing transition-related treatments that many medical associations support.

Sen. Donna Campbell, R-New Braunfels, is championing a bill that would bar doctors from providing such treatments — but only if they’re used to help a child gender transition. During a debate March 16 on her Senate Bill 14, Campbell and opponents of transition-related care portrayed doctors who provide such care as opportunists capitalizing on a “social contagion” with treatments that lack sufficient scientific data that could determine whether the care is safe and effective.

“I got into the Senate, or government, because I wanted government out of our lives,” Campbell said during the Senate State Affairs Committee hearing. “But if there comes a time when a profession, such as the medical profession, cannot regulate itself to protect patients, protect children, then the government needs to step in.”

Yet medical groups, doctors and transgender Texans say the scores of lawmakers backing such bans are either missing the point of how transition-related health care helps trans people — or are deliberately misconstruing information to target an already marginalized group of people.

[What transition-related health care is available to transgender kids in Texas? Here’s what you should know.]

They say puberty blockers and hormone therapies — transitition-related surgery involving sex organs is almost never performed on children — are aimed at improving the mental health of trans kids, who are far more likely to be depressed and attempt suicide than their cisgender peers. A 2015 report by the National Center for Transgender Equality found 40% of the roughly 27,000 transgender people surveyed had attempted suicide — almost nine times the average rate in the country.

Dr. Jessica Zwiener, an endocrinologist who works with trans youth and adults in Houston, told lawmakers in both her testimonies against SB 14 and the identical House Bill 1686 that her patients’ mental health dramatically improves once they start taking hormones — such as when trans girls take estrogen and trans boys take testosterone.

“They become more outgoing, they take better care of themselves, they try harder in school. They’re just happier; they can see a future,” Zwiener testified on SB 14. “Nobody talks about that.”

In 2021, the Senate passed a bill similar to SB 14, but that measure died in the Texas House. This year, though, a majority of House members have also signed on as authors or co-authors to HB 1686.

Spanning around 11 hours on March 27, the House Public Health Committee’s discussion on HB 1686 touched on similar debates as those of SB 14 regarding the science and research behind transition-related care for trans youth, including puberty blockers and hormone therapies. The committee has also seen more pushback against social transitioning and psychiatric care for trans youth, particularly from Republican State Rep. Tony Tinderholt of Arlington.

“Would you agree with me that trying to psychologically transition these children is harmful to them, along with what the bill already covers?” Tinderholt asked.

State Rep. Tom Oliverson, the Cypress Republican who filed HB 1686, responded that they are “not neutral acts” — but noted that their “effects are a little less well understood than the effects of the medicines.”

Tinderholt also repeatedly asked medical providers to define woman — and whether they would “push” their patients and families to go to another state to access transition-related care, if the legislation passes.

On the other hand, the three openly gay Democrats sitting on the House committee — state Reps. Ann Johnson of Houston, Jolanda Jones of Houston and Venton C. Jones of Dallas — invoked their own personal stories to fight HB 1686.

“You may not remember the moment you found out you were straight. I remember the moment I knew I was gay and it’s because society told me there was something wrong about me,” Johnson said, pushing back against the argument that there’s an overwhelming reliance on youths’ self-perception in providing care. “I hope that this state will find a way to make decisions that [are] compassionate and protecting of all Texas children.”

At the March 27 House committee hearing, fewer than 100 people registered in support of HB 1686, while over 2,800 were against the legislation. Around 470 people signed up to testify — though the committee heard from just several dozen witnesses by the end of the hearing. Rep. Stephanie Klick, a Fort Worth Republican who chairs the committee, said public comments can still be submitted until March 31 — and HB 1686 was left pending in committee.

After the House committee hearing ended, the bill’s opponents chanted “Klick lies, kids die” while lying on the ground inside the Capitol to protest the hearing’s midnight cutoff.

“Protect trans kids,” they later chanted while marching to an outdoor rotunda near the committee hearing room. A few hours earlier, hundreds of LGBTQ Texans and advocacy groups had also filled that outdoor rotunda to rally against the legislation and the numerous other bills that would upend the lives of the community.

Meanwhile, SB 14 has moved quickly this legislative session. Hundreds of people debated the bill for hours on March 16. Senate Affairs Committee members voted 8-3 along party lines March 20 to advance it to the full Senate. Lt. Gov. Dan Patrick made the matter a priority for the Senate this year. The full chamber could vote on SB 14 this week.

