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By Rose Hoban
Deanna Adkins remembers one of her former patients, a 17-year-old who was struggling to come out to their parents as transgender.
“The parents were struggling with understanding what was going on, and the child did come out to them themselves, of their own accord,” she recalled in a recent interview. “And then the parents were very upset and very verbally abusive, and the patient became very distraught and self harmed in a very extensive manner.”
The teenager didn’t feel safe at home and decided to leave. They ended up living on the streets, Adkins said.
The parents reached out to Adkins, who leads the Child and Adolescent Gender Care Clinic at Duke Health where the child was being treated. They were desperate to find their child, but even working together, they were unable to reach them.
That was three years ago.
“The child never returned home, and we don’t know what happened to them. They’re still missing,” she recalled.
These are the kinds of stories that come to mind when Adkins thinks about a bill that’s been moving quickly through the North Carolina senate this past week. The proposed legislation would limit how schools could respond to students seeking advice and counseling around their gender identity and would require schools to tell parents if their child asks to use a different name or pronouns at school.
The bill, called a Parents’ Bill of Rights, revives a bill from the previous legislative session that would restrict instruction and discussion about gender identity, sexual activity or sexuality in kindergarten through fourth grade classrooms unless a child asks a question about it in the context of classroom activity.
Advocates such as Adkins say that these types of laws hurt LGBTQ students by forcibly outing them to their families, even if those families are not accepting of their identities. Those same advocates are organizing opposition to another proposed bill filed last week in the House of Representatives that would forbid gender-affirming treatment in anyone younger than 18.
Nathan Copeland, a Duke child and adolescent psychologist, said providers had been bracing for such bills.
“I’m shocked this came so early in the legislative year, that this was the first priority,” he said.
School is a safe place
A lot of kids questioning their gender identity begin talking about it with their friends at school or a trusted adult before they talk to their parents, explained Mary Evers, a clinical psychologist who has worked with adolescents who are exploring their sexuality and gender identity. Many times that trusted adult is a school counselor or teacher, she said.
Evers and other providers who work with teens say that kids often need some space away from their parents to experiment and work things out before they approach even supportive parents. Having a law that would require notification of parents before the young person is ready would, “disrupt their process,” she said.
“Talking to their parents is much more anxiety-provoking, even for the kids who know their parents will be supportive,” Evers said.
She explained that relying more on peers and people outside the family is part of adolescent development, where kids are becoming more independent of parents. She said it’s also because these young people want to be more sure of themselves and have a better handle on their desires before talking to parents.
“They don’t really want to do the exploring with their parents,” she said. “They want to be able to tell their parents.”
Evers, Adkins and others also worry about families that might not be supportive of kids who are grappling with these issues for themselves.
“There can be physical abuse, where parents become physically violent toward their kids who’ve come out as transgender,” or they can be emotionally abusive, verbally abusive, said Will Hall, an assistant professor at the UNC Chapel Hill School of Social Work. Hall researches mental health issues among LGBTQ kids.
“There’s mental health consequences there in terms of depression, anxiety, suicidality — and then a lot of kids will run away from home,” she said. And the research supports this.
“Three quarters of trans and nonbinary youth report generalized anxiety disorder symptoms in the past few weeks,” Adkins said, quoting statistics from a survey done in 2020. “Sixty percent of transgender and nonbinary youth engaged in self harm in the past 12 months. One in five trans and nonbinary youth have attempted suicide in the past 12 months. And they are two and a half to four times higher risk for substance use disorder.”
She also noted that transgender and nonbinary youth are at higher risk for eating disorders.
Adkins said these statistics are not a function of the kids being mentally ill so much as they reflect kids’ reaction to the stigma and shame. They struggle with anxiety and their feelings about how they’ll be accepted, and they worry about what their families will say and do.
About 9 out of ten transgender and nonbinary youth say recent debates around such legislation have negatively impacted their mental health, according to polling done by the national advocacy organization The Trevor Project.
“In particular, policies that require schools to tell a student’s parent or guardian if they request to use a different name or pronoun at school make 67 percent of trans youth feel angry, 54 percent feel stressed, 51 percent feel scared, 46 percent feel nervous and 43 percent feel sad,” Gabby Doyle from The Trevor Project said in a statement.
Meanwhile, Adkins pointed to research showing that transgender people with strong family and community support have about the same suicide risk as non-transgender people.
Generational shifts in acceptance
More people in “Generation Z,” born between 1997 and 2003, identify as LGBTQ than in previous generations. Most of those respondents told a 2022 Gallup poll that they identified as bisexual. A little more than 3 percent of Gen Z respondents told Gallup that they identified as transgender or at some “other” place along the gender continuum.
“These young adults are coming of age, including coming to terms with their sexuality or gender identity, at a time when Americans increasingly accept gays, lesbians and transgender people,” the Gallup poll wrote in summation.
In 2021, Gallup found that about half of young adults say they know someone who is transgender, while only a quarter of people over 50 say they do.
“There’s a lot more acceptance” among younger generations, Evers said. For example, she explained, they have no trouble adjusting if a friend decides to change their pronouns.
“They’re just on it,” she said. “There’s no adjustment.”
Providers say that the number of young people making any transition is relatively small. In eight years at the gender care clinic, Adkins said she’s taken care of about 700 kids from all over the state.
“The vast majority of my patients are 16 and older,” she said. “There are more patients that are coming to me now than before between the ages of 14 and 16, because we have more scientific data.”
The House bill that would forbid any care that would affect an adolescent’s gender presentation before the age of 18 is an overreach, she said, because so few teens actually receive that kind of treatment.
“The number of kids that I have taken care of who are on puberty blockers, truly young kids… I’ve only had 10 to 15 patients,” she said. She said she’s treated even fewer kids younger than 18 with surgery — only about seven or eight.
“These are not like rash decisions that, you know, a child wakes up on Monday and decides they identify as a boy and they start hormones on Wednesday,” said Riley Smith, a family doctor from UNC Health who works with children and adolescents in this population. “That’s just not the reality.”
“What we look for, before we think about any medical interventions or permanent changes, is an identity that has been consistent, persistent and insistent,” for at least six months, he explained.
Providers could face fines, discipline
A bevy of national medical organizations has come out in opposition to bills similar to those introduced in North Carolina last week. In addition to affecting young people, these bills have ramifications for providers, they say.
The Parents’ Bill of Rights bill would fine providers who provide transgender-accommodating health care services to someone under 18 without a parents’ consent to a $5,000 fine and disciplinary action by their licensing board. The treatment ban bill would enact a $1,000 fine for providers who give care, even with parental consent, and disciplinary action from a licensing board.
The Parents’ Bill of Rights bill mentions, but leaves untouched, current provisions in North Carolina law that guarantee privacy rights and allow for kids under the age of 18 the right to consent to contraceptive services. Teens under 18 also currently have the right to consent to treatment for sexually transmitted infections and prenatal care without explicit parental consent. The state statute that gives young people those rights also gives young people the ability to seek out care for substance or alcohol abuse or for “emotional disturbance.”
But people younger than 18 already need a parent’s consent for accessing abortion services, as well as most other medical procedures
Neither bill would change any of these rights for teens.
Practitioners say they’re frustrated by these proposals because they can do an end-run around their work with kids to help them have more open and productive conversations with their parents and family.
In response, health providers are urgently organizing their opposition to the proposed legislation. Adkins said that she’s seeing more emails and having more conversations with providers about crafting formal statements and appearing in person at the legislature in the coming weeks.
Correction: This article initially stated that Riley Smith is a psychiatrist. He is a family medicine physician.