What I Saw Providing Gender-Affirming Care to Trans Kids in Tennessee

Conservative lawmakers have introduced hundreds of bills in recent years that target transgender youth’s ability to access medical care and participate in public life. On Wednesday, the Supreme Court will hear oral arguments around one of these legislative attacks: Tennessee’s ban on treatments for transgender minors, including puberty blockers, hormone therapy, and surgery. (Cisgender youth are not prohibited from pursuing the same treatments.) The challenge, which alleges that the ban violates trans youth’s Equal Protection rights under the 14th Amendment, could have implications nationwide.

As of this writing, Tennessee and 25 other states have banned gender-affirming care for minors despite protests from leading medical organizations such as the American Medical Association and the American Psychiatric Association. These laws impact nearly 40 percent of all trans youth in the country, according to the Human Rights Campaign. The plaintiffs in Skrmetti include L.W., a 16-year-old transgender girl; her parents; and two other families. Also suing is Dr. Susan Lacy, a board-certified OB/GYN with three decades of experience who treats trans patients in Memphis. I spoke with Lacy about what it was like to work with trans youthbefore and after Tennessee’s ban andthe biggest misconceptions people have about gender-affirming care.

How and why did you first expand to providing gender-affirming care?After nearly 19 years at a private practice group with general OB-GYN, I left to work at a local nonprofit. One part of their mission was providing transgender care. I’ve always found hormone management very interesting as a gynecologist. With my patients who get masculinizing care, I was very familiar with their hormonal environment from a gynecologic standpoint. And then for feminizing therapy, I was very familiar with the medication and the hormones. It fit well. Once I started providing care, I realized how many people needed it and how limited their options were.

A patient within the last couple months told me, “I feel like I’m a Mac and I was operating with a Windows system. My brain, and the way my brain was operating, didn’t fit who I was.” As a scientist, that was compelling to me. This is a brain chemistry issue. I had a patient some years ago who was probably 20 years old and came from a small town in Alabama to see me. They had been diagnosed with multiple personality disorder by their hometown psychiatrist and had been on multiple high-dose antipsychotic medications. But once they got off those medicines and got on testosterone, that was all they needed. They finally felt like everything was working correctly. This is a concept that we don’t understand as well as we should. There are real issues in the way people process things and the way they function that can change once they’re in the right hormonal environment.

How many minors came to you for care? What share of your practice were those patients?
I don’t have any minors that are getting hormonal management at this point because of the law. It varies, but I have probably between 600 and 700 total trans patients in my practice. At the time that the law was passed, about 25 of them were minors. I never treated pre-pubertal children with puberty blockers, because I do believe that needs input from a pediatric endocrinologist. I know and have a relationship with a great pediatric endocrinologist in Memphis who was providing that care. Sometimes we would work together: She would do the initial treatment when patients were younger, and then as they would get a little bit older and maybe needed contraceptive management, she would refer them to me.

When a minor and their family came to you for care, how did you explain the process and their options to them?
With all of my patients, whether they were minors or not, the first question I always ask is: “Tell me about your journey to this point.” I want to have a good idea of what their expectations are, what they’ve read, what they’ve looked at online, what their worries are. With minors, I always required parental consent and a psychological evaluation, with a letter from a psychologist. Once we have a good starting point, depending on what their goals were, we would talk about doing more masculinizing or feminizing treatment.

A real piece of misinformation is that this is a rapid process. The reality is that it takes a while for individuals to become aware of what gender identity means. Sometimes parents come in and their kids have been expressing this gender identity since they were two, but there’s a wide range. A lot of times they’ll say, “I started feeling this when I was 10, 11, 12.” Then it took them a year or two to tell their parents. It takes the parents time, often months, sometimes years, to say, “Okay, we’re ready to explore this.” By the time they’re sitting in my office, it has been quite a journey.

Two other concerns are that, first, this is permanent, and secondarily that it’s risky. When I sat with parents, they were looking at their child and thinking about the long-term risks and benefits. The first thing that I tried to have a conversation about is that the risks associated with hormonal transition are very low. I’ll use my own family as an analogy. It’s not a perfect example, but I have four children assigned male at birth. One of my children identifies as a trans female. She came out a year after I started providing care, so my decision really had nothing to do with it. She’s a fraternal twin. For this example, let’s say her twin was female, too. I would be trying to approximate the same hormonal environment that their sibling of that gender has. We’re never trying to do dramatic change. We’re just trying to approximate the hormone complement of the gender with which they identify, or if they identify as non-binary, the hormonal complement that will achieve the goals that we want to achieve. We’re not trying to overshoot it. It’s not excessive. If you do it safely and appropriately, you’re giving a hormonal compliment that would approximate someone of that sex and same age. When I put it in those terms, it’s very helpful for parents, particularly when they have multiple kids, like, “Okay, we’re just trying to get this compliment to be similar to their sisters or their brothers.”