The issue is fraught with vehement political division. SB 14 and similar bills are among a bevy of legislation Republican lawmakers are pushing that could upend the lives of LGBTQ Texans. During the March 16 hearing on SB 14, GOP activist Steven Hotze went on an anti-trans tirade, calling doctors who provide this type of health care pedophiles. Sen. José Menéndez, D-San Antonio, asked Hotze not to lob baseless and incendiary attacks. Menéndez said trans people are “living their true selves.”

“That’s bullshit,” Hotze replied before he was kicked out of the hearing.

Care aimed at mental health

Transition-related care works to address mental health issues associated with gender dysphoria — the distress someone experiences when their gender identity doesn’t match the sex assigned at birth. Not all transgender people experience gender dysphoria, though depression and suicidal ideation are often worsened by the discrimination and stigma transgender people face.

Parents are involved in making decisions about the practices and treatments that make the most sense for transgender children. Doctors overwhelmingly follow a care timeline recommended by major medical associations. Many recommend waiting until a trans child can give informed consent, usually around age 16, before beginning hormone therapy. Medical providers are dissuaded from pushing young people to identify as transgender, socially transition or begin medical treatments.

Campbell said transition-related care does not help children overcome depression or anxiety related to gender dysphoria, even though several studies have demonstrated decreases in depression or anxiety symptoms for transgender youth receiving medical care that facilitates transitioning.

A study funded by the National Institute of Health and published in January — which followed over 300 young trans people for two years while they were receiving hormone therapies — found decreased symptoms of depression and anxiety and improvements in life satisfaction. There’s an abundance of research indicating transition-related care improves the mental health and well-being of transgender youth and adults. A recent survey conducted by the Washington Post and the Kaiser Family Foundation found 78% of the transgender respondents said living as the gender with which they identify has made them more satisfied with their lives.

Campbell did not return multiple requests for comment, but her statements in last Thursday’s hearing and her written support of SB 14 contained multiple claims that contrasted with guidance released by major medical associations and peer-reviewed research.

Campbell is a doctor herself. She received a medical degree from Texas Tech University. Campbell completed her residency in ophthalmology, a surgical specialty in eye disorders. She is also a board-certified emergency medicine physician, according to her campaign website.

Critics of puberty blockers and hormone therapies, including Campbell, say there isn’t sufficient data to indicate these treatments address gender dysphoria.

Megan Mooney, a licensed psychologist in Houston who represented the Texas Psychological Association in testifying against SB 14, said the science is clear about the mental health benefits of medical interventions, including puberty blockers and hormone treatments, for transgender youth.

Mooney also said there is data about the potential harms of delaying treatment, which shows that patients who receive transition-related care at later ages are at increased risk of suicidal attempts and self-harm.

“I urge you to consider what science tells us consistently: Gender-affirming medical care is the recommended, evidence-based approach to treat gender dysphoria in youth,” Mooney said in this month’s hearing. “This legislation will harm children as opposed to helping them.”

Zwiener acknowledged there aren’t large-scale studies stretching back decades about the long-term effects of puberty blockers and hormone therapy on transgender youth. She said that’s because, until recently, this care was relatively uncommon. She also said research institutions have not historically been interested in this area of study, given the stigma and lack of funding.

“The solution to ‘lack of data’ is more studies, not banning care — especially when the smaller studies and anecdotal evidence are overwhelmingly positive,” Zwiener said.

“A huge shift”

In this month’s Senate State Affairs Committee hearing, Campbell said puberty blockers, hormone therapy and surgery are permanent treatments. Puberty blockers are reversible after a person stops using them, and hormone therapies are partially reversible, major medical associations say. Minors can sometimes undergo surgeries on their breasts and chests — but only around ages 16 or 17, and only in specific circumstances after doctors weigh a patient’s situation with family support. Kids rarely, if ever, receive what’s called “bottom surgery,” or procedures involving their genitals.

Campbell claimed that most children will grow out of gender dysphoria with appropriate counseling. Opponents of transition-related care in Texas have pointed to studies that claimed roughly 80% of children with gender dysphoria eventually “detransition.” Working groups have found deficiencies in research supporting that statistic, including insufficient study sizes and unreliable sampling techniques.

A recent study published by the American Academy of Pediatrics followed over 300 trans youth over five years after social transitioning and found less than 3% of those children detransitioned.

“A lot of it just kind of comes down to the whole alternative facts thing, like what is true and what is not true,” Zwiener said.

Critics of transition-related care have called transgender identity a “social contagion.” Campbell and others have also suggested the significant increases in the number of children seeking transition-related care should raise suspicions.

“This leaves room to speculate a potential profit motive for those who perform these purely elective and very expensive procedures,” the Senate Research Center’s analysis of Campbell’s bill says.

Doctors who treat transgender patients say the growing visibility and social acceptance of trans people is driving the increasing numbers of youth identifying as transgender.

Zwiener said that adult patients in their 50s and 60s came to her after stumbling across the trans community online and realizing there were others who shared their same sense of identity.

Doctors who spoke with The Texas Tribune said medical providers closely follow guidelines established by the American Academy of Pediatrics, the World Professional Association for Transgender Health and the Endocrine Society when administering transition-related care.

Puberty blockers and hormone therapies, like many medical treatments, can have side effects. That includes bone mineralization and the potential for fertility loss. But doctors say the positive impact of transition-related care on mental health outweighs the risks of those side effects.

The families Zwiener works with are well aware of the side effects, even if the majority don’t have prior experiences with transgender people. But they’re following the medical guidance of professionals and the pleas of their children, Zwiener said, because parents want the best outcome for their kids.

“We’re talking about these [minor bone density issues] … when it’s just such a huge shift in these kids’ lives,” Zwiener said.

Walking a political tightrope

Campbell criticized Texas medical associations for supporting transition-related care, which she alleged harmed children. Those who oppose her SB 14 include the Texas Pediatric Society and the Texas Psychological Association.

The Texas Medical Association, though, has not taken a position. That group previously opposed similar legislation. But Dr. John Carlo, a member of the association’s board of trustees, said the group is remaining neutral in hopes that it can continue discussions with lawmakers and help shape the legislation.

TMA wants to ensure children already receiving transition-related treatments — approved by their medical team — continue receiving that care, Carlo said. This includes allowing any youth, including those from out of state, to continue taking hormone therapy or puberty blockers while hospitalized for an extended time in a Texas hospital, TMA President Gary Floyd said during the Monday hearing for HB 1686. The association also wants to make sure that doctors who provide the care don’t lose their licenses.

Carlo said TMA’s Council on Legislation is weighing each bill individually and making judgements that will best serve patients in Texas.

“We’re not essentially closing the door on any one argument, because I think at this point this is such a highly politicized topic,” Carlo said. “What we’re trying to do is maintain a basis of scientific evidence, look at it from the perspective of how we best take care of patients.”

Andrea Segovia, senior field and policy adviser for the Transgender Education Network of Texas, said people should be able to decide what’s best for their own health care with their doctors. The scope of transition-related care is different for every trans person, Segovia said, and is not a one-size-fits-all approach.

“This blanket approach that we see with this health care [ban], but also in general when talking about trans issues, affects people’s freedoms and liberties in the state of Texas, where we are the state that says freedom and liberty matters the most to us,” Segovia said.

Republican Texas lawmakers and officials — and far-right groups — have politicized several aspects of LGBTQ peoples’ lives in recent years. This legislative session, GOP lawmakers are also trying to severely restrict classroom lessons, school activities and teacher guidance about sexual orientation and gender identity. They are also pushing bills that would limit when kids can see drag shows and restrict the college sports teams that trans student athletes can join.

Earlier this year, the Tribune found that a small but influential cadre of activists and extremist groups have fueled anti-drag panic as they characterize all drag as inherently sexual. Those claims have then been used to justify legislation targeting the LGBTQ community as a whole, often under the guise of protecting kids.

After GOP lawmakers failed to ban puberty blockers and hormone treatments for trans kids in 2021, Republican Attorney General Ken Paxton issued a nonbinding legal opinion that equated transition-related care with child abuse. Gov. Greg Abbott then sent a letter to the Department of Family and Protective Services directing the agency to investigate parents who provided transition-related care to their transgender children. LGBTQ advocacy groups are fighting that directive, which a Travis County judge largely blocked last year. But Paxton earlier this month also asked that the injunction be lifted.

Zwiener said the threat of banning transition-related care has actually made doctors closely adhere to best practices and pay attention to their patients’ progress and outcomes — despite what opponents say about the field of care.

“People who support gender-affirming care are always very worried that it’s going to be taken away, or it’s going to be made illegal, and so people tend to do things very conservatively, very by the book,” she said.

Maia Spoto contributed to this story.

Disclosure: The Texas Medical Association and Texas Tech University have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.

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