In terms of permanency, voice deepening is permanent. Breast growth is not reversible, but that also does not happen overnight. Other changes like facial hair growth would be reversible. In terms of fertility, that’s a little bit of an open question because we don’t have enough data. There are countless people out there who have stopped their therapy to have a pregnancy, or have a pregnancy with a partner years after hormonal transition. But all of the changes are gradual. If someone were to decide after three to six months that they wanted to stop treatment, generally they’re not going to have long-term results. Sometimes that’s frustrating, of course, they want results to happen faster. But it is essentially a second puberty, and that didn’t happen that fast the first time.

Did the minors you treated struggle with this being a gradual process?
They always came in ready to go. They’re essentially pulling their parents in the door. The kids this age have been online, they’ve seen YouTube videos, they’ve seen TikTok videos, they’ve been on Instagram. Some of that is good, some of it is not, but they’re very well-informed and often very savvy. In their minds, they’ve been waiting a long time. So a lot of them have anxiety and stress around this—their biggest concern is, “This is something I feel ready to do and I’m ready to start.”

If you only listened to the right’s rhetoric, you’d think scores of kids are getting surgery to change their sex without their parents knowing. Would it have even been possible for you to provide that care without parental consent?
No. It always had to be done with parental consent. And the other thing is, the Tennessee law actually has specifically excluded surgery, but minors are not having surgery generally. Even those adult patients that do have surgery, it’s always quite gradual. When I see my patients for the first time, I always tell ‘em that you really have to break this down into steps. It’s too much to think about hormone transition and doing labs and then potentially doing surgery. With the rare exception, we don’t even start that conversation until about a year into treatment. Most of the surgeons will hold to that. Certainly for minors, nobody’s getting referred to surgery. But even for people that are older, it’s still a further step in the process.

What happened after Tennessee banned gender-affirming care for minors? How did it impact your patients?
It was extremely devastating in terms of their mental health. So many of these patients would say, “I feel great. My parents are fine with this. We’re all on board. How can they take this away from me?” There’s a bewilderment, because to them, they’re just living their lives. They don’t understand how someone can tell them that they can’t do that. There’s a lot of anger and frustration, course, but we had about a year to plan. My patients were mostly 16 and above—some of them a little bit younger—so we were able to create a plan that would carry them through. We had to help some of them figure out resources and places that they could potentially go to continue care. The closest place is Southern Illinois, I do have patients that have gone there. Some of them chose to stop hormonal care and plan to resume.

I can think of multiple patients who came in with parents who were supportive, but still a little uncomfortable and nervous. They were not certain about what the right treatment strategy was going to be. Once we talked about their options, we ended up in a good place, but those conversations are not happening anymore. So let’s say a child who’s 15 years old and tells their parents that they’re trans, the parents in this state are pretty much now saying, “We can’t do anything about it. You’re just going to have to wait.” It’s creating a support structure for denial. Because this is the official law, parents can say, “We can’t do this, and you probably shouldn’t do this because there’s this law that says you shouldn’t.” It is stifling the conversation and the fact-finding that was happening before. I think it is very dangerous.

A concern in general is that a lot of kids have mental health issues. That’s a very significant issue—when you look at the rates of suicidal thoughts and suicidal attempts among trans kids, it’s just really high. It also is a very significant problem with my younger trans who are not minors. Those who are 18 to 25: They often are still on parental insurance. They may be in college or they may be working or they may be living at home, and they don’t have a lot of support because their parents are not supportive. So while they are at an age where they can seek care, the family is not inclined to support them. So while yes, this law definitely affects the minors most, we’re also seeing a pretty chilling effect in the younger post-adolescent patients.

Why did you decide to join this lawsuit?
First off, I’m an independent practitioner. I also have a trans child. My child is no longer a minor, but I think that we need to be addressing these issues and bringing them to the forefront. And I have a lot of experience—I also do a lot of hormone management with menopausal patients. These things inform one another; I’ve learned a lot about hormones from trans care and my menopause management.

I also felt like somebody had to speak up for this. The minors have their perspective, which is extremely compelling and they are voices that need to be heard. But I’ve seen hundreds of people now, thousands and thousands if you add up the number of visits. It gives me an opinion and an experience that is unique in terms of having seen so many different patients in so many different scenarios.

Many families with trans children are concerned about retaliation because of how hostile the political environment is to trans rights right now. Have you faced any sort of retaliation or threats? Are you worried about it? 
You always worry. You always have to be smart about what you do. My patients just want to live their lives and feel like themselves, to go through life and not have anybody bother them and not bother anybody else. Since the election, I’ve had so many of my trans patients talking about getting their passports and getting their IDs in line, saying, “Where might I move to? What’s going to happen? Is my care going to be available?” These are not minors. Fear is the goal. The goal of all of this is to stifle people and suppress them and not have their voices be heard. I am lucky and I have a lot of familial support. Somebody has to do it.

This interview has been edited and condensed for length and clarity